Acute Intracranial Hemorrhage Research Articles

Lack of Association of Chronological Age and Antithrombotic Agents With Acute Intracranial Hemorrhage in the Group of Older Adults With Traumatic Brain Injury.

Some reports suggest that older patients with traumatic brain injury (TBI) are more likely to experience acute intracranial hemorrhage, resulting in poor outcomes. However, the association between precise chronological age and use of antithrombotic agents with acute intracranial hemorrhage in these patients remains unknown. The aim of this study was to determine factors associated with acute intracranial hemorrhage and poor outcomes in patients with TBI, including chronological age and use of antithrombotic agents. Patients hospitalized for TBI between January 2006 and December 2021 were included. Patients were categorized by age groups of <65 years, 65 to 74 years, 75 to 84 years, and ≥85 years. Associations between each age group and acute intracranial hemorrhage, a poor outcome at discharge, and in-hospital mortality were evaluated. The cohort included 1086 patients, with 713 (65.7%) in the ≥65 age group. Although chronological age was associated with acute intracranial hemorrhage in patients aged <65 years (odds ratio [OR] 1.02; 95% CI 1.01-1.03), it was not associated with patients aged ≥65 years. None of the antithrombotic agents investigated were associated with acute intracranial hemorrhage in the group aged ≥65 years. Although chronological age was associated with a poor outcome in patients aged <65 years (OR 1.03; 95% CI 1.01-1.07), it was not associated in those aged ≥65 years. The ≥85 year age group (OR 2.30; 95% CI 1.18-4.51) compared with <65 years were significantly associated with a poor outcome. None of the antithrombotic agents investigated were associated with a poor outcome in the group aged ≥65 years. Our findings confirmed the lack of an association of chronological age and antithrombotic agents with acute intracranial hemorrhage in the group of older adults with TBI. Our findings suggest that antithrombotic agents may be safely used, even in older adults.

7087 An Unusual Movement Disorder, Case of Diabetic Striatopathy!

Abstract Disclosure: S. Azmat: None. O. Lodhi: None. R. Safi: None. H. harb: None. H. Ashok: None. M.F. Siddiqui: None. J.L. Gilden: None. Background: Non-ketotic Hyperglycemia Hemichorea-Hemiballismus Syndrome (NKH-CB) is rare complication of poorly controlled diabetes mellitus (DM) characterized by continuous, irregular jerky movements localized to one side of the body. It is commonly seen in type 2 DM and is often presented in females of East Asian descent. NKH-CB is often misdiagnosed due to its rarity and radiographic features easily mistaken for intracerebral hemorrhage.Case: A 70-year-old Latino male with type 2 diabetes mellitus, hypertension, bipolar disorder and past history of two cerebrovascular accidents presented to ED with non-radiating, midsternal chest pain. ACS was ruled out with negative serial troponins and normal EKG. Vital signs were significant for elevated blood pressure 151/64 mmHg. Labs showed blood glucose=447 mg/dL. Physical examination revealed large amplitude involuntary movements in left upper and lower extremities and facial region. He also veered to the left when ambulating. The patient reported that these abnormal movements were occurring for last three weeks although sensation was preserved bilaterally. Code stroke was called; non-contrast CT showed unilateral hyper density of the right caudate and putamen with no evidence of acute intracranial hemorrhage or large arterial territory infarction. CT Angiogram did not show any signs of stenosis or occlusion. He received intravenous fluids and 8 units lispro insulin in ED. Was admitted for further evaluation and received basal/bolus insulin therapy with target blood glucose of 140-160 mg%. He also received risperidone for his mental condition. Subsequent testing revealed hemoglobin A1C of 16.9% (reference range: &amp;lt; 5.7%). MRI Brian showed unilateral T1 hyperintensity involving right caudate and putamen corresponding to the hypodensity seen on CT. Neurology service was consulted. Based on clinical signs/symptoms coupled with neuroimaging, he was diagnosed with non-ketotic Hyperglycemia Hemichorea-Hemiballismus Syndrome. On day 2 with resolution of hyperglycemia, amplitude and frequency of involuntary arm movements were minimal. The patient was discharged with Lantus 7 and metformin 1000 mg for DM and risperidone for symptoms management. Conclusion: Diabetic neuropathy is commonly known to result in small and/or large fiber sensorimotor polyneuropathy, proximal motor, and acute mononeuropathies as well as entrapments, radiculopathies, autonomic neuropathies, and even cognitive disorders. This case describes rare case of simultaneous NKH-CB with history of CVA and antipsychotic medication use in a patient with poorly controlled DM which resolved with treatment of hyperglycemia. Thus offers valuable insights into the diagnostic challenges associated with this condition as well as potential links to other neurological complications. One should also remain vigilant of potential onset of seizures commonly seen with NKH. Presentation: 6/3/2024

Association between the serum glucose-to-potassium ratio and clinical outcomes in ischemic stroke patients after endovascular thrombectomy.

