Fatal Intracerebral Hemorrhage Research Articles

Abstract 213: Stroke Severity Adjusted EMS Triage Has Benefits for Bypassed Primary Stroke Centers

Background: Stroke Severity Adjusted EMS triage (SSAET) has been recommended to bypass Primary Stroke Centers (PSC) and transport acute severe strokes to Comprehensive Stroke Centers (CSC) for Neurosurgery, endovascular intervention and research to develop new treatments. There is increased emphasis on hospitals' stroke major complication and mortality rates. Some Hospitalists are reluctant to admit Intracerebral hemorrhage (ICH) patients without in house Neurosurgery coverage. Outcome differences of directly admitted PSC and bypassed CSC patients have not yet been described. Methods: Florida Hospital Stroke Program requests Seminole County EMS use SSAETbypass of Florida Hospital Altamonte PSC to transport acute severe stroke 9.1 miles away to Florida Hospital Orlando CSC. We retrospectively analyzed 310 suspected acute severe strokes/Transient Ischemic attacks(TIA) EMS bypassed to the CSC from 2006 to 2012 and 643 strokes/TIA's transported directly to the PSC. Differences inLength of stay (LOS), frequency of in-hospital mortality/discharge to hospice and major complications (respiratory failure, infection, DVT, PE, MI or recurrent stroke in house) were calculated. Results: The PSC lost an average of 3.69 patients to the CSC each month. The 5.52 day PSC patient average LOS was similar to the bypassed CSC patient 6.00 day LOS. Approximately 1 of every 8 bypassed CSC patients (39 of 310) received Neurosurgery or Endovascular intervention not available at the PSC. Comparing PSC patients to a subset of 209 verified stroke/TIA bypassed CSC patients showed the PSC was 15 times less likely to admit a ICH that dies in hospital or is discharged to hospice (0.6%, 4 of 643) than to be bypassed with such a patient (9.6%, 20 of 209), Odds ratio =15.38, 95% CI =5.2 to 45.5, P<0.0001. The PSC was less likely to admit any stroke (ICH or ischemic) that suffered a major complication (13%, 71 of 643) than to be bypassed with such a patient (34%, 81 of 209), Odds ratio =2.54, 95% CI =1.78 - 3.62, P<0.0001. Conclusion: SSAET bypass was especially effective for diverting fatal ICH away from a PSC without in house Neurosurgery. The bypassed PSC was less likely to admit a strokepatient with a major complication.

Multiple Intracerebral Hemorrhages Prior to the Diagnosis of Acute Lymphocytic Leukemia

Intracerebral Hemorrhage (ICH) can be seen in patients with acute leukemia, however, it is extremely rare to present ICH as the initial presentation in previously undiagnosed acute leukemia. Only four cases were reported in the English literature. This 17-year-old male was admitted with sudden onset of headache, nausea and vomiting. Three days before this admission, he visited an ophthalmological department for bilateral blurred vision. Bilateral retinal hemorrhages were detected by the funduscopic examination; however, further examinations were not performed at that time. On arrival at our hospital, his Glasgow Coma Scale was 8 (E2, V3, M3) and urgent head CT scan showed multiple Computed Tomography (CT) head demonstrated multiple ICHs. On admission, his White Blood Cell (WBC) count was 584,000/μl with evidence of blast crisis, and platelet count was 18,000/μl. Despite urgent platelet and plasma transfusions, his conscious level deteriorated, and the patient died 12 hours after the admission due to respiratory failure. The importance of correct diagnosis and early management of leukemia is emphasized, which may prevent blast crisis and disseminated intravascular coagulation leading to fatal ICH.

Histopathological assessment of fatal ipsilateral intraparenchymal hemorrhages after the treatment of supraclinoid aneurysms with the Pipeline Embolization Device

Delayed ipsilateral intraparenchymal hemorrhage has been observed following aneurysm treatment with the Pipeline Embolization Device (PED). The relationship of this phenomenon to the device and/or procedure remains unclear. The authors present the results of histopathological analyses of the brain sections from 3 patients in whom fatal ipsilateral intracerebral hemorrhages developed several days after uneventful PED treatment of supraclinoid aneurysms. Microscopic analyses revealed foreign material occluding small vessels within the hemorrhagic area in all patients. Further analyses of the embolic materials using Fourier transform infrared (FTIR) spectroscopy was conducted on specimens from 2 of the 3 patients. Although microscopically identical, the quantity of material recovered from the third patient was insufficient for FTIR spectroscopy. FTIR spectroscopy showed that the foreign material was polyvinylpyrrolidone (PVP), a substance that is commonly used in the coatings of interventional devices. These findings are suggestive of a potential association between intraprocedural foreign body emboli and post-PED treatment-delayed ipsilateral intraparenchymal hemorrhage.

