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Kaufmann J, Buecke P, Meinel T, Beyeler M, Scutelnic A, Kaesmacher J, Mujanović A, Dobrocky T, Arsany H, Peters N, Z'Graggen W, Jung S, Seiffge D. Frequency of ischaemic stroke and intracranial haemorrhage in patients with reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES) - A systematic review. Eur J Neurol 2024; 31:e16246. [PMID: 38470001 DOI: 10.1111/ene.16246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) may cause ischaemic stroke and intracranial haemorrhage. The aim of our study was to assess the frequency of the afore-mentioned outcomes. METHODS We performed a PROSPERO-registered (CRD42022355704) systematic review and meta-analysis accessing PubMed until 7 November 2022. The inclusion criteria were: (1) original publication, (2) adult patients (≥18 years), (3) enrolling patients with PRES and/or RCVS, (4) English language and (5) outcome information. Outcomes were frequency of (1) ischaemic stroke and (2) intracranial haemorrhage, divided into subarachnoid haemorrhage (SAH) and intraparenchymal haemorrhage (IPH). The Cochrane Risk of Bias tool was used. RESULTS We identified 848 studies and included 48 relevant studies after reviewing titles, abstracts and full text. We found 11 studies on RCVS (unselected patients), reporting on 2746 patients. Among the patients analysed, 15.9% (95% CI 9.6%-23.4%) had ischaemic stroke and 22.1% (95% CI 10%-39.6%) had intracranial haemorrhage. A further 20.3% (95% CI 11.2%-31.2%) had SAH and 6.7% (95% CI 3.6%-10.7%) had IPH. Furthermore, we found 28 studies on PRES (unselected patients), reporting on 1385 patients. Among the patients analysed, 11.2% (95% CI 7.9%-15%) had ischaemic stroke and 16.1% (95% CI 12.3%-20.3%) had intracranial haemorrhage. Further, 7% (95% CI 4.7%-9.9%) had SAH and 9.7% (95% CI 5.4%-15%) had IPH. CONCLUSIONS Intracranial haemorrhage and ischaemic stroke are common outcomes in PRES and RCVS. The frequency reported in the individual studies varied considerably.
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Affiliation(s)
- Jana Kaufmann
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Philipp Buecke
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Adnan Mujanović
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Thomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Hakim Arsany
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Nils Peters
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
- Stroke Center, Hirslanden Clinic, Zurich, Switzerland
| | - Werner Z'Graggen
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
- Department of Neurosurgery, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
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Kremer J, Jahn J, Klein S, Farag M, Borst T, Karck M. Early versus Delayed Surgery in Patients with Left-Sided Infective Endocarditis and Stroke. J Cardiovasc Dev Dis 2023; 10:356. [PMID: 37623369 PMCID: PMC10455129 DOI: 10.3390/jcdd10080356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Timing of surgery remains controversial in patients with infective endocarditis and stroke. Guidelines on infective endocarditis suggest delaying surgery for up to 4 weeks. However, with early heart failure due to progression of the infection or recurrent septic embolism, urgent surgery becomes imperative. METHODS Out of 688 patients who were surgically treated for left-sided infective endocarditis, 187 presented with preoperative neurological events. The date of cerebral stroke onset was documented in 147 patients. The patients were stratified according to timing of surgery: 61 in the early group (0-7 days) vs. 86 in the delayed group (>7 days). Postoperative neurological outcome was assessed by the modified Rankin Scale. RESULTS Preoperative sepsis was more prevalent in patients with preoperative neurological complications (46.0% vs. 29.5%, p < 0.001). Patients with haemorrhagic stroke were operated on later (19.8% vs. 3.3%, p = 0.003). Postoperative cerebrovascular accidents were comparable between both groups (p = 0.13). Overall, we observed good neurological outcomes (p = 0.80) and a high recovery rate, with only 5% of cases showing neurological deterioration after surgery (p = 0.29). In-hospital mortality and long-term survival were not significantly different in the early and delayed surgery groups (log-rank, p = 0.22). CONCLUSIONS Early valve surgery in high-risk patients with infective endocarditis and stroke can be performed safely and is not associated with worse outcomes.
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Affiliation(s)
- Jamila Kremer
- Department of Cardiac Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Joshua Jahn
- Department of Cardiac Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Sabrina Klein
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Mina Farag
- Department of Cardiac Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Tobias Borst
- Pharmacy Department, Erlangen University Hospital, Palmsanlage 3, 91054 Erlangen, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
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Jacobwitz M, Favilla E, Patel A, Giglia TM, Taing K, Ravishankar C, Gaynor JW, Licht DJ, McGuire JL, Beslow LA. Neurologic complications of infective endocarditis in children. Cardiol Young 2023; 33:463-472. [PMID: 35546418 PMCID: PMC9652479 DOI: 10.1017/s1047951122001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To define the frequency and characteristics of acute neurologic complications in children hospitalised with infective endocarditis and to identify risk factors for neurologic complications. STUDY DESIGN Retrospective cohort study of children aged 0-18 years hospitalised at a tertiary children's hospital from 1 January, 2008 to 31 December, 2017 with infective endocarditis. RESULTS Sixty-eight children met Duke criteria for infective endocarditis (43 definite and 25 possible). Twenty-three (34%) had identified neurologic complications, including intracranial haemorrhage (25%, 17/68) and ischaemic stroke (25%, 17/68). Neurologic symptoms began a median of 4.5 days after infective endocarditis symptom onset (interquartile range 1, 25 days), though five children were asymptomatic and diagnosed on screening neuroimaging only. Overall, only 56% (38/68) underwent neuroimaging during acute hospitalisation, so additional asymptomatic neurologic complications may have been missed. Children with identified neurologic complications compared to those without were older (48 versus 22% ≥ 13 years old, p = 0.031), more often had definite rather than possible infective endocarditis (96 versus 47%, p < 0.001), mobile vegetations >10mm (30 versus 11%, p = 0.048), and vegetations with the potential for systemic embolisation (65 versus 29%, p = 0.004). Six children died (9%), all of whom had neurologic complications. CONCLUSIONS Neurologic complications of infective endocarditis were common (34%) and associated with mortality. The true frequency of neurologic complications was likely higher because asymptomatic cases may have been missed without screening neuroimaging. Moving forward, we advocate that all children with infective endocarditis have neurologic consultation, examination, and screening neuroimaging. Additional prospective studies are needed to determine whether early identification of neurologic abnormalities may direct management and ultimately reduce neurologic morbidity and overall mortality.
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Affiliation(s)
- Marin Jacobwitz
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emmanuelle Favilla
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Amisha Patel
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Therese M Giglia
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kimberly Taing
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer L McGuire
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Swan D, Thachil J. Challenges in managing patients on anticoagulation: Thrombocytopenia, resumption after bleeding and recurrent thrombosis. J R Coll Physicians Edinb 2022; 52:341-349. [PMID: 36317384 DOI: 10.1177/14782715221134720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Prescribing of anticoagulation is increasing worldwide. This is partly reflective of an aging population with cardiovascular comorbidities such as arrhythmias and prosthetic heart valves, alongside improvements in cancer treatments and survival. In this review, we discuss three common challenges faced by clinicians. These concern the management of patients with thrombosis and thrombocytopenia, resumption of anticoagulation in patients with a history of gastrointestinal or intracranial haemorrhage, and how to approach and treat a patient with recurrent thrombosis on anticoagulation. We consider the available evidence including relevant published recommendations and propose practical management suggestions to aid clinicians faced with these dilemmas.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, St James Hospital, Dublin, Ireland
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
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Ageely GA, Alsulami SS, Alkenani AA, Albeshri EEMS. Cardiac myxoma presenting with multisystem involvement. Saudi Med J 2022; 43:1057-1061. [PMID: 36104063 PMCID: PMC9987664 DOI: 10.15537/smj.2022.43.9.20220346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
A cardiac myxoma is a rare tumor that could be incidental or present with common symptoms due to embolization. A minority of cases are attributed to carney complex, a rare inherited disease. A 73-year-old Asian male presented with acute left-side weakness, slurred speech, gait imbalance, and subacute constitutional symptoms. Left atrial myxoma was discovered by computed tomography and confirmed by echocardiography. Brain imaging revealed pituitary macroadenoma with subarachnoid and intraventricular hemorrages. The hormonal profile confirmed pituitary apoplexy, for which hormone replacement was initiated. Workup also revealed multiple endocrine tumors and excluded infection and malignancy. Myxoma resection could not be carried out, due to the patient's rapid clinical deterioration and death.Furthermore, the presence of cardiac myxoma, non-functioning pituitary macroadenomas, and pituitary apoplexy is extremely rare and rarely documented in the literature. Therefore, we emphasize clinical awareness of rare conditions with atypical presentations to improve outcomes.
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Affiliation(s)
- Ghofran A. Ageely
- From the Department of Internal Medicine, Radiology Division, Rabigh Medical College, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Salhah S. Alsulami
- From the Department of Internal Medicine, Radiology Division, Rabigh Medical College, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Ahad A. Alkenani
- From the Department of Internal Medicine, Radiology Division, Rabigh Medical College, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Ebtihal EMS. Albeshri
- From the Department of Internal Medicine, Radiology Division, Rabigh Medical College, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
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Gordana T, Koraljka G, Ruža G, Desiree CH, Ostojić SB, Branka GĆ. Severe intracranial haemorrhage in neonatal alloimmune thrombocytopenia due to antibodies against human platelet antigen 1b: Case report and literature review. Transfus Med 2022; 32:269-275. [PMID: 35730350 DOI: 10.1111/tme.12892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 06/01/2022] [Accepted: 06/08/2022] [Indexed: 12/01/2022]
Abstract
Fetal/neonatal alloimmune thrombocytopenia (FNAIT) is a rare life-threatening disorder, leading to severe thrombocytopenia and potentially bleeding, with intracranial haemorrhage (ICH) being the most serious complication. We report on a FNAIT case with fourth-degree ICH that arose due to antibodies against human platelet antigen (HPA)-1b. The male infant, born to an otherwise healthy mother, presented with severe signs of ICH soon after delivery. Since only moderate thrombocytopenia was noted and there were no active signs of bleeding, the infant did not receive intravenous immunoglobulins (IVIg) or platelet transfusion. Spontaneous recovery of platelets was noted on the eighth day of life, but permanent neurological impairment remained as a consequence of ICH. We report the results of HPA and human leukocyte antigen (HLA) antibodies in the mother's and the infant's sera, the family's HPA genotype and the mother's HLA genotype, and summarise previously described cases of FNAIT due to anti-HPA-1b antibodies in the literature. FNAIT with severe ICH due to anti-HPA-1b antibodies is rarely diagnosed. An association between HLA genes and sensitization to HPA-1b antibodies was not demonstrated. The severity of FNAIT and the occurrence of ICH is often difficult to predict. In this case, the infant presented with moderate thrombocytopenia and ICH, with subsequent permanent consequences.
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Affiliation(s)
- Tomac Gordana
- Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Gojčeta Koraljka
- Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia.,University of Applied Health Sciences, Zagreb, Croatia
| | - Grizelj Ruža
- School of Medicine, University of Zagreb, Zagreb, Croatia.,Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Coen Herak Desiree
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Sanja Baršić Ostojić
- Clinical Department for Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Golubić Ćepulić Branka
- Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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Søyland MH, Tveiten A, Eltoft A, Øygarden H, Varmdal T, Indredavik B, Mathiesen EB. Wake-up stroke and unknown-onset stroke; occurrence and characteristics from the nationwide Norwegian Stroke Register. Eur Stroke J 2022; 7:143-150. [PMID: 35647309 PMCID: PMC9134780 DOI: 10.1177/23969873221089800] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/09/2022] [Indexed: 09/17/2023] Open
Abstract
Introduction Population-based knowledge of the characteristics of wake-up stroke and unknown-onset stroke is limited. We compared occurrence and characteristics of ischaemic and haemorrhagic wake-up stroke, unknown-onset stroke and known-onset stroke in a nationwide register-based study. Patients and methods We included patients registered in the Norwegian Stroke Register from 2012 through 2019. Age, sex, risk factors, clinical characteristics, acute stroke treatment and discharge destination were compared according to stroke type and time of onset. Results Of the 60,320 patients included, 11,451 (19%) had wake-up stroke, 11,098 (18.4%) had unknown time of onset and 37,771 (62.6%) had known symptom onset. The proportion of haemorrhagic stroke was lower among wake-up stroke patients (1107/11,451, 9.7%, 95% CI: 9.1-10.2) than for known-onset stroke (5230/37,771, 13.8%, 95% CI: 13.5-14.2) and for unknown-onset stroke (1850/11,098, 16.7%, 95% CI: 16.0-17.4). Mild stroke (NIHSS <5) was more frequent in ischaemic wake-up stroke (5364/8308, 64.6%, 95% CI: 63.5-65.5) than in known-onset (16,417/26,746, 61.4%, 95% CI: 60.8-62.0) and unknown-onset stroke (3242/5853, 55.4%, 95% CI: 54.1-56.7), while baseline characteristics were otherwise similar to known-onset stroke. Unknown-onset stroke patients were more often female, lived alone and had more severe strokes compared to wake-up stroke and known-onset stroke patients. Unknown-onset stroke patients were more often in need of community-based health care on discharge and had a higher in-hospital mortality. Discussion and conclusions Ischaemic wake-up strokes shared baseline characteristics with known-onset strokes, but tended to be milder. Ischaemic unknown-onset stroke patients differed significantly from wake-up stroke, emphasising the importance of considering them as separate entities.