The baseline glucose-to-potassium ratio (GPR) is associated with poor outcomes in patients with acute brain injury and intracranial hemorrhage. However, the impact of serum GPR on clinical outcomes after endovascular thrombectomy (EVT) is unclear. This study aimed to evaluate the association between the GPR at admission and functional outcomes at 90 days after EVT. We retrospectively reviewed our database for patients with acute ischemic stroke involving an anterior circulation large-vessel occlusion who received EVT between October 2019 and December 2021. The baseline serum GPR was measured after admission. The primary outcome was a 90-day poor outcome, which was defined as a modified Rankin scale score of 3-6. A total of 273 patients (mean age, 70.9 ± 11.9 years; 161 men) were finally included for analyses. During the 90-day follow-up, 151 patients (55.3%) experienced an unfavorable outcome. After adjusting for demographic characteristics and other potential confounders, the increased GPR was significantly associated with a higher risk of a 90-day poor outcome (odds ratio, 1.852; 95% confidence interval, 1.276-2.688, p = 0.001). Similar results were observed when the GPR was analyzed as a categorical variable. In addition, the restricted cubic spline observed a positive and linear association between the GPR and poor outcomes at 90 days (p = 0.329 for linearity; p = 0.001 for linearity). Our study found that ischemic stroke patients with the higher GPR at admission were more likely to have an unfavorable prognosis at 3 months, suggesting that GPR may be a potential prognostic biomarker for ischemic stroke after EVT.

Profile of antiplatelet regimens for emergent carotid stenting in tandem occlusion. Systematic review and meta-analysis

AimTo investigate the optimum antiplatelet therapy regimen (APTR) for emergent carotid artery stenting following mechanical thrombectomy (MT) in stroke patients with tandem occlusion. MethodsA literature search was performed on Pubmed/OVID/Cochran's CENTRAL database for studies from 2015 to 2022. Patient characteristics, antiplatelet regimen type, mTICI, 90 days-mRS, acute in-stent thrombosis (AIST), mortality, intracranial hemorrhage (ICH), and sample size were recorded. Exclusion criteria were non-English literature, sample size < 5 patients, other anticoagulant/antiplatelet therapy, and 100 % stent insertion in one study arm. The studies were assessed using MINORS/GRADE. Meta-analysis and meta-regression with a random effects model were performed. The outcomes were: 90 days-mRS, death, AIST and ICH ResultsFive-hundred-twenty-four studies were retrieved. After applying the exclusion criteria, the final population included 19/534 studies (3.6 %) for 880 patients (46.3 per article). I^2 and Q’s Cochrane were 86.4 % and 132.5 for mRS, 19.9 % and 17.5 for death, 0 % and 9.4 for acute in-stent thrombosis and 62.1 % and 39.7 for intra-cranial haemorrhages, respectively.Patients in the aspirin subgroup had a significantly lower rate of functional independence (mRS≤2) than those in the DAPT subgroup (47 % [CI95 % 42.0 %-52.0 %] vs. 61.9 % [CI95 % 50.8–72.9]; p=0.0007;OR 0.75[CI95 % 0.56–1.01], p=0.06). DAPT significantly decreased the death rate compared with aspirin (8.6 % [CI95 % 5.3 %-11.9 %] vs. 16.7 % [CI95 11.1 %-22.2 %]; p=0.0012). Anti-GPIIb/IIIa demonstrated a trend of increasing the probability of mortality versus DAPT (OR 1.88[CI95 % 0.93–3.86], p=0.08.No significant differences were observed between AIST and ICH in the treatment groups. ConclusionDAPT may increases the chance of obtaining an mRS score ≤2 and reduces mortality.

