Acute Intracranial Hemorrhage Research Articles

Detection and categorization of acute intracranial hemorrhage subtypes using a multilayer DenseNet‐ResNet architecture with improved random forest classifier

SummaryIn this article, the detection and categorization of acute intracranial hemorrhage (ICH) subtypes using a multilayer DenseNet‐ResNet architecture with improved random forest classifier (IRF) is proposed to detect the subtypes of intracerebral hemorrhage with high accuracy and less computational time. Here, the brain CT images are taken from the physionet repository publicly dataset. Then the images are preprocessed to eliminate the unwanted noises. After that, the image features are extracted by using multilayer densely connected convolutional network (DenseNet) combined with residual network (ResNet) architecture with multiple convolutional layers. The subtypes are epidural hemorrhage (EDH), subarachnoid hemorrhage (SAH), intraparenchymal hemorrhage (IPH), subdural hemorrhage (SDH), intraventricular hemorrhage (IVH) are classified by using an IRF classifier with high accuracy. The simulation process is carried out in MATLAB site. The proposed multilayer‐DenseNet‐ResNet‐IRF attains higher accuracy 23.44%, 31.93%, 42.83%, 41.9% is compared with the existing methods, such as deep learning algorithm for automatic detection and classification of acute intracranial hemorrhages in head CT scans (ICH‐DC‐2D‐CNN), fusion‐based deep learning along nature‐inspired algorithm for the diagnosis of intracerebral hemorrhage (ICH‐DC‐FSVM), and detection of intracranial hemorrhage on CT scan images using convolutional neural network (ICH‐DC‐CNN) and double fully convolutional networks (FCNs), respectively.

The effect of atorvastatin on the blood-brain barrier biomarkers in acute intracerebral hemorrhage, a pilot clinical trial

ObjectivePrior studies have shown statins provide neuroprotection by targeting secondary brain injury pathways and regulating cytokine production. We aimed to evaluate the association between statin administration and molecular outcomes in acute Intracranial hemorrhages (ICHs). MethodsAdult patients with acute spontaneous ICH were recruited and randomly allocated into two groups: group A received atorvastatin (40 mg/day) orally in addition to routine antihypertensive medications, while group B only received routine antihypertensives. Serum levels of matrix metalloproteinase-9 (MMP-9), and vascular endothelial growth factor (VEGF), as primary outcomes, were measured at baseline, and after 45 days. ResultsThirty-nine ICH patients (group A: 20; group B: 19) were analyzed. A notable elevation in VEGF and a reduction in MMP-9 levels were detected in group A compared to those in group B (P-value = 0.024 and 0.008, respectively). ConclusionOur data suggest that atorvastatin in the acute phase of ICH could improve the serum levels of neuroprotective molecular biomarkers.

Acute myocardial infarction and concomitant acute intracranial hemorrhage: clinical characteristics and outcomes

This study aimed to evaluate the demographic and clinical characteristics, treatments and outcomes of concomitant acute myocardial infarction (AMI) and acute intracranial hemorrhage (ICH). All patients diagnosed with concomitant AMI...

Cerebral dural arteriovenous fistulas

The cerebral dural arteriovenous (AV) fistula is arare cerebral vascular malformation. Clinical presentation varies from asymptomatic to acute intracranial bleeding. Classification is based on the venous drainage with arisk assessment of bleeding. The carotid-cavernous fistula is asubtype with its own classification and treatment approaches. Nowadays, dural fistulas can be diagnosed using high-resolution and time-resolved tomographic methods. Catheter angiography with subsequent interdisciplinary discussion should be performed for precise classification and therapy planning. Both endovascular and surgical treatment methods are available.

Cerebral Digital Subtraction Angiography in Acute Intracranial Hemorrhage: Considerations in Critically Ill Children

Cerebrovascular disorders are an important cause of morbidity and mortality in children. Although minimally invasive, cerebral digital subtraction angiography (DSA) has been shown to be safe in children and is a valuable, and perhaps underutilized, technique for the diagnosis and management of pediatric cerebrovascular disorders in the critical care setting. Through a case-based approach, we explore the utility of DSA in critically ill children with acute intracranial hemorrhage (ICH). We discuss the use of DSA in the acute management of aneurysm and arteriovenous malformation rupture as well as cerebral vasospasm. Those caring for critically ill children with acute ICH should consider cerebral DSA as part of a comprehensive approach to the diagnosis and management of these conditions.

Urokinase Is Safe and Effective in Reducing Recurrence in Chronic Subdural Hematoma After Burr-Hole Drainage

This study aimed to evaluate the safety and efficacy of subdural urokinase in reducing the recurrence of chronic subdural hematoma (cSDH). Consecutive adults with cSDH and burr-hole drainage from 1 January 2013 to 31 December 2017 were retrospectively analyzed. Clinical records, radiologic images, laboratory data, and medication records were reviewed. The primary outcome was the recurrence rate of cSDH in patients with or without urokinase instillation. Secondary outcomes included complication rates such as infection and acute intracranial hemorrhage. Univariate and multivariate analyses were conducted to identify independent factors associated with cSDH recurrence. A total of 297 consecutive patients were identified for analysis. The average dosage of urokinase instillation via the subdural drain into the subdural space was 15,800 units (5000-60,000 units) over a mean duration of 2 days (1-6 days). The symptomatic recurrence rate of cSDH was significantly lower with urokinase at 3.0% versus 11.7% with no urokinase (odds ratio: 0.234; P=0.022). Univariate analysis and multivariate analysis showed that bilateral cSDH and the presence of underlying liver disease were significantly associated with higher recurrence, while the instillation of urokinase was significantly and independently associated with lower recurrence (odds ratio= 0.311; P= 0.005). Complication rates including infection and hemorrhage were comparable with patients with or without urokinase and had no significant difference. Instillation of urokinase was safe for patients with cSDH. The recurrence rate of cSDH was significantly lower with urokinase.

Poor education and urgent information need for emergency physicians about rare diseases in China

BackgroundRare diseases are serious and chronic diseases that affect no more than 1 person in 2000 (in European Union criteria). Patients suffering from RDs may come to the emergency department for life-threatening symptoms, such as acute aortic dissection, intracranial haemorrhage, and severe respiratory distress. Diagnostic delay of rare disease patients is common and often caused by low rare disease awareness among physicians. The main aim of this study was to investigate Chinese emergency physicians’ basic knowledge, information access and educational needs regarding rare diseases. An online questionnaire was completed by Chinese emergency physicians during January and March 2021.Methods and resultsA total of 539 emergency physicians, including 200 females and 339 males, responded to the questionnaire-based study. More than half of the respondents were from Tertiary A hospitals and had engaged in medical clinical work for more than 10 years. Only 4.27% of respondents correctly estimated the prevalence of rare diseases. A few respondents knew the exact number of RDs in the first official list of rare diseases in 2018. A total of 98.5% of respondents rated their knowledge about rare diseases as minimal or insufficient. Most emergency physicians preferred to obtain information through search engines instead of specialized websites on rare diseases. A lack of practice guidelines or consensus was considered the most important reason for the diagnostic delay of RD. Practice guidelines or consensus and professional websites on rare diseases are urgently needed for emergency physicians.ConclusionThe investigation shows poor knowledge of rare diseases among emergency physicians. Practice guidelines and professional websites on rare diseases were the primary urgent needs for emergency physicians. Specialized RD courses should also be added to medical education.

The association between serum glucose to potassium ratio on admission and short-term mortality in ischemic stroke patients

High serum glucose to potassium ratio (GPR) at admission is implicated for a poor outcome in acute brain injury, acute intracranial hemorrhage, and aneurysmal subarachnoid hemorrhage. However, the relationship between GPR and the outcome of ischemic stroke (IS) remains unknown. In all, 784 IS patients from a large emergency Norwegian cohort were included for secondary analysis. The exposure and outcome were GPR at baseline and all-cause mortality within 30 days after the first admission. Multivariable logistic regression analysis was performed to estimate the risk of 30-day mortality based on GPR levels. In addition, we examined whether there was a nonlinear relationship between admission GPR and 30-day mortality using two-piecewise linear regression with a smoothing function and threshold level analysis. The results of multivariable regression analysis showed that GPR at baseline was positively associated with the 30-day mortality (OR 2.01, 95% CI 1.12, 3.61) after adjusting for potential confounders (age, gender, department, serum sodium, serum albumin, serum-magnesium, hypertension, heart failure, chronic renal failure, and pneumonia). When GPR was translated to a categorical variable, the ORs and 95% CIs in the tertiles 2 to 3 versus the tertile 1 were 1.24 (0.60, 2.56) and 2.15 (1.09, 4.24), respectively (P for trend = 0.0188). Moreover, the results of the two-piecewise linear regression and curve fitting revealed a linear relationship between GPR and 30-day mortality. In IS patients, GPR is positively correlated with 30-day mortality, and the relationship between them is linear. The GPR at admission may be a promising predictor for the short-term outcome in IS patients.

ICH-LR2S2: a new risk score for predicting stroke-associated pneumonia from spontaneous intracerebral hemorrhage

PurposeWe develop a new risk score to predict patients with stroke-associated pneumonia (SAP) who have an acute intracranial hemorrhage (ICH).MethodWe applied logistic regression to develop a new risk score called ICH-LR2S2. It was derived from examining a dataset of 70,540 ICH patients between 2015 and 2018 from the Chinese Stroke Center Alliance (CSCA). During the training of ICH-LR2S2, patients were randomly divided into two groups – 80% for the training set and 20% for model validation. A prospective test set was developed using 12,523 patients recruited in 2019. To further verify its effectiveness, we tested ICH-LR2S2 on an external dataset of 24,860 patients from the China National Stroke Registration Management System II (CNSR II). The performance of ICH-LR2S2 was measured by the area under the receiver operating characteristic curve (AUROC).ResultsThe incidence of SAP in the dataset was 25.52%. A 24-point ICH-LR2S2 was developed from independent predictors, including age, modified Rankin Scale, fasting blood glucose, National Institutes of Health Stroke Scale admission score, Glasgow Coma Scale score, C-reactive protein, dysphagia, Chronic Obstructive Pulmonary Disease, and current smoking. The results showed that ICH-LR2S2 achieved an AUC = 0.749 [95% CI 0.739–0.759], which outperforms the best baseline ICH-APS (AUC = 0.704) [95% CI 0.694–0.714]. Compared with the previous ICH risk scores, ICH-LR2S2 incorporates fasting blood glucose and C-reactive protein, improving its discriminative ability. Machine learning methods such as XGboost (AUC = 0.772) [95% CI 0.762–0.782] can further improve our prediction performance. It also performed well when further validated by the external independent cohort of patients (n = 24,860), ICH-LR2S2 AUC = 0.784 [95% CI 0.774–0.794].ConclusionICH-LR2S2 accurately distinguishes SAP patients based on easily available clinical features. It can help identify high-risk patients in the early stages of diseases.

Between Scylla and Charybdis: Risks of Early Therapeutic Anticoagulation for Venous Thromboembolism After Acute Intracranial Hemorrhage (S21.010)

Between Scylla and Charybdis: Risks of Early Therapeutic Anticoagulation for Venous Thromboembolism After Acute Intracranial Hemorrhage (S21.010)

Artificial Intelligence with Statistical Confidence Scores for Detection of Acute or Subacute Hemorrhage on Noncontrast CT Head Scans.

To present a method that automatically detects, subtypes, and locates acute or subacute intracranial hemorrhage (ICH) on noncontrast CT (NCCT) head scans; generates detection confidence scores to identify high-confidence data subsets with higher accuracy; and improves radiology worklist prioritization. Such scores may enable clinicians to better use artificial intelligence (AI) tools. This retrospective study included 46 057 studies from seven "internal" centers for development (training, architecture selection, hyperparameter tuning, and operating-point calibration; n = 25 946) and evaluation (n = 2947) and three "external" centers for calibration (n = 400) and evaluation (n = 16 764). Internal centers contributed developmental data, whereas external centers did not. Deep neural networks predicted the presence of ICH and subtypes (intraparenchymal, intraventricular, subarachnoid, subdural, and/or epidural hemorrhage) and segmentations per case. Two ICH confidence scores are discussed: a calibrated classifier entropy score and a Dempster-Shafer score. Evaluation was completed by using receiver operating characteristic curve analysis and report turnaround time (RTAT) modeling on the evaluation set and on confidence score-defined subsets using bootstrapping. The areas under the receiver operating characteristic curve for ICH were 0.97 (0.97, 0.98) and 0.95 (0.94, 0.95) on internal and external center data, respectively. On 80% of the data stratified by calibrated classifier and Dempster-Shafer scores, the system improved the Youden indexes, increasing them from 0.84 to 0.93 (calibrated classifier) and from 0.84 to 0.92 (Dempster-Shafer) for internal centers and increasing them from 0.78 to 0.88 (calibrated classifier) and from 0.78 to 0.89 (Dempster-Shafer) for external centers (P < .001). Models estimated shorter RTAT for AI-prioritized worklists with confidence measures than for AI-prioritized worklists without confidence measures, shortening RTAT by 27% (calibrated classifier) and 27% (Dempster-Shafer) for internal centers and shortening RTAT by 25% (calibrated classifier) and 27% (Dempster-Shafer) for external centers (P < .001). AI that provided statistical confidence measures for ICH detection on NCCT scans reliably detected and subtyped hemorrhages, identified high-confidence predictions, and improved worklist prioritization in simulation.Keywords: CT, Head/Neck, Hemorrhage, Convolutional Neural Network (CNN) Supplemental material is available for this article. © RSNA, 2022.

Midline Shift Due to Acute Intracranial Hemorrhage in the Surgical ICU: Bedside or OR for Decompression?

Midline Shift Due to Acute Intracranial Hemorrhage in the Surgical ICU: Bedside or OR for Decompression?

Expanded dengue syndrome presenting with acute liver failure, acute kidney injury, pancreatic involvement, coagulopathy, and multiple intracranial hemorrhages in a young child: a case report

BackgroundDengue is a mosquito-borne viral infection that typically occurs in tropical and subtropical countries. The clinical manifestations of dengue infection range from an asymptomatic subclinical course to severe dengue shock syndrome. Besides, dengue can affect any organ in the body and can present with atypical manifestations.Case presentationWe report a 6-year-old previously healthy Tamil child who had dengue complicated with multiorgan involvement. She initially presented with high fever, headache, body aches for 5 days, blood and mucus diarrhea, hematuria, and right knee joint swelling for 2 days. Dengue NS1 antigen was positive on day 2 of febrile illness. She was managed symptomatically in the local hospital for 3 days and transferred to the tertiary care hospital for further management. She was eventually diagnosed as having dengue hemorrhagic fever complicated with multiorgan involvement including acute liver failure, pancreatic involvement, coagulopathy, arthritis, acute kidney injury, and multiple intracranial hemorrhages. The constellation of disease manifestations was identified as expanded dengue syndrome. She was managed with fresh blood, platelet, and cryoprecipitate transfusions and intravenous antibiotics in addition to renal and liver support in the intensive care unit. On day 14 of illness, she deteriorated while on the ventilator and died due to multiple intracranial hemorrhages.ConclusionThe reported child with dengue hemorrhagic fever developed several unusual presentations such as acute liver and renal failure, disseminated intravascular coagulopathy, pancreatic involvement, and multiple intracranial hemorrhages, which form part of expanded dengue syndrome. In the seriously unwell child, it is important to look for unusual complications actively to improve outcomes.

Between Scylla and Charybdis: risks of early therapeutic anticoagulation for venous thromboembolism after acute intracranial hemorrhage

Objective To assess the risk of hematoma expansion in patients with acute intracranial hemorrhage (ICH) requiring therapeutic anticoagulation for the treatment of venous thromboembolism. Methods We retrospectively reviewed all patients at our institution between 2014 and 2019 who were therapeutically anticoagulated for venous thromboembolism within 4 weeks after ICH. We included subtypes of traumatic ICH and spontaneous intraparenchymal hemorrhage. Our main outcome was the incidence of hematoma expansion within 14 days from initiating therapeutic anticoagulation. Hematoma expansion was defined as (1) radiographically proven expansion leading to cessation of therapeutic anticoagulation or (2) death due to hematoma expansion. Secondary outcomes included mortality due to hematoma expansion and characteristics associated with hematoma expansion. Results Fifty patients met inclusion criteria (mean age: 54 years, 80% male, 76% Caucasian); 24% had undergone a neurosurgical procedure prior to therapeutic anticoagulation. Median time from ICH to therapeutic anticoagulation initiation was 9.5 days (IQR 4–17), 40% received therapeutic anticoagulation in <7 days after ICH. Six patients (12%) developed hematoma expansion, of whom two (4%) died. While not statistically significant, patients with hematoma expansion tended to be older (57.8 vs. 53.5 years), were anticoagulated sooner (4 vs. 10 days), presented with lower GCS (50% vs. 39% with GCS <8), higher hematoma volume (50% vs. 42% >30 cc), and higher SDH diameter (16 mm vs. 8.35 mm). There was a trend towards greater risk of hematoma expansion for patients undergoing endoscopic ICH evacuation (16% vs. 2%, p = 0.09); patients with hematoma expansion were more likely to present with hydrocephalus (67% vs. 16%, p = 0.02). Conclusions Our study is among the first to explore characteristics associated with hematoma expansion in patients undergoing therapeutic anticoagulation after acute ICH. Larger studies in different ICH subtypes are needed to identify determinants of hematoma expansion in this high-acuity population.

MRI findings in COVID-19 positive and COVID-19 negative patients presenting with acute neurological symptoms – a case-control study

Background &amp; Objective: Neurological manifestations of novel-coronavirus disease (COVID-19) have been described in various studies. None of these studies has compared the findings in COVID-19 patients with COVID-negative patients presenting with similar clinical symptomatology during the same period. We undertook this case-control study with an aim to establish a direct relationship between COVID-19 infection and CNS related clinical and imaging presentations. Methods: This study was a review of retrospectively collected data of the patients who presented with different neurological symptoms to a tertiary care hospital in India. Based on results of Reverse transcriptase-polymerase chain reaction for SARS-Co-V-2, patients were classified into COVID-19 positive and COVID-19 negative groups. MRI findings in both groups were reviewed for acute ischemic stroke, intracranial bleed and other acute imaging abnormalities. Basic demographic information and stroke-related co-morbidities were also compared. Results: Eighty four patients in COVID-19 positive group and 323 patients in COVID-19 negative group underwent brain MRI for acute neurological symptoms during the same period. There was no statistically significant difference in presenting symptoms, sex distribution and risk factors for stroke. There was a higher prevalence of increased coagulability in COVID-19 positive group (p-value = 0.009). No statistically significant association was observed for infarcts or their hemorrhagic transformation, intracranial bleed, intracranial infection or dural sinus thrombosis. An association was found between acute diffuse leukoencephalopathy and COVID-19 infection (p value &lt; 0.05). Conclusion: The current study points towards a weak direct association between COVID-19 infection and acute abnormalities in MRI brain studies, especially in patients with pre-existing co-morbidities.

European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management.

The safety and efficacy of mobile stroke units (MSUs) in prehospital stroke management has recently been investigated in different clinical studies. MSUs are ambulances equipped with a CT scanner, point-of-care lab, telemedicine and are staffed with a stroke specialised medical team. This European Stroke Organisation (ESO) guideline provides an up-to-date evidence-based recommendation to assist decision-makers in their choice on using MSUs for prehospital management of suspected stroke, which includes patients with acute ischaemic stroke (AIS), intracranial haemorrhage (ICH) and stroke mimics. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and aggregated data meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements are provided where sufficient evidence was not available to provide recommendations based on the GRADE approach. We found moderate evidence for suggesting MSU management for patients with suspected stroke. The patient group diagnosed with AIS shows an improvement of functional outcomes at 90days, reduced onset to treatment times and increased proportion receiving IVT within 60min from onset. MSU management might be beneficial for patients with ICH as MSU management was associated with a higher proportion of ICH patients being primarily transported to tertiary care stroke centres. No safety concerns (all-cause mortality, proportion of stroke mimics treated with IVT, symptomatic intracranial bleeding and major extracranial bleeding) could be identified for all patients managed with a MSU compared to conventional care. We suggest MSU management to improve prehospital management of suspected stroke patients.

Craniotomies following acute traumatic brain injury in Finland\u2014a national study between 1997 and 2018

BackgroundA number of patients who sustain a traumatic brain injury (TBI) require surgical intervention due to acute intracranial bleeding. The aim of this retrospective study was to assess the national trends of acute craniotomies following TBI in the Finnish adult population.MethodsThe data were collected retrospectively from the Finnish Care Register for Health Care (1997–2018). The study cohort covered all first-time registered craniotomies following TBI in patients aged 18 years or older. A total of 7627 patients (median age = 59 years, men = 72%) were identified.ResultsThe total annual incidence of acute trauma craniotomies decreased by 33%, from 8.6/100,000 in 1997 to 5.7/100,000 in 2018. The decrease was seen in both genders and all age groups, as well as all operation subgroups (subdural hematoma, SDH; epidural hematoma, EDH; intracerebral hematoma, ICH). The greatest incidence rate of 15.4/100,000 was found in patients 70 years or older requiring an acute trauma craniotomy. The majority of surgeries were due to an acute SDH and the patients were more often men. The difference between genders decreased with age (18–39 years = 84% men, 40–69 = 78% men, 70 + years = 55% men). The median age of the patients increased from 58 to 65 years during the 22-year study period.ConclusionsThe number of trauma craniotomies is gradually decreasing; nonetheless, the incidence of TBI-related craniotomies remains high among geriatric patients. Further studies are needed to determine the indications and derive evidence-based guidelines for the neurosurgical care of older adults with TBIs to meet the challenges of the growing elderly population.

Abstract TP114: High Prevalence Of Acute Cerebrovascular Injury On Brain Magnetic Resonance Imaging In Acute Respiratory Distress Syndrome

Background: Acute Respiratory Distress Syndrome (ARDS) is an acute inflammatory respiratory failure condition that may be associated with secondary cerebrovascular injury. We aimed to describe the prevalence and types of cerebrovascular injuries detected by brain MRI among ARDS patients. Methods: We reviewed a single-center ARDS registry data from a tertiary medical center from January 2010 to October 2018. Patients who underwent brain MRI during their index hospitalization were identified. MRIs were reviewed by two independent reviewers. Acute cerebrovascular injuries were classified as acute cerebral ischemia (ischemic infarct and hypoxic ischemic brain injury [HIBI]) or intracranial hemorrhage (ICH) including intraparenchymal hemorrhage, subarachnoid hemorrhage, subdural hematoma, and cerebral microbleeds (CMBs). Descriptive statistics were conducted. Results: Of the 678 ARDS patients, 66 (9.7%) underwent brain MRI during their ARDS illness. The median time from hospital admission to MRI was 10 days (interquartile range 4-17). Of 66, 31 (47%) had MRI evidence of acute cerebrovascular injuries including acute cerebral ischemia in 33% (22/66) and ICH in 21% (14/66). Among those with cerebral ischemia, common findings were bilateral globus pallidus infarcts (n=7), multifocal ischemic infarcts (n=5), and HIBI (n=3). Twelve (86%) with CMBs constituted the most common type of ICH, followed by intraparenchymal hemorrhage (14%). Patient demographics, Charlson Comorbidity Index, or disease severity as measured by the presence of sepsis/sepsis shock, cardiac arrest, extracorporeal membrane oxygenation use, admission Acute Physiology and Chronic Health Evaluation III Score, Sequential Organ Failure Assessment Score, or admission PaO 2 /FiO 2 ratio did not differ among patients with and without cerebrovascular injury including cerebral ischemia or ICH. In-hospital mortality was significantly greater in ARDS patients with acute cerebral ischemia compared to those without ischemia (55% vs 27%, p=0.03). Conclusion: Among selected patients with ARDS who underwent brain MRI, a half had secondary cerebrovascular injury including acute cerebral ischemia and CMBs.

Abstract TMP20: Cerebrovascular Injury Associated With COVID-19 And Non-COVID-19 Acute Respiratory Distress Syndrome

Background: Neurologic complications of Coronavirus Disease 2019 (COVID-19) may be associated with neurotropism of the virus or secondary brain injury from systemic inflammation. Acute respiratory distress syndrome (ARDS) is associated with cerebrovascular injury, including both ischemia and hemorrhage. We aimed to compare brain MRI findings of COVID-19 associated ARDS with non-COVID-19 ARDS. Methods: A registry of patients with COVID-19 from March 2020 through July 2021 from a hospital network was reviewed. Patients who met criteria for ARDS by Berlin definition and underwent MRI during their hospitalization were included. These patients were matched 1:1 by age and sex with patients who underwent MRI from another registry of patients of ARDS in the same hospital between 2010 and 2018. Cerebrovascular injury was classified as either acute cerebral ischemia (ischemic infarct or hypoxic ischemic brain injury) or intracranial hemorrhage (ICH) including intraparenchymal hemorrhage, subarachnoid hemorrhage, subdural hematoma, and cerebral microbleeds (CMBs). Results: Of 13,319 patients with COVID-19 infection, 26 patients had ARDS and MRI. Sixty-six of 678 non-COVID-19 ARDS patients had an MRI and were matched 1:1 by age and sex resulting in 23 matched pairs. The median age was 66 and 59% of patients were male. Patients with COVID-19 ARDS were more likely to have hypertension and chronic kidney disease but otherwise baseline medical characteristics were similar. ARDS severity as determined by PaO2/FiO2 ratio at ICU admission was similar between both groups. No difference was seen in the prevalence of cerebrovascular injury (52% vs 61%, p=0.8), cerebral ischemia (35% vs 43%, p=0.8), ICH (43% vs 48%, p=1.0), or CMBs (43% vs 39% p=1.0) on MRI between the COVID-19 and non-COVID-19 cohorts. However, two unique patterns of injury were seen only among COVID-19 patients: hemorrhagic leukoencephalitis (3 patients, 12%) and bilateral cerebral peduncular ischemia with microhemorrhage (2 patients, 8%). Conclusion: Cerebrovascular injury was common in both COVID-19 and non-COVID-19 ARDS without significant frequency difference. However, COVID-19 ARDS had unique neuroimaging patterns that may indicate distinct patterns of brain injury of COVID-19.

Abstract WP67: Safety And Effects Of High-frequency Repetitive Transcranial Magnetic Stimulation In Acute Intracranial Hemorrhage Patients

Background and Purpose: Repetitive transcranial magnetic stimulation (rTMS) in chronic intracranial hemorrhage (ICH) is beneficial, it has been poorly investigated in rTMS for acute ICH. Our aim is to investigate safety and effects of rTMS in acute ICH. Methods: We prospectively performed high-frequency rTMS to consecutive patients with acute ICH within 24 hours from onset between April 2019 and March 2021. Exclusion criteria were: 1) subcortical ICH; 2) ventricular perforation; 3) history of symptomatic stroke; 4) surgical management for ICH; 5) disturbance of consciousness; 6) over 80 years old at admission; and 7) convulsion after onset. Inclusion criterion was 1) persistent paralysis with a NIHSS scale 1 of higher for at least 3 days after onset. The comparison was made with historical control group; patients who met the same criteria between April 2016 and March 2019. We evaluated incidence of epilepsy and exacerbation of NIHSS score in rTMS group. We also compared clinical background and outcome among groups. Results: A total of 40 patients (29 male, median age 56 years, median NIHSS score on admission 13) were enrolled. Of them, 18 patients (45%) were rTMS group. The median (IQR) time from onset to the start of rTMS is 9 (6-12) days. There were no case of epilepsy or exacerbation of NIHSS after the start of rTMS. There were no significant differences in median age (54 years vs 57 years, p=0.70), median hemorrhage volume at admission (9.3 ml vs 11.3 ml, p=0.43) or median NIHSS score on admission (13 vs 12, p=0.99) among groups. Favorable 90 days outcome (modified Rankin Scale score of 0-2) was frequently observed in rTMS group (67% vs 27%, p = 0.02). Conclusion: High-frequency rTMS may be safe and effective in acute intracranial hemorrhage patients.