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Affiliation(s)
- Mary-Helen Søyland
- Department of Neurology, Hospital of
Southern Norway, Kristiansand, Norway
- Department of Clinical Medicine, UiT
The Arctic University of Norway, Tromsø, Norway
| | - Arnstein Tveiten
- Department of Neurology, Hospital of
Southern Norway, Kristiansand, Norway
| | - Agnethe Eltoft
- Department of Clinical Medicine, UiT
The Arctic University of Norway, Tromsø, Norway
- Department of Neurology, University
Hospital of North Norway, Tromsø, Norway
| | - Halvor Øygarden
- Department of Neurology, Hospital of
Southern Norway, Kristiansand, Norway
- University of Agder, Kristiansand,
Norway
| | - Torunn Varmdal
- Norwegian University of Science and
Technology, Trondheim, Norway
| | - Bent Indredavik
- Norwegian University of Science and
Technology, Trondheim, Norway
- Department of Medicine, St. Olav’s
Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ellisiv B Mathiesen
- Department of Clinical Medicine, UiT
The Arctic University of Norway, Tromsø, Norway
- Department of Neurology, University
Hospital of North Norway, Tromsø, Norway
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Mayorga-Corvacho J, Vergara-Garcia D, Benavides C, Riveros WM. Ruptured brain arteriovenous malformation in a pregnant woman: a case report. Br J Neurosurg 2022:1-4. [PMID: 35510560 DOI: 10.1080/02688697.2022.2064426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 11/24/2021] [Accepted: 04/06/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Brain arteriovenous malformations (bAVMs) are vascular lesions that commonly present with intracranial haemorrhage. Pregnancy has been associated with an increased risk of bAVM rupture. However, their natural history in pregnant women is uncertain. CASE DESCRIPTION A 27-year-old female at 28 weeks of gestation presented with a compromised neurological status secondary to a ruptured left frontal Spetzler-Martin scale (SM) III + bAVM. An emergent caesarean section was performed due to the high risk of foetal distress. Endovascular treatment successfully controlled the bleeding site, and stereotactic radiosurgery was offered as a subsequent treatment option. CONCLUSION bAVMs should be considered in pregnant women with intracranial haemorrhage. The management of these lesions during pregnancy is controversial. Surgical risk and foetal development should be considered when selecting a management strategy.
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Affiliation(s)
- Juliana Mayorga-Corvacho
- Neurosurgery Department, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
| | - David Vergara-Garcia
- Neurosurgery Department, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
| | - Camilo Benavides
- Neurosurgery Department, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
| | - William Mauricio Riveros
- Neurosurgery Department, Center for Research and Training in Neurosurgery (CIEN), Samaritana University Hospital, Rosario University School of Medicine, Bogotá, Colombia
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9
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Zanon E, Pasca S, Demartis F, Tagliaferri A, Santoro C, Cantori I, Molinari AC, Biasoli C, Coppola A, Luciani M, Sottilotta G, Ricca I, Pollio B, Borchiellini A, Tosetto A, Peyvandi F, Frigo AC, Simioni P. Intracranial Haemorrhage in Haemophilia Patients Is Still an Open Issue: The Final Results of the Italian EMO.REC Registry. J Clin Med 2022; 11:jcm11071969. [PMID: 35407576 PMCID: PMC8999820 DOI: 10.3390/jcm11071969] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Intracranial hemorrhage (ICH) is a highly serious event in patients with haemophilia (PWH) which leads to disability and in some cases to death. ICH occurs among all ages but is particularly frequent in newborns. Aim: The primary aim was to assess the incidence and mortality due to ICH in an Italian population of PWH. Secondary aims were to evaluate the risk factors for ICH, the role of prophylaxis, and the clinical management of patients presenting ICH. Methods: A retrospective-prospective registry was established in the network of the Italian Association of Haemophilia Centers to collect all ICHs in PWH from 2009 to 2019 reporting clinical features, treatments, and outcomes. Results: Forty-six ICHs were collected from 13 Centers. The ICHs occurred in 15 children (10 < 2 years), and in 31 adults, 45.2% of them with mild hemophilia. Overall, 60.9% patients had severe haemophilia (15/15 children). Overall ICH incidence (×1000 person/year) was 0.360 (0.270−0.480 95% CI), higher in children <2 years, 1.995 (1.110−3.442 95% CI). Only 7/46 patients, all with severe haemophilia, had received a prophylactic regimen before the ICH, none with mild. Inhibitors were present in 10.9% of patients. In adult PWHs 17/31 suffered from hypertension; 85.7% of the mild subjects and 29.4% of the moderate/severe ones (p < 0.05). ICH was spontaneous in the 69.6% with lower rate in children (46.7%). Surgery was required in 21/46 patients for cerebral hematoma evacuation. Treatment with coagulation factor concentrates for at least three weeks was needed in 76.7% of cases. ICH was fatal in 30.4% of the cases. Of the survivors, 50.0% became permanently disabled. Only one-third of adult patients received long term prophylaxis after the acute treatment. Conclusion: The results from our Registry confirm the still high incidence of ICH in infants <2 years and in adults, particularly in mild PWHs presenting hypertension and its unfavorable outcomes. The majority of PWHs were treated on-demand before ICH occurred, suggesting the important role of prophylaxis in preventing such life-threatening bleeding.
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Affiliation(s)
- Ezio Zanon
- Haemophilia Center-General Medicine, Padua University Hospital, 35128 Padua, Italy;
- Correspondence: ; Tel.: +39-049-8212-2666
| | - Samantha Pasca
- Department of Biomedical Sciences, Padua University Hospital, 35128 Padua, Italy;
| | - Francesco Demartis
- Centre for Bleeding Disorders, Careggi University Hospital of Florence, 50134 Florence, Italy;
| | - Annarita Tagliaferri
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, 43126 Parma, Italy; (A.T.); (A.C.)
| | - Cristina Santoro
- Hematology Division, Umberto I University Hospital of Rome, 00185 Rome, Italy;
| | - Isabella Cantori
- Haemophilia Center, Department of Transfusion Medicine, Hospital of Macerata, 62100 Macerata, Italy;
| | - Angelo Claudio Molinari
- Regional Reference Centre for Hemorrhagic Diseases, Thrombosis and Hemostasis Unit, Gaslini Children Hospital of Genoa, 16147 Genova, Italy;
| | - Chiara Biasoli
- Haemophilia Center, Transfusion Medicine, Department of Clinical Pathology, Hospital of Cesena, 47521 Cesena, Italy;
| | - Antonio Coppola
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, 43126 Parma, Italy; (A.T.); (A.C.)
| | - Matteo Luciani
- Haemostasis and Thrombosis Center, Onco-Hematology Department, Bambin Gesù Children Hospital of Rome, 00165 Roma, Italy;
| | - Gianluca Sottilotta
- Haemophilia Center, Department of Onco-Hematology and Radioterapy, Hospital of Reggio Calabria, 89124 Reggio Calabria, Italy;
| | - Irene Ricca
- Transfusion Medicine, Department of Diagnostic, Regina Margherita Children Hospital of Turin, 10126 Turin, Italy; (I.R.); (B.P.)
| | - Berardino Pollio
- Transfusion Medicine, Department of Diagnostic, Regina Margherita Children Hospital of Turin, 10126 Turin, Italy; (I.R.); (B.P.)
| | | | - Alberto Tosetto
- Hemorrhagic and Thrombotic Diseases Unit, S. Bortolo Hospital of Vicenza, 36100 Vicenza, Italy;
| | - Flora Peyvandi
- Hemophilia and Thrombosis Center, University Hospital of Milan, 20132 Milan, Italy;
| | - Anna Chiara Frigo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health Padua University Hospital, 35122 Padova, Italy;
| | - Paolo Simioni
- Haemophilia Center-General Medicine, Padua University Hospital, 35128 Padua, Italy;
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10
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Elsamadicy E, Kundishora A, Turan S. Worm Sign: A possible first-trimester sonographic marker for intracranial haemorrhage resulting in significant cortical disruption. Australas J Ultrasound Med 2021; 24:112-116. [PMID: 34765420 DOI: 10.1002/ajum.12240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Fetal intracranial haemorrhage (ICH) is a pathophysiological process involving haemorrhagic and hypoxic-ischaemic insults resulting in antenatal brain damage. Insults to the central nervous system are usually not detected until the second or third trimester. In this case presentation, we present a possible prenatal ultrasound marker, 'worm sign', representing cortical disruption secondary to suspected ICH at 13 weeks' gestation. According to current literature review, this is one of the first cases of ICH, diagnosed in the first-trimester and highlights the importance of early neurovascular and structural evaluation of the fetal brain at the time of first-trimester ultrasound screening.
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Affiliation(s)
- Emad Elsamadicy
- Department of Obstetrics, Gynecology & Reproductive Sciences University of Maryland School of Medicine Baltimore MA USA
| | - Adam Kundishora
- Department of Neurosurgery Yale University School of Medicine New Haven CT USA
| | - Sifa Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences University of Maryland School of Medicine Baltimore MA USA
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11
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Yu Q, Zhao T, Liu M, Cao D, Li J, Li Y, Xia M, Wang X, Zheng T, Liu C, Mu X, Sun P. Targeting NLRP3 Inflammasome in Translational Treatment of Nervous System Diseases: An Update. Front Pharmacol 2021; 12:707696. [PMID: 34526897 PMCID: PMC8435574 DOI: 10.3389/fphar.2021.707696] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/18/2021] [Indexed: 12/14/2022] Open
Abstract
Neuroinflammatory response is the immune response mechanism of the innate immune system of the central nervous system. Both primary and secondary injury can activate neuroinflammatory response. Among them, the nucleotide-binding oligomerization domain-like receptor protein 3 (NLRP3) inflammasome plays a key role in the inflammatory response of the central system. Inflammasome is a type of pattern recognition receptor, a cytoplasmic polyprotein complex composed of members of the Nod-like receptor (NLR) family and members of the pyrin and HIN domain (PYHIN) family, which can be affected by a variety of pathogen-related molecular patterns or damage-related molecular patterns are activated. As one of the research hotspots in the field of medical research in recent years, there are increasing researches on immune function abnormalities in the onset of neurological diseases such as depression, AD, ischemic brain injury and cerebral infarction, the NLRP3 inflammasome causes the activated caspase-1 to cleave pre-interleukin-1β and pre-interleukin-18 into mature interleukin-1β and interleukin-18, in turn, a large number of inflammatory factors are produced, which participate in the occurrence and development of the above-mentioned diseases. Targeted inhibition of the activation of inflammasomes can reduce the inflammatory response, promote the survival of nerve cells, and achieve neuroprotective effects. This article reviews NLRP3 inflammasome's role in neurological diseases and related regulatory mechanisms, which providing references for future research in this field.
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Affiliation(s)
- Qingying Yu
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Tingting Zhao
- School of Foreign Languages, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Molin Liu
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Duo Cao
- College of Life Science, Yan’an University, Yan’an, China
| | - Jiaxin Li
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yanling Li
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Mengyao Xia
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiaoyu Wang
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Tingting Zheng
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Chuanguo Liu
- Innovation Research Institute of Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiangyu Mu
- School of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Peng Sun
- Innovation Research Institute of Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
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12
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Tarantino MD. Occurrence and management of severe bleeding episodes in patients with hereditary factor X deficiency. Haemophilia 2021; 27:531-543. [PMID: 34021672 PMCID: PMC8361996 DOI: 10.1111/hae.14223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/12/2020] [Indexed: 11/29/2022]
Abstract
Vitamin K-dependent factor X (FX) plays an important role in thrombin formation, and a deficiency in FX can cause impaired coagulation, the severity of which is usually correlated with the degree of deficiency. Due to the critical role that FX plays in the coagulation cascade, FX deficiency is associated with a higher risk of bleeding than deficiencies in other coagulation factors. Patients with the hereditary autosomal-recessive homozygous form of FX deficiency, which occurs in approximately 1:1,000,000 individuals worldwide, are often diagnosed when they present with spontaneous life-threatening haemorrhage (most often intracranial haemorrhage) during the first month of life. In addition to central nervous system bleeds, other severe bleeding types experienced by such patients may include umbilical cord bleeding, gastrointestinal or pulmonary haemorrhage, intramuscular haematomas and/or haemarthrosis. Delayed treatment or inadequate replacement of FX may result in developmental delays, musculoskeletal disabilities or death. The high risk of recurrent severe bleeding necessitates prophylactic replacement therapy for many individuals with severe FX deficiency. Available products for replacement therapy include plasma-derived FX concentrate and prothrombin complex concentrates. Fresh-frozen plasma may be used when concentrates are not available but is a less efficient means of FX replacement. This article reviews the literature on severe bleeding in individuals with hereditary FX deficiency and discusses current treatment options.
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Affiliation(s)
- Michael D. Tarantino
- Bleeding and Clotting Disorders InstituteUniversity of Illinois College of MedicinePeoriaILUSA
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13
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Ince J, Mankoo AS, Kadicheeni M, Swienton D, Panerai RB, Robinson TG, Minhas JS. Cerebrovascular tone and resistance measures differ between healthy control and patients with acute intracerebral haemorrhage: exploratory analyses from the BREATHE-ICH study. Physiol Meas 2021; 42. [PMID: 33853052 DOI: 10.1088/1361-6579/abf7da] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/14/2021] [Indexed: 11/12/2022]
Abstract
Objective.Cerebral autoregulation impairment in acute neurovascular disease is well described. The recent BREATHE-ICH study demonstrated improvements in dynamic cerebral autoregulation, by hypocapnia generated by hyperventilation, in the acute period following intracranial haemorrhage (ICH). This exploratory analysis of the BREATHE-ICH dataset aims to examine the differences in hypocapnic responses between healthy controls and patients with ICH, and determine whether haemodynamic indices differ between baseline and hypocapnic states.Approach.Acute ICH patients were recruited within 48 h of onset and healthy volunteers were recruited from a university setting. Transcranial Doppler measurements of the middle cerebral artery were obtained at baseline and then a hyperventilation intervention was used to induce hypocapnia. Patients with ICH were then followed up at 10-14 D post-event for repeated measurements.Main results.Data from 43 healthy controls and 12 patients with acute ICH met the criteria for statistical analysis. In both normocapnic and hypocapnic conditions, significantly higher critical closing pressure and resistance area product were observed in patients with ICH. Furthermore, critical closing pressure changes were observed to be sustained at 10-14 D follow up. During both the normocapnic and hypocapnic states, reduced autoregulation index was observed bilaterally in patients with ICH, compared to healthy controls.Significance.Whilst this exploratory analysis was limited by a small, non-age matched sample, significant differences between ICH patients and healthy controls were observed in factors associated with cerebrovascular tone and resistance. These differences suggest underlying cerebral autoregulation changes in ICH, which may play a pivotal role in the morbidity and mortality associated with ICH.