Time of Brain Imaging In Patients With An Acute Traumatic Intracranial Haemorrhage

Abstract Background We observed variation in timing of CT brain imaging in patients presenting with a history of trauma. The objective of this audit was to determine adherence to local ED CT Head Criteria in patients with a confirmed traumatic ICH. Methods Retrospective point prevalence audit of patients with a confirmed intracranial haemorrhage over a five-month period using our neurotrauma work-stream data. Exploration of CT timing between Criteria A (within 60 minutes) and Criteria B (within 8 hours). Characteristics reviewed included Gender, Age, Time of presentation to ED, Day of Arrival, GCS on presentation, Mechanism of Injury and Time of CT completion. Results 68 patients over the five-month period had a confirmed ICH: 48 male, 20 female. The median age was 62 years (range 17-97). Falls of less than 2 metres were the most frequent cause of injury (n=44, 65%), with 60% of these occurring in patients aged over 65 years of age. 67% (n=31) of patients meeting Criteria A did not have a CT Brain completed within 60 minutes. 14% (n=3) of patients meeting Criteria B did not have a CT Brain completed within 8 hours. Of patients meeting criteria who did not have a timely CT, 11 patients presented out of hours. Patients aged less than 65 years of age were less likely to meet target CT timing; 71% (n=24). Conclusion This audit highlights that only 33% of patients meeting Criteria A had brain imaging within one hour. Older adults were more likely to meet target CT timing than younger adults. Lack of ED access to radiology out of hours was deemed to be the main barrier to meeting target CT timing. We are working alongside our radiology department to secure no discussion trauma CT scans in ED out of hours. We plan to re-audit following the implementation of this change.

An Artificial Intelligence Algorithm Integrated into the Clinical Workflow Can Ensure High Quality Acute Intracranial Hemorrhage CT Diagnostic.

Intracranial hemorrhage (ICH) is alife-threatening condition requiring rapid diagnostic and therapeutic action. This study evaluates whether Artificial intelligence (AI) can provide high-quality ICH diagnostics and turnaround times suitable for routine radiological practice. Aconvolutional neural network (CNN) was trained and validated to detect ICHs on DICOM images of cranial CT (CCT) scans, utilizing about 674,000 individually labeled slices. The CNN was then incorporated into acommercial AI engine and seamlessly integrated into three pilot centers in Germany. Areal-world test-dataset was extracted and manually annotated by two experienced experts. The performance of the AI algorithm against the two raters was assessed and compared to the inter-rater agreement. The overall time ranging from data acquisition to the delivery of the AI results was analyzed. Out of 6284 CCT examinations acquired in three different centers, 947 (15%) had ICH. Breakdowns of hemorrhage types included 8% intraparenchymal, 3% intraventricular, 6% subarachnoidal, 7% subdural, < 1% epidural hematomas. Comparing the AI's performance on asubset of 255 patients with two expert raters, it achieved asensitivity of 0.90, aspecificity of 0.96, an accuracy of 0.96. The corresponding inter-rater agreement was 0.84, 0.98, and 0.96. The overall median processing times for the three centers were 9, 11, and 12 min, respectively. We showed that an AI algorithm for the automatic detection of ICHs can be seamlessly integrated into clinical workflows with minimal turnaround time. The accuracy was on par with radiology experts, making the system suitable for routine clinical use.

Comparative effectiveness and safety of direct oral anticoagulants and warfarin in atrial fibrillation patients with dementia.

Developing an effective stroke prevention strategy is crucial for elderly atrial fibrillation (AF) patients with dementia. This is due to the limited and inconsistent evidence available on this topic. In this nationwide, population-based cohort study, we aim to compare the effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in AF patients with dementia. We identified AF patients with dementia, aged 50 years or older, from Taiwan's National Health Insurance Research Database between 2010 and 2019. The primary outcome was a composite of hospitalizations due to ischemic stroke, acute myocardial infarction, intracranial hemorrhage, or major bleeding, as well as all-cause mortality. We used 1:1 propensity score matching and Cox proportional hazard models to adjust for confounding factors when comparing outcomes between warfarin and DOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) users or warfarin and each individual DOAC. There were 2952 patients in the DOAC-warfarin matched cohort. The apixaban-, dabigatran-, edoxaban-, and rivaroxaban-warfarin matched cohorts had 2346, 2554, 1684, and 2938 patients, respectively. The DOAC group, when compared to warfarin, was associated with a lower risk of both the composite outcome (hazard ratio (HR), 0.81; 95% confidence interval (CI) 0.69-0.95) and ischemic stroke (HR 0.65; 95% CI 0.48-0.87). Apixaban (HR 0.79; 95% CI 0.66-0.94), dabigatran (HR 0.64; 95% CI 0.53-0.77), and rivaroxaban (HR 0.82; 95% CI 0.70-0.97) were also associated with a lower risk of the composite outcome. Compared to warfarin, DOACs, whether as a group or apixaban, dabigatran, or rivaroxaban individually, were associated with a reduced risk of the composite outcome in elderly patients with concurrent AF and dementia.

