The optimal use of tranexamic acid (TXA) in trauma care is a matter of intense discussion, particularly with respect to its indications, dosage, temporal window, and thromboembolic adverse effects. This review is based on publications retrieved by a selective literature search on the indications, effects, mechanism of action, and side effects of TXA (January 2022 to December 2025). Three randomized, controlled trials (RCTs), three observational studies, eight secondary analyses, and 16 meta-analyses were evaluated. TXA administration lowers the mortality of severely traumatized patients (e.g., with a relative risk [RR] of 0.73 [0.56;0.96]). The currently available evidence is inconsistent, and many of the effects found in published studies lie within the range of random fluctuation. The reduction of mortality depends on TXA administration at the earliest possible time in the first 90 minutes after trauma (this temporal window is more important than the question of pre- vs. in-hospital administration), as well as on the nature of the injury, particularly in patients with hemorrhagic shock. Among patients with isolated traumatic brain injury, no consistent effect on mortality has been shown, but there may be an effect on the progression of intracranial bleeding. Multiple studies point to a thromboembolic risk, which is dose-dependent, with a marked rise at 4 g (hazard ratio [HR] 5.33, 95% confidence interval [1.94;14.63]). In patients without shock, the reported absolute risk difference for mortality ranges from -5% to +5%, and that for thromboembolic adverse events from -0.2% to +4%. For trauma patients with life-threatening hemorrhage, especially those in hemorrhagic shock, it is recommended that TXA be given as early as possible (before arrival in the hospital) in a single dose of 1-2 g (15-30 mg/kg body weight [BW]). When this is done, the benefit appears to be greater than the thromboembolic risk.

Automated intracranial hemorrhage (ICH) detection tools are widespread, yet data are limited regarding their performance in real-world practice. We retrospectively analyzed noncontrast CT head images of consecutive code stroke patients from January 2022 to February 2023 at a comprehensive stroke center. Patients were included if their indication was stroke, and images were assessed by the automated platform. Radiology reports were considered the gold standard. The primary outcome was the performance of the automated software tool compared with that of board-certified radiologists in ICH detection. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated using SAS software. Of 1,434 code stroke CT scans, 1,402 (98%) were analyzed using the automated detection tool. Thirty-two studies were considered nondiagnostic because of severe motion degradation, and these were excluded. The mean patient age was 67 ± 16 years, with 51% of patients being women and 65% of patients being White. The software tool accurately identified 105 of 129 ICH cases (81%) and 1,255 of the 1,273 non-ICH cases (99%). The sensitivity, specificity, positive predictive value, and negative predictive value with 95% CIs were 81% (74%-88%), 99% (98%-99%), 85% (78%-91%), and 98% (97%-99%), respectively. Automated software sensitivity was highest for intra-axial hemorrhage (IAH) at 94%. Extra-axial hemorrhage (EAH) had a sensitivity of just 43%. Sensitivity of mixed IAH and EAH was 89%, representing a significant increase from isolated EAH. Automated ICH detection software demonstrates high accuracy in detecting ICH in real-world practice. Sensitivity for IAH is particularly high, with detection of EAH reaching acceptable parameters when co-presenting with IAH but lacking in isolation.

Early Mobilization Outcomes With Tenecteplase Treatment in Acute Ischemic Stroke (EMOTE-TNK) Study: Safety and Tolerability.

