Acute Intracranial Hemorrhage Research Articles

Abnormal Cerebral FDG Accumulation in Acute Intracerebral and Subarachnoid Hemorrhages Due to Different Mechanisms.

Changes in cerebral glucose metabolism after acute intracranial hemorrhage have been rarely described. We present a patient with abnormal cerebral FDG accumulation in acute intracerebral and subarachnoid hemorrhages due to different mechanisms on FDG PET/CT. The patient received conservative management and died 2 months later. This case demonstrated the different mechanisms of cerebral FDG accumulation in different types of intracranial hemorrhage, which may be helpful for future research to optimize patient care.

FRI647 Hemiballismus - A Rare Presentation Of Uncontrolled Diabetes Mellitus Type 2

Abstract Disclosure: C.L. Macrohon: None. M.L. Kanapi: None. Background: Diabetic Striatopathy is a rare disease with a prevalence of 1 in 100,000 and is more commonly seen in elderly women with poor glycemic control. It is an acute movement disorder characterized by sudden, non-purposeful jerking movements secondary to non-ketotic hyperglycemia. This is associated with high-intensity signals on T1-weighted magnetic resonance imaging of the brain noted at the basal ganglia. Case: We have a case of an 80-year old female who came in due to a four-day history of persistent involuntary, non-purposeful jerking of her right upper extremity accompanied by episodes of agitation and visual hallucinations. She has Diabetes Mellitus Type 2 for the past 20 years on Glibenclamide and Metformin. However, self-monitoring of blood glucose revealed fasting glucose levels as high as 300mg/dl. She was asymptomatic hence did not have regular follow-up with her primary care physician. She had no history of previous cerebrovascular disease. Family history was unremarkable. Upon examination, she was disoriented to place but answers appropriately to questions and did not have any speech abnormalities. On inspection it was noted that she had high amplitude involuntary flailing of the right upper extremity accompanied by non-purposeful jerking of her right lower extremity. Initial blood glucose level was 354mg/dl with an Hba1c of 13.7%. Serum ketones was within normal limits with a value of 0.1mmol/L. A plain Magnetic Resonance Imaging of the brain was done which showed a region of T1 weighted hyperintensity with no corresponding abnormal restricted diffusion nor increased susceptibility signals involving the left lentiform nucleus with no evidence of acute infarction nor intracranial hemorrhage noted. At this time, patient was co-managed by Endocrinology and Neurology service with an impression of a Diabetic Striatopathy. For the hemiballism and other neurologic manifestations such as agitation, visual hallucinations and disorientation patient was given risperidone and clonazepam. Blood glucose was then managed through cautious insulin therapy as well as hydration. On the third hospital day, there was noted resolution of right-sided hemiballismus and at this time glycemic control was improved. Conclusion: Proper identification and diagnosis is essential in managing Diabetic striatopathy. Although this may be a rare presentation of uncontrolled diabetes mellitus, clinicians should be aware of the possibility of an acute movement disorder as an unveiling symptom. This shows the importance of prompt blood glucose measurement in these acute cases. Once identified, adequate glycemic control through insulin therapy remains to be the center and most effective therapeutic management for the resolution of these hyperkinetic symptoms. Presentation: Friday, June 16, 2023

Prediabetes is an incremental risk factor for adverse cardiac events: A nationwide analysis

Background and aimsPrediabetes is defined as a state of impaired glucose metabolism with hemoglobin A1c (HbA1c) levels that precede those of a diabetic state. There is increasing evidence that suggests that hyperglycemic derangement in prediabetes leads to microvascular and macrovascular complications even before progression to overt diabetes mellitus. We aim to identify the association of prediabetes with acute cardiovascular events. MethodsWe utilized the National inpatient sample 2018-2020 to identify adult hospitalizations with prediabetes after excluding all hospitalizations with diabetes. Demographics and prevalence of other cardiovascular risk factors were compared in hospitalizations with and without prediabetes using the chi-square test for categorical variables and the t-test for continuous variables. Multivariate regression analysis was further performed to study the impact of prediabetes on acute coronary syndrome, acute ischemic stroke, intracranial hemorrhage, and acute heart failure. ResultsHospitalizations with prediabetes had a higher prevalence of cardiovascular risk factors like hypertension, hyperlipidemia, obesity, and tobacco abuse. In addition, the adjusted analysis revealed that hospitalizations with prediabetes were associated with higher odds of developing acute coronary syndrome (OR-2.01; C.I:1.94-2.08; P<0.001), acute ischemic stroke (OR-2.21; 2.11-2.31; p<0.001), and acute heart failure (OR-1.41; C.I.: 1.29-1.55; p<0.001) as compared to hospitalizations without prediabetes. ConclusionsOur study suggests that prediabetes is associated with a higher odds of major cardiovascular events. Further prospective studies should be conducted to identify prediabetes as an independent causative factor for these events. In addition, screening and lifestyle modifications for prediabetics should be encouraged to improve patient outcomes.

Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma

BackgroundAlthough clinical decision rules exist for patients with head injuries, no tool assesses patients with unknown trauma events. Patients with uncertain trauma may have unnecessary brain imaging. ObjectiveThis study evaluated risk factors and outcomes of geriatric patients with uncertain head injury. MethodsThis prospective cohort study included geriatric patients with definite or uncertain head injury presenting to two emergency departments (EDs). Patients were grouped as definite or uncertain head trauma based on history and physical examination. Outcomes were intracranial hemorrhage (ICH) on head computed tomography (CT), need for neurosurgical intervention, and mortality. Risk factors assessed included gender, alcohol use, tobacco use, history of dementia, anticoagulant use, antiplatelet use, and Glasgow Coma Scale (GCS) score < 15. ResultsWe enrolled 2905 patients with definite head trauma and 950 with uncertain head trauma. Rates of acute ICH (10.7% vs. 1.5%; odds ratio [OR] 8.02; 95% confidence interval [CI] 4.67–13.76), delayed ICH (0.7% vs. 0.1%; OR 6.58; 95% CI 4.67–13.76), and neurosurgical intervention (1.2% vs. 0.3%; OR 3.74; 95% CI 1.15–12.20) were all higher in definite vs. uncertain head injuries. There were no differences in mortality. Patients with definite trauma had higher rates of ICH with male gender (OR 1.58; 95% CI 1.24–1.99), alcohol use (OR 1.62; 95% CI 1.25–2.09), antiplatelet use (OR 1.84; 95% CI 1.46–2.31), and GCS score < 15 (OR 3.24; 95% CI 2.54–4.13). Patients with uncertain trauma had no characteristics associated with increased ICH. ConclusionsAlthough ICH rates among patients with uncertain head trauma was eight times lower than those with definite head trauma, the risk of ICH is high enough to warrant CT imaging of all geriatric patients with uncertain head injury.

Intracranial Hemorrhage Presenting With ST-Segment Elevation and T-Wave Inversion Concerning for Acute Myocardial Infarction.

Acute neurologic injury and increased intracranial pressure are associated with electrocardiographic (ECG) changes that include rhythm disturbances as well as ECG mimics of myocardial ischemia, such as focal or diffuse ST-segment or T-wave abnormalities. Both the mechanism and significance of these ECG changes are not clear. The authors report a case of a patient with a complex medical history who became hypotensive after he presented with acute intracranial hemorrhage. A subsequent ECG showing ST-segment elevation in the inferior and lateral leads was concerning for acute myocardial infarction. ST-segment elevation in the setting of acute intracranial hemorrhage can lead to diagnostic confusion and/or premature narrowing of the differential diagnosis. This case report starts with an example of this exact scenario, provides a concise overview of potential mechanisms, and concludes with several possible strategies that the emergency provider can use to identify this effect in an undifferentiated patient.

Essential information for neurorecovery clinical trial design: trajectory of global disability in first 90 days post-stroke in patients discharged to acute rehabilitation facilities