Response to Letter Regarding Article, “Endovascular Stroke Therapy: Tirofiban Is Associated With Risk of Fatal Intracerebral Hemorrhage and Poor Outcome”

We would like to thank Schlachetzki et al for their comments and interest in our article about the administration of tirofiban, which may cause a higher incidence of fatal intracerebral hemorrhage and poor outcome in patients who have received endovascular stroke therapy.1,2 We fully agree with the highlighted limitations, which were already mentioned in our article (eg, higher rate of stenting in the tirofiban group). Of course, the main limitation is the nonrandomized study design, which gives imbalances between the groups. A further limitation of our study is that tirofiban was not only administered after stent implantation, but also in patients in whom endothelial damage was suspected (for example, …

Elderly patients (>75 years) with intermediate risk pulmonary embolism and acute right ventricle pressure overload treated with systemic thrombolysis: 6 years experience of a single center

Purpose: The benefits of extending thrombolysis (TBL) to clinically stable elderly patients (pts) with acute pulmonary embolism (PE) and excessive right ventricular (RV) pressure overload remains controversial. The aim of this study was to assess the effect of TBL plus unfractionated heparin (UFH) versus UFH alone on echocardiographically detected pulmonary systolic pressure (PsP) and short-term clinical outcome in haemodynamically stable elderly pts (>75 years old) with PE and PsP> 50 mmHg in absence of RV hypertrophy (RV free wall thickness < 5mm). Methods: According to the European Society of Cardiology PE guidelines (2008), pts were classified into high, intermediate and low risk of early mortality. A shock index, defined as heart rate divided by systolic blood pressure, was calculated in all pts on admission. Echocardiography was performed at the time of EP diagnosis and repeated 24 hours after the starter of therapy. TBL (tPA, 100 mg) and UFH were infused at approved regimens for PE. Results: Between January 2007 and December 2012, 95 pts were referred to our institute for objectively confirmed acute PE, 66 (69.3%) were > 75 years old (age 83.8±4.5 years, 58 females). In this subgroup of pts there were 3 high (4,5%), 46 intermediate (69,7%) and 17 low risk pts (25,8%); PsP> 50 mmHg without RV hypertrophy was detected in 30 elderly pts with intermediate risk PE; the shock index was > 1 in 84% and in 57% of intermediate risk elderly pts, with or without PsP >50 mmHg, respectively. 15 pts received TBL plus UFH (group A, age 82.9±4.9 years) and 15 were treated with UFH alone (group B, age 84.8.±3.9 years). Both groups were well matched with regard to features and clinical presentation. The PsP decreased from a pretreatment value of 64±14mmHg to 37±14 mmHg at 24 hours for group A and from 62±14 mmHg to 46±15 mmHg for group B pts (p<0.001). There were no fatal bleeding episodes or intracerebral hemorrhage in both treatment groups. One patient of the group B developed a cardiogenic shock and died during hospitalization. Conclusions: Our study shows that pts with PE are more often elderly pts with intermediate risk of early death. Echocardiographic evidence of PsP > 50 mmHg and normal RV free wall thickness selects pts at increased risk for adverse clinical outcome. For those pts, TBL results safe and effective, leading to a significant early reduction in the PsP.

Acute interventional recanalisation of vertebrobasilar stenoses by angioplasty: complications and 12 months follow up