Postoperative Acute Intracranial Hemorrhage and Venous Thromboembolism in Patients with Brain Metastases Receiving Acetylsalicylic Acid Perioperatively.

Cranial operations are associated with a high risk of postoperative intracranial hemorrhage (pICH) and venous thromboembolic events, along with increased mortality and morbidity. With the use of acetylsalicylic acid (ASA) for prophylaxis becoming more prevalent, the risk of bleeding when ASA is administered preoperatively is unknown, as are the effects of discontinuation upon the occurrence of thromboembolic events, especially in societies with aging demographics. To address these questions, a retrospective analysis was performed using medical records and radiological images of 1862 patients subjected to brain tumor surgery over a decade in our department. The risk of pICH was compared in patients with metastases receiving ASA treatment versus patients not receiving ASA treatment. The occurrence of venous thromboembolic events after surgery was also evaluated. The study group consisted of 365 patients with different types of brain metastases. In total, 20 patients suffered pICH and 7 of these were associated with clinical neurological deterioration postoperatively. Of the 58 patients who took ASA preoperatively, 2 patients experienced pICH, compared with 5 patients in the non-ASA impact group (p = 0.120). Patients who took ASA were not at significantly higher risk of pICH and therefore a worse outcome compared to the group without ASA. Therefore, these data suggest that in patients at high cardiovascular risk, ASA can be safely continued during elective brain tumor surgery.

Accuracy and time efficiency of a novel deep learning algorithm for Intracranial Hemorrhage detection in CT Scans

PurposeTo evaluate a deep learning-based pipeline using a Dense-UNet architecture for the assessment of acute intracranial hemorrhage (ICH) on non-contrast computed tomography (NCCT) head scans after traumatic brain injury (TBI).Materials and methodsThis retrospective study was conducted using a prototype algorithm that evaluated 502 NCCT head scans with ICH in context of TBI.Four board-certified radiologists evaluated in consensus the CT scans to establish the standard of reference for hemorrhage presence and type of ICH. Consequently, all CT scans were independently analyzed by the algorithm and a board-certified radiologist to assess the presence and type of ICH. Additionally, the time to diagnosis was measured for both methods.ResultsA total of 405/502 patients presented ICH classified in the following types: intraparenchymal (n = 172); intraventricular (n = 26); subarachnoid (n = 163); subdural (n = 178); and epidural (n = 15). The algorithm showed high diagnostic accuracy (91.24%) for the assessment of ICH with a sensitivity of 90.37% and specificity of 94.85%. To distinguish the different ICH types, the algorithm had a sensitivity of 93.47% and a specificity of 99.79%, with an accuracy of 98.54%. To detect midline shift, the algorithm had a sensitivity of 100%. In terms of processing time, the algorithm was significantly faster compared to the radiologist’s time to first diagnosis (15.37 ± 1.85 vs 277 ± 14 s, p < 0.001).ConclusionA novel deep learning algorithm can provide high diagnostic accuracy for the identification and classification of ICH from unenhanced CT scans, combined with short processing times. This has the potential to assist and improve radiologists’ ICH assessment in NCCT scans, especially in emergency scenarios, when time efficiency is needed.

Utility of thromboelastography to assess the effect of anticoagulation reversal in intracranial hemorrhage.

Intracranial hemorrhage (ICH) is a serious complication associated with oral anticoagulant use and is associated with significant morbidity and mortality. Although anticoagulation reversal agents are utilized as standard of care, practitioners are limited in their ability to assess degree of anticoagulation reversal for direct oral anticoagulants (DOACs). There is a clinical need identify biomarkers to assess anticoagulation status in patients with DOAC-associated ICH to ensure hemostatic efficacy of anticoagulation reversal agents in the acute setting. The purpose of this study was to assess the utility of thromboelastography (TEG) to assess the impact of anticoagulation reversal in patients presenting to the emergency department (ED) with DOAC-associated ICH. We conducted a prospective, observational cohort study in adult patients presenting to the ED with acute DOAC-associated ICH. Patients were excluded if last DOAC dose was >48 hours prior to hospital arrival, if they experienced polytrauma, were pregnant, incarcerated, had a history of hepatic failure or coagulopathy, or received anticoagulation reversal with products other than prothrombin complex concentrates (PCCs). We collected baseline TEG samples from participants prior to anticoagulation reversal, as well as 30-minutes, 12-hours, and 24-hours post-reversal. TEG samples were also collected from participants who transferred to our facility after reversal at ED presentation, as well as 12- and 24-hours post-reversal. Pre-reversal TEG was collected on 10 participants prior to DOAC reversal. A significant decrease in TEG R-time was observed at 30 minutes post-reversal. R-time increased at 12- and 24-hours to baseline levels. Significant changes were not observed in K-time, clot strength, maximum amplitude, or coagulation index. TEG R-time may be able to detect a change in anticoagulation activity of DOACs in ICH after anticoagulation reversal. R-time decreases acutely after anticoagulation reversal and rebounds at 12- and 24-hours post-reversal.