BackgroundMany stroke recovery interventions are most beneficial when started 2-14d post-stroke, a time when patients become eligible for inpatient rehabilitation facilities (IRF) and neuroplasticity is often at its peak. Clinical trials focused on recovery need to expand the time from this plasticity to later outcome timepoints.MethodsThe disability course of patients with acute ischemic stroke (AIS) and intracranial hemorrhage (ICH) enrolled in Field Administration of Stroke Therapy Magnesium (FAST-MAG) Trial with moderate-severe disability (modified Rankin Scale [mRS] 3–5) on post-stroke day4 who were discharged to IRF 2-14d post-stroke were analyzed.ResultsAmong 1422 patients, 446 (31.4%) were discharged to IRFs, including 23.6% within 2-14d and 7.8% beyond 14d. Patients with mRS 3–5 on day4 discharged to IRFs between 2-14d accounted for 21.7% (226/1041) of AIS patients and 28.9% (110/381) of ICH patients, (p < 0.001). Among these AIS patients, age was 69.8 (± 12.7), initial NIHSS median 8 (IQR 4–12), and day4 mRS = 3 in 16.4%, mRS = 4 in 50.0%, and mRS = 5 in 33.6%. Among these ICH patients, age was 62.4 (± 11.7), initial NIHSS median 9 (IQR 5–13), day 4 mRS = 3 in 9.4%, mRS = 4 in 45.3%, and mRS = 5 in 45.3% (p < 0.01 for AIS vs ICH). Between day4 to day90, mRS improved ≥ 1 levels in 72.6% of AIS patients vs 77.3% of ICH patients, p = 0.3. For AIS, mRS improved from mean 4.17 (± 0.7) to 2.84 (± 1.5); for ICH, mRS improved from mean 4.35 (± 0.7) to 2.75 (± 1.3). Patients discharged to IRF beyond day14 had less improvement on day90 mRS compared with patients discharged between 2-14d.ConclusionsIn this acute stroke cohort, nearly 1 in 4 patients with moderate-severe disability on post-stroke day4 were transferred to IRF within 2-14d post-stroke. ICH patients had nominally greater mean improvement on mRS day90 than AIS patients. This course delineation provides a roadmap for future rehabilitation intervention studies.

Pearls and pitfalls in emergency CT neuroangiography through the lens of bias and error.

Computed tomography angiography (CTA) of the head and neck is central in emergency department (ED) evaluation of clinically suspected acute stroke and intracranial hemorrhage. Timely and accurate detection of acute findings is crucial for best clinical outcomes; missed or delayed diagnosis can be devastating. Our pictorial essay presents twelve CTA cases that provided significant diagnostic dilemmas to on-call trainees while reviewing current bias and error classifications in radiology. Among others, we discuss anchoring, automation, framing, satisfaction of search, scout neglect and zebra-retreat bias. Each imaging vignette depicts a potential diagnostic "pitfall" while introducing types of cognitive bias/error before concluding with a concrete "pearl" for CTA interpretation. We believe that familiarity with bias and error is particularly important in the ED setting where high case volume, high acuity and radiologist fatigue intersect. Particular attention to personal cognitive biases and these potential CTA pitfalls may help emergency radiologists transition from habit-driven pattern recognition to analytical thinking, ultimately improving diagnostic decision making.

Real-world clinical outcomes among US Veterans with oral factor xa inhibitor–related major bleeding treated with andexanet alfa or 4-factor prothrombin complex concentrate

Oral factor Xa (FXa) inhibitors significantly reduce incidence of stroke and thromboembolic events in patients with atrial fibrillation or venous thromboembolism. Due to various factors and the lack of a randomized controlled trial comparing andexanet alfa to usual care, non-specific replacement agents including 4 F-PCC are still used off-label for FXa inhibitor bleed management. Clinical and mortality data were extracted from the inpatient medical data and Veteran Affairs (VA) vital status files over the time of March 2014 through December 2020. Propensity score-weighted models were used for this retrospective cohort study using data from the Veterans Affairs Informatics and Computing Infrastructure (VINCI). The study included 255 patients (85-andexanet alfa and 170-4 F-PCC) exposed to an oral factor Xa inhibitor and hospitalized with an acute major, gastrointestinal (GI), intracranial (ICH) or other bleed. In-hospital mortality was significantly lower in the andexanet alfa cohort compared to the 4 F-PCC cohort (10.6% vs. 25.3%, p = 0.01). Propensity score–weighted Cox models reveal a 69% lower hazard of in-hospital mortality for those treated with andexanet alfa (HR 0.31, 95% CI 0.14–0.71) compared to those treated with 4 F-PCC. Additionally, those treated with andexanet alfa had a lower 30-day mortality rate and lower 30-day hazard of mortality in the weighted Cox model (20.0% vs. 32.4%, p = 0.039; HR 0.54, 95% CI 0.30–0.98) compared to those treated with 4 F-PCC. Among 255 US veterans with major bleeding in the presence of an oral factor Xa inhibitor, treatment with andexanet alfa was associated with lower in-hospital and 30-day mortality than treatment with 4 F-PCC.

The Case Files

The Case Files

Clinical Indicators for Primary Cranial CT Imaging after Mild Traumatic Brain Injury-A Retrospective Analysis.