In acute symptomatic vertebrobasilar artery stenosis, the use of mechanical recanalisation remains controversial. The complication rate of acute interventional recanalisation (aIR) has to be considered, as evidence from randomised trials is lacking. In a single centre retrospective case series, we here describe complications and outcome after aIR. We retrospectively assessed aIR in a tertiary care centre and included the following parameters: indication for aIR, national institute of health stroke scale (NIHSS) score on admission, recanalisation by thrombolysis in myocardial infarction score (TIMI) grades, post-interventional complications, mortality, NIHSS and modified Rankin scale at follow-up and rate of restenosis. We identified 14 aIR (14 percutaneous transluminal angioplasty with or without stent implantation in 12 patients; 6/12 with thrombolysis; n = 6 vertebral artery, n = 8 basilar artery; 4 women, mean age 67 years). Mortality was 25 % (3/12) after 7 days and 42 % (5/12) after 12 months. In 12/14, interventions are complete (TIMI 3, 86 %), in 2/14, a partial recanalisation (TIMI 2, 14 %) was achieved. In one case, a peri-interventional fatal intracerebral haemorrhage occurred (1/12, 8 %). At late follow-up (mean 342 days), one re-occlusion (1/7, 14 %) and one recurrent stroke (1/12, 8 %) were observed. In our single centre series of vertebrobasilar aIR recanalisation rate was high. However, procedural safety and clinical outcome varied considerably. The results of aIR need to be assessed in multicentric registers to define the procedural risk and outcome in the clinical setting.

Tissue-Type Plasminogen Activator for Stroke Mimics

In the April issue of Stroke , we have yet another study on the safety of tissue-type plasminogen activator (tPA) for patients with stroke mimics (SM). Zinkstok et al1 conducted a multicenter retrospective analysis of patients with SM treated with tPA at primary and community hospitals. With 100 patients reported in the largest series to date, the authors found, like all the previous cohort studies, a low rate of symptomatic intracerebral hemorrhage and death.2,3 There were no instances of orolingual edema or fatal intracerebral hemorrhages. The incidence of SM in their cohort among all tPA-treated patients was on the lower end of other reports: 2% to 31%.2,4–6 This rate is also much lower than the 7% misdiagnosis rate reported for emergency departments in which tPA was administered without a stroke team evaluation.7 In fact, …

Endovascular Stroke Therapy

To investigate the relationship between severe bleeding complications and outcome after mechanical thrombectomy with or without glycoprotein-IIb/IIIa inhibitor tirofiban treatment. The study included prospectively collected data of consecutive patients with acute ischemic stroke in whom mechanical thrombectomy was perfomed in the years 2006 to 2011. Of 162 patients, 128 patients had anterior circulation stroke, and 34 patients had posterior circulation stroke. Additional treatment with tirofiban was given to 30 of 128 patients with anterior circulation stroke and to 20 of 34 patients with posterior circulation stroke. Treatment with tirofiban did not influence recanalization rates. Fatal intracerebral hemorrhage occurred more frequently in tirofiban-treated patients in the entire cohort (12.0% vs 2.7%; P=0.03) and in tirofiban-treated patients with anterior circulation stroke (13.3% vs 3.1%; P=0.05). Logistic regression found age (odds ratio, 1.17; 95% confidence interval, 1.00-1.37; P=0.05) and tirofiban treatment (odds ratio, 3.03; 95% confidence interval, 1.50-4.05; P=0.04) to be independent predictors for fatal intracerebral hemorrhage. Tirofiban treatment was also an independent predictor for poor outcome (odds ratio, 6.60; 95% confidence interval, 1.06-41.52; P=0.04) in addition to National Institute of Health Stroke Scale (odds ratio, 1.08; 95% confidence interval, 1.00-1.17; P=0.05). In endovascular stroke therapy, additional treatment with the glycoprotein-IIb/IIIa inhibitor tirofiban is associated with increased risk of fatal intracerebral hemorrhage and poor outcome.

Genetic and cellular basis of cerebral cavernous malformations: implications for clinical management

Cerebral cavernous malformations (CCMs) are a diffuse cerebrovascular disease affecting approximately 0.5% of the population. A CCM is characterized by abnormally enlarged and leaky capillaries arranged in mulberry-like structures with no clear flow pattern. The lesion might predispose to seizures, focal neurological deficits or fatal intracerebral hemorrhage. However, a CCM can also remain neurologically silent. It might either occur sporadically or as an inherited disorder with incomplete penetrance and variable expressivity. Due to advances in imaging techniques, the incidence of CCM diagnoses are increasing, and the patient must be managed on a multidisciplinary basis: genetic counselling, treatment if needed, and follow-up. Advances have been made using radiological and pathological correlates of CCM lesions adding to the accumulated knowledge of this disease, although management of these patients is very variable among centers. This review is aimed at providing an update in genetic and molecular insights of this condition. Included are implications for genetic counselling, and possible approaches to prevention and treatment that derive from the understanding of pathogenetic mechanisms.