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Affiliation(s)
- Jonathan Ince
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - Alex S Mankoo
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - Meeriam Kadicheeni
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - David Swienton
- Department of Radiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Jatinder S Minhas
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
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14
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Mason JA, Young G. Emicizumab prophylaxis in infants with severe haemophilia A without inhibitors: Illustrative real-world cases to support shared decision-making. Haemophilia 2021; 27:724-729. [PMID: 34085367 DOI: 10.1111/hae.14353] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Emicizumab has been shown to be safe and effective for prevention of bleeds in patients with severe haemophilia A (SHA), both with and without inhibitors. The subcutaneous administration and long half-life make emicizumab an attractive option for prophylaxis in infants with SHA, however data to inform treatment decisions in this younger age group are almost absent. AIM The aim of this report is to share real world experience to illustrate how the availability of emicizumab has shifted the prophylaxis paradigm in the management of infants with SHA. METHOD We selected four cases from our own cohort of infants with SHA to outline the rationale for emicizumab prophylaxis in a range of scenarios familiar to paediatric haemophilia treaters. RESULTS In Case 1 emicizumab was commenced at 7 days following initial treatment of neonatal ICH with a FVIII infusion. In Case 2 emicizumab was commenced at 5 weeks due to parental anxiety regarding the potential for ICH during infancy. Case 3 commenced emicizumab at 15 months in lieu of standard primary prophylaxis. Case 4 switched to emicizumab prophylaxis at 14 months after a period of primary prophylaxis with FVIII concentrates to alleviate parental anxiety regarding future inhibitor development. No patient had any bleeding events after commencement of emicizumab (median follow up 12 months), and no drug-related adverse effects were observed. CONCLUSION Despite the paucity of data in infants with SHA the potential role of emicizumab prophylaxis should be discussed with families when clinically relevant, with decisions tailored to individual need.
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Affiliation(s)
- Jane A Mason
- Queensland Haemophilia Centre, Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Little Red Drop Haematology, The Wesley Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, California, USA.,University of Southern California Keck School of Medicine, Los Angeles, California, USA
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15
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Mann O, Peery D, Bader Segev R, Klainbart S, Kelmer E, Sobarzo A, Shub V, Rapoport K, Shamir MH, Chai O. CT findings and the prognostic value of the Koret CT score in cats with traumatic brain injury. J Feline Med Surg 2021; 24:91-97. [PMID: 33847537 PMCID: PMC8807991 DOI: 10.1177/1098612x211005306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aims of this study were to evaluate associations between abnormal head CT findings and outcome, and to examine the prognostic value of the Koret CT score (KCTS) in cats sustaining acute traumatic brain injury (TBI). METHODS The medical records of cats hospitalised with TBI that underwent head CT scans within 72 h of admission were retrospectively reviewed. CT scans were evaluated independently by a radiologist and a neurologist who were blinded to the outcome. A KCTS and modified Glasgow Coma Scale (MGCS) were assigned to each cat and the association between abnormal CT findings, KCTS, MGCS and outcome were analysed. RESULTS Fourteen cats were included in the study: nine (64.2%) survivors and five (35.7%) non-survivors. Of the nine cats that were discharged, one was a short-term survivor (10 days) and eight (57.1%) were long-term survivors (⩾6 months). Abnormal CT findings included lateral ventricle asymmetry/midline shift (42.8%), intracranial haemorrhage (35.7%), caudotentorial lesions (14.2%) and cranial vault fractures (14.2%), all of which were depressed. Intracranial haemorrhage was found to be significantly and negatively associated with short-term (P = 0.005) and long-term (P = 0.023) survival. KCTS was significantly associated with short-term survival (P = 0.002) and long-term survival (P = 0.004). A KCTS cut-off value of 2 yielded a 100% sensitivity and 100% specificity for short-term survival and 100% sensitivity and 80% specificity for long-term survival. A MGCS cut-off value of ⩾13 was associated with a 100% sensitivity and 100% specificity for short-term survival, and with a 100% sensitivity and 80% specificity for long-term survival. CONCLUSIONS AND RELEVANCE KCTS, performed up to 72 h from injury, can be used as an additional diagnostic tool for the prediction of survival in cats with TBI.
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Affiliation(s)
- Ohad Mann
- Department of Emergency and Critical Care, Koret School of Veterinary Medicine Teaching Hospital, Hebrew University of Jerusalem, Rehovot, Israel
| | - Dana Peery
- Department of Radiology, Koret School of Veterinary Medicine Teaching Hospital, Hebrew University of Jerusalem, Rehovot, Israel
| | - Ronnie Bader Segev
- Department of Emergency and Critical Care, Koret School of Veterinary Medicine Teaching Hospital, Hebrew University of Jerusalem, Rehovot, Israel
| | - Sigal Klainbart
- Department of Emergency and Critical Care, Koret School of Veterinary Medicine Teaching Hospital, Hebrew University of Jerusalem, Rehovot, Israel
| | - Efrat Kelmer
- Department of Emergency and Critical Care, Koret School of Veterinary Medicine Teaching Hospital, Hebrew University of Jerusalem, Rehovot, Israel
| | - Ariel Sobarzo
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Pre-Clinical Research Center, Health Faculty, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Vered Shub
- Emergency and Specialist Veterinary Center, Ben-Shemen Youth Village, Israel
| | - Kira Rapoport
- Department of Neurology and Neurosurgery, Koret School of Veterinary Medicine Teaching Hospital, Hebrew University of Jerusalem, Rehovot, Israel
| | - Merav H Shamir
- Department of Neurology and Neurosurgery, Koret School of Veterinary Medicine Teaching Hospital, Hebrew University of Jerusalem, Rehovot, Israel
| | - Orit Chai
- Department of Neurology and Neurosurgery, Koret School of Veterinary Medicine Teaching Hospital, Hebrew University of Jerusalem, Rehovot, Israel
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16
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Styczen H, Gawlitza M, Abdullayev N, Brehm A, Serna-Candel C, Fischer S, Gerber J, Kabbasch C, Psychogios MN, Forsting M, Henkes H, Maus V. Mechanical thrombectomy in acute ischaemic stroke patients with pre-interventional intracranial haemorrhage following intravenous thrombolysis. Neuroradiol J 2021; 34:456-461. [PMID: 33840277 PMCID: PMC8551424 DOI: 10.1177/19714009211009112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Data on outcome of endovascular treatment in patients with acute ischaemic
stroke due to large vessel occlusion suffering from intravenous
thrombolysis-associated intracranial haemorrhage prior to mechanical
thrombectomy remain scarce. Addressing this subject, we report our
multicentre experience. Methods A retrospective analysis of consecutive acute ischaemic stroke patients
treated with mechanical thrombectomy due to large vessel occlusion despite
the pre-interventional occurrence of intravenous thrombolysis-associated
intracranial haemorrhage was performed at five tertiary care centres between
January 2010–September 2020. Baseline demographics, aetiology of stroke and
intracranial haemorrhage, angiographic outcome assessed by the Thrombolysis
in Cerebral Infarction score and clinical outcome evaluated by the modified
Rankin Scale at 90 days were recorded. Results In total, six patients were included in the study. Five individuals
demonstrated cerebral intraparenchymal haemorrhage on pre-interventional
imaging; in one patient additional subdural haematoma was observed and one
patient suffered from isolated subarachnoid haemorrhage. All patients except
one were treated by the ‘drip-and-ship’ paradigm. Successful reperfusion was
achieved in 4/6 (67%) individuals. In 5/6 (83%) patients, the
pre-interventional intracranial haemorrhage had aggravated in
post-interventional computed tomography with space-occupying effect.
Overall, five patients had died during the hospital stay. The clinical
outcome of the survivor was modified Rankin Scale=4 at 90 days
follow-up. Conclusion Mechanical thrombectomy in patients with intravenous thrombolysis-associated
intracranial haemorrhage is technically feasible. The clinical outcome of
this subgroup of stroke patients, however, appears to be devastating with
high mortality and only carefully selected patients might benefit from
endovascular treatment.
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Affiliation(s)
- Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | - Matthias Gawlitza
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Germany
| | - Nuran Abdullayev
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Germany
| | - Alex Brehm
- Department of Neuroradiology, University Hospital Basel, Switzerland
| | | | - Sebastian Fischer
- Department of Radiology, Neuroradiology and Nuclear Medicine, Ruhr-University Bochum, Germany
| | - Johannes Gerber
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Germany
| | - Christoph Kabbasch
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Germany
| | | | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Klinikum Stuttgart, Germany
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, Ruhr-University Bochum, Germany
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17
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Krzystanek E, Gawryluk J, Arkuszewski M. Fatal intracranial haemorrhage in a hypertensive patient with atrial fibrillation and coronavirus disease 2019. Neuroradiol J 2021; 34:147-150. [PMID: 33307996 PMCID: PMC8041405 DOI: 10.1177/1971400920978438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
We present a case of a fatal cerebral haemorrhage in an 82-year-old male patient with coronavirus disease 2019 (COVID-19), who was taking prophylactic oral anticoagulation because of atrial fibrillation (rivaroxaban 20 mg q.d. for two years). On admission, the patient was deeply comatose, mechanically ventilated, with tachycardia up to 150 bpm, high blood pressure >210/120 mmHg and a body temperature >39°C. A computed tomography scan of the head showed a large intracerebral haemorrhage located in the deep structures of the right hemisphere, with a mass effect and bleeding to the ventricles. Rivaroxaban was discontinued at admission. The patient tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but he did not have typical symptoms of pneumonia. In the following days, the patient's neurological condition did not improve, and a fever of up to 40°C and abnormal coagulation parameters remained resistant to pharmacotherapy. The patient developed multi-system organ failure and died on day 8. Here, we review the recent literature and discuss the possible association of SARS-CoV-2-mediated endothelial injury and cardiovascular disorders with cerebrovascular complications. We postulate that anti-inflammatory treatment in COVID-19 and the stabilisation of endothelium functions can be particularly important in patients with pre-existing cardiovascular conditions.
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Affiliation(s)
- Ewa Krzystanek
- Department of Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Justyna Gawryluk
- Department of Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
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18
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Takagi M, Tanaka K, Miwa K, Sasaki M, Koga M, Hirano T, Kamiyama K, Yagita Y, Nagakane Y, Hoshino H, Terasaki T, Yakushiji Y, Kudo K, Ihara M, Yoshimura S, Yamaguchi Y, Shiozawa M, Toyoda K. The bleeding with antithrombotic therapy study 2: Rationale, design, and baseline characteristics of the participants. Eur Stroke J 2021; 5:423-431. [PMID: 33598561 DOI: 10.1177/2396987320960618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022] Open
Abstract
Aims The bleeding risk of current antithrombotic strategies in clinical settings, including recently developed agents, needs to be clarified. Methods and Design In an investigator-initiated, prospective, multicentre, observational study, patients with cerebrovascular or cardiovascular diseases who were taking oral antiplatelet or anticoagulant agents were enrolled. Compulsory multimodal magnetic resonance images were acquired at baseline to assess cerebral small vessel disease. Six-month follow-up will be performed for two years. The primary outcome is major bleeding as defined by the International Society on Thrombosis and Hemostasis. Results Between October 2016 and March 2019, 5306 patients (71.7 ± 11.2 years old, 1762 women) were enrolled. Previous intracranial haemorrhage was documented in 181 patients (3.4%), cerebrovascular disease (including asymptomatic) requiring antithrombotic therapy in 5006 patients (94.3%), and atrial fibrillation in 1061 patients (20.0%). At entry, 3726 patients (70.2%) were taking antiplatelet agents alone, including 551 (10.4%) using dual antiplatelet agents, 1317 (24.8%) taking anticoagulants alone, and the remaining 263 (5.0%) taking both. The leading antiplatelet agent was clopidogrel (2014 patients), and the leading combination of dual antiplatelet medication was clopidogrel plus aspirin (362). Use of direct oral anticoagulants (1029 patients, 19.4%) exceeded warfarin use (554, 10.4%). The number of pivotal bleeding events exceeded 200 in April 2020. Conclusions This study is expected to provide the incidence of bleeding complications of recent oral antithrombotics in clinical practice and identify their associations with underlying small vessel disease and other biomarkers. Novel risk stratification models for bleeding risk will be able to be created based on the study results.