Diagnostic Accuracy of Cone-Beam CT for Acute Intracranial Hemorrhage: A Systematic Review and Meta-Analysis

ObjectiveOur purpose was to synthesize evidence in the literature to determine the diagnostic accuracy of cone-beam CT (CBCT) for the detection of intracranial hemorrhage (ICH) and hemorrhage types, including intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and intraventricular hemorrhage (IVH). MethodsWe performed a meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Our protocol was registered with International Prospective Register of Systematic Reviews (PROSPERO-CRD42021261915). Systematic searches were last performed on April 30, 2024, in EMBASE, PubMed, Web-of-Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases. Inclusion criteria were (1) studies reporting diagnostic metrics of CBCT for ICH and (2) studies using a reference standard to determine ICH. Exclusion criteria were (1) case reports, abstracts, reviews and (2) studies without patient-level data. Pooled estimates and 95% confidence intervals (CIs) were calculated for diagnostic odds ratios (DORs), sensitivity, and specificity using random-effects and common-effects models. Mixed methods appraisal tool was used to evaluate risk of bias. ResultsSeven studies were included in the meta-analysis yielding 466 patients. Mean or median age ranged from 54 to 75 years. Female patients represented 51.4% (222 of 432) in reported studies. Multidetector CT was the reference standard in all studies. DOR, pooled sensitivity, and pooled specificity for ICH were 5.28 (95% CI: 4.11-6.46), 0.88 (95% CI: 0.79-0.97), and 0.99 (95% CI: 0.98-1.0). Pooled sensitivity for IPH, SAH, and IVH was 0.98 (95% CI: 0.95-1.0), 0.82 (95% CI: 0.57-1.0), and 0.78 (95% CI: 0.55-1.0). Pooled specificity for IPH, SAH, and IVH was 0.99 (95% CI: 0.98-1.0), 0.99 (95% CI: 0.97-1.0), and 1.0 (95% CI: 0.98-1.0). DiscussionCBCT had moderate DOR and high pooled specificity for ICH and hemorrhage types. However, pooled sensitivity varied by hemorrhage type, with the highest sensitivity for IPH, followed by SAH and IVH.

Modified Rankin Scale disability status at day 4 poststroke is an informative predictor of long-term day 90 outcome

BackgroundLong-term disability after stroke is standardly assessed 3 months post-onset, using the modified Rankin Scale (mRS). The value of an early, day 4 mRS assessment for projecting the 3-month disability outcome has not been formally investigated. MethodsIn this cohort of patients with acute cerebral ischemia and intracranial hemorrhage, we analyzed day 4 and day 90 mRS assessments in the NIH Field Administration of Stroke Therapy– Magnesium (FAST-MAG) Phase 3 trial. The performance of day 4 mRS, alone and as part of multivariate models, in predicting day 90 mRS was assessed using correlation coefficients, percent agreement, and the kappa statistics. ResultsAmong the 1573 acute cerebrovascular disease (ACVD) patients, 1206 (76.7%) had acute cerebral ischemia (ACI), while 367 (23.3%) had intracranial hemorrhage. Among all 1573 ACVD patients, day 4 mRS and day 90 mRS correlated strongly, Spearman's rho=0.79, in unadjusted analysis with weighted kappa of 0.59. For dichotomized outcomes, simple carry-forward of the day 4 mRS performed fairly well in agreeing with day 90 mRS: mRS 0-1 (kappa=0.67), 85.4%; mRS 0-2 (k=0.59), 79.5%; fatal outcome, 88% (k=0.33). Correlations of 4d and 90d mRS were stronger for ACI than ICH patients, 0.76 vs 0.71. ConclusionsIn this acute cerebrovascular disease patient cohort, assessment of global disability performed on day 4 is highly informative regarding long-term, 3-month mRS disability outcome, alone, and even more strongly in combination with baseline prognostic variables. The day 4 mRS is a useful measure for imputing the final patient disability outcome in clinical trials and quality improvement programs.