Rhinocerebral mucormycosis complicated by massive cerebral hemorrhage

Rhinocerebral mucormycosis is a rare but usually fatal infection caused by fungi from the order Mucorales. These fungi has strong predilection for growth into arteries, lymphatics and nerves and this is the reason for their rapid spread to adjacent tissues with accompanying tissue ischemia and infarction due to vascular occlusion after a fibrin reaction and mucor thrombus. We describe a 54 year old Thai national male with poorly controlled type 2 diabetes, ischemic heart disease, hypertension and renal impairment who presented to the emergency department with fever, vomiting and painful left eye swelling, which progressed rapidly leading to complete opthalmoplegia and vision loss. The diagnosis of mucormycosis was confirmed later and was the patient was started on Amphotericin B therapy. Despite stable clinical course, he suddenly developed a fatal intracerebral hemorrhage and died within 24 hours of the bleed. We wonder weather patients with cerebral fungal infection should perhaps have an early neurosurgical intervention to rule out the presence of mycotic aneurysm; particularly that many cases of fatal cerebral bleed have been reported in association with Rhinocerebral mucormycosis.

Intracranial Aneurysms: Midterm Outcome of Pipeline Embolization Device—A Prospective Study in 143 Patients with 178 Aneurysms

To evaluate the midterm clinical and angiographic outcomes after pipeline embolization device (PED) placement for treatment of intracranial aneurysms. This prospective nonrandomized multicenter study was approved by the review boards of all involved centers; informed consent was obtained. Patients (143 patients, 178 aneurysms) with unruptured saccular or fusiform aneurysms or recurrent aneurysms after previous treatment were included and observed angiographically for up to 18 months and clinically for up to 3 years. Study endpoints included complete aneurysm occlusion; neurologic complications within 30 days and up to 3 years; clinical outcome of cranial nerve palsy after PED placement; angiographic evidence of occlusion or stenosis of parent artery and that of occlusion of covered side branches at 6, 12, and 18 months; and clinical and computed tomographic evidence of perforator infarction. There were five (3.5%) cases of periprocedural death or major stroke (modified Rankin Scale [mRS] > 3) (95% confidence interval [CI]: 1.3%, 8.4%), including two posttreatment delayed ruptures, two intracerebral hemorrhages, and one thromboembolism. Five (3.5%) patients had minor neurologic complications within 30 days (mRS = 1) (95% CI: 1.3%, 8.4%), including transient ischemic attack (n = 2), small cerebral infarction (n = 2), and cranial nerve palsy (n = 1). Beyond 30 days, there was one fatal intracerebral hemorrhage and one transient ischemic attack. Ten of 13 patients (95% CI: 46%, 93.8%) completely recovered from symptoms of cranial nerve palsy within a median of 3.5 months. Angiographic results at 18 months revealed a complete aneurysm occlusion rate of 84% (49 of 58; 95% CI: 72.1%, 92.2%), with no cases of parent artery occlusion, parent artery stenosis (<50%) in three patients, and occlusion of a covered side branch in two cases (posterior communicating arteries). Perforator infarction did not occur. PED placement is a reasonably safe and effective treatment for intracranial aneurysms. The treatment is promising for aneurysms of unfavorable morphologic features, such as wide neck, large size, fusiform morphology, incorporation of side branches, and posttreatment recanalization, and should be considered a first choice for treating unruptured aneurysms and recurrent aneurysms after previous treatments. http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120422/-/DC1.

Factor XIII‐A subunit Val34Leu polymorphism in fatal hemorrhagic stroke

Blood coagulation factor XIII (FXIII) plays a key role in the protection of fibrin clot against fibrinolysis, in the cross-linking of fibrin and its mechanical strength. The role of the FXIII-A subunit Val34Leu polymorphism with fatal primary intracerebral hemorrhages (PICH) has not been studied. We evaluated retrospectively the prevalence of this polymorphism in stroke patients with fatal PICH and population control matched for age and gender. The prevalence of this polymorphism was determined for patients with fatal PICH (n=98, female/male: 41/57) and controls. DNA was obtained from peripheral white blood cells in case of controls and from paraffin-embedded tissue sections in case of fatal PICH. The odds for increasing the risk of PICH against the control group were 5.429, 3.286, and 7.661 for total, female, and male patients, respectively. The Leu34Leu homozygous variant of the FXIII Val34Leu polymorphism significantly increased the risk of fatal PICH stroke in men.