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Affiliation(s)
- Masahito Takagi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | | | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Tadashi Terasaki
- Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshitaka Yamaguchi
- Department of Neurology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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19
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Rohaert C, Labarque V. Spontaneous intracranial haemorrhage as initial presentation of haemophilia in infants and children: A case report and systematic literature review. Haemophilia 2021; 27:e398-e401. [PMID: 33421035 DOI: 10.1111/hae.14239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 11/23/2020] [Accepted: 12/10/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Celine Rohaert
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Veerle Labarque
- Department of Pediatric Hemato-Oncology, University Hospitals Leuven, Leuven, Belgium
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20
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Bressan S, Monagle P, Dalziel SR, Borland ML, Phillips N, Kochar A, Lyttle MD, Cheek JA, Neutze J, Oakley E, Dalton S, Gilhotra Y, Hearps S, Furyk J, Babl FE. Risk of traumatic intracranial haemorrhage in children with bleeding disorders. J Paediatr Child Health 2020; 56:1891-1897. [PMID: 32810331 DOI: 10.1111/jpc.15073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 12/19/2022]
Abstract
AIM To assess computerised tomography (CT) use and the risk of intracranial haemorrhage (ICH) in children with bleeding disorders following a head trauma. METHODS Design: Multicentre prospective observational study. SETTING 10 paediatric emergency departments (ED) in Australia and New Zealand. PATIENTS Children <18 years with and without bleeding disorders assessed in ED following head trauma between April 2011 and November 2014. INTERVENTIONS Data collection of patient characteristics, management and outcomes. MAIN OUTCOME MEASURES Rate of CT use and frequency of ICH on CT. RESULTS Of 20 137 patients overall, 103 (0.5%) had a congenital or acquired bleeding disorder. CT use was higher in these patients compared with children without bleeding disorders (30.1 vs. 10.4%; rate ratio 2.91 95% CI 2.16-3.91). Only one of 31 (3.2%) children who underwent CT in the ED had an ICH. This patient rapidly deteriorated in the ED on arrival and required neurosurgery. None of the patients with bleeding disorders who did not have a CT obtained in the ED or had an initial negative CT had evidence of ICH on follow up. CONCLUSIONS Although children with a bleeding disorder and a head trauma more often received a CT scan in the ED, their risk of ICH seemed low and appeared associated with post-traumatic clinical findings. Selective CT use combined with observation may be cautiously considered in these children based on clinical presentation and severity of bleeding disorder.
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Affiliation(s)
- Silvia Bressan
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Paul Monagle
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Health, Auckland, New Zealand.,Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Natalie Phillips
- Emergency Department, Children's Hospital Queensland, Brisbane, Queensland, Australia.,Child Health Research Centre, School of Medicine, University of Queensland, Centre for Children's Health Research, Brisbane, Queensland, Australia
| | - Amit Kochar
- Emergency Department, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Mark D Lyttle
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Bristol Children's Hospital, Bristol, UK.,Academic Department of Emergency Care, University of the West of England, Bristol, UK
| | - John A Cheek
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Jocelyn Neutze
- Emergency Department, Kidzfirst Middlemore Hospital, Auckland, New Zealand
| | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Sarah Dalton
- Emergency Department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Yuri Gilhotra
- Emergency Department, Children's Hospital Queensland, Brisbane, Queensland, Australia
| | - Stephen Hearps
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jeremy Furyk
- Emergency Department, The Townsville Hospital, Townsville, Queensland, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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21
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Lai CH, Hsieh CY, Barnado A, Huang LC, Chen SC, Tsai LM, Shyr Y, Li CY. Outcomes of acute cardiovascular events in rheumatoid arthritis and systemic lupus erythematosus: a population-based study. Rheumatology (Oxford) 2020; 59:1355-1363. [PMID: 31600392 DOI: 10.1093/rheumatology/kez456] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 09/04/2019] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Patients with RA and SLE have an excess cardiovascular risk. We aimed to evaluate outcomes of acute cardiovascular events in these patients. METHODS Using a nationwide database of Taiwan, we identified adult patients who experienced first-time acute myocardial infarction (n = 191 008), intracranial haemorrhage (n = 169 923) and ischaemic stroke (n = 486 890) over a 13-year period. Odds ratios (ORs) of in-hospital mortality and hazard ratios (HRs) of overall mortality and adverse outcomes during long-term follow-up in relation to RA and SLE were estimated with adjustment for potential confounders. RESULTS In each cohort, 748, 410 and 1419 patients had established RA; 256, 292 and 622 patients had SLE. Among acute myocardial infarction patients, RA and SLE were associated with in-hospital mortality (RA: OR 1.61, 95% CI 1.33, 1.95; SLE: OR 2.31, 95% CI 1.62, 3.28) and overall mortality. Additionally, RA (HR 1.28, 95% CI 1.18, 1.38) and SLE (HR 1.46, 95% CI 1.27, 1.69) increased the risk of major adverse cardiac events. After intracranial haemorrhage, patients with RA and SLE had higher risks of in-hospital mortality (RA: OR 1.61, 95% CI 1.26, 2.06; SLE: OR 3.00, 95% CI 2.33, 3.86) and overall mortality. After ischaemic stroke, RA and SLE increased in-hospital mortality (RA: OR 1.45, 95% CI 1.15, 1.83; SLE: OR 2.18, 95% CI 1.57, 3.02), overall mortality and recurrent cerebrovascular events (RA: HR 1.10, 95% CI 1.002, 1.21; SLE: HR 1.31, 95% CI 1.14, 1.51), among which ischaemic stroke (HR 1.39, 95% CI 1.19, 1.62) was more likely to recur in SLE patients. CONCLUSION Both RA and SLE are consistently associated with adverse outcomes following acute cardiovascular events, highlighting the necessity of integrated care for affected patients.
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Affiliation(s)
- Chao-Han Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
| | - April Barnado
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li-Ching Huang
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sheau-Chiann Chen
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Liang-Miin Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Yu Shyr
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
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22
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Gurnari C, Breccia M, Di Giuliano F, Scalzulli E, Divona M, Piciocchi A, Cicconi L, De Bellis E, Venditti A, Del Principe MI, Arcese W, Lo-Coco F, Garaci F, Voso MT. Early intracranial haemorrhages in acute promyelocytic leukaemia: analysis of neuroradiological and clinico-biological parameters. Br J Haematol 2020; 193:129-132. [PMID: 32808672 DOI: 10.1111/bjh.17018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/09/2020] [Indexed: 12/18/2022]
Abstract
Acute promyelocytic leukaemia (APL) represents a modern success of precision medicine. However, fatalities occurring within the first 30 days of induction treatment, in particular intracranial haemorrhage (ICH), remain the main causes of death. We studied the clinico-biological characteristics of 13 patients with APL who experienced ICH. Compared to 85 patients without this complication, patients with ICH were older and more frequently had high-risk APL. Moreover, positivity for the 'swirl' sign at neuroradiological imaging and hydrocephalus were predictors of a fatal outcome, together with lower fibrinogen, prolonged international normalized ratio (INR) and higher lactate dehydrogenase levels.
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Affiliation(s)
- Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Massimo Breccia
- Department of Translational and Precision Medicine, University 'La Sapienza' of Rome, Rome, Italy
| | - Francesca Di Giuliano
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Emilia Scalzulli
- Department of Translational and Precision Medicine, University 'La Sapienza' of Rome, Rome, Italy
| | - Mariadomenica Divona
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.,Saint Camillus International, University of Health Sciences, Rome, Italy
| | | | - Laura Cicconi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Eleonora De Bellis
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Adriano Venditti
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - William Arcese
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Lo-Coco
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Garaci
- Neuroradiology Unit, Department of Biomedicine and Preventio, University of Rome "Tor Vergata", Rome, Italy.,San Raffaele Cassino, Cassino, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.,Laboratorio di Neuro-Oncoematologia, Fondazione Santa Lucia, Rome, Italy
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23
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Béres-Molnár KA, Folyovich A, Szloboda P, Szendrey-Kiss Z, Bereczki D, Bakos M, Várallyay G, Szabó H, Nyári I. Simultaneous subdural, subarachnoideal and intracerebral haemorrhage after rupture of a peripheral middle cerebral artery aneurysm. Ideggyogy Sz 2020; 73:213-216. [PMID: 32579312 DOI: 10.18071/isz.73.0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo-gical examination excluded mycotic etiology of the aneu-rysm and "normal aneurysm wall" was described. The brain stem haemorrhage - Duret bleeding - was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.
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Affiliation(s)
| | - András Folyovich
- Department of Neurology and Stroke, Szent János Hospital, Budapest
| | - Péter Szloboda
- Department of Neurosurgery, Szent János Hospital, Budapest
| | | | | | - Mária Bakos
- Department of Radiology, Szent János Hospital, Budapest
| | | | - Huba Szabó
- Department of Pathology, Szent János Hospital, Budapest
| | - István Nyári
- Department of Neurosurgery, Szent János Hospital, Budapest
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24
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Svensson EH, Abul-Kasim K, Engström G, Söderholm M. Risk factors for intracerebral haemorrhage - Results from a prospective population-based study. Eur Stroke J 2020; 5:278-285. [PMID: 33072882 PMCID: PMC7538759 DOI: 10.1177/2396987320932069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction While the relationship between hypertension and incident intracerebral
haemorrhage is well established, other risk factors are less clear. This
study examined risk factors for primary intracerebral haemorrhage,
separately for lobar and non-lobar intracerebral haemorrhage. Patients and methods Incidence of intracerebral haemorrhage was studied among 28,416 individuals
from the population-based Malmö Diet and Cancer cohort. Intracerebral
haemorrhage cases were ascertained using the Swedish Hospital Discharge
Register and the Stroke Register of Malmö, validated by review of hospital
records and images, and classified by location by a neuroradiologist.
Multivariable Cox regression was used. Results Three hundred and thirty-three intracerebral haemorrhages occurred, mean
follow-up time was 18.4 years. Systolic blood pressure (hazard ratio per
10 mmHg 1.19 [95% confidence interval 1.13–1.26], diastolic blood pressure
(hazard ratio 1.42 [1.27–1.59]), oral anticoagulants (hazard ratio 4.26
[2.17–8.38]), smoking (hazard ratio 1.45 [1.14–1.87]), living alone (hazard
ratio 1.32 [1.04–1.69]) and low apolipoprotein B (hazard ratio per 10 mg/dL:
0.94 [0.90–0.99]) were significantly associated with incident intracerebral
haemorrhage after multivariable adjustment. Systolic blood pressure, smoking
and oral anticoagulants were associated with lobar intracerebral
haemorrhage. Systolic blood pressure, diastolic blood pressure, living alone
and diabetes were associated with non-lobar intracerebral haemorrhage.
Diabetes and diastolic blood pressure showed significantly different
relationships with lobar and non-lobar intracerebral haemorrhage. Alcohol,
apolipoprotein A1, body mass index, waist circumference, physical activity
and education were not independently associated with intracerebral
haemorrhage. Discussion and conclusions: Blood pressure, smoking, low
apolipoprotein B, oral anticoagulants and living alone were associated with
intracerebral haemorrhage. Diabetes was associated with non-lobar
intracerebral haemorrhage only. Further research is required on differences
between lobar and non-lobar intracerebral haemorrhage.
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Affiliation(s)
- Edith H Svensson
- Cardiovascular Research - Epidemiology, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Kasim Abul-Kasim
- Radiology Diagnostics, Department of Translational Medicine, Lund University, Malmö, Sweden.,Department of Radiology, Skåne University Hospital, Malmö, Sweden
| | - Gunnar Engström
- Cardiovascular Research - Epidemiology, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Martin Söderholm
- Cardiovascular Research - Epidemiology, Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Neurology, Skåne University Hospital, Lund and Malmö, Sweden
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25
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Andersson NG, Wu R, Carcao M, Claeyssens-Donadel S, Kobelt R, Liesner R, Mäkipernaa A, Ranta S, Ljung R. Long-term follow-up of neonatal intracranial haemorrhage in children with severe haemophilia. Br J Haematol 2020; 190:e101-e104. [PMID: 32519345 DOI: 10.1111/bjh.16740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Nadine G Andersson
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden.,Department for Thrombosis and Hemostasis, Skåne University Hospital, Malmö, Sweden
| | - Runhui Wu
- Hematology-Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Manuel Carcao
- Division of Haematology/Oncology and Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | | | - Rainer Kobelt
- Hämophiliezentrum, Wabern and Children's Hospital of the University of Bern, Bern, Switzerland
| | - Ri Liesner
- Great Ormond Hospital for Children NHS Trust Haemophilia Centre, London, UK
| | - Anne Mäkipernaa
- Children's Hospital and Haematology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Susanna Ranta
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren Children´s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Rolf Ljung
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
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26
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Cuenca AG, Hardy S, Shah U, Lawlor D, Ordulu Z, Sierra Velez D, Olshan K, Butler W, Yeh H. Pediatric liver transplant following near catastrophic head bleed: Lessons learned. Pediatr Transplant 2020; 24:e13646. [PMID: 31960553 DOI: 10.1111/petr.13646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 10/22/2019] [Accepted: 12/09/2019] [Indexed: 11/29/2022]
Abstract
Evaluation for liver transplant candidacy is a multidisciplinary effort that involves all aspects of clinical care including social work, nutrition, and a multitude of medical specialties. The prognosis of a pretransplant clinical condition is integrated into the decision to list a patient. Herein, we report a successful liver transplant and recovery of a 3-month-old male following a large right hemispheric subdural hematoma related to acute coagulopathy secondary to undiagnosed end-stage liver disease. On presentation with jaundice, lethargy, and unequal pupils, a CT scan was obtained which demonstrated a large right subdural hematoma with herniation. Once his coagulopathy was corrected, he went for decompressive craniectomy. He survived with medically controlled seizures and improving L-sided neglect and extremity weakness. Six weeks later, given his continued neurologic recovery and worsening liver function, the decision was made to list him for liver transplantation. One month later, he underwent orthotopic liver transplant. His post-operative hospital course was complicated by DVTs and heparin-induced thrombocytopenia, but no neurologic decline, and he was eventually discharged from the hospital on post-op day 26. Three years later, he has a well-functioning allograft and no clinically evident neurologic deficits. The prognosis following pediatric neurologic trauma remains somewhat unclear as recovery and neurologic examinations can be influenced by numerous extrinsic factors. This is one of the first reports of near full neurologic recovery of a pediatric liver transplant recipient following a large subdural hematoma with herniation.