The primary aim was to determine the clinical indicators for primary cranial CT imaging in patients after mild traumatic brain injury (mTBI). The secondary aim was to evaluate the need for post-traumatic short-term hospitalization based on primary clinical and CT findings. This was an observational retrospective single-centre study of all the patients who were admitted with mTBI over a five-year period. Demographic and anamnesis data, the clinical and radiological findings, and the outcome were analyzed. An initial cranial CT (CT0) was performed at admission. Repeat CT scans (CT1) were performed after positive CT0 findings and in cases with in-hospital secondary neurological deterioration. Intracranial hemorrhage (ICH) and the patient's outcome were evaluated using descriptive statistical analysis. A multivariable analysis was performed to find associations between the clinical variables and the pathologic CT findings. A total of 1837 patients (mean age: 70.7 years) with mTBI were included. Acute ICH was detected in 102 patients (5.5%), with a total of 123 intracerebral lesions. In total, 707 (38.4%) patients were admitted for 48 h for in-hospital observation and six patients underwent an immediate neurosurgical intervention. The prevalence of delayed ICH was 0.05%. A Glasgow Coma Scale (GCS) of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of fracture were identified as clinical factors with significantly higher risk of acute ICH. None of the 110 CT1 presented clinical relevance. A GCS of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures should be considered absolute indicators for primary cranial CT imaging. The reported incidence of immediate and delayed traumatic ICH was very low and hospitalization should be decided individually considering both the clinical and CT findings.

Artificial intelligence for detection of intracranial haemorrhage on head computed tomography scans: diagnostic accuracy in Hong Kong.

The use of artificial intelligence (AI) to identify acute intracranial haemorrhage (ICH) on computed tomography (CT) scans may facilitate initial imaging interpretation in the accident and emergency department. However, AI model construction requires a large amount of annotated data for training, and validation with real-world data has been limited. We developed an algorithm using an open-access dataset of CT slices, then assessed its utility in clinical practice by validating its performance on CT scans from our institution. Using a publicly available international dataset of >750 000 expert-labelled CT slices, we developed an AI model which determines ICH probability for each CT scan and nominates five potential ICH-positive CT slices for review. We validated the model using retrospective data from 1372 non-contrast head CT scans (84 [6.1%] with ICH) collected at our institution. The model achieved an area under the curve of 0.842 (95% confidence interval=0.791-0.894; P<0.001) for scan-based detection of ICH. A pre-specified probability threshold of ≥50% for the presence of ICH yielded 78.6% accuracy, 73% sensitivity, 79% specificity, 18.6% positive predictive value, and 97.8% negative predictive value. There were 62 true-positive scans and 22 false-negative scans, which could be reduced to six false-negative scans by manual review of model-nominated CT slices. Our model exhibited good accuracy in the CT scan-based detection of ICH, considering the low prevalence of ICH in Hong Kong. Model refinement to allow direct localisation of ICH will facilitate the use of AI solutions in clinical practice.

Data lake-driven analytics identify nocturnal non-dipping of heart rate as predictor of unfavorable stroke outcome at discharge

BackgroundPost-stroke heart rate (HR) and heart rate variability (HRV) changes have been proposed as outcome predictors after stroke. We used data lake-enabled continuous electrocardiograms to assess post-stroke HR and HRV, and to determine the utility of HR and HRV to improve machine learning-based predictions of stroke outcome.MethodsIn this observational cohort study, we included stroke patients admitted to two stroke units in Berlin, Germany, between October 2020 and December 2021 with final diagnosis of acute ischemic stroke or acute intracranial hemorrhage and collected continuous ECG data through data warehousing. We created circadian profiles of several continuously recorded ECG parameters including HR and HRV parameters. The pre-defined primary outcome was short-term unfavorable functional outcome after stroke indicated through modified Rankin Scale (mRS) score of > 2.ResultsWe included 625 stroke patients, 287 stroke patients remained after matching for age and National Institute of Health Stroke Scale (NIHSS; mean age 74.5 years, 45.6% female, 88.9% ischemic, median NIHSS 5). Both higher HR and nocturnal non-dipping of HR were associated with unfavorable functional outcome (p < 0.01). The examined HRV parameters were not associated with the outcome of interest. Nocturnal non-dipping of HR ranked highly in feature importance of various machine learning models.ConclusionsOur data suggest that a lack of circadian HR modulation, specifically nocturnal non-dipping, is associated with short-term unfavorable functional outcome after stroke, and that including HR into machine learning-based prediction models may lead to improved stroke outcome prediction.

