Acute Intracranial Hemorrhage Research Articles

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.

240 Impact of a Large Geographical Area on Outcomes in Acute Traumatic Intracranial Extra-axial Haemorrhage Requiring Urgent Surgical Evacuatio

INTRODUCTION: The Princess Alexandra Hospital (PAH) Department of Neurosurgery services a population of 1.85 million people over a 420,000 km2 area in Queensland, Australia. Increased distance from a neurosurgical centre has previously been correlated with poorer outcomes in traumatic brain injury. METHODS: This single-centre retrospective study identified patients aged 16-85 who underwent evacuation of an acute traumatic subdural (ASDH) or extradural haemorrhage (EDH) between 2016 and 2022. Initial Glasgow Coma Score (GCS), pupillary abnormalities, time to intervention, distance from PAH and the Extended Glasgow Outcome Scale (GOS-E) at 6 months were recorded. RESULTS: 106 and 50 patients underwent evacuation of ASDH and EDH respectively. In the ASDH group, age was inversely correlated (p = 0.03, r2 = 0.04) and the motor component of the initial GCS was directly correlated (p = 0.002, r2 = 0.09) with GOS-E at 6 months. Distance from PAH directly correlated with an increased time to intervention (p&lt;0.0001, r2 = 0.23) but did not correlate with GOS-E at 6 months (p = 0.09). There was no difference between survivors and non-survivors regarding distance from PAH (43.43 ± 75.05 km vs. 25.56 ± 41.32 km, p = 0.15) or time to operation (276.14 ± 192.77 mins vs. 217.40 ± 147.27 mins, p = 0.08). This was also found for survivors with poor (GOS-E &lt;6) and fair (GOS-E = 6) recovery at 6 months. In the EDH group there was no correlation between distance, time to operative intervention, age or initial motor score with outcomes at 6 months. CONCLUSIONS: Whilst increased distance from treatment centre correlated with increased time to surgical intervention for ASDH, it did not impact on survival or functional outcomes at 6 months. For ASDH requiring urgent evacuation, increasing age and severity of primary brain injury are predictors of poorer long-term outcomes.

April 2024 Critical Care Case of the Month: A 53-year-old Man Presenting with Fatal Acute Intracranial Hemorrhage and Cryptogenic Disseminated Intravascular Coagulopathy

No abstract available. Manuscript truncated after 150 words. History of Present Illness: A 53-year-old man was admitted for acute onset of left hemiparesis, left facial droop and dysarthria witnessed by his wife (a nurse) while they were watching TV that evening. She reported the patient had no previous history of coronary artery disease or cerebral vascular disease, prior to an admission occurring three weeks earlier. The patient presented at that time with acute, severe left-sided chest pain that began while he was doing some heavy yardwork. While being evaluated in the emergency department (ED), he developed left-sided facial numbness, hemiparesis and dysarthria. A CT scan of the brain was normal. Neurological symptoms resolved before lytic therapy could be administered. Troponins and EKG were normal. A D-dimer was &gt;20 mg/L, but a CTA of the chest showed no pulmonary embolism and was otherwise unrevealing. The chest pain resolved without specific therapy. Subsequent CTA of the head and neck and …

Prevalence and Outcomes of Patients With Acute Ischemic Stroke With Concomitant ST-Segment-Elevation Myocardial Infarction (Results From National Inpatient Sample 2016-2019).

Acute myocardial infarction may concomitantly occur with acute ischemic stroke. The prevalence, complications, and outcomes of acute ST-segment-elevation myocardial infarction (STEMI) in patients hospitalized with acute ischemic stroke are not well studied. We examined hospitalized patients with acute ischemic stroke who were included in the National Inpatient Sample from 2016 to 2019. Acute ischemic stroke and STEMI were defined by using the International Classification of Diseases-Tenth Revision diagnostic codes. Patients with Non-STEMI were excluded. The prevalence of complications and outcomes were expressed as percentages. Multivariable logistic regression analysis was used to examine the association of STEMI with a primary outcome of mortality and secondary outcomes. A subgroup analysis of patients with STEMI who underwent percutaneous coronary intervention was also performed. Of the total (n=2 080 795) patients with acute ischemic stroke, 0.3% (n=6275; mean age, 70.5 years, 50.1% females, 69.5% White) also had STEMI diagnosed during the hospitalization. Of these, 1775 (28.3%) died in the STEMI group and 76 435 (3.7%) died in the group without STEMI. The most frequent complications in the STEMI group were acute kidney injury, intracranial hemorrhage, and ventricular arrhythmias. All secondary outcomes were associated with the diagnosis of STEMI (odds ratio [OR], 3.19 [95% CI, 2.82-3.6]; P≤0.001). STEMI was associated with mortality (OR, 8.37 [95% CI, 7.25-9.66]; P≤0.001) and intracranial hemorrhage (OR, 2.23 [95% CI, 1.84-2.70]; P≤0.001). Percutaneous coronary intervention was performed in 14.3% of STEMI subgroup patients. Percutaneous coronary intervention is not associated with mortality (OR, 0.93 [95% CI, 0.6-1.43]; P=0.7), and intracranial hemorrhage (OR, 1.54 [95% CI, 0.0.93-2.56]; P=0.1). Patients with acute ischemic stroke with STEMI have a higher percentage of mortality. Percutaneous coronary intervention in the subgroup of patients with acute ischemic stroke with concomitant STEMI was not associated with increased odds of mortality and intracranial hemorrhage.

Utility of Routine Surveillance Head Computed Tomography After Receiving Therapeutic Anticoagulation in Patients with Acute Traumatic Intracranial Hemorrhage

IntroductionPatients with traumatic intracranial hemorrhage (tICH) are at increased risk of venous thromboembolism and may require anticoagulation. We evaluated the utility of surveillance computed tomography (CT) in patients with tICH who required therapeutic anticoagulation. MethodsThis single institution, retrospective study included adult patients with tICH who required anticoagulation within 4-weeks and had a surveillance head CT within 24-hours of reaching therapeutic anticoagulation levels. The primary outcome was hematoma expansion (HE) detected by the surveillance CT. Secondary outcomes included 1) changes in management in patients with HE on the surveillance head CT, 2) HE in the absence of clinical changes, and 3) mortality due to HE. We also compared mortality between patients who did and did not have a surveillance CT. ResultsOf 175 patients, 5 (2.9%) were found to have HE. Most (n=4, 80%) had changes in management including anticoagulation discontinuation (n=4), reversal (n=1), and operative management (n=1). Two patients developed symptoms or exam changes prior to the head CT. Of the 3 patients (1.7%) without preceding exam changes, each had only very minor HE and did not require operative management. No patient experienced mortality directly attributed to HE. There was no difference in mortality between patients who did and those who did not have a surveillance scan. ConclusionsOur findings suggest that most patients with tICH who are started on anticoagulation could be followed clinically, and providers may reserve CT imaging for patients with changes in exam/symptoms or those who have a poor clinical examination to follow.

Imaging of intracranial hemorrhage in photon counting computed tomography using virtual monoenergetic images

PurposeTo determine the optimal virtual monoenergetic image (VMI) for detecting and assessing intracranial hemorrhage in unenhanced photon counting CT of the head based on the evaluation of quantitative and qualitative image quality parameters.MethodsSixty-three patients with acute intracranial hemorrhage and unenhanced CT of the head were retrospectively included. In these patients, 35 intraparenchymal, 39 intraventricular, 30 subarachnoidal, and 43 subdural hemorrhages were selected. VMIs were reconstructed using all available monoenergetic reconstruction levels (40–190 keV). Multiple regions of interest measurements were used for evaluation of the overall image quality, and signal, noise, signal-to-noise-ratio (SNR), and contrast-to-noise-ratio (CNR) of intracranial hemorrhage. Based on the results of the quantitative analysis, specific VMIs were rated by five radiologists on a 5-point Likert scale.ResultsSignal, noise, SNR, and CNR differed significantly between different VMIs (p < 0.001). Maximum CNR for intracranial hemorrhage was reached in VMI with keV levels > 120 keV (intraparenchymal 143 keV, intraventricular 164 keV, subarachnoidal 124 keV, and subdural hemorrhage 133 keV). In reading, no relevant superiority in the detection of hemorrhage could be demonstrated using VMIs above 66 keV.ConclusionFor the detection of hemorrhage in unenhanced CT of the head, the quantitative analysis of the present study on photon counting CT is generally consistent with the findings from dual-energy CT, suggesting keV levels just above 120 keV and higher depending on the location of the hemorrhage.However, on the basis of the qualitative analyses, no reliable statement can yet be made as to whether an additional VMI with higher keV is truly beneficial in everyday clinical practice.

Ventriculo-atrial shunt in idiopathic intracranial hypertension

PurposeCSF diversion is a recognised intervention in idiopathic intracranial hypertension (IIH), particularly in the presence of vision-threatening papilledema. Although ventriculo-atrial (VA) shunt insertion is a routine neurosurgical procedure, ventriculoperitoneal and lumboperitoneal shunts have been mostly used in this particular indication. This study aims to look at a single centre’s experience with VA shunts in idiopathic intracranial hypertension (IIH).MethodsRetrospective case series with a review of electronic records over a 10-year period; exclusion criteria were duplication of same shunt insertion, no VA shunt insertion, paediatric patients and indication other than IIH. Notes were reviewed for demographics, shunt survival (defined by time prior to revision) and reasons for revision.ResultsEight VA shunt procedures were identified in 6 patients (mean age at insertion 34 ± 10 years) with a mean follow-up of 58 ± 25 months. All shunts were secondary procedures; 2 revisions from lumbo-pleural, 2 from ventriculopleural, 2 from ventriculoatrial and one each from ventriculoperitoneal and combined lumbo-/ventriculoperitoneal. At 50 months, 75% of VA shunts had survived, compared to only 58.3% of VPleural shunts in patients with IIH. Revisions were required due to acute intracranial bleed (1 case)—revised at day 1, and thrombus at distal site (1 case)—revised at day 57. Both shunts were later reinserted. From the latest clinic letters, all patients had their treatment optimised with this procedure, although only two patients had documented resolved papilloedema post-procedure.ConclusionsVentriculo-atrial shunts are a safe and efficacious alternative option for CSF diversion in IIH. In this series, only 1 shunt was revised for a VA shunt-specific complication.

Abstract WP169: Thromboelastography as a Biomarker of Emergent Direct-Acting Oral Anticoagulant Reversal With Prothrombin Complex Concentrates for Intracranial Hemorrhage

Prothrombin complex concentrates (PCCs) are used to emergently reverse direct-acting oral anticoagulant (DOAC) activity. PCCs are recommended as an alternative to recombinant coagulation factor-Xa to reverse anticoagulation activity of apixaban or rivaroxaban. Measuring the degree of anticoagulation reversal in this population is limited. Thromboelastography (TEG) has been used to detect the presence of DOAC plasma levels in patients chronically taking a DOAC but has not been utilized to measure the effect on anticoagulant activity after PCC administration. We aimed to determine whether TEG R-time is useful in detecting the impact of PCC administration on anticoagulation activity in patients with anti-factor Xa-associated intracranial hemorrhage (ICH). We prospectively evaluated the utility of TEG to assess anticoagulation activity after factor Xa inhibitor reversal with 4-factor PCC. Adults with ICH taking apixaban or rivaroxaban were included. Patients were excluded if their last known dose of anticoagulation was &gt;48 hours prior to arrival, had known apixaban or rivaroxaban blood levels &lt;20 ng/mL, or had the following comorbidities: hepatic failure, hereditary disorders of hemostasis, polytrauma, or pregnancy. TEG samples were collected before PCC administration (if available), and 0.5, 12, and 24 hours after PCC administration. Thirty-one patients were enrolled between November 2022 and August 2023. The median PCC dose was 24.5 units/kg (IQR 20.3-26.9 units/kg; n=29). Nine patients received anticoagulation reversal after baseline TEG collection; the remainder received anticoagulation reversal at transferring facilities. Baseline R-time was negatively correlated with time since last dose of DOAC (n=9). A median decrease in R-time of 0.8 minutes after PCC (IQR -1.6 - 0.3; n=8) was found in patients with baseline TEG collection. R-time rebounded by a median of 0.75 minutes (IQR 0.2-2.0; n=8) from 0.5 hours to 12 hours after PCC administration (n=8). TEG R-time, a measure that inversely correlates with the degree of anticoagulant effect, rapidly decreases after PCC in patients taking DOACs that present with acute ICH. TEG R-time rebounds 12 hours after PCC administration. TEG-R time may be a useful biomarker in DOAC reversal with PCC.

Dispensing pharmacy chains and direct anticoagulants: Potential associations with patient outcomes.

Pharmacy chains can differ with respect to the characteristics of their patient populations as well as their nonprescription products, services, and practices, and thus may serve as a surrogate for potential unmeasured confounding in observational studies of prescription drugs. This study evaluates whether a single-source drug can have different patient outcomes based on the dispensing pharmacy chain. Separate analyses for two anticoagulant drugs, rivaroxaban and apixaban, were conducted using Medicare Fee-for-Service claims evaluating the association between dispensing pharmacy chain and outcomes of acute myocardial infarction, ischemic stroke, intracranial hemorrhage, gastrointestinal (GI) bleeding, all-cause mortality, and major GI bleeding. Inverse probability of treatment weighting (IPTW) was used to balance baseline covariates across pharmacy chain cohorts, and outcome association was assessed with a Cox Proportional Hazards model. We observed no differences in outcomes across pharmacy chains for apixaban recipients. Rivaroxaban recipients from pharmacy chain C, however, had lower rates of GI bleeding (adjusted HR 0.83; 95% CI 0.69-1.00) and ischemic stroke (adjusted HR 0.57; 95% CI 0.38-0.87) as compared to chain A in primary analyses with a 3-day grace period. The results moved closer to the null when 14- and 30-day grace periods were implemented. These results suggest that dispensing pharmacy chains may have the potential to act as a confounder of associations between drug exposure and outcome in some observational studies. Additional studies of potential confounding by pharmacy chain are needed. Further evaluation of potential pharmacy chain effects on safe use would be of value.

Acute intracranial hemorrhage in 76 COVID-19 patients during the first and second pandemic waves

Background/Aim. There is limited data on the frequency of intracranial hemorrhage (ICrH) in the first wave [beta variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] and second wave (delta variant of SARS-CoV-2) coronavirus disease 2019 (COVID-19) pandemic. The aim of this study was to analyze the appearance of ICrH in COVID-19 patients (CP). Methods. Among 505 CP treated at the Special Hospital for Cerebrovascular Diseases ?Sveti Sava? intermittently during the 2020-2021 period, ICrH was diagnosed in 76 (15.1%) patients. The available information from the medical records regarding clinical, demographic, as well as radiological data (multislice computed tomography examination of the endocranium) was collected and analyzed. Results. In the first wave, out of 308 CP, 63 (20.5%) were diagnosed with ICrH. In the second wave, out of 197 CP, ICrH was diagnosed in 13 (6.6%) patients, which was a statistically significant difference (p &lt; 0.002). There was no statistically significant difference for the presence of hyper-tension (p = 0.271), diabetes mellitus (p = 0.558), and chronic obstructive pulmonary disease (p = 0.794) among CP with ICrH comparing the two waves of the pandemic. However, a statistically significant difference was proven in the frequency of patients with atrial fibrillation and anticoagulant drug therapy (p = 0.021 each). There was no statistically significant difference in the frequency of patients with fever (p = 0.637), fatigue (p = 0.587), hemiparesis (p = 0.831), respiratory symptoms (p = 0.289), and loss of consciousness (p = 0.247). D-dimer values in the second pandemic wave were statistically significantly lower (p = 0.003). The combina-tion of ischemic stroke and ICrH was six times more common in the second wave (p = 0.003). However, cer-ebral parenchymal hemorrhage was two times less frequent (p = 0.001) in the second wave but with statisti-cally higher frequencies of multifocal (23.1%) and dif-fuse type (36.4%) of ICrH (p = 0.007). Combined hem-orrhages, as well as subarachnoid and subdural subtypes, were more common in the second wave (23.1% each). Fatal outcomes occurred in 38.1% of patients in the first wave compared to 69.2% in the second wave (p = 0.039). Conclusion. In the first pandemic wave of COVID-19, ICrH in CP was significantly more frequent and D-dimer was singled out in laboratory analyses, the values of which were statistically significantly higher in comparison with second wave. In the second wave of COVID-19, parenchymal ICrH was less frequent and multifocal and diffuse ICrH were more common in CP with ICrH. The mortality rate was very high in the sec-ond wave.

Consideration of Brain CT Imaging Standard for Mild Head Injuries.

It has been reported that various clinical criteria indicate computed tomography (CT) examination for mild head injury (MHI). However, the decision to perform CT for MHI largely depends on the physician. Data on severe head injuries is available in sources such as the Japan Neurotrauma Data Bank, but only a few data has been collected on MHI. A total of 1688 patients with MHI (Glasgow Coma Scale 14 and 15) treated at our hospital from June 2017 to May 2019 were reviewed. CT was performed in 1237 patients (73.28%), and intracranial hemorrhage was detected in 50 patients. Three patients deteriorated, and all were surgically treated. Statistical analysis of the presence or absence of acute intracranial hemorrhage and "risk factors for complications of intracranial lesions in MHI" showed significant differences in unclear or ambiguous accident history (p = 0.022), continued post-traumatic amnesia (p < 0.01), trauma above the clavicles including clinical signs of skull fracture (skull base or depressed skull fracture) (p = 0.012), age <60 years (p < 0.01), coagulation disorders (p < 0.01), and alcohol or drug intoxication (p < 0.01). The 453 patients who did not satisfy these risk factors included only one patient with intracranial hemorrhage, so the negative predictive value was 99.78%. This study shows that the "risk factors for complications of intracranial lesions in MHI" are effective criteria for excluding acute intracranial hemorrhage and CT should be actively considered for patients with the above factors that showed significant differences.

Relationship between extravascular leakage and clinical outcome on computed tomography of isolated traumatic brain injury.

This study investigated whether contrast extravasation on computed tomography (CT) angiography in patients with traumatic brain injury (TBI) is associated with death or surgical procedures. Patients over 18 years old, directly brought in by ambulance with an isolated head injury and confirmed to have acute intracranial hemorrhage on a CT scan upon admission between 2010 and 2020, were included. The primary outcome was mortality, and the secondary outcome was neurosurgical procedures performed from admission to discharge from the intensive care unit. Multivariable logistic regression analyses were performed to evaluate the association between these outcomes and contrast extravasation. The analysis included 188 patients with a median age of 65 years, 123 men (65.4%), 34 deaths (18.1%), and 91 surgeries (48.4%). Among the 66 patients with contrast extravasation, 22 (33.3%) died and 47 (71.2%) required surgery. Among the 122 patients with no contrast extravasation, 12 (9.8%) died, and 44 (36.1%) required surgery. The presence or absence of extravascular leakage was associated with death (odds ratio, 3.6 [95% CI: 1.2-12.2]) and surgery (odds ratio, 7.6 [95% CI: 2.5-22.7]). Contrast extravasation was associated with mortality and performance of surgery in patients with an isolated head injury.

Low LDL-C/HDL-C Ratio is Associated with Poor Clinical Outcome After Intracerebral Hemorrhage: A Retrospective Analysis of Multicenter, Prospective Cohort Data in China.

The association between low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C) ratio and the clinical outcomes of acute intracranial hemorrhage (ICH) remains unclear. In this study, we attempt to investigate whether low LDL-C/HDL-C ratio is associated with poor clinical outcomes in patients with ICH. The database was collected from a multicenter, prospective, observational cohort study, conducted in 13 hospitals in Beijing from January 2014 to September 2016. A total of 1,964 patients with ICH were initially screened in our database. Next, we selected patients with admission serum lipid information for retrospective analysis. Patients were categorized into four groups based on LDL-C/HDL-C ratio quartiles. The main outcomes were 30-day and 90-day poor functional outcome, which is defined as modified Rankin Scale score of 3 to 6, and 90-day all-cause death. Logistic regression was used to assess the association between LDL-C/HDL-C ratio and 30-day or 90-day poor functional outcome. Kaplan-Meier survival analysis and Cox regression were used to assess the association between LDL-C/HDL-C ratio and 90-day all-cause death. Restricted cubic splines were used to explore the nonlinear association between LDL-C/HDL-C ratio and the outcome of patients with ICH. A total of 491 patients with spontaneous ICH were finally enrolled in our study. The mean age was 57.6years old, and 72.1% (357/491) were men. After adjustment for confounders, patients in the lowest LDL-C/HDL-C quartile (< 1.74) had a significantly higher risk of 30-day and 90-day poor functional outcome compared with those in the highest quartile (> 3.16; 30-day: adjusted odds ratio 3.61, 95% confidence interval 1.68-7.72; 90-day: adjusted odds ratio 2.82, 95% confidence interval 1.33-5.95). Restricted cubic splines depicted a nonlinear association between LDL-C/HDL-C ratio and 90-day poor functional outcomes, indicating LDL-C/HDL-C ratio of 3.1-3.5 was correlated with better 90-day functional outcome. However, no significant correlation was found between low LDL-C/HDL-C ratio and 90-day all-cause death. Lower LDL-C/HDL-C ratio (< 1.74) is independently associated with an increased risk of poor functional outcome in patients with ICH. In the population of patients whom we studied, there is a nonlinear association between LDL-C/HDL-C ratio and 90-day poor functional outcome, and patients with an LDL-C/HDL-C ratio of 3.1 to 3.5 tend to have the lowest risk of 90-day poor functional outcome.

Role of Non-Contrast Computed Tomography in Evaluation of Traumatic Brain Injury

Head trauma is a major public health concern throughout the world, and is the most serious of all health problems facing developed countries. [1] In this new era of radiology, computed tomography scan has become the basic primary modality of choice for the initial assessment of head injury patients. It is also easily available, faster and highly accurate in detecting skull fractures and acute intracranial hemorrhage. [2] A prospective study was conducted based on convenience sampling at Department of Radiology, Ankur Matrika Hospital, Jammu, among 50 patients who were all referred for NCCT head investigation. The study was performed to determine the clinical findings, type of fracture and site of fracture. The study concluded that NCCT head investigation is the best primarily modality for patients with history of traumatic brain injury. Keywords: NCCT Head, MDCT, tomography, reconstruction.

Successful Management of Intracranial Hemorrhage with Emicizumab in a Newborn with Severe Hemophilia a: A Case Report

Introduction Intracranial hemorrhage (ICH) is the second most common first hemorrhage in neonates with congenital Hemophilia, with an incidence of 3.4-4.0%. Nearly half (41%) of ICHs occur within the first week of life. ICH is the most feared complication of hemophilia with a high rate of morbidity and up to 20% of mortality. Timely diagnosis and prompt treatment are critical, even though the clinical signs of ICH in neonates are difficult to assess. Most studies recommend infusion of Factor VIII (FVIII) rising its plasma level to 100% as soon as possible. Unfortunately, approximately 25% to 40% of neonates develop inhibitors against FVIII after substitutive treatment; the percentage may be even higher in neonates with ICH requiring prolonged continuous treatment over days to weeks. We report a case of ICH in a newborn with severe haemophilia A (HA) treated with an initial-single dose of FVIII concentrate and then only with emicizumab. Case report A male neonate, born at 38+4 weeks of gestation by cesarean delivery, presented abnormal bleeding on his third day of life after heel blood sampling. Activated Partial Thromboplastin test resulted 147 seconds and FVIII was less then 1%. Family history for bleeding disorders was negative. A cerebral ultrasound scan documented a brain area suspicious for intracranial hemorrhage. Before transferring the neonate to the neonatal intensive care unit (NICU), he received an additional intravenous dose of vitamin K and 10 ml/kg fresh frozen plasma. On admission in NICU, the neonate presented alert and responsive with stable hemodynamics and vital signs. A second brain ultrasound and head MRI confirmed an intracerebral hemorrhage in the left parieto-occipital area near the splenium of the corpus callosum associated with subdural hematoma in the left temporo-occipital, occipito-mesial area, in falx cerebri and left tentorium cerebelli. Neonate received tranexamic acid infusions 40 mg/kg die and 50 IU/Kg of intravenous recombinant factor VIII concentrate (octocog alfa). Then, it was decided to start treatment with Emicizumab, a bispecific antibody mimicking FVIII, at a dose of 3 mg/kg subcutaneously once a week for 4 weeks, continuing prophylaxis at 1.5 mg/kg once a week.Serial brain ultrasound revealed progressive reduction of the ICH extension over the following weeks; one month later, brain MRI confirmed the improvement. The neonate's clinical condition remained always stable; he never showed seizures or neurological signs of impaired consciousness and his neurodevelopment is appropriate for age. MRI performed at three months of age documented complete resolution of the cerebral hemorrhage. Discussion Intensive FVIII replacement therapy for ICH in pups is associated with a high risk of inhibitor formation.Emicizumab, a humanised bispecific monoclonal antibody, is indicated for routine prophilaxis in patients with severe HA with and without antibodies to FVIII. Emicizumab is attractive due to its weekly or even longer dosing intervals and subcutaneous route of administration but, despite the baseline hemostasis achieved with emicizumab, acute bleeding events may still require aggressive therapy. Theoretically, it needs few days to be hemostatically effective but its in vitro coagulant potential in neonate is heterogeneous, thus we can not completely explain the therapeutic success with only one dose of FVIII. Conclusions The combined use of emicizumab and antifibrinolytics was successful in treating acute intracranial hemorrhage. To the best of our knowledge, this is the first pediatric case of successful management of intracranial hemorrhage with emicizumab in a newborn with severe HA.

Risks of cardiovascular events after acute ischemic stroke and intra-cranial hemorrhage

Abstract Background The occurrence of acute ischemic stroke and intra-cranial hemorrhage (ICH) would result in severe stress for patients which may trigger cardiovascular (CV) events. In the present study, we aimed to report and compare the risks of CV events of patients who experienced ischemic stroke and ICH. Also, we analyzed the associations between the severities of stroke/ICH and risks of CV events. Methods A total of 413,000 and 131,313 patients who experienced acute ischemic stroke and ICH and did not have past history of acute myocardial infarction (AMI), heart failure (HF), atrial fibrillation (AF) and ventricular arrhythmia (VA) were identified from the Taiwan National Health Insurance Research Database, respectively. Risks of CV events within 90 days after stroke and ICH were analyzed and compared. Results There were 2.77% and 1.75% of patients who suffered from CV events after ischemic stroke and ICH, respectively. The risks of AMI (odds ratio [OR] 0.702, 95%CI 0.618-0.798), HF (OR 0.708, 95%CI 0.661-0.759), AF (OR 0.534, 95%CI 0.502-0.569) and any events (OR 0.626, 95%CI 0.598-0.655) were lower for patients with ICH compared to those with ischemic stroke (Figure 1). For patients with acute ICH, the risks of CV events expect for AF significantly increased from mild to severe ICH (Figure 2). For patients with acute ischemic stroke, all the risks of CV events were higher among patients with severe stroke. Conclusions When managing patients with acute ischemic stroke and ICH, the risks of acute CV events should also be kept in mind. The impacts of acute CV events on the long-term prognosis of these patients deserve a further study.

Abstract 18126: A Rare Case of a Left Ventricular Papillary Fibroelastoma With an Initial Presentation of Unilateral Vision Loss

A 59-year-old female with hypertension presented with acute onset of decreased vision in the right eye. She reported waking up 3 days prior to admission with sudden onset of shadow in the right eye appearing like a falling curtain which eventually progressed to total visual loss. She also complained of headaches and palpitations. The patient denied pain, nausea, vomiting, photophobia, changes in speech, aphasia, facial weakness, arm or leg weakness or numbness. She states that this is her first experience of vision loss. At the time of admission, she was hypertensive to 170/100s and started on amlodipine 5mg and losartan 25mg. Neurology and ophthalmology were consulted for concerns of stroke and new vision loss. She was started on heparin drip, aspirin 81mg, atorvastatin 80mg, and methylprednisolone 1g. Ocular examination revealed right brachial retinal artery occlusion. MRI brain showed chronic microvascular changes, but no acute intracranial hemorrhage or infarction. CT angiogram of the neck showed mild soft plaque in right carotid bifurcation. Transthoracic echocardiogram revealed a 1.6cm x 1.6cm left ventricular mobile mass which appeared to be attached to the posteromedial papillary muscle and left ventricle ejection fraction of 60%. The patient underwent open heart surgery for removal of the mass. The mass was confirmed to be a papillary fibroelastoma attached to the left ventricular trabeculum. The mitral valve and subvalvular apparatus were not involved. New onset of stroke or acute vision loss is generally a result of thromboembolism. Most times it can be caused by a clot formed in a patient with atrial fibrillation. In other cases, it can be due to a ruptured cholesterol plaque. However, primary cardiac tumors are rare, especially ones on the papillary muscle. We presented a rare case of papillary fibroelastoma that possibly embolized causing acute unilateral vison loss. This case reinforces the importance of cardiac imaging in new stroke or acute vision loss.

Differential diagnosis of acute intracranial hemorrhage and calcification by cranial dual-energy computed tomography.

To evaluate the application value of dual-energy computed tomography (DECT) in the differential diagnosis of acute intracranial hemorrhage and calcification. This retrospective study involved patients who underwent non-contrast-enhanced cranial DECT in Anhui Wannan Rehabilitation Hospital from January 2015 to November 2022. The processed mixed images obtained after DECT were used as the conventional CT images. Each hyperdense lesion was analyzed based on virtual non-calcium and calcium overlay and classified as calcification or hemorrhage. The sensitivity, specificity, and accuracy of conventional CT and DECT were calculated by the chi-square test according to the unified reference standard. Sixty-six hyperdense intracranial lesions of 60 patients were analyzed; of these lesions, 41 (62.12%) were calcifications and 25 (37.88%) were hemorrhages. The sensitivity, specificity, and accuracy of DECT in identifying hemorrhage were 96.00%, 100%, and 98.48%, respectively, while those of conventional CT were 72.00%, 97.56%, and 87.88%, respectively. Of the 66 lesions, 4 (6.06%) could not be qualitatively identified and 3 (4.55%) were misdiagnosed by conventional CT but correctly identified by DECT. DECT can accurately distinguish acute intracranial hemorrhage from calcification, especially in cases that are difficult to diagnose by conventional CT.

Head injury in older adults presenting to the ambulance service: who do we convey to the emergency department, and what clinical variables are associated with an intracranial bleed? A retrospective case–control study

ObjectiveMost older adults with traumatic brain injuries (TBI) reach the emergency department via the ambulance service. Older adults, often with mild TBI symptoms, risk being under-triaged and facing poor outcomes. This study aimed to identify whether sufficient information is available on the scene to an ambulance clinician to identify an older adult at risk of an intracranial haemorrhage following a head injury.MethodsThis was a retrospective case–control observational study involving one regional ambulance service in the UK and eight emergency departments. 3545 patients aged 60 years and over presented to one regional ambulance service with a head injury between the 1st of January 2020 and the 31st of December 2020. The primary outcome was an acute intracranial haemorrhage on head computed tomography (CT) scan in patients conveyed to the emergency department (ED). A secondary outcome was factors associated with conveyance to the ED by the ambulance clinician.ResultsIn 2020, 2111 patients were conveyed to the ED and 162 patients were found to have an intracranial haemorrhage on their head CT scan. Falls from more than 2 m (adjusted odds ratio (aOR) 3.45, 95% CI 1.78–6.40), chronic kidney disease (CKD) (aOR 2.80, 95% CI 1.25–5.75) and Clopidogrel (aOR 1.98, 95% CI 1.04–3.59) were associated with an intracranial haemorrhage. Conveyance to the ED was associated with patients taking anticoagulant and antiplatelet medication or a visible head injury or head injury symptoms.ConclusionThis study highlights that while most older adults with a head injury are conveyed to the ED, only a minority will have an intracranial haemorrhage following their head injury. While mechanisms of injury such as falls from more than 2 m remain a predictor, this work highlights that Clopidogrel and CKD are also associated with an increased odds of tICH in older adults following a head injury. These findings may warrant a review of current ambulance head injury guidelines.

A rare case report: isolated midbrain lacunar infarct affecting the ipsilateral medial longitudinal fasciculus causing internuclear ophthalmoplegia effect

Isolated medial longitudinal fasciculus infarct is rare and can also be associated with cranial nerve nuclei or extra-nuclear regions leading to respective neurological deficit. We report a case of 73-year-old woman presenting with a 24 hour of confusion, abnormal eye movement and unsteady gait on a background history of uncontrolled diabetes mellitus (DM), hypertension and Alzheimer’s disease. Her examination found to have dysdiadokinesia in left upper limb and inability to adduct right eyeball on left lateral gaze, without affecting the pupil. She was not oriented to time and place while before this event she could. Her examination found to have normal power in limbs and sensation. Her computed tomography (CT) brain showed no evidence of acute infarction or intracranial bleed. Magnetic resonance imaging (MRI) brain demonstrated acute lacunar infarct involving the ipsilateral medial longitudinal fasciculus. This case demonstrates rare brainstem infarct affecting medial longitudinal fasciculus region below the IIIrd cranial nerve nucleus giving features of internuclear ophthalmoplegia affecting medial rectus muscle without affecting autonomic fibres of IIIrd cranial nerve due to which the pupil is not affected. We recommend strict control of predisposing conditions, mainly diabetes and hypertension to reduce the incidence of brainstem stroke.