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Affiliation(s)
- Alex G Cuenca
- Surgery/Abdominal Transplant, Massachusetts General Hospital, Boston, MA, USA.,Pediatric Transplant Center, Boston Children's Hospital, Boston, MA, USA
| | - Stephen Hardy
- Pediatrics/Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Uzma Shah
- Pediatrics/Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - David Lawlor
- Surgery/Pediatric Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Zehra Ordulu
- Pathology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Katherine Olshan
- Pediatrics/Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - William Butler
- Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi Yeh
- Surgery/Abdominal Transplant, Massachusetts General Hospital, Boston, MA, USA
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27
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Kim JY, Kim SH, Myong JP, Choi Y, Hwang YM, Kim TS, Kim JH, Jang SW, Oh YS, Lee MY. Ten-year trends in the incidence, treatment and outcomes of patients with mitral stenosis in Korea. Heart 2020; 106:746-750. [PMID: 32029525 PMCID: PMC7229898 DOI: 10.1136/heartjnl-2019-315883] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/29/2019] [Accepted: 12/10/2019] [Indexed: 11/17/2022] Open
Abstract
Objective Mitral stenosis increases the risk of atrial fibrillation (AF) and stroke. Large data underlying the trend in incidence, treatment and outcomes of mitral stenosis are lacking. Methods Based on the Health Insurance Review and Assessment Service database in Republic of Korea, patients who were diagnosed with mitral stenosis between 2007 and 2016 were enrolled. Trends in the incidence rate and changing patterns of treatment and outcome for stroke and systemic embolism and intracranial haemorrhage (ICH) were analysed. Results A total of 42 075 patients (mean age 60.7±13.5 years, 13 303 (31.6%) male) were included in the present study. The number included 27 824 (66.1%) patients with mitral stenosis and comorbid AF. The age-standardised annual incidence rate per 100 000 of mitral stenosis in Korea decreased remarkably from 10.3 to 3.6 over 10 years. The use of anticoagulation therapy increased consistently. The annual incidence of stroke and systemic embolism showed signs of plateau, while the incidence of ICH increased. Conclusions The overall incidence rate of mitral stenosis in Korean population has decreased remarkably. As increasing the use of vitamin K antagonist, the annual incidence rate of ICH was increased but the rate of stroke incidence reached a plateau. Alternative effective anticoagulation strategy should be investigated.
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Affiliation(s)
- Ju Youn Kim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jun Pyo Myong
- Department of Occupational and Environmental Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - You Mi Hwang
- Division of Cardiology, Department of Internal Medicine, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae-Seok Kim
- Division of Cardiology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Won Jang
- Division of Cardiology, Department of Internal Medicine, St Vincent's Hospital Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Man-Young Lee
- Division of Cardiology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of South Korea
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28
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Agrawal A, Cardinale M, Frenia D, Mukherjee A. Cerebellar Haemorrhage Leading to Sudden Cardiac Arrest. ACTA ACUST UNITED AC 2020; 6:71-3. [PMID: 32104734 DOI: 10.2478/jccm-2020-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 01/29/2020] [Indexed: 11/29/2022]
Abstract
Introduction Intracranial haemorrhage (ICH) is a known, but a rare cause of out of hospital cardiac arrest (OHCA). It results in the development of non-shockable rhythms such as asystole or pulseless electrical activity (PEA). Case Report A 77- years old male had an OHCA without any prodrome. An emergency medical services (EMS) team responded to an emergency call and intubated the patient at the site before transporting him to the Acute Care Hospital, New Brunswick, New Jersey, USA. On admission, a non-contrast computed tomography scan of the head revealed a large cerebellar haemorrhage. Non-traumatic ICH is a rare cause of OHCA. Although subarachnoid haemorrhage causing cardiac arrest has been described in the literature, cerebellar haemorrhage leading to cardiac arrest is rare. The mechanism by which ICH patients develop cardiac arrest is likely explained by a massive catecholamine surge leading to cardiac stunning. Conclusion A non-shockable rhythm in the seting of a sudden cardiac arrest should raise alarms for a primary non-cardiac ethology, especially a primary cerebrovascular event. The absence of brainstem reflexes increases the likelihood of an intracranial process.
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29
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Navarro-Almenzar B, Cerezo-Manchado JJ, Caro-Martinez C, García-Candel F, Flores Blanco PJ, Ruiz GE, Andreu Cayuelas JM, Montoya FA, Cascales A, Lova Navarro A, García Alberola A, Andrés Pascual Figal D, Bailen Lorenzo JL, Manzano-Fernández S. Real-life behaviour of direct oral anticoagulants in a Spanish cohort with non-valvular atrial fibrillation: Refase Registry. Curr Med Res Opin 2019; 35:2035-2041. [PMID: 31335222 DOI: 10.1080/03007995.2019.1647735] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Aim: To analyse the effectiveness and safety of DOAC (direct oral anticoagulants) in non-valvular atrial fibrillation (NVAF) patients attending clinical practice.Methods: Retrospective study of AF patients who started treatment with DOAC from January 1, 2013 to December 31, 2016 in three Spanish hospitals. Mean follow-up was 1.6 years. The primary outcomes were rates of all-cause death, ischaemic stroke, and bleeding. These outcomes were also studied depending on correct dosage adjustment and standard/adjusted dose.Results: The study included 2494 patients (age = 76.0 ± 9.5 years, CHA2DS2-VASc = 4.0 ± 1.6). The most prescribed DOAC was rivaroxaban (41.1%). Patients taking dabigatran were the youngest (mean age = 73.1 ± 10.3 years), with better kidney function (mean CrCl = 80.6 ± 35.8 ml/min) and lower CHA2DS2-VASc (3.7 ± 1.4) and HAS-BLED (2.1 ± 0.9) scores. Patients taking apixaban were the oldest, and had the highest CHA2DS2-VASc and HAS-BLED scores (4.3 ± 1.6 and 2.6 ± 0.9, respectively). Rates of stroke/major bleeding/intracranial bleeding were 1.8/3.0/0.3 events per 100 patient-years, respectively, with no differences among DOAC. Based on dose adjustment according to technical data, it was observed that 517 patients (23.5%) received DOAC doses inconsistent with labelling (p < .001) and, within this group, under-dosed patients had a higher death rate although it did not reach a significant result after multivariate adjustment.Conclusions: The results of safety and efficacy are very similar to those of other previously published national registries. There were no differences among the different types of DOAC regarding outcomes. However, it was found that people taking the adjusted dose of the drug seemed to have a higher risk of death. A non-negligible proportion of patients received DOAC doses inconsistent with labelling (mostly underdose).
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Affiliation(s)
- Begoña Navarro-Almenzar
- Servicio de Hematología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Juan José Cerezo-Manchado
- Servicio de Hematología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - César Caro-Martinez
- Servicio de Cardiología, Hospital Vega Baja, Orihuela, Alicante, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain
| | - Faustino García-Candel
- Servicio de Hematología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Pedro José Flores Blanco
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Ginés Elvira Ruiz
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - José Miguel Andreu Cayuelas
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Francisco Arregui Montoya
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Almudena Cascales
- Servicio de Hematología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Alejandro Lova Navarro
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Arcadio García Alberola
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | - Domingo Andrés Pascual Figal
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
| | | | - Sergio Manzano-Fernández
- Servicio de Cardiología. Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Universidad de Murcia, El Palmar, Spain
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30
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Abstract
In this study, we present the design considerations of a device to assist in the
potential treatment of hemorrhagic stroke with the aim of stopping blood from
flowing out into brain tissue. We present and model three designs for the
clinical scenarios when saccular aneurysms rupture in the middle cerebral artery
in the brain. We evaluate and model these three designs using computer aided
design software, SolidWorks, which allows the devices to be tested using finite
element analysis and also enables us to justify that the materials chosen were
suitable for potential use. Computational fluid dynamics modelling were used to
demonstrate and analyse the flow of blood through the artery under conditions of
normal and ruptured states. We conclude that our device could potentially be
useful in the treatment of hemorrhagic stroke, and the modelling process is
useful in assisting in determining the performance of our devices.
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Affiliation(s)
| | - Gillian Pearce
- School of Engineering and Applied Science, Aston University, Birmingham, UK
| | - Rachel Hepton
- The School of Life & Health Sciences, Aston University, Birmingham, UK
| | - Julian Wong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Iham F Zidane
- Mechanical Engineering Department, College of Engineering and Technology, Arab Academy for Science, Technology and Maritime Transport (AASTMT), Alexandria, Egypt
| | - Xianghong Ma
- School of Engineering and Applied Science, Aston University, Birmingham, UK
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31
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Mahmood A, Roberts I, Shakur-Still H. A nested randomised trial of the effect of tranexamic acid on intracranial haemorrhage and infarction in traumatic brain injury (CRASH-3 trial intracranial bleeding mechanistic study): Statistical analysis plan. Wellcome Open Res 2019; 3:99. [PMID: 31143842 PMCID: PMC6530602 DOI: 10.12688/wellcomeopenres.14731.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2019] [Indexed: 02/02/2023] Open
Abstract
Background: The CRASH-3 trial is a randomised trial on the effect of tranexamic acid (TXA) versus placebo on death and disability in traumatic brain injury (TBI). The CRASH-3 intracranial bleeding mechanistic study (IBMS) is a randomised trial nested within the CRASH-3 trial to examine the effect of TXA versus placebo on intracranial bleeding and infarction. Methods: Patients eligible for the CRASH-3 trial, with a GCS of 12 or less or intracranial bleeding on a pre-randomisation CT scan are eligible for the IBMS. The occurrence of intracranial bleeding, infarction, haemorrhagic oedematous lesions, mass effect and haemorrhage evacuation is examined within 28 days of randomisation using routinely collected brain scans. The primary outcome is the volume of intra-parenchymal bleeding in patients randomised within three hours of injury (adjusted for prognostic covariates). Secondary outcomes include a composite "poor" outcome, progressive and new intracranial bleeding, intracranial bleeding after neurosurgery and cerebral infarcts seen up to 28 days post-randomisation. All outcomes will be compared between treatment groups. Statistical analyses: The primary outcome will be analysed using a covariate adjusted linear mixed model. The same analysis will be done separately for patients who undergo haemorrhage evacuation post-randomisation. We will express the effect of TXA on the composite outcome, new and progressive bleeding using relative risks and 95% CIs, and on cerebral infarcts using hazard ratios and 95% CIs. We will conduct sensitivity analyses assuming missing data are MCAR or MNAR. Conclusion: The IBMS will provide information on the mechanism of action of TXA in TBI. This pre-specified statistical analysis plan is a technical extension of the published protocol. Trial registration: The CRASH-3 trial was prospectively registered at the International Standard Randomised Controlled Trials registry (19 July 2011) and ClinicalTrials.gov (25 July 2011). The registries were updated with details for the IBMS on 20 December 2016.
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Affiliation(s)
- Abda Mahmood
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
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32
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Abstract
Head injury is a common cause for hospital admission and additionally 250,000 UK inpatients fall during hospital admissions annually. Head injury most commonly occurs as a result of falls from standing height in older adults. Older adults are frequently frail and multi-morbid; many have indications for anticoagulation and antiplatelet agents. The haemorrhagic complications of head injury occur in up to 16% of anticoagulated patients sustaining a head injury. These patients suffer adverse outcomes from surgery as a result of medical complications. Although geriatric trauma models are evolving to meet the demand of an ageing trauma population, medical support to trauma services is commonly delivered by general physicians, many of whom lack experience and training in this field. Determining the role of surgery and interrupted anticoagulation requires careful personalised risk assessment. Appreciation of the opposing risks can be challenging; it requires an understanding of the evidence base in both surgery and medicine to rationalise decision making and inform communication. This article aims to provide an overview for the physician with clinical responsibility for patients who have sustained head injury.
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Jensen MP, Ziff OJ, Banerjee G, Ambler G, Werring DJ. The impact of selective serotonin reuptake inhibitors on the risk of intracranial haemorrhage: A systematic review and meta-analysis. Eur Stroke J 2019; 4:144-152. [PMID: 31259262 DOI: 10.1177/2396987319827211] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 01/08/2019] [Indexed: 01/11/2023] Open
Abstract
Introduction Observational studies have suggested increased risk of intracranial haemorrhage (ICrH) in patients receiving selective serotonin reuptake inhibitors (SSRIs). We sought to clarify the impact of SSRIs on ICrH, accounting for study methodology. Patients and methods A comprehensive search of Medline, Embase and the Cochrane Library from 1960 to December 2017 identified studies comparing SSRIs with control. The outcomes (first-ever and recurrent ICrH) were meta-analysed using a random effects model. Results Twenty-four observational studies and three randomised trials were available for meta-analysis, totalling 4,844,090 patient-years of follow-up. Those receiving SSRIs were more likely to be female (p = 0.01) and have depression (p < 0.001). Compared to controls, SSRI users had a significantly increased risk of ICrH (relative risk (RR) 1.26, 95%CI 1.11-1.42). Although SSRI use was associated with increased ICrH risk in those without previous ICrH (RR 1.31, 95%CI 1.15-1.48), this was not the case in those with previous ICrH (RR 0.95, 95%CI 0.83-1.09). Sensitivity analysis according to the bleeding definition reported demonstrated that although 'haemorrhagic stroke' was associated with SSRIs (RR 1.40, 95%CI 1.13-1.72), intracerebral haemorrhage was not (RR 1.11, 95%CI 0.86-1.42). Additional sensitivity analyses demonstrated a stronger association between SSRIs and ICrH in studies with a high (p < 0.001) compared to low risk of bias (p = 0.09) and with retrospective (p < 0.001) compared to prospective (p=0.31) study designs. Discussion Although SSRIs are associated with an increased risk of ICrH, the association is partly accounted for by important biases and other methodological limitations in the available observational data. Conclusion Our findings suggest there is insufficient high-quality data to advise restriction of SSRIs because of concern regarding ICrH risk.