Deep Learning to Detect Intracranial Hemorrhage in a National Teleradiology Program and the Impact on Interpretation Time.

The diagnostic performance of an artificial intelligence (AI) clinical decision support solution for acute intracranial hemorrhage (ICH) detection was assessed in a large teleradiology practice. The impact on radiologist read times and system efficiency was also quantified. A total of 61 704 consecutive noncontrast head CT examinations were retrospectively evaluated. System performance was calculated along with mean and median read times for CT studies obtained before (baseline, pre-AI period; August 2021 to May 2022) and after (post-AI period; January 2023 to February 2024) AI implementation. The AI solution had a sensitivity of 75.6%, specificity of 92.1%, accuracy of 91.7%, prevalence of 2.70%, and positive predictive value of 21.1%. Of the 56 745 post-AI CT scans with no bleed identified by a radiologist, examinations falsely flagged as suspected ICH by the AI solution (n = 4464) took an average of 9 minutes 40 seconds (median, 8 minutes 7 seconds) to interpret as compared with 8 minutes 25 seconds (median, 6 minutes 48 seconds) for unremarkable CT scans before AI (n = 49 007) (P < .001) and 8 minutes 38 seconds (median, 6 minutes 53 seconds) after AI when ICH was not suspected by the AI solution (n = 52 281) (P < .001). CT scans with no bleed identified by the AI but reported as positive for ICH by the radiologist (n = 384) took an average of 14 minutes 23 seconds (median, 13 minutes 35 seconds) to interpret as compared with 13 minutes 34 seconds (median, 12 minutes 30 seconds) for CT scans correctly reported as a bleed by the AI (n = 1192) (P = .04). With lengthened read times for falsely flagged examinations, system inefficiencies may outweigh the potential benefits of using the tool in a high volume, low prevalence environment. Keywords: Artificial Intelligence, Intracranial Hemorrhage, Read Time, Report Turnaround Time, System Efficiency Supplemental material is available for this article. © RSNA, 2024.

A Bedside Screening Tool for Acute Intracranial Hemorrhages in Intubated Children using Continuous Quantitative Electroencephalography Monitoring

Abstract Significance Recognition of intracranial hemorrhage is challenging in children who require deep sedation to tolerate mechanical ventilation. The Correlate Of Injury to the Nervous System (COIN) index may enable real-time recognition of intracranial hemorrhage at bedside. Methods Retrospective analysis of electroencephalography (EEG) data from children with spontaneous intracranial hemorrhage while intubated and sedated in the pediatric intensive care unit. Patients were selected for having normal head imaging at time of EEG start and required demonstration of hemorrhage on repeat imaging following an uninterrupted period of EEG recording. Power spectrum data were analyzed to yield a COIN value and visualization for every 4 seconds of recording. EEG recordings were subdivided based on COIN-risk alarm states (low, medium, or high). Changes in COIN were compared with changes in commercially available quantitative EEG trending software. COIN values for each subdivision were compared within cases using the Wilcoxon Rank-Sum Test. Results Two children developed spontaneous intracranial hemorrhage while intubated. COIN shows transitions from low-to-medium (p &lt; 0.001) and medium-to-high-risk (p &lt; 0.001 in both cases) alarm states. Discrete transitions in COIN alarm state preceded clinical recognition of hemorrhage by several hours. COIN visualized focal power attenuation concordant with hemorrhage localization. In both cases, qualitative EEG was not reported to have focal abnormalities during the medium-risk alarm state. Conclusion COIN may assist in real-time recognition of intracranial hemorrhage in children at bedside. Further study and development are required for clinical implementation of COIN in several clinical settings where patients are at high risk of new or worsening intracranial hemorrhage.

Contrast-induced transient cortical blindness

A 58-year-old Malay man with a history of ischemic heart disease, well-controlled diabetes mellitus, and hypertension presented with sudden loss of vision after he underwent angiogram (cardiac catheterization) with contrast. Post-angiogram, his visual acuity deteriorated gradually to no perception of light bilaterally within 1 h duration. Clinically, there was no new intraocular pathology and neurologic examination was normal. An urgent noncontract computed tomography (CT) scan of the brain showed the presence of contrast in the venous sinuses but no obvious acute intracranial hemorrhage. Bilateral frontal and anterior parietal regions appeared hypodense with loss of gray white matter differentiation and relative effacement of the sulci. CT brain reported that infarction or cerebral edema may represent. Patient’s condition was observed, and after 24 h, his vision recovered to baseline and he was discharged well.