The Clinical Value of Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio for Predicting Hematoma Expansion and Poor Outcomes in Patients with Acute Intracerebral Hemorrhage.

There is little knowledge of the effect of inflammatory markers on the prognoses of hematoma expansion (HE) in patients with intracranial hemorrhage (ICH). We evaluated the impact of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) on HE and worse outcomes after acute ICH. This study included 520 consecutive patients with ICH from the registry database enrolled over 80 months. Patients' whole blood samples were collected upon arrival in the emergency department. Brain computed tomography scans were performed during hospitalization and repeated at 24 h and 72 h. The primary outcome measure was HE, defined as relative growth >33% or absolute growth <6 mL. A total of 520 patients were enrolled in this study. Multivariate analysis showed that NLR and PLR were associated with HE (NLR: odds ratio [OR], [95% CI] = 1.19 [1.12-1.27], p < 0.001; PLR: OR, [95% CI] = 1.01 [1.00-1.02], p = 0.04). Receiver operating characteristic curve analysis revealed that NLR and PLR could predict HE (AUC of NLR: 0.84, 95% CI [0.80-0.88], p < 0.001; AUC of PLR: 0.75 95% CI [0.70-0.80], p < 0.001). The cut-off value of NLR for predicting HE was 5.63, and that of PLR was 23.4. Higher NLR and PLR values increase HE risk in patients with ICH. NLR and PLR were reliable for predicting HE after ICH.

Role of Repeat Digital Subtraction Angiography in Acute Spontaneous Intracranial Haemorrhage of Unexplained Origin

Objective: to evaluate the role of repeat digital subtraction angiography in acute spontaneous intracranial haemorrhage of unexplained origin. Methods: This was a cross-sectional observational study. A total of 70 patients were included in the study. CT scan examination was done in all the patients. All patients had DSA with diatrizoate meglumine and diatrizoate sodium via transfemoral route. Results: CT was positive among 97% (68/70) patients. Out of 70 patients, initial DSA was failed to demonstrate the cause of acute spontaneous intracranial haemrrhage among 75.7% (53/70) patients. 15.7% (11/70) were suggestive of aneurysm, 7.1% (5/70) were AVM and 1.4% (1/70) had tumorogenic. Among 53 patients with negative DSA, 62.3% (33/53) were hypertensive origin and 37.7% (20/53) were non-hypertensive. Conclusion: This study shows that the false negative rate is nil and DSA is the serious undertaking. With this fact that it is concluded that repeat pandigital subtraction angiography is not required unless further bleeding occur.

Deep learning based automatic detection algorithm for acute intracranial haemorrhage: a pivotal randomized clinical trial

Acute intracranial haemorrhage (AIH) is a potentially life-threatening emergency that requires prompt and accurate assessment and management. This study aims to develop and validate an artificial intelligence (AI) algorithm for diagnosing AIH using brain-computed tomography (CT) images. A retrospective, multi-reader, pivotal, crossover, randomised study was performed to validate the performance of an AI algorithm was trained using 104,666 slices from 3010 patients. Brain CT images (12,663 slices from 296 patients) were evaluated by nine reviewers belonging to one of the three subgroups (non-radiologist physicians, n = 3; board-certified radiologists, n = 3; and neuroradiologists, n = 3) with and without the aid of our AI algorithm. Sensitivity, specificity, and accuracy were compared between AI-unassisted and AI-assisted interpretations using the chi-square test. Brain CT interpretation with AI assistance results in significantly higher diagnostic accuracy than that without AI assistance (0.9703 vs. 0.9471, p < 0.0001, patient-wise). Among the three subgroups of reviewers, non-radiologist physicians demonstrate the greatest improvement in diagnostic accuracy for brain CT interpretation with AI assistance compared to that without AI assistance. For board-certified radiologists, the diagnostic accuracy for brain CT interpretation is significantly higher with AI assistance than without AI assistance. For neuroradiologists, although brain CT interpretation with AI assistance results in a trend for higher diagnostic accuracy compared to that without AI assistance, the difference does not reach statistical significance. For the detection of AIH, brain CT interpretation with AI assistance results in better diagnostic performance than that without AI assistance, with the most significant improvement observed for non-radiologist physicians.