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Affiliation(s)
- Melanie P Jensen
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Oliver J Ziff
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Gargi Banerjee
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | | | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
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Valenzuela I, Hunter MD, Sundheim K, Klein B, Dunn L, Sorabella R, Han SM, Willey J, George I, Gutierrez J. Clinical risk factors for acute ischaemic and haemorrhagic stroke in patients with infective endocarditis. Intern Med J 2019; 48:1072-1080. [PMID: 29740951 DOI: 10.1111/imj.13958] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/20/2018] [Accepted: 04/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Stroke as a complication of infective endocarditis portends a poor prognosis, yet risk factors for stroke subtypes have not been well defined. AIM To identify risk factors associated with ischaemic and haemorrhagic strokes. METHODS A retrospective patient chart review was performed at a single US academic centre to identify risk factors and imaging for patients who were 18 years or older with infectious endocarditis (IE) and stroke diagnoses. Differences in patient characteristics by stroke status were assessed using univariate analysis, χ2 or student's t-test as well as logistic regression models for multivariable analyses and correlation matrices to identify possible collinearity between variables and to obtain odds ratios (OR) and their 95% confidence intervals. RESULTS A final sample of 1157 participants was used for this analysis. The total number of non-surgical strokes was 178, with a prevalence of 15.4% (78% ischaemic, 10% parenchymal haemorrhages, 8% subarachnoid haemorrhages and 4% mixed ischaemic/haemorrhagic). Multivariate risk factors for ischaemic stroke included prior stroke (OR 2.0, 1.3-3.1), Staphylococcus infection (OR 2.0, 1.3-3.0), mitral vegetations (OR 2.2, 1.4-3.3) and valvular abscess (OR 2.7, 1.7-4.3). Risk factors for haemorrhagic stroke included fungal infection (OR 6.4, 1.2-34.0), male gender (OR 3.5, 1.4-8.3) and rheumatic heart disease (OR 3.3, 1.1-10.4). CONCLUSION Among patients with IE, there exist characteristics that relate differentially to ischaemic and haemorrhagic stroke risk.
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Affiliation(s)
- Ives Valenzuela
- College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Madeleine D Hunter
- College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Kathryn Sundheim
- College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Bradley Klein
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
| | - Lauren Dunn
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
| | - Robert Sorabella
- Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Sang M Han
- Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Joshua Willey
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
| | - Isaac George
- Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York, USA
| | - Jose Gutierrez
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
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35
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Mahmood A, Roberts I, Shakur-Still H. A nested randomised trial of the effect of tranexamic acid on intracranial haemorrhage and infarction in traumatic brain injury (CRASH-3 trial intracranial bleeding mechanistic study): Statistical analysis plan. Wellcome Open Res 2019; 3:99. [PMID: 31143842 PMCID: PMC6530602 DOI: 10.12688/wellcomeopenres.14731.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2019] [Indexed: 02/02/2023] Open
Abstract
Background: The CRASH-3 trial is a randomised trial on the effect of tranexamic acid (TXA) on death and disability in traumatic brain injury (TBI). The CRASH-3 intracranial bleeding mechanistic study (IBMS) is a randomised trial nested within the CRASH-3 trial to examine the effect of TXA on intracranial bleeding and infarction. Methods: Patients eligible for the CRASH-3 trial, with a GCS of 12 or less or intracranial bleeding on a pre-randomisation CT scan are eligible for the IBMS. The occurrence of intracranial bleeding, infarction, haemorrhagic oedematous lesions, mass effect and haemorrhage evacuation is examined within 28 days of randomisation using routinely collected brain scans. The primary outcome is the volume of intra-parenchymal bleeding in patients randomised within three hours of injury (adjusted for prognostic covariates). Secondary outcomes include a composite "poor" outcome, progressive and new intracranial bleeding, intracranial bleeding after neurosurgery and cerebral infarcts seen up to 28 days post-randomisation. All outcomes will be compared between treatment groups. Statistical analyses: The primary outcome will be analysed using a covariate adjusted linear mixed model. The same analysis will be done separately for patients who undergo haemorrhage evacuation post-randomisation. We will express the effect of TXA on the composite outcome, new and progressive bleeding using relative risks and 95% CIs, and on cerebral infarcts using hazard ratios and 95% CIs. We will conduct sensitivity analyses assuming missing data are MCAR or MNAR. Conclusion: The IBMS will provide information on the mechanism of action of TXA in TBI. This pre-specified statistical analysis plan is a technical extension of the published protocol. Trial registration: The CRASH-3 trial was prospectively registered at the International Standard Randomised Controlled Trials registry (19 July 2011) and ClinicalTrials.gov (25 July 2011). The registries were updated with details for the IBMS on 20 December 2016.
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Affiliation(s)
- Abda Mahmood
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
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36
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Khalid SI, Carlton A, Glick RP. Identification of reversible causes of minority inequity in stroke: severity related to race and socio-economic status. Brain Inj 2018; 32:1477-1483. [PMID: 30325276 DOI: 10.1080/02699052.2018.1497204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Previous reports of a higher incidence and risk of stroke in minorities were associated primarily with race and ethnicity, yet the relationship between socio-economic status (SES) and racial disparities in stroke is less well known. We have investigated the effects of SES on the incidence of stroke type and its severity in minorities. METHODS The clinical and demographic data on 140 patients diagnosed with a stroke in the North Lawndale neighbourhood of Chicago, one of the city's poorest communities, were collected prospectively over a 13-month period and then were retrospectively analysed. RESULTS Overall, haemorrhagic stroke occurred in 31% of cases, differing from the previously reported haemorrhagic stroke incidence of 15%. When accounting for SES, the incidence of haemorrhagic stroke in the uninsured versus the privately or Medicaid-insured increased to 50%. Uninsured African-American patients experienced even higher rates of haemorrhagic stroke at 55%. CONCLUSIONS Patients who are uninsured minorities may be at an increased risk for severe strokes. This increase in risk appears to be related to the increased incidence of risk factors and lack of treatment. The lack of funds, care access, and limited education in these patients may be related to their increase in risk factors. This paper identifies potentially reversible environmental and societal factors that can lead to improved outcomes in indigent minority patients.
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Affiliation(s)
- Syed I Khalid
- a Department of Neurosurgery , Rush University , Chicago , IL, USA.,b Department of Neurosurgery, Rosalind Franklin University of Medicine and Science , Chicago Medical School , North Chicago, IL
| | - Adam Carlton
- b Department of Neurosurgery, Rosalind Franklin University of Medicine and Science , Chicago Medical School , North Chicago, IL
| | - Roberta P Glick
- a Department of Neurosurgery , Rush University , Chicago , IL, USA
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37
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Hoshino T, Sissani L, Labreuche J, Bousser MG, Chamorro A, Fisher M, Ford I, Fox KM, Hennerici MG, Mattle HP, Rothwell PM, Gabriel Steg P, Vicaut E, Amarenco P. Non-cardioembolic stroke/transient ischaemic attack in Asians and non-Asians: A post-hoc analysis of the PERFORM study. Eur Stroke J 2018; 4:65-74. [PMID: 31165096 DOI: 10.1177/2396987318797245] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/06/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction We aimed to compare the characteristics and vascular outcomes between Asian and non-Asian patients with non-cardioembolic stroke/transient ischaemic attack receiving antiplatelet monotherapy and to identify population-specific predictors for recurrent events. Patients and methods We conducted a post-hoc analysis of data from the PERFORM study, in which 19,100 patients (mean age, 67.2 years; male, 63%; 2178 Asian and 16,922 non-Asian patients) with non-cardioembolic ischaemic stroke/transient ischaemic attack were randomised to aspirin or terutroban and followed for two years. The primary outcome was a composite of major adverse cardiovascular events (non-fatal myocardial infarction, non-fatal stroke and cardiovascular death). Results There was no difference in major adverse cardiovascular events risk between Asian and non-Asian populations (11.1% vs. 10.5%; p = 0.39). However, Asian patients were at significantly higher risk of intracranial haemorrhage (2.4% vs. 1.3%; hazard ratio (HR) 1.87; 95% confidence interval (CI) 1.34-2.60; p < 0.001) and major bleeding (5.4% vs. 4.1%; HR 1.30; 95% CI 1.04-1.61; p = 0.02). Stroke risk was significantly higher in Asian than in non-Asian populations among patients with lacunar stroke (7.4% vs. 4.5%; p = 0.02). In multivariable analysis, diastolic blood pressure (HR per 5 mm Hg 1.08; 95% CI 1.01-1.16; p = 0.03) and diabetes (HR 1.36; 95% CI 1.22-1.52; p < 0.001) were independent predictors of major adverse cardiovascular events for Asian and non-Asian patients, respectively.Conclusion: Compared with non-Asian patients, Asian patients had significantly higher risk of haemorrhagic events when given antiplatelet monotherapy for secondary prevention after non-cardioembolic stroke/transient ischaemic attack. Lacunar stroke and elevated diastolic blood pressure were more associated with recurrence risk in Asian patients.
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Affiliation(s)
- Takao Hoshino
- Department of Neurology and Stroke Center, Hôpital Bichat, APHP and Université Paris-Diderot-Sorbonne, Paris, France.,INSERM Laboratory for Vascular Translational Sciences 1148 and Département Hospitalo-Universitaire FIRE, Paris, France.,Department of Neurology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Leila Sissani
- Department of Neurology and Stroke Center, Hôpital Bichat, APHP and Université Paris-Diderot-Sorbonne, Paris, France.,INSERM Laboratory for Vascular Translational Sciences 1148 and Département Hospitalo-Universitaire FIRE, Paris, France
| | - Julien Labreuche
- INSERM Laboratory for Vascular Translational Sciences 1148 and Département Hospitalo-Universitaire FIRE, Paris, France.,Université de Lille, CHU Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, Lille, France
| | | | - Angel Chamorro
- Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Marc Fisher
- Harvard Medical School, Beth Israel Deaconess Medical Center, MA, USA
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Kim M Fox
- NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK
| | | | - Heinrich P Mattle
- Neurologische Klinik und Poliklinik, Universität Bern, Inselspital, Bern, Switzerland
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Philippe Gabriel Steg
- INSERM Laboratory for Vascular Translational Sciences 1148 and Département Hospitalo-Universitaire FIRE, Paris, France.,NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK.,Department of Cardiology, Hôpital Bichat, Paris, France
| | - Eric Vicaut
- Department of Biostatistics, Hôpital Fernand Widal, Paris, France
| | - Pierre Amarenco
- Department of Neurology and Stroke Center, Hôpital Bichat, APHP and Université Paris-Diderot-Sorbonne, Paris, France.,INSERM Laboratory for Vascular Translational Sciences 1148 and Département Hospitalo-Universitaire FIRE, Paris, France
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38
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Mahmood A, Roberts I, Shakur-Still H. A nested randomised trial of the effect of tranexamic acid on intracranial haemorrhage and infarction in traumatic brain injury (CRASH-3 trial intracranial bleeding mechanistic study): Statistical analysis plan. Wellcome Open Res 2018; 3:99. [PMID: 31143842 PMCID: PMC6530602 DOI: 10.12688/wellcomeopenres.14731.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2018] [Indexed: 02/02/2023] Open
Abstract
Background: The CRASH-3 trial is a randomised trial on the effect of tranexamic acid (TXA) on death and disability in traumatic brain injury (TBI). The CRASH-3 intracranial bleeding mechanistic study (IBMS) is a randomised trial nested within the CRASH-3 trial to examine the effect of TXA on intracranial bleeding and infarction. Methods: Patients eligible for the CRASH-3 trial, with a GCS of 12 or less or intracranial bleeding on a pre-randomisation CT scan are eligible for the IBMS. The occurrence of intracranial bleeding, infarction, haemorrhagic oedematous lesions, mass effect and haemorrhage evacuation is examined within 28 days of randomisation using routinely collected brain scans. The primary outcome is the volume of intracranial bleeding in patients randomised within three hours of injury (adjusted for prognostic covariates). Secondary outcomes include progressive and new intracranial bleeding, intracranial bleeding after neurosurgery and new cerebral infarcts up to 28 days post-randomisation. All outcomes will be compared between treatment groups. Statistical analyses: The primary outcome will be analysed using absolute measures (ANCOVA) and relative measures (ratios). The same analysis will be done separately for patients who undergo haemorrhage evacuation post-randomisation. We will express the effect of TXA on new and progressive bleeding using relative risks and 95% CIs, and on cerebral infarcts using hazard ratios and 95% CIs. If any missing post-randomisation scans appear to be missing not at random, we will conduct sensitivity analyses to explore the implications. Conclusion: The IBMS will provide information on the mechanism of action of TXA in TBI. This pre-specified statistical analysis plan is a technical extension of the published protocol. Trial registration: The CRASH-3 trial was prospectively registered at the International Standard Randomised Controlled Trials registry (19 July 2011) and ClinicalTrials.gov (25 July 2011). The registries were updated with details for the IBMS on 20 December 2016.
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Affiliation(s)
- Abda Mahmood
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
| | - Haleema Shakur-Still
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, WC1E7HT, UK
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39
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García Sánchez P, Molina Gutiérrez MÁ, Martín Sánchez J, Inisterra Viu L, García García S, Rivas Pollmar MI, Martín Salces M, Álvarez Román MT, Jiménez Yuste V. Head trauma in the haemophilic child and management in a paediatric emergency department: Descriptive study. Haemophilia 2018; 24:e187-e193. [PMID: 29873151 DOI: 10.1111/hae.13526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Haemophilia is one of the most common inherited bleeding disorders in the Emergency Department (ED). The most dangerous site of bleeding is the central nervous system. AIMS To describe the characteristics of haemophiliacs arrived to our ED following a head trauma and to analyse the incidence of intracranial haemorrhage (ICH). MATERIALS AND METHODS Retrospective, analytical, observational study, conducted in a Paediatric ED. We included haemophilic patients aged from birth to 16 years who consulted after a head trauma over a 6-year period. Data collected included age, type of haemophilia and head trauma, symptoms, prophylaxis status, CT imaging, treatment and number of visits to the ED. RESULTS About 46 males and 85 episodes were analysed. The median age was 2.38 years. Severe haemophilia A was the most frequent type of disease (50%). All head injuries were mild, and the most frequent mechanism was a collision with an object (38.8%). In 62 episodes (72.9%) the patients were asymptomatic. The rest 23 events had symptomatology, being the most common headache (26%), emesis (21.7%) and drowsiness (17.4%). Head CT was obtained in 31 episodes, founding altered results in 10 (6 of them corresponding to ICH). All the patients with ICH had symptomatology. About 37 episodes required admission. CONCLUSION Intracranial haemorrhage is one of the most dangerous events in haemophiliacs and it may occur after a head trauma. Our study suggests that, in case of head trauma, CT must be obtained in symptomatic patients and in those with additional risk factors. Asymptomatic patients must have prolonged observation.
