Fibrinolytic Treatment Research Articles

Spontaneous intracerebral hemorrhage – patients retrospectively consent to fibrinolytic surgery despite poor neurological outcome and reduced health-related quality of life

Spontaneous intracerebral hemorrhage (ICH) might lead to devastating consequences. Nonetheless, subjective interpretation of life circumstances might vary. Recent data from ischemic stroke patients show that there might be a paradox between clinically rated neurological outcome and self-reported satisfaction with quality of life. Our hypothesis was that minimally invasive surgically treated ICH patients would still give their consent to stereotactic fibrinolysis despite experiencing relatively poor neurological outcome. In order to better understand the patients’ perspective and to enhance insight beyond functional outcome, this is the first study assessing disease-specific health-related quality of life (hrQoL) in ICH after fibrinolytic therapy. We conducted a retrospective analysis of patients with spontaneous ICH treated minimally invasive by stereotactic fibrinolysis. Subsequently, using standardized telephone interviews, we evaluated functional outcome with the modified Rankin Scale (mRS), health-related Quality of Life with the Quality of life after