ACUTE VENOUS THROMBOEMBOLISM IS COMMON FOLLOWING ACUTE NECROTIZING PANCREATITIS AND IS ASSOCIATED WITH WORSE CLINICAL OUTCOMES.

While splanchnic vein thrombosis (SVT) is a well-known local complication of acute pancreatitis, extra-splanchnic VTE (ESVT) is inadequately studied. Here, we aim to explore the incidence of VTE in acute necrotizing pancreatitis (ANP) and the associated mortality. This is a retrospective cohort study utilizing an electronic health record database. Adults with a diagnosis of ANP from January 2017 to December 2022 were identified using appropriate ICD-10-CM codes. The primary outcome was development of acute ESVT within one month of ANP. Secondary outcomes were 90-day mortality, 30-day rehospitalization, and oral anticoagulant (OAC) use in patients with ESVT. Propensity score matching (1:1) was performed for baseline characteristics and common comorbidities. 17,942 (7.11%) patients were diagnosed with ANP during the study period and about 10% (1,737) of them had a diagnosis of ESVT. Of all VTE, 61% were ESVT with or without SVT, and 63% (N = 1,799) were SVT. 90-day mortality (16.3% vs. 5.7%, risk ration, RR 2.86 [95% CI 2.29-3.56]) and 30-day rehospitalization (31% Vs 19%, RR 1.63 [95% CI 1.49-1.79]) were higher in patients with ESVT compared to non-VTE patients. 60% of patients with ESVT were on OAC and OAC use was associated with lower 90-day mortality (8.9% vs. 19.4%, RR 0.46) without increased risk of adverse events, like - acute gastrointestinal bleeding, intracranial bleeding, or need for packed red cell transfusion. Systemic VTE is common in patients with ANP and may contribute to increased mortality and risk of readmissions. Prospective studies can confirm our findings and explore the role of aggressive VTE prophylaxis in patients with ANP during hospital stay, and in the immediate ambulatory period.

Low Incidence of Delayed Intracranial Hemorrhage in Geriatric Emergency Department Patients on Preinjury Anticoagulation Presenting with Blunt Head Trauma

BackgroundDelayed intracranial hemorrhage (ICH) after head injury in older patients taking anticoagulants has been reported to be as high as 7.2%. Other studies suggest much lower rates. Its incidence and clinical management are controversial, with some recommending observation and repeat head imaging at 24 h. ObjectiveOur study aims to assess the incidence of delayed ICH in geriatric Emergency Department (ED) head trauma patients prescribed preinjury anticoagulants. MethodsWe performed a prospective cohort study conducted at two hospital EDs from August 2019 to July 2020. All patients aged 65 years or older with acute head injury were eligible for enrollment. We conducted telephone follow-up at 14 and 60 days, and a chart review at 90 days. The primary study outcome was incidence of delayed ICH, which was defined as an initial negative head computed tomography scan followed by subsequent ICH believed to be caused by the initial traumatic event. We compared the rates of delayed ICH between patient cohorts based on anticoagulant use. ResultsThere were 3425 patients enrolled: 2300 (67.2%) were not on an anticoagulant, 249 (7%) were on preinjury warfarin, 780 (22.7%) were on a direct-acting oral anticoagulant, and 96 (2.8%) were on enoxaparin or heparin. The median age was 82 years (interquartile range 65-107), the majority were female (55.2%), and almost all were Caucasian (84.3%). An acute ICH was identified in 229 of 3425 (6.7%, 95% confidence interval 6–8%) and delayed ICH in 13 (0.4%, 95% confidence interval 0.2–0.6%). There were no differences in rates of delayed ICH between those who had been prescribed anticoagulants vs. those who had not (p = 0.45). ConclusionsThe incidence of delayed ICH is very low in older ED head trauma patients on prescribed pre-injury anticoagulants. Our data have important clinical implications for the management of blunt head trauma among older ED patients on anticoagulants.