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Affiliation(s)
- P García Sánchez
- Paediatric Emergency Department and Hematology Department, La Paz University Hospital, Madrid, Spain
| | - M Á Molina Gutiérrez
- Paediatric Emergency Department and Hematology Department, La Paz University Hospital, Madrid, Spain
| | - J Martín Sánchez
- Paediatric Emergency Department and Hematology Department, La Paz University Hospital, Madrid, Spain
| | - L Inisterra Viu
- Paediatric Emergency Department and Hematology Department, La Paz University Hospital, Madrid, Spain
| | - S García García
- Paediatric Emergency Department and Hematology Department, La Paz University Hospital, Madrid, Spain
| | - M I Rivas Pollmar
- Paediatric Emergency Department and Hematology Department, La Paz University Hospital, Madrid, Spain
| | - M Martín Salces
- Paediatric Emergency Department and Hematology Department, La Paz University Hospital, Madrid, Spain
| | - M T Álvarez Román
- Paediatric Emergency Department and Hematology Department, La Paz University Hospital, Madrid, Spain
| | - V Jiménez Yuste
- Paediatric Emergency Department and Hematology Department, La Paz University Hospital, Madrid, Spain
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40
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Cordonnier C, Lemesle G, Casolla B, Bic M, Caparros F, Lamblin N, Bauters C. Incidence and determinants of cerebrovascular events in outpatients with stable coronary artery disease. Eur Stroke J 2018; 3:272-280. [PMID: 31008358 DOI: 10.1177/2396987318772684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/26/2018] [Indexed: 01/25/2023] Open
Abstract
Introduction There are limited data on cerebrovascular events in patients with stable coronary artery disease. To study the risk of cerebrovascular event, the relative proportion of ischaemic stroke and intracranial haemorrhage, and their prognostic factors in stable coronary artery disease are investigated. Patients and methods The CORONOR registry prospectively recruited, between February 2010 and April 2011, 4184 unselected stable coronary artery disease outpatients. All events occurring during a five-year follow-up were adjudicated. Results Ninety-six patients had an ischaemic stroke and 34 had an intracranial haemorrhage, reaching a cumulative incidence after five years of 3.2 (2.7-3.8)%. During the same period, 677 deaths and 170 myocardial infarctions (ST-elevation MI, n = 55; non-ST-elevation MI, n = 115) occurred. In elderly individuals, the number of cerebrovascular events was higher than that of myocardial infarctions and largely exceeded that of ST-elevation myocardial infarctions. Predictors of ischaemic stroke were: previous history of stroke (subhazard ratio (SHR)=3.16(1.95-5.14)), absence of statin therapy at inclusion (SHR = 2.45(1.47-4.10), increasing age (SHR = 1.45(1.16-1.82) per 10-year increase) and diabetes mellitus (SHR = 1.65(1.10-2.49)). Predictors of intracranial haemorrhage were: combination of vitamin K antagonists with an antiplatelet agent at inclusion (SHR = 5.41(2.49-11.75), single antiplatelet therapy as reference), and increasing age (SHR = 1.47(1.12-1.93) per 10-year increase). Discussion In stable coronary artery disease patients, the brain deserves attention. In patients at high risk of ischaemic stroke, secondary prevention could be intensified. Our results raise awareness of the hazard of the association of antiplatelet drugs with oral anticoagulants in stable coronary artery disease patients. Conclusion While improving the prevention of future vaso-occlusive events should be our ultimate goal in coronary artery disease patients, the net clinical benefit of our treatments should carefully be studied.
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Affiliation(s)
- Charlotte Cordonnier
- Université de Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Lille, France
| | - Gilles Lemesle
- Université de Lille, Inserm U1011, Institut Pasteur, CHU Lille, Department of Cardiology, Lille, France
| | - Barbara Casolla
- Université de Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Lille, France
| | - Matthieu Bic
- Department of Cardiology, Centre Hospitalier, Lens, France
| | - François Caparros
- Université de Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Lille, France
| | - Nicolas Lamblin
- Université de Lille, Inserm U1167, Institut Pasteur, CHU Lille, Department of Cardiology, Lille, France
| | - Christophe Bauters
- Université de Lille, Inserm U1167, Institut Pasteur, CHU Lille, Department of Cardiology, Lille, France
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41
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Dreikorn M, Milacic Z, Pavlovic V, Meuth SG, Kleinschnitz C, Kraft P. Immunotherapy of experimental and human stroke with agents approved for multiple sclerosis: a systematic review. Ther Adv Neurol Disord 2018; 11:1756286418770626. [PMID: 29774055 PMCID: PMC5949925 DOI: 10.1177/1756286418770626] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 03/23/2018] [Indexed: 12/11/2022] Open
Abstract
Background 'Thromboinflammation' describes a novel concept in stroke pathophysiology that has opened up the possibility of immunotherapeutic approaches which could become promising strategies for targeted stroke therapies in the future. Methods We reviewed current evidence for agents approved for multiple sclerosis in preclinical and clinical stroke studies. A systematic review was performed in accordance with the PRISMA statement, searching MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 16 October 2017. Results The review included 52 of 629 identified studies, consisting of 5 clinical and 47 preclinical trials. Most of the studies showed beneficial effects of the evaluated immunotherapeutic drugs in terms of reduction in morphological lesion size and improvement in functional outcome. Nevertheless, the significance of these findings is limited due to the high degree of heterogeneity. Conclusions Immunotherapy of stroke might be effective and could become a promising treatment strategy, but larger clinical trials with standardized interventions and outcome measures are needed.
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Affiliation(s)
- Mirjam Dreikorn
- Department of Neurology, Hospital Main-Spessart, Lohr, Germany
| | - Zeljko Milacic
- Department of Neurology, Hospital Main-Spessart, Lohr, Germany
| | | | - Sven G Meuth
- Department of Neurology, University Hospital Münster, Münster, Germany
| | | | - Peter Kraft
- Department of Neurology, Hospital Main-Spessart, Grafen-von-Rieneck-Str. 5, 97816 Lohr, Germany
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42
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Chalmers EA, Alamelu J, Collins PW, Mathias M, Payne J, Richards M, Tunstall O, Williams M, Palmer B, Mumford A. Intracranial haemorrhage in children with inherited bleeding disorders in the UK 2003-2015: A national cohort study. Haemophilia 2018; 24:641-647. [PMID: 29635852 DOI: 10.1111/hae.13461] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Intracranial haemorrhage in children with inherited bleeding disorders is a potentially life-threatening complication and presents a significant therapeutic challenge. AIM To define the characteristics, management and outcomes of intracranial haemorrhage presenting in UK children ≤16 years of age with inherited bleeding disorders from 2003 to 2015. METHOD Retrospective analysis of children treated at UK haemophilia centres. RESULTS Of 66 children presenting with Intracranial haemorrhage (ICH), 82% had haemophilia A or B, 3% VWD and 15% a rare IBD. The IBD was a severe phenotype in 91%. The rates of ICH were 6.4 and 4.2 per 1000 patient years for haemophilia A and B, respectively. Median age at presentation was 4 months (33% neonates; 91% children <2 years of age). In neonates, delivery was spontaneous vaginal (SV) in 11, instrumental in 6, caesarean in 4 and unknown in 1. In children with haemophilia, the risk of ICH after instrumental delivery was 10.6 times greater than after SV delivery. Trauma was more common in children >2 years (67%) than in children 1 month to 2 years (18%; P = .027). Prior to ICH, only 4.5% of children were on prophylaxis. 6% of haemophiliacs had an inhibitor. The median duration of initial replacement therapy was 15 days. Mortality was 13.5%. Neurological sequelae occurred in 39% of survivors, being more common following intracerebral bleeding. In haemophilia survivors, 52% subsequently developed a FVIII inhibitor. CONCLUSION Intracranial haemorrhage occurs most frequently in children with severe IBDs, during the first 2 years of life and in children not receiving prophylaxis. Intracranial haemorrhage often occurs without documented trauma.
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Affiliation(s)
- E A Chalmers
- Department of Haematology, Royal Hospital for Children, Glasgow, UK
| | - J Alamelu
- Department of Paediatric Haematology, Evelina Children's Hospital, London, UK
| | - P W Collins
- School of Medicine, Cardiff University, Cardiff, UK
| | - M Mathias
- Department of Haematology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - J Payne
- Department of Haematology, Sheffield Children's Hospital, Sheffield, UK
| | - M Richards
- Department of Haematology, Leeds Children's Hospital, Leeds, UK
| | - O Tunstall
- Bristol Haemophilia Comprehensive Care Centre, Bristol Royal Hospital for Children, Bristol, UK
| | - M Williams
- Haemophilia Centre, Birmingham Childrens' Hospital, Birmingham, UK
| | - B Palmer
- The National Haemophilia Database, Manchester, UK
| | - A Mumford
- Department of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
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Sharma R, Dearaugo S, Infeld B, O'Sullivan R, Gerraty RP. Cerebral amyloid angiopathy: Review of clinico-radiological features and mimics. J Med Imaging Radiat Oncol 2018; 62:451-463. [PMID: 29604173 DOI: 10.1111/1754-9485.12726] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/01/2018] [Indexed: 01/02/2023]
Abstract
Cerebral amyloid angiopathy (CAA) is an important cause of lobar intracerebral haemorrhage (ICH) in the elderly, but has other clinico-radiological manifestations. In the last two decades, certain magnetic resonance imaging (MRI) sequences, namely gradient-recalled echo imaging and the newer and more sensitive susceptibility-weighted imaging, have been utilised to detect susceptibility-sensitive lesions such as cerebral microbleeds and cortical superficial siderosis. These can be utilised sensitively and specifically by the Modified Boston Criteria to make a diagnosis of CAA without the need for 'gold-standard' histopathology from biopsy. However, recently, other promising MRI biomarkers of CAA have been described which may further increase precision of radiological diagnosis, namely chronic white matter ischaemia, cerebral microinfarcts and lobar lacunes, cortical atrophy, and increased dilated perivascular spaces in the centrum semiovale. However, the radiological manifestations of CAA, as well as their clinical correlates, may have other aetiologies and mimics. It is important for the radiologist to be aware of these clinico-radiological features and mimics to accurately diagnose CAA. This is increasingly important in a patient demographic that has a high prevalence for use of antiplatelet and antithrombotic medications for other comorbidities which inherently carries an increased risk of ICH in patients with CAA.
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Affiliation(s)
- Rohit Sharma
- Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
| | - Stephanie Dearaugo
- Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
| | - Bernard Infeld
- Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
| | - Richard O'Sullivan
- Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
- Healthcare Imaging Services, Melbourne, Victoria, Australia
| | - Richard P Gerraty
- Department of Medicine, Monash University, The Alfred Hospital, Melbourne, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
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Tabibian S, Shams M, Naderi M, Dorgalaleh A. Prenatal diagnosis in rare bleeding disorders-An unresolved issue? Int J Lab Hematol 2018; 40:241-250. [PMID: 29476647 DOI: 10.1111/ijlh.12789] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 01/11/2018] [Indexed: 11/30/2022]
Abstract
Intracranial haemorrhage (ICH) is the most dreadful complication, and the main cause of death among patients with rare bleeding disorders (RBD) and prenatal diagnosis (PND) is a preventative lifesaving program. A total of 39 PNDs were reported in the literature through a search on PubMed, EMBASE, SCOPUS and Web of Science databases, most often for congenital factor (F) XIII and FVII deficiencies and rarely in FX, FV deficiencies and afibrinogenemia. The main cause to request a PND is ICH and related morbidity and mortality. Different molecular methods including direct sequencing and linkage analysis as well as polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) for a specific mutation are the most common used methods for PND, while factor assay and combination of molecular and factor assay also were used. In this research, 7 severely affected foetuses were identified during PND including 3 foetuses with FXIII deficiency, 3 with FVII deficiency and 1 with FX deficiency. Out of these 7 cases, intrauterine ICH occurred in 1 case with FXIII deficiency, 1 was electively aborted and 1 case with severe FVII deficiency received intrauterine factor transfusion. Postdelivery ICH was reported for 1 patient with severe FVII deficiency within the first month of life. All other pregnancies were uneventful.
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Affiliation(s)
- S Tabibian
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - M Shams
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran.,Department of Medical Laboratory, Faculty of Paramedical Sciences, Babol University of Medical Sciences, Babol, Iran
| | - M Naderi
- Genetic Research Center in Non-Communicable Disease, Zahedan University of Medical sciences, Zahedan, Iran
| | - A Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
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45
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Marco Garbayo JL, Koninckx Cañada M, Pérez Castelló I, Faus Soler MT, Perea Ribis M. Hospital admissions for bleeding events associated with treatment with apixaban, dabigatran and rivaroxaban. Eur J Hosp Pharm 2017; 26:106-112. [PMID: 31157109 DOI: 10.1136/ejhpharm-2017-001390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 09/22/2017] [Accepted: 10/10/2017] [Indexed: 12/30/2022] Open
Abstract
Objectives To analyse the hospital admissions for bleeding events associated with treatment with direct oral anticoagulants (DOACs). To describe the characteristics and outcomes of those patients. Methods A retrospective observational study was carried out in the framework of an integral risk management plan of drugs and proactive pharmacovigilance of hospital admissions for bleeding associated with apixaban, dabigatran and rivaroxaban from April 2015 through December 2016. Cases were identified using the information management tool of Orion Clinic (hospital electronic medical history) and by reviewing the hospital discharge reports. Various biometric, clinical and pharmacotherapeutic variables of each patient were registered. Results 37 hospitalisation episodes for DOAC-induced bleeding in 32 patients (15 received rivaroxaban, 9 apixaban and 8 dabigatran) were detected, representing an incidence rate of 3.44 per 100 person-years (95% CI 2.35 to 4.86). The most common bleeding site was gastrointestinal (27 cases, 73.0%). Intracranial bleeding was rare (three cases, 8.1%). Four patients (12.5%) were receiving DOACs at full doses and had a 'dose reduction indication'. The mean (SD) length of stay was 8.4 (5.2) days. Three patients (8.1%) died during the hospitalisation. Among bleeding episodes without fatal outcome, DOACs were stopped in 14 cases, continued in 14 cases, switched for another DOAC in two cases and the dose was reduced in four cases. Conclusions DOACs are associated with serious bleeding events that require hospitalisation. The risk/benefit ratio assessment considering patient preferences and an individualised follow-up, especially in patients who are elderly, polymedicated or have impaired renal function, can help to reinforce the safe use of DOACs.
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Affiliation(s)
- José Luis Marco Garbayo
- Department of Hospital Pharmacy, Francesc de Borja Hospital of Gandia, Gandia, Valencia, Spain
| | - Manuel Koninckx Cañada
- Department of Hospital Pharmacy, Francesc de Borja Hospital of Gandia, Gandia, Valencia, Spain
| | - Isabel Pérez Castelló
- Department of Hospital Pharmacy, Francesc de Borja Hospital of Gandia, Gandia, Valencia, Spain
| | - María Teresa Faus Soler
- Department of Hospital Pharmacy, Francesc de Borja Hospital of Gandia, Gandia, Valencia, Spain
| | - Mariam Perea Ribis
- Department of Internal Medicine, Francesc de Borja Hospital of Gandia, Gandia, Valencia, Spain
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46
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Lewartowska-Nyga D, Nyga K, Skotnicka-Klonowicz G. [Can infrascanner be useful in hospital emergency departments for diagnosing minor head injury in children?]. Dev Period Med 2017; 21:51-59. [PMID: 28551693 PMCID: PMC8522988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/01/2017] [Indexed: 04/04/2024]
Abstract
AIM The aim of the study was to determine whether Infrascanner screening is a test which would facilitate excluding acute intracranial bleeding in children after minor head injury and thus make it possible to limit indications for computed tomography in those children. MATERIAL AND METHODS The study enrolled 155 children aged 2-18 years after a minor or moderate head injury. The children were assessed using the Glasgow Coma Scale, examined by Infrascanner screening. Those who had relvant indications also had head computed tomography. RESULTS A negative Infrascanner screening result (no intracranial bleeding) was noted in 151 children. The Infrascanner result was positive in 4 children. Head computed tomography was performed in 28 of the 155 children. The conformity of the Infrascanner result with the computed tomography image was found in 26 children: no evidence of intracranial bleeding in 24 children and confirmation of intracranial haematoma in 2 children. The sensitivity of the screening was 66.67% and its specificity 98.68%. The positive and negative predictive values of the screening were 50% and 99.34%, respectively. The reliability of the test results was 98.06%. CONCLUSION The Infrascanner seems to be a useful device in diagnosing children after minor head injury in the emergency department and its portability makes it possible to use it in practically all settings. Introducing the device into management standards in children after minor head injury might facilitate selecting those after minor head injury who are not at risk of intracranial bleeding and contribute to a reduction in the number of imaging investigations being performed and decrease the number of hospitalisations.
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Affiliation(s)
- Dorota Lewartowska-Nyga
- Oddział Kardiologii i Reumatologii dla Dzieci II Katedra Pediatrii UM w Łodzi Ośrodek Pediatryczny im. M. Konopnickiej, Centralny Szpital Kliniczny UM wŁodziPoland
| | - Kamil Nyga
- Centrum Medycyny Rodzinnej i Społeczności Lokalnych UM wŁodziPoland
| | - Grażyna Skotnicka-Klonowicz
- Oddział Kliniczny Medycyny Ratunkowej dla Dzieci II Katedra Pediatrii UM w Łodzi Ośrodek Pediatryczny im. M. Konopnickiej, Centralny Szpital Kliniczny UM wŁodziPoland
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Lewartowska-Nyga D, Nyga K, Skotnicka-Klonowicz G. [Can infrascanner be useful in hospital emergency departments for diagnosing minor head injury in children?]. Dev Period Med 2017. [PMID: 28551693 PMCID: PMC8522988 DOI: 10.34763/devperiodmed.20172101.5159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIM The aim of the study was to determine whether Infrascanner screening is a test which would facilitate excluding acute intracranial bleeding in children after minor head injury and thus make it possible to limit indications for computed tomography in those children. MATERIAL AND METHODS The study enrolled 155 children aged 2-18 years after a minor or moderate head injury. The children were assessed using the Glasgow Coma Scale, examined by Infrascanner screening. Those who had relvant indications also had head computed tomography. RESULTS A negative Infrascanner screening result (no intracranial bleeding) was noted in 151 children. The Infrascanner result was positive in 4 children. Head computed tomography was performed in 28 of the 155 children. The conformity of the Infrascanner result with the computed tomography image was found in 26 children: no evidence of intracranial bleeding in 24 children and confirmation of intracranial haematoma in 2 children. The sensitivity of the screening was 66.67% and its specificity 98.68%. The positive and negative predictive values of the screening were 50% and 99.34%, respectively. The reliability of the test results was 98.06%. CONCLUSION The Infrascanner seems to be a useful device in diagnosing children after minor head injury in the emergency department and its portability makes it possible to use it in practically all settings. Introducing the device into management standards in children after minor head injury might facilitate selecting those after minor head injury who are not at risk of intracranial bleeding and contribute to a reduction in the number of imaging investigations being performed and decrease the number of hospitalisations.
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Affiliation(s)
- Dorota Lewartowska-Nyga
- Oddział Kardiologii i Reumatologii dla Dzieci II Katedra Pediatrii UM w Łodzi Ośrodek Pediatryczny im. M. Konopnickiej, Centralny Szpital Kliniczny UM wŁodziPoland,Dorota Lewartowska-Nyga Klinika Kardiologii i Reumatologii Dziecięcej, II Katedra Pediatrii Centralny Szpital Kliniczny Uniwersytetu Medycznego w Łodzi Ośrodek Pediatryczny im. M. Konopnickiej ul. Sporna 36/50, 91-738 Łódź tel. (+48 42) 617-77-00 fax +(48 42) 617-77-03
| | - Kamil Nyga
- Centrum Medycyny Rodzinnej i Społeczności Lokalnych UM wŁodziPoland
| | - Grażyna Skotnicka-Klonowicz
- Oddział Kliniczny Medycyny Ratunkowej dla Dzieci II Katedra Pediatrii UM w Łodzi Ośrodek Pediatryczny im. M. Konopnickiej, Centralny Szpital Kliniczny UM wŁodziPoland
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Brogan RJ, Kontojannis V, Garara B, Marcus HJ, Wilson MH. Near-infrared spectroscopy (NIRS) to detect traumatic intracranial haematoma: A systematic review and meta-analysis. Brain Inj 2017; 31:581-588. [PMID: 28440675 DOI: 10.1080/02699052.2017.1287956] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES AND METHODS Head injury is the most common trauma presentation to UK emergency departments, with around 1.2 million patients each year. The key management principal for this time critical illness remains early surgical intervention. With the development of handheld near-infrared spectroscopy (NIRS) devices, there is now the possibility of triaging and diagnosing these patients immediately, where computed tomography (CT) scanner is unavailable. NIRS has two related but distinct potential uses within clinical medicine. Firstly, as a triage tool both in hospital and prehospital settings by doctors, nurses or paramedics as determined by its negative predictive value (NPV). Secondly, as a diagnostic aid as determined by its positive predictive value (PPV). The aim of this systematic review and meta-analysis is therefore to interrogate the current literature on NIRS in detecting intracranial haematomas. RESULTS NIRS technology has a cross-study sensitivity of 78%, specificity of 90%, PPV of 77%, and a NPV of 90%, which does not meet current standards as a diagnostic/triage tool in the populations studied. Additionally, its use is limited to those without extracranial injuries and may also be complicated by long scan times. CONCLUSION Larger and more heterogeneous studies are required for specifically evaluating NIRS performance in detecting intracranial lesions requiring emergency evacuation.
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Affiliation(s)
- Robert J Brogan
- a Imperial Neurotrauma Centre, The Major Trauma Centre, Imperial College London , London , UK
| | - Vassilios Kontojannis
- a Imperial Neurotrauma Centre, The Major Trauma Centre, Imperial College London , London , UK
| | - Bhavin Garara
- a Imperial Neurotrauma Centre, The Major Trauma Centre, Imperial College London , London , UK
| | - Hani J Marcus
- a Imperial Neurotrauma Centre, The Major Trauma Centre, Imperial College London , London , UK
| | - Mark H Wilson
- a Imperial Neurotrauma Centre, The Major Trauma Centre, Imperial College London , London , UK
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Gieling EM, van den Ham HA, van Onzenoort H, Bos J, Kramers C, de Boer A, de Vries F, Burden AM. Risk of major bleeding and stroke associated with the use of vitamin K antagonists, nonvitamin K antagonist oral anticoagulants and aspirin in patients with atrial fibrillation: a cohort study. Br J Clin Pharmacol 2017; 83:1844-1859. [PMID: 28205318 DOI: 10.1111/bcp.13265] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 01/18/2017] [Accepted: 01/30/2017] [Indexed: 11/30/2022] Open
Abstract
AIMS Nonvitamin K antagonist oral anticoagulants (NOACs) are now available for the prevention of stroke in patients with atrial fibrillation (AF) as an alternative to vitamin K antagonists (VKA) and aspirin. The comparative effectiveness and safety in daily practice of these different drug classes is still unclear. The objective of this study was to evaluate the risk of major bleeding and stroke in AF patients using NOACs, VKAs or aspirin. METHODS A retrospective cohort study was conducted among AF patients using the UK Clinical Practice Research Datalink (March 2008-October 2014). New users of VKAs, NOACs and low dose aspirin were followed from the date of first prescription of an antithrombotic drug until the occurrence of stroke or major bleeding. Analyses were adjusted for a history of comorbidities and drug use with Cox regression analysis. RESULTS A total of 31 497 patients were eligible for the study. The hazard ratio (HR) of major bleeding was 2.07 [95% confidence interval (CI) 1.27-3.38] for NOACs compared with VKAs, which was mainly attributed by the increased risk of gastrointestinal bleeding (HR 2.63, 95% CI 1.50-4.62). This increased bleeding risk was restricted to women (HR 3.14, 95% CI 1.76-5.60). Aspirin showed a similar bleeding risk as VKAs. NOACs showed equal effectiveness as VKA in preventing ischaemic stroke (HR 1.22, 95% CI 0.67-2.19). VKAs were more effective than aspirin (HR 2.18, 95% CI 1.83-2.59). CONCLUSIONS NOACs were associated with a higher risk on gastrointestinal bleeding, particularly in women. The use of NOACs in patients who are vulnerable for this type of bleeding should be carefully considered. NOACs and VKAs are equally effective in preventing stroke. Aspirin was not effective in the prevention of stroke in AF.
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Affiliation(s)
| | - Hendrika A van den Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands
| | | | | | - Cornelis Kramers
- Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.,Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Frank de Vries
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands.,Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, UK
| | - Andrea M Burden
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands.,Division of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
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50
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Mazlan-Kepli W, MacIsaac RL, Walters M, Bath PM, Dawson J. Antiplatelet therapy following ischaemic stroke - Continue or change pre-existing therapy? Eur Stroke J 2017; 2:31-36. [PMID: 31008300 DOI: 10.1177/2396987316678728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/19/2016] [Indexed: 10/20/2022] Open
Abstract
Introduction Antiplatelet therapy is routinely prescribed early after ischaemic stroke. Many patients will already be taking antiplatelet therapy and it is unknown whether these patients should continue the same antiplatelet treatment or switch to a different regimen. Methods We selected patients with ischaemic stroke from the Virtual International Stroke Trials Archive database who were prescribed antiplatelets both before and after their stroke and who had detailed records of adverse events after stroke. We compared patients who changed to a new antiplatelet regimen after their stroke to those who continued the same regimen. The primary outcome was recurrent ischaemic stroke within 90 days after their index stroke and the secondary outcome was intracranial haemorrhage (ICH) or extracranial haemorrhage (ECH). We used logistic regression analysis and adjusted for age and baseline NIHSS. Results A total of 1129 participants were included. Of these, 538 subjects changed antiplatelet regimen post stroke and 591 continued the same regimen. A recurrent ischaemic event occurred in 4.1% of subjects who changed regimen and 4.3% who continued unchanged (adjusted OR = 0.93; 95% CI 0.54-1.75, p = 0.929). The incidence of ICH and ECH within the first 90 days was similar in both groups (2.4% vs. 2.6% (adjusted OR = 1.02; 95% CI 0.48-2.18, p = 0.955) and 4.7% vs. 2.9% (adjusted OR = 1.82; 95% CI 0.96-3.43, p = 0.065), respectively). Discussion The analysis was performed using a non-randomised registry data. Conclusion In patients who suffer ischaemic stroke whilst taking antiplatelets, a change in antiplatelet regimen was not associated with an altered risk of early recurrent ischaemic stroke rate or bleeding. However, the results must be interpreted in view of the low event rates.
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Affiliation(s)
- Wardati Mazlan-Kepli
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rachael L MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Matthew Walters
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Philip Mw Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
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