Serum LDH Levels in Normotensive and Preeclamptic-Eclamptic Pregnant Women and Its Correlation With Fetomaternal Outcome.

Background One of the most prevalent medical issues observed during pregnancy is hypertension. Hypertensive disorders of pregnancy (HDP) and their consequences affect around 5-10% of all pregnancies globally. Preeclampsia is caused by endothelial dysfunction, which causes widespread endothelial leakage and contributes to potentially fatal consequences, such as eclampsia, placental abruption, disseminated intravascular coagulation (DIC), severe renal failure, pulmonary edema, and hepatocellular necrosis. As a result, looking for predictive markers for at-risk pregnancies that can suggest poor maternal or fetal outcomes is critical. Elevated levels of lactate dehydrogenase (LDH), as a sign of cellular damage and dysfunction, can be utilized as a biochemical marker in pregnancy-induced hypertension (PIH) as it represents the severity of the disease, and the occurrence of problems, and has also been demonstrated to co-relate with fetomaternal outcomes. Methodology A total of 230 singleton pregnant women of 28-40 weeks of gestational age were enrolled in this study. All women were divided into two groups - normotensive and preeclamptic-eclamptic groups; the second group was further divided intomild preeclampsia, severe preeclampsia, and eclampsia, based on blood pressure and the presence of proteinuria. Serum lactate dehydrogenase levels were measured in both groups and correlated with their fetomaternal outcome. Results Mean serum lactate dehydrogenase (LDH) levelin eclamptic women was 1515.86 ± 754, in severely preeclamptic women was 932.2 ± 448, mild preeclamptic women were 580.5±213, while in normotensive women mean LDH level was 378.6 ± 124. The difference between normotensive and preeclamptic-eclamptic women was statistically significant (p < 0.001). The complications in the preeclamptic-eclamptic group were increased significantly in women with LDH > 800 IU/L, 600-800 IU/L compared to those who had < 600 IU/L LDH levels. Conclusions Serum LDH levels were significantly higher in women of preeclamptic-eclamptic group compared to the normotensive pregnant women. Higher LDH levels were positively correlated with disease severity and maternal complications like placental abruption, hemolysis elevated liver enzymes low platelet count (HELLP), disseminated intravascular coagulation (DIC), acute renal failure, intracranial hemorrhage, pulmonary edema, and maternal death and for fetal complications like preterm, intrauterine growth restriction (IUGR), APGAR at 1 minute < 7, APGAR at 5 minutes < 7, low birth weight (LBW), neonatal intensive care unit (NICU) admission and intrauterine fetal death (IUFD).

The association between direct oral anticoagulant concentration upon acute stroke and stroke outcome

BackgroundThis study aimed to investigate the association between direct oral anticoagulant (DOAC) concentration upon acute ischemic stroke (IS) or intracranial hemorrhage (ICH) and stroke outcomes. MethodsPatients aged ≥20 years treated with DOACs, including dabigatran, rivaroxaban, apixaban, or edoxaban, and developed acute IS or ICH were enrolled to measure DOAC concentration at the time of hospital presentation by using ultrahigh-performance liquid chromatography with tandem mass spectrometry. Ischemic stroke patients was categorized into low (<50 ng/mL) and effective (≥50 ng/mL) groups. The primary outcome was poor functional outcomes at 3 months (modified Rankin Scale scores of 4–6). ResultsA total of 138 patients were enrolled, including 105 IS (76.1%) and 33 ICH patients. In the IS cohort, the average DOAC concentration was 85.7 ± 88.6 ng/mL (low DOAC concentration: 42.9%). Low level group had numerically higher NIHSS (14 versus 9, p = 0.37), significantly poorer functional outcomes at 3 months (odds ratio [OR], 5.08 [1.32, 19.63]), and higher chance of stroke-in-evolution (OR, 6.83 [1.64, 28.41]). In the ICH cohort, the average DOAC concentration was 128.9 ± 111.9 ng/mL. Reversal therapy was administered in 60.6% of patients. Hematoma growth occurred in 35.7% patients. The DOAC concentration was similar across patients with or without reversal therapy, and with or without hematoma growth. ConclusionAmong DOAC users who developed IS, low drug concentrations at hospital presentation predicted poor outcomes.