Variants in COL4A1 and COL4A2 are associated with a multisystem disorder characterized by prominent neurologic involvement that includes intracranial hemorrhages, white matter injury, neurodevelopmental impairment, and epilepsy. The phenotypic spectrum, however, is broad, and disease subgroups have not been robustly identified. The objective of this study was to distinguish pediatric subgroups based on age at symptom onset. This was a retrospective cohort study of pediatric patients with variants in COL4A1 or COL4A2 seen at a single center between January 2008 and October 2024. Patients were included if they had likely pathogenic/pathogenic variants or variants of uncertain significance with consistent clinical phenotype and were followed for ≥6 months. Medical records, laboratory data, and neuroimaging were reviewed. Patients were stratified by age at symptom onset into perinatal, early childhood, and late childhood onset (up to 28 days, up to 4 years, and up to 18 years, respectively). Of the 44 patients meeting inclusion criteria, 33 had variants in COL4A1, 10 in COL4A2, and 1 in both. Neurologic features, such as global developmental delay, cerebral palsy, and epilepsy, were common in perinatal and early childhood cases. In COL4A1-related disease, such neurologic features were present in 14/17 and 8/9 cases, respectively. These features similarly occurred in all patients with perinatal (n = 3) and early childhood (n = 6) onset of COL4A2-related disease. Conversely, these manifestations were less common in late childhood presentations of either disorder (n = 6 total), occurring in 33% of patients. Extracentral nervous system manifestations, particularly ocular abnormalities and renal disease, were predominantly seen in COL4A1-related disease. Neuroimaging in perinatal and early childhood presentations frequently demonstrated periventricular hemorrhagic infarction (20/26 and 6/9 of COL4A1 and COL4A2 patients). Isolated leukoencephalopathy was universally present in late childhood onset patients. The pediatric phenotype of COL4A1/2-related disorder varies by age at disease onset. Perinatal and early childhood presentations (≤4 years) have a prominent neurologic phenotype with severe developmental delays, cerebral palsy, and epilepsy, correlating on imaging with sequelae from brain injury during prenatal brain development. Late childhood presentations (>4 years) have a milder phenotype, typically with isolated leukoencephalopathy on imaging.

SWDL: Stratum-Wise Difference Learning with deep Laplacian pyramid for semi-supervised 3D intracranial hemorrhage segmentation

Traumatic intracranial hemorrhage with blood-fluid level

ICH-ASNet: Automatic Prompt-based segmentation for intracranial hemorrhage in CT images

Background diabetes mellitus is prevalent among patients with acute ischemic stroke (AIS). The prognostic significance of long-term insulin treatment status, a marker of diabetes severity and duration, on outcomes after mechanical thrombectomy (MT) is not well characterized at the national level. Methods we performed a retrospective cohort study using the National Inpatient Sample (2006-2022) to identify adult AIS hospitalizations treated with MT and concomitant diabetes. Patients were categorized by documented long-term insulin use versus no such documentation, as a proxy for diabetes severity and disease burden. Primary outcomes were in-hospital mortality and non-home discharge. Secondary outcomes included peri-procedural complications. Propensity score matching was followed by machine learning to estimate adjusted risk differences (ARDs). Results we identified 7,859 matched discharges (3,931 insulin; 3,928 non-insulin). The proportion of MT patients with diabetes increased from 19.9% in 2006 to 31.5% in 2022; insulin use doubled from 11.6% to 20.4% of the diabetic subgroup. For the two pre-specified primary outcomes, insulin treatment status was associated with a higher adjusted risk of non-home discharge (ARD + 6.8% points; 95% CI, + 2.2 to + 11.4; P = 0.004), while in-hospital mortality did not differ between groups (13.6% vs. 14.5%; P = 0.254). In exploratory secondary analyses of peri-procedural complications, insulin-coded status was associated with lower rates of intracranial hemorrhage (- 4.8 points; 95% CI, - 9.1 to - 0.4), pulmonary complications (- 3.6 points; 95% CI, - 6.9 to - 0.3), and neurological complications (- 0.8 points; 95% CI, - 1.6 to 0.0), all with borderline statistical significance and without adjustment for multiplicity. Conclusions diabetes is increasingly prevalent among patients undergoing MT. Patients with documented long-term insulin use are more likely to require institutional discharge but experience lower complication rates. Insulin treatment status, likely reflecting diabetes severity and chronicity, may serve as a marker of functional prognosis and peri-procedural risk rather than a direct indicator of treatment effect. Future studies with pharmacologic data are warranted to individualize management strategies after thrombectomy. Clinical Trial Number: not applicable.

Fibrinogen levels may influence the effect of intravenous thrombolysis. We aimed to investigate the efficacy and safety of tenecteplase across different baseline fibrinogen levels in acute ischaemic stroke due to large vessel occlusion (LVO) in the extended time window. We performed a post hoc analysis of the Tenecteplase Reperfusion Therapy in Acute Ischaemic Cerebrovascular Events-III (TRACE-III) trial. Patients who presented within 4.5 to 24h after symptom onset with anterior LVO, salvageable brain tissue, and no access to endovascular thrombectomy were randomised (1:1) to receive either 0.25mg/kg tenecteplase or standard medical treatment. We categorised patients into groups with non-elevated fibrinogen (≤ 4.0g/L) and elevated fibrinogen levels (> 4.0g/L). The primary outcome was the absence of disability, which was defined as a score of 0 to 1 on the modified Rankin scale (mRS) at 90days. The safety outcomes were symptomatic intracranial haemorrhage (sICH) within 36h and all-cause mortality within 90days. We included 498 of the 516 patients in the TRACE-III trial who had baseline fibrinogen data. Among them, 426 (85.5%) had non-elevated fibrinogen, and 72 (14.5%) had elevated fibrinogen. Compared with standard medical treatment, tenecteplase significantly increased the proportion of mRS scores of 0-1 at 90days among patients with non-elevated fibrinogen (35.0% vs. 25.7%; relative rate [RR] 1.55; 95% confidence interval [CI] 1.03-2.37; P = 0.04). No significant difference was observed in those with elevated fibrinogen (16.7% vs. 11.1%; RR 1.60; 95%CI 0.42-6.78; P = 0.50). Safety outcomes were similar between the two treatment groups across fibrinogen categories. Among patients with LVO presenting within 4.5 to 24h after stroke onset, those with non-elevated fibrinogen levels may receive greater benefit from tenecteplase in reducing disability risk without increasing the incidence of sICH, compared to those with elevated fibrinogen levels. TRACE-III Trial registration: ClinicalTrials.gov identifier, NCT05141305.

Implementing Artificial Intelligence for Intracranial Hemorrhage Detection.

Hemorrhagic transformation after endovascular thrombectomy can occur either immediately (early intracranial hemorrhage [ICH]) or on follow-up imaging (delayed ICH), possibly reflecting distinct mechanisms and outcomes. This study aim to investigate the incidence and prognosis of early and delayed ICH and to examine how postprocedural blood pressure (BP) relates to delayed ICH. We analyzed consecutive patients undergoing endovascular thrombectomy (May 2019 through December 2024) who underwent post-endovascular thrombectomy dual energy computed tomography and follow-up imaging. Early ICH was defined as high attenuation on virtual noncontrast of dual energy computed tomography; delayed ICH was defined as new hemorrhage on follow-up after a negative virtual noncontrast. Hourly BP between dual energy computed tomography and follow-up was collected. Outcomes were 90-day functional independence (modified Rankin Scale score of 0-2) and 90-day death. Among 268 patients, early ICH occurred in 32 (11.9%) patients, delayed ICH in 99 (36.9%), and no ICH in 137 (51.1%). Versus no ICH, delayed ICH was associated with lower odds of functional independence (adjusted odds ratio, 0.49 [95% CI, 0.25-0.94]) without a higher mortality rate (adjusted odds ratio, 1.48 [95% CI, 0.70-3.18]). Within delayed ICH, type of hemorrhagic infarction related to less functional independence, whereas type of parenchymal hematoma related to both functional dependence and death. Higher postprocedural systolic BP was associated with delayed ICH, with thresholds at mean >150 mm Hg and peak >166 mm Hg. Delayed ICH was more common than early ICH and independently associated with worse outcomes. Dual energy computed tomography facilitated temporal distinction of hemorrhage and revealed BP-related risks for delayed ICH, suggesting that delayed ICH may be preventable through optimized BP management.

Objective We updated a network meta-analysis of randomized controlled trials to compare the risk of intracranial hemorrhage (ICH) between direct oral anticoagulants (DOACs) and Vitamin K Antagonists (VKAs) in detail across Venous thromboembolism and atrial fibrillation. Methods PubMed, EMBASE, Web of Science, and the Cochrane Library databases were searched up to January 5, 2026. The incidence of ICH was investigated. Using frequentist network meta-analysis, interventions that were not compared directly could be compared indirectly by the 95% confidence interval (CI), making the search results more intuitive. Based on surface under the cumulative ranking curves (SUCRA), the relative ranking probability of each group was generated. Results Twenty randomised controlled trials (127,267 patients) were included. Compared with apixaban, VKAs (OR: 2.40, 95% CI: 1.62–3.56) had a higher risk of bleeding, and the difference was significant. Compared with dabigatran, rivaroxaban (OR: 1.89, 95% CI: 1.18–3.04) and VKAs (OR: 2.83, 95% CI: 2.00–3.99) had a higher risk of bleeding, and the difference was significant. Compared with edoxaban, rivaroxaban (OR: 1.60, 95% CI: 1.04–2.47) and VKAs (OR: 2.39; 95% CI: 1.81–3.17) had a higher risk of bleeding, and the difference was significant. Compared with rivaroxaban, VKAs (OR: 1.50; 95% CI: 1.08–2.07) had a higher risk of bleeding, and the difference was significant. In the ranking of the cumulative probability of ICH, dabigatran (SUCRA 87.6) had the highest safety, followed by apixaban (SUCRA 68.6), edoxaban (SUCRA 67.5), rivaroxaban (SUCRA 26.1), and VKAs (SUCRA 0.2). Conclusions All DOACs had a lower risk of ICH than VKAs. Dabigatran may be the safest choice among any anticoagulant regarding risk of ICH. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261336668 , identifier CRD420261336668.

The effects of intravenous thrombolytic agents on fibrinogen differ due to structural differences among the agents. Using data from the RAISE (Reteplase Versus Alteplase for Acute Ischemic Stroke) trial, we aimed to investigate the impact of differences in baseline plasma fibrinogen levels on the efficacy and safety of reteplase versus alteplase within 4.5 hours of acute ischemic stroke symptom onset. This post hoc subgroup analysis of the multicenter RAISE trial categorized participants by baseline fibrinogen levels: low (<2 g/L), normal (2-4 g/L), and high (>4 g/L). The primary efficacy outcome was excellent functional outcome at 90 days (modified Rankin scale score of 0 or 1). The primary safety outcome was symptomatic intracranial hemorrhage within 36 hours. A total of 1373 patients with acute ischemic stroke were included. Ninety-two in the low fibrinogen group (<2 g/L), 1178 in the normal fibrinogen group (2-4 g/L), and 103 in the high fibrinogen group (>4 g/L). Adjusted risk ratios of primary efficacy outcome were 1.13 (95% CI, 0.97-1.32) for the low fibrinogen group, 1.13 (95% CI, 1.04-1.23) for the normal fibrinogen group, and 1.09 (95% CI, 0.84-1.42) for the high fibrinogen group. The primary safety outcome showed no difference between reteplase and alteplase in the 3 fibrinogen subgroups. Among patients with acute ischemic stroke who were treated with either reteplase or alteplase within 4.5 hours after symptom onset, there was no difference observed in the relative efficacy and safety between the 2 groups across the 3 fibrinogen subgroups. However, these findings should be interpreted cautiously and require validation in larger, adequately powered prospective studies. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05295173.

Inherited platelet function disorders (IPFDs) are rare, heterogeneous conditions that pose diagnostic and management challenges. While bleeding in Glanzmann thrombasthenia (GT) and Bernard-Soulier syndrome (BSS) is well characterized, milder or unclassified IPFDs remain poorly defined. To characterize the bleeding phenotype, treatment patterns, and diagnostic distribution of IPFDs across the United States using the national ATHNdataset. We conducted a retrospective cohort study using the ATHNdataset, a deidentified registry maintained by the American Thrombosis and Hemostasis Network. Clinical outcomes, including bleeding events, laboratory data, treatments, and procedures, were analyzed for participants with IPFDs between 2013 and 2022 and with active follow-up from January 2021 to December 2022. Among 2302 individuals with IPFDs, 8.1% as GT, 2.4% as BSS, 7.0% as granule defects, and 81.6% as IPFD-other. Among 985 participants with active follow-up, 236 bleeding events were reported across 251 patients. The most common events were epistaxis (42.8%), followed by soft tissue (14.4%) and oral bleeding (13.9%). Notably, intracranial hemorrhage occurred in 8 patients and joint bleeds in 82, reflecting significant morbidity across all subtypes. Median ISTH-BAT scores were elevated-13 in GT, 16 in dense-granule defects, and 7 in unclassified IPFDs-exceeding reported population norms. Regarding hemostatic management, antifibrinolytics were used in over half of all patients, with desmopressin and platelet transfusions being used less frequently. By defining the clinical spectrum, treatment utilization, and residual diagnostic uncertainty across IPFDs, this study underscores the importance of improving diagnostic precision and care for patients with platelet function disorders in the modern era.

Composite small vessel disease scores predict hemorrhagic transformation after thrombectomy: a machine learning study.

Congenital factor X (FX) deficiency is an exceedingly rare hemorrhagic condition. Severe deficiency frequently manifests in early life and can lead to life-threatening hemorrhagic consequences, such as intracranial hemorrhage. Because of its infrequency and vague initial symptoms, early diagnosis is challenging. We report a case of a full-term female neonate who presented with persistent umbilical stump bleeding and progressive scalp swelling. Labs were consistent with hypocoagulability. Imaging of the head revealed a large subgaleal, subdural, and cerebellar hematomas. Coagulation factor measurement confirmed a severe congenital FX deficiency. The patient received vitamin K, fresh frozen plasma (FFP), blood transfusion, and was referred for management with replacement therapy. The patient was discharged in stable condition. Early neonatal bleeding, including umbilical and subgaleal hemorrhage, may be the initial manifestations of severe congenital FX deficiency, even in the absence of family history. Rapid diagnosis, proper replacement, and a multidisciplinary approach will ensure optimum outcomes.

The objective of this study was to determine the sensitivity of national databases for identifying aneurysm rupture events in patients with unruptured intracranial aneurysms and determine their suitability for follow-up for patients in the Risk of Aneurysm Rupture (ROAR) Study. ROAR is a longitudinal cohort study that has recruited 20,000 patients with unruptured intracranial aneurysms with detailed baseline clinical and imaging data collected for each participant. These patients will be followed-up using UK national databases for hospital admissions (HES-APC) and national databases of deaths (CRD) to identify aneurysm rupture events for the purpose of rupture risk prediction. To assess the suitability of national databases for this, a cohort of patients with unruptured intracranial aneurysms was identified at a single neurosurgery centre from records between 2006–2020. Patients were linked to the national databases to identify instances containing intracranial haemorrhage diagnosis codes. All returned hospital admissions underwent case note and CT scan review to confirm the true diagnosis or cause of death. Of 1,544 patients, 74 were identified to have suffered a subsequent aneurysmal rupture. The national databases of hospital admissions and deaths identified 57 hospital admissions for aneurysm rupture. The national database of deaths identified an additional 16 out-of-hospital deaths due to aneurysm rupture of which 11 (68.8%) were confirmed on post-mortem. Local hospital records identified one additional inpatient admission for aneurysm rupture. Based on the observed proportions of admissions missing from the national databases and local hospital records, an estimated 1.03 admissions for rupture were predicted to be missed by both. The estimated sensitivity of a national database search strategy for identifying admissions for aneurysm rupture was 96.6%, and 98.3% if combined with local hospital records. National databases can detect rupture events in patients with unruptured intracranial aneurysms with high sensitivity and are ideally suited to long-term follow-up in large longitudinal cohort studies.

Several clinical trials have shown the benefit of endovascular thrombectomy (EVT) in patients with large ischemic core infarction. However, the imaging selection modalities used for patient selection have differed across studies. This study aimed to assess the efficacy, safety, and prognostic factors of EVT in patients with large ischemic core selected only on the basis of Diffusion-Weighted Imaging Alberta Stroke Program Early CT Score (DWI-ASPECTS). This single-center study, conducted from 2019 to 2024, included patients with anterior circulation acute large vessel occlusion and stratified them into three groups according to DWI-ASPECTS: non-large ischemic core (≥ 6) treated with EVT (n = 77), large ischemic core (3-5) treated with EVT (n = 91), and large ischemic core (3-5) treated with medical management alone (n = 70). The primary outcome was functional independence at 90days, defined as a modified Rankin Scale (mRS) score of 0-2. Secondary endpoints included symptomatic intracranial hemorrhage (sICH) within 48h and mortality within 90days. Multivariate binary logistic regression was performed to identify factors associated with functional independence in the large-ischemic-core EVT group. Patients with large ischemic core treated with EVT had a significantly higher rate of 90-day functional independence than those who received medical management (53.8% vs 28.6%, P = 0.001). No significant differences in sICH or mortality were observed between the large-ischemic-core EVT and medical management groups. However, compared with patients with non-large ischemic core treated with EVT, those with large ischemic core treated with EVT had a lower rate of functional independence (53.8% vs 70.1%, P = 0.039). In the large ischemic core EVT group, intravenous thrombolysis (OR 0.164, P = 0.018) and parenchymal hematoma type 2 (PH2) hemorrhage (OR 25.641, P = 0.012) were independent predictors of 90-day outcomes. In this cohort, EVT was associated with improved 90-day functional outcomes in patients with large ischemic core (DWI-ASPECTS 3-5) compared with medical management alone, without a statistically significant increase in sICH or mortality. Intravenous thrombolysis and PH2 hemorrhage were identified as independent predictors of outcome. These results require further confirmation in larger and adequately powered studies.

HSV Encephalitis-Induced Intracranial Hemorrhage: Surgical Pathology Case.

Endovascular thrombectomy (EVT) is a time-sensitive treatment for acute ischemic stroke, and hub-and-spoke systems have expanded patient access to this intervention. However, overcrowding at comprehensive stroke centers (CSCs) remains a significant challenge, particularly in regions with limited resources. Immediate retransfer of patients to spoke hospitals after EVT could help alleviate capacity strain, yet evidence on the safety and outcomes of this practice is limited. We conducted a retrospective analysis of consecutive patients who underwent EVT at a tertiary stroke center in Bucharest, Romania, between June 2024 and October 2025, all of whom were transferred from regional spoke hospitals. Patients were classified as 'retransferred' if they returned immediately to the referring hospital, or as 'kept' if they remained at the CSC. The primary outcome was the 3-month modified Rankin Scale (mRS) score, analyzed as an ordinal variable. Inverse probability of treatment weighting (IPTW) was used to adjust for confounding by indication, and secondary outcomes included functional independence (mRS 0-2), mortality, and symptomatic intracranial hemorrhage (sICH). Of 305 patients, 194 (63.6%) were retransferred and 111 (36.4%) remained at the CSC. Transfer distance was the strongest differentiator between groups. After IPTW adjustment that included transport distance, no significant difference was observed in the ordinal mRS distribution (adjusted common OR 1.30, 95% CI 0.95 to 1.77, P=0.104). Functional independence rates (26.3% vs 34.7%, P=0.250) and sICH rates (13.0% vs 16.9%, P=0.579) were comparable between groups. Immediate retransfer to spoke centers after EVT did not result in a significant difference in functional outcomes. Further larger studies that include data on hemodynamic stability and respiratory status are needed to establish definitively the safety of retransfer after thrombectomy.