Hemiplegia and thrombolysis

Hemiplegia at stroke onset may be considered a contraindication for thrombolytic therapy. We describe the outcome of patients with ischaemic stroke presenting with hemiplegia and treated with intravenous alteplase (tPA). All patients treated with tPA for acute ischaemic stroke between 1995 and 2010 were prospectively recorded in the Helsinki Stroke Thrombolysis Registry. Patients with basilar artery occlusion (BAO) were excluded. Hemiplegia was defined as no visible voluntary movement on ipsilateral arm and leg. Of all treated patients (n = 1579), we excluded those with BAO (n = 152). Of remaining 1427 patients, 81 (6%) had hemiplegia at baseline. By 24 h, three had died and 20 retained their total hemiplegia. At day 7, a further nine had died, and 10 had persistent hemiplegia. A good 3-month outcome, modified Rankin Scale (mRS, 0-2), was observed in 23%, independence in ambulatory function (mRS 3) in further 16%, while 9% were bedridden and 20% dead. A wide clinical spectrum of neurological deficits coexisted with hemiplegia. With advanced age, more neurological functions lost, and with early radiological signs, the prognosis of patients with hemiplegia deteriorated. With combined fixed eye deviation (n = 23), half were either bedridden (n = 3) or dead (n = 9) by 3 months, and fatal intracerebral haemorrhage were common (n = 5). Hemiplegia at presentation should not prevent thrombolytic therapy by itself, as limb movements are likely to return, and two of five thrombolysis-treated patients will walk independently by 3 months. With combined fixed eye deviation, the outcome is poorer and haemorrhagic complications are common.

Factors Associated with Favorable Response to Hyperbaric Oxygen Therapy among Patients Presenting with Iatrogenic Cerebral Arterial Gas Embolism

Iatrogenic cerebral arterial gas embolism (CAGE) is an uncommon but potentially a fatal condition. Hyperbaric oxygen (HBO2) therapy is the only definitive treatment for patients with CAGE presenting with acute neurologic deficits. We reviewed medical records and neuroimaging of consecutive CAGE patients treated with HBO2 at a state referral hyperbaric facility over a 22-year period. We analyzed the effect of demographics, source of intra-arterial gas, signs and symptoms, results of imaging studies, time between event and HBO2 treatment, and response to HBO2 treatment in 36 consecutive patients. Favorable outcome was defined by complete resolution or improvement of CAGE signs and symptoms at 24 h after HBO2 treatment. Unfavorable outcome was defined by unchanged or worsened neurologic signs and symptoms or in hospital death. A total of 26 (72%) of the 36 patients had favorable outcome. Patients with favorable outcome were younger compared to those with unfavorable outcome (mean age [years, SD] 44.7 ± 17.8 vs. 58.1 ± 24.1, p = 0.08). Cardiopulmonary symptoms were significantly more common in CAGE related to venous source of gas compared to arterial source (p = 0.024) but did not influence the rate of favorable outcomes. Adjusted multivariate analysis demonstrated that time from event to HBO2 ≤ 6 h (positively) and the presence of infarct/edema on head computerized tomography (CT)/magnetic resonance imaging (MRI) before HBO2 (negatively) were independent predictors of favorable outcome at 24 h after HBO2 treatment [odds ratio (OR) 9.08 confidence interval (CI) (1.13-72.69), p = 0.0376, and (OR) 0.034 (CI) (0.002-0.58), p = 0.0200, respectively]. Two of the 36 patients were treated with thrombolytics because of acute focal deficits and suspected ischemia-one with intravenous and the second with intra-arterial thrombolysis. The latter patient developed fatal intracerebral hemorrhage. A high proportion of CAGE patients treated with HBO2 had favorable outcomes. Time-to-HBO2 ≤ 6 h increased the odds of favorable outcome, whereas the presence of infarct/edema on CT/MRI scan before HBO2 reduced the odds of a favorable outcome. Timely diagnosis and differentiation from thrombo-embolic ischemic events appears to be an important determinant of successful HBO2 treatment.

Endovascular treatment of tandem occlusions of the anterior cerebral circulation with solitaire FR thrombectomy system. Initial experience

PurposeThe optimal treatment in the acute phase of cervical internal carotid occlusion associated with intracranial obstruction is a matter of debate. In this study, we report our experience using the Solitaire FR revascularization device and synchronous intravenous fibrinolysis. The distal occlusion was treated with Solitaire FR before the proximal one in all cases, a technique not reported so far in the literature. MethodsWe examined all cases of tandem occlusion treated in our institution between November 2009 and November 2010. The proximal occlusion was treated using manual thromboaspiration in order to achieve intracranial recanalization as rapid as possible. When necessary, stenting was performed after the reconstitution of the intracranial vessel. Morphological and clinical results were recorded in the immediate post-operative phase and at the three-month follow-up. Clinical success was defined as a mRS at 3 months ≤2. ResultsFour male and six female patients were treated (mean age 66 years). The cervical carotid was recanalized in all cases and the intracranial vessel (TICI≥2b) in eight. Adverse events were recorded in four patients of which three were asymptomatic. These included two cases of subarachnoid hemorrhage, one case of traumatic dissection, and one case of fatal intra-cerebral hemorrhage seven days following the procedure. At the three-month follow-up a mRS≤2 was observed in four patients. ConclusionsThe described approach for the treatment of tandem occlusions is promising with regard to both morphological and clinical assessments and thus may be considered a valid tool in acute stroke.

Abstract 3665: COL4A1 and COL4A2 Mutations cause Genetically Modifiable Cerebrovascular Diseases

Mutations in the type IV collagen alpha 1 gene (COL4A1) cause Cerebrovascular Diseases (CVDs) in mice and human patients. Patients with COL4A1 mutations suffer from a broad range of CVDs, from infantile porencephaly to debilitating or fatal intracerebral hemorrhage (ICH), to subclinical cerebral microbleeds, suggesting that environmental and other genetic factors may influence their phenotypes. COL4A1 is one of the most abundant proteins in basement membranes and forms heterotrimers with COL4A2. Among possible pathogenic mechanisms are cellular stress due to the toxic intracellular aggregation of the COL4A1 and COL4A2 proteins and/or their absence in the basement membrane. Our first goal is to identify the relative contributions of COL4A1 and COL4A2 mutations to sporadic ICH and to understand the cellular mechanisms and genetic complexity underlying the disease. We identified novel COL4A1 mutations and for the first time, we discovered COL4A2 mutations in a cohort of 96 patients with sporadic ICH. Using a cell-based assay we determined that the mutations impair COL4A1 and COL4A2 secretion. We showed that mutant COL4A1 or COL4A2 proteins accumulate within the cell where they titrate normal COL4A1 and COL4A2 proteins. Interestingly, we found that some of the mutations can ultimately result in endoplasmic reticulum (ER) stress and activation of the Unfolded Protein Response. Our second goal was to test the hypothesis that differences in genetic context could contribute to phenotypic variability in human patients. Thus, we characterized CVD in Col4a1 mutant mice with two different genetic backgrounds. Using cerebral magnetic resonance imaging and histological analysis, we show that one or more genetic modifiers from the CAST/EiJ strain significantly reduce the size and frequency of ICHs detected in Col4a1 mutant mice on a C57BL/6J background. In conclusion, we found that both COL4A1 and COL4A2 mutations cause ICH in human patients, our results support that ER stress could be involved in the pathogenesis and we showed that genetic context is crucial for expressivity and severity of the CVD. We predict that ongoing experiments to better understand the cell biology of COL4A1 and COL4A2 mutations and the mechanisms of genetic modification could lead to targeted therapeutics to reduce the risk of CVD in patients with COL4A1 or COL4A2 mutations.

Abstract 3199: Factors Associated with Favorable Response to Hyperbaric Oxygen Therapy among Patients Presenting with Iatrogenic Cerebral Arterial Gas Embolism

Background: Iatrogenic cerebral arterial gas embolism (CAGE) is an uncommon but potentially fatal condition. Hyperbaric oxygen (HBO 2 ) treatment is the only first line treatment for patients with CAGE presenting with acute neurological deficits. Methods: We reviewed medical records and neuroimaging of consecutive CAGE patients treated with HBO 2 at a state referral hyperbaric facility over a 22 year period. We analyzed the effect of demographics, source of intra-arterial gas, signs and symptoms, results of imaging studies, time between insult and HBO 2 treatment, and response to HBO 2 treatment in 36 consecutive patients. Favorable outcome was defined by complete resolution or improvement of CAGE signs and symptoms. Unfavorable outcome was defined by unchanged or worsened neurologic signs and symptoms or in hospital death. Results: A total of 26 (72%) of the 36 patients had favorable outcome. Patients with favorable outcome were younger compared to those with unfavorable outcome (mean age [years, SD] 44.7± 17.8 vs. 58.1 ± 24.1, p-value=0.08). Time-to-HBO 2 ≤ 6 hours was significantly associated with favorable outcome compared ≥ 6 hrs (p-value = 0.025). Cardiopulmonary symptoms associated with CAGE were significantly more common in venous source of gas compared to arterial (p-value = 0.024) but did not influence the rate of favorable outcomes. Two of 36 patients were treated with thrombolytics due to acute focal deficits and suspected ischemia - one with intravenous and the second one with intra-arterial thrombolysis. The later patient developed fatal intracerebral hemorrhage. Conclusions: A high proportion of CAGE patients treated with HBO2 had favorable outcomes. Young age and time-to-HBO 2 ≤ 6 hours were associated with higher rate of favorable outcome. Timely diagnosis and differentiation from thrombo-embolic ischemic events is an important determinant of successful HBO2 treatment.

Fatal intracranial hemorrhage as the initial presentation of acute lymphocytic leukemia: case report

Hemorrhagic complications of acute leukemia are well described and are a common cause of mortality in these patients. However, to our knowledge, fatal intracerebral hemorrhage (ICH) as an initial presentation of acute lymphocytic leukemia (ALL) has only been reported once. We report a case of previously undiagnosed ALL presenting with ICH. Our patient is a 17-year old male who was found unresponsive several hours after complaining of headache. Initial emergency room evaluation found the patient to have anisocoria with a fixed and dilated right pupil and demonstrated evidence of decorticate posturing. Imaging revealed a large right-sided intraparenchymal hemorrhage, intraventricular hemorrhage, midline shift, and uncal herniation. Laboratory evaluation showed marked leukocytosis with blastic predominance and evidence of disseminated intravascular coagulopathy. Emergent surgical intervention was performed. However, despite evacuation of the hematoma, the patient eventually progressed to clinical brain death. Usually, ICH is seen in ALL patients after the diagnosis has been made. We report a unique case of fatal intracranial hemorrhage as the initial presentation of ALL and discuss the possible management dilemmas to treat such entities. ALL should be kept in the broad differential diagnosis of spontaneous ICH, especially in a young patient with evidence of severe coagulopathy.

P-023 Endovascular treatment of tandem occlusions of the anterior cerebral circulation

Background and purposeThe optimal treatment in the acute phase of cervical internal carotid artery (CICA) occlusion associated with carotid “T” or middle cerebral artery obstruction is a matter of debate....

High-Flow Extracranial-to-Intracranial Excimer Laser–Assisted Nonocclusive Anastomosis Bypass for Symptomatic Carotid Artery Occlusion

A high-flow bypass is theoretically more effective than a conventional low-flow bypass in preventing strokes in patients with symptomatic carotid artery occlusion and a compromised hemodynamic state of the brain. To study the results of excimer laser-assisted nonocclusive anastomosis (ELANA) high-flow extracranial-to-intracranial (EC-IC) bypass surgery in these patients. Between August 1998 and May 2008, 24 patients underwent ELANA EC-IC bypass surgery because of transient ischemic attacks or minor ischemic stroke associated with carotid artery occlusion. We retrospectively collected information. Follow-up data were updated by structured telephone interviews between May and September 2008. In all patients, the ELANA EC-IC bypass was patent at the end of surgery with a mean flow of 106 ± 41 mL/min. Within 30 days after the operation, 22 patients (92%) had no major complication, whereas 2 patients (8%) had a fatal intracerebral hemorrhage. During follow-up of a mean 4.4 ± 2.4 years, the bypass remained patent in 18 of the 22 surviving patients (82%) with a mean flow of 141 ± 59 mL/min. All patients with a patent bypass remained free of transient ischemic attacks and ischemic stroke. In 4 patients, the bypass occluded, accompanied by ipsilateral transient ischemic attacks in 2 patients, ipsilateral ischemic stroke in 1 patient, and contralateral ischemic stroke in another patient. ELANA EC-IC bypass surgery in patients with carotid artery occlusion is technically feasible and results in cessation of ongoing transient ischemic attacks and minor ischemic strokes, but carries a risk of postoperative hemorrhage.