Machine learning-based CT radiomics model to discriminate the primary and secondary intracranial hemorrhage

It is challenging to distinguish between primary and secondary intracranial hemorrhage (ICH) purely by imaging data, and the two forms of ICHs are treated differently. This study aims to evaluate the potential of CT-based machine learning to identify the etiology of ICHs and compare the effectiveness of two regions of interest (ROI) sketching methods. A total of 1702 radiomic features were extracted from the CT brain images of 238 patients with acute ICH. We used the Select K Best method, least absolute shrinkage, and selection operator logistic regression to select the most discriminable features with a support vector machine to build a classifier model. Then, a ten-fold cross-validation strategy was employed to evaluate the performance of the classifier. From all quantitative CT-based imaging features obtained by two sketch methods, eighteen features were selected respectively. The radiomics model outperformed radiologists in distinguishing between primary and secondary ICH in both the volume of interest and the three-layer ROI sketches. As a result, a machine learning-based CT radiomics model can improve the accuracy of identifying primary and secondary ICH. A three-layer ROI sketch can identify primary versus secondary ICH based on the CT radiomics method.

Role of CT Angiography in Detection of Extracranial Carotid and Vertebral Artery Disease in Patients With Acutely Ruptured Intracranial Aneurysms

Introduction: Computed tomography (CT) and CT angiography are standard imaging modalities for suspected acute intracerebral hemorrhage due to ruptured intracranial aneurysms. In this clinical setting, several protocols of computed tomography and CT angiography may be implemented. The standard CT angiography protocol is limited to intracranial vessels. The extended protocol may also include carotid and vertebral arteries and the aortic arch.Objective: To define the CT angiography role in detection of extracranial carotid and vertebral artery disease and clinical significance of this method for patients with suspected acute intracerebral hemorrhages due to ruptured intracranial aneurysms.Materials and methods: The study included 275 neurosurgical patients with acute nontraumatic intracranial hemorrhages due to ruptured intracranial aneurysms who were treated in Scientific Research Institute – Ochapovsky Regional Clinical Hospital No. 1 (Krasnodar, Russian Federation) from September 2017 to August 2020. Computed tomography and CT angiography were performed in all patients. The scanned area included both intracranial and extracranial arteries (an arch-to-vertex angiogram) to detect extracranial carotid and vertebral artery diseases such as stenoses, occlusions, tortuosity, and hypoplasia.Results: Atherosclerosis of internal carotid and vertebral arteries was diagnosed in 95 patients (34.5% of the total number of patients included in the study). In 13 (4.7%) patients these stenoses were hemodynamically significant. We identified a high frequency of tortuous carotid and vertebral arteries (122 cases, 44.3%) and vertebral artery hypoplasia (59 cases, 21.5%). The carotid and vertebral artery stenoses and congenital anomalies of vertebral arteries (however, not of carotid arteries) were associated with a higher incidence of unfavorable outcomes after endovascular treatment of intracranial aneurysms.Conclusions: The optimal CT angiography protocol for acute nontraumatic intracranial hemorrhage should focus on the arteries of the head and neck (up to the aortic arch). This protocol shows higher detection rate of concomitant anomalies of carotid and vertebral arteries. These findings are important for planning and successful performance of endovascular treatment for intracranial aneurysms.

A case of successful intraventricular thrombolysis and external ventricular drain treatment in primary intraventricular hemorrhage

Intraventricular hemorrhage (IVH), accounting for about 45% of acute spontaneous intracranial hemorrhage (ICH), is often associated with obstructive hydrocephalus and poor functional outcomes [1] [2]. Obstructive hydrocephalus and increased intracranial pressure are common after IVH because of an obstruction of normal cerebrospinal fluid (CSF) flow and absorption by blood clots. An external ventricular drain (EVD) - a temporary system that permits drainage of cerebral spinal fluid (CSF) from the ventricles to an external closed system) has been indicated for patients with IVH with hydrocephalus and neurologic decline [3]. However, the treatment with EVD alone is often not sufficiently effective due to a likely potential obstruction of the catheter by blood clots. Intraventricular fibrinolysis (IVF) via the extra-ventricular drain has been known to speed clot resolution and maintain the EVD functionality [4]. However, it is also possible that the risk of hemorrhage, infection, and CFS pleocytosis may be increased with IVF therapy, but these have not been demonstrated so far. We report a clinical case of primary IVH with acute obstructive hydrocephalus, successfully treated with a combination of EVD and direct intraventricular injection of rt-PA into the lateral ventricles. This treatment contributes to confirm that combination of EVD and thrombolysis could be considered as a treatment option for selected patients.