An efficient deep neural network for automatic classification of acute intracranial hemorrhages in brain CT scans

BackgroundRecent advancements in deep learning models have demonstrated their potential in the field of medical imaging, achieving remarkable performance surpassing human capabilities in tasks such as classification and segmentation. However, these modern state-of-the-art network architectures often demand substantial computational resources, which limits their practical application in resource-constrained settings. This study aims to propose an efficient diagnostic deep learning model specifically designed for the classification of intracranial hemorrhage in brain CT scans. MethodOur proposed model utilizes a combination of depthwise separable convolutions and a multi-receptive field mechanism to achieve a trade-off between performance and computational efficiency. The model was trained on RSNA datasets and validated on CQ500 dataset and PhysioNet dataset. ResultThrough a comprehensive comparison with state-of-the-art models, our model achieves an average AUROC score of 0.952 on RSNA datasets and exhibits robust generalization capabilities, comparable to SE-ResNeXt, across other open datasets. Furthermore, the parameter count of our model is just 3 % of that of MobileNet V3. ConclusionThis study presents a diagnostic deep-learning model that is optimized for classifying intracranial hemorrhages in brain CT scans. The efficient characteristics make our proposed model highly promising for broader applications in medical settings.

Predictors of acute post-thrombectomy intracranial hemorrhage expansion in anterior circulation infarcts

Background Post-mechanical thrombectomy (MT) intracranial hemorrhage (ICH) is a major source of morbidity in treated acute ischemic stroke patients with large vessel occlusion. ICH expansion may further contribute to morbidity. We sought to identify factors associated with ICH expansion on imaging evaluation post-MT. Methods We performed a retrospective cohort study of patients undergoing MT at a single comprehensive stroke center. Per protocol, patients underwent dual-energy head CT (DEHCT) post-MT followed by a 24-h interval non-contrast enhanced MRI. ICH expansion was defined as any increase in blood volume between the two studies if identified on the DEHCT. Univariate and multivariable analyses were performed to identify risk factors for ICH expansion. Results ICH was identified on DEHCT in 13% of patients ( n = 35/262), with 20% (7/35) demonstrating expansion on interval MRI. The average increase in blood volume was 11.4 ml (SD 6.9). Univariate analysis identified anticoagulant usage (57% vs 14%, p = 0.03), petechial hemorrhage inside the infarct margins or intraparenchymal hematoma on DEHCT (ECASS-II HI2/PH1/PH2) (71% vs 14%, p &lt; 0.01), basal ganglia hemorrhage (71% vs 21%, p = 0.02), and basal ganglia infarction (86% vs 32%, p = 0.03) as factors associated with ICH expansion. Multivariate regression demonstrated that anticoagulant usage (OR 20.3, 95% C.I. 2.43–446, p &lt; 0.05) and ECASS II scores of HI2/PH1/PH2 (OR 11.7, 95% C.I. 1.24–264, p &lt; 0.05) were significantly predictive of ICH expansion. Conclusion Expansion of post-MT ICH on 24-h interval MRI relative to immediate post-thrombectomy DEHCT is significantly associated with baseline anticoagulant usage and petechial hemorrhage inside the infarct margins or presence of intraparenchymal hematoma (ECASS-II HI2/PH1/PH2).

Association between Serum Lactate Dehydrogenase Level and 30-day Mortality in Patients with Intracranial Hemorrhage with Acute Leukemia in the Induction Phase: A Cohort Study.

Objectives This study aimed to identify the association between lactate dehydrogenase (LDH) levels and 30-day mortality in patients with intracranial hemorrhage (ICH) with acute leukemia during the induction phase. Methods This cohort study included patients with acute leukemia with ICH during induction. We evaluated serum LDH levels upon admission. Multivariable Cox regression analyzed the LDH 30-day mortality association. Interaction and stratified analyses based on factors like age, sex, albumin, white blood cell count, hemoglobin level, and platelet count were conducted. Results We selected 91 patients diagnosed with acute leukemia and ICH. The overall 30-day mortality rate was 61.5%, with 56 of the 91 patients succumbing. Among those with LDH levels ≥ 570 U/L, the mortality rate was 74.4% (32 out of 43), which was higher than the 50% mortality rate of the LDH < 570 U/L group (24 out of 48) ( p = 0.017). In our multivariate regression models, the hazard ratios and their corresponding 95% confidence intervals for Log2 and twice the upper limit of normal LDH were 1.27 (1.01, 1.58) and 2.2 (1.05, 4.58), respectively. Interaction analysis revealed no significant interactive effect on the relationship between LDH levels and 30-day mortality. Conclusions Serum LDH level was associated with 30-day mortality, especially in patients with LDH ≥ 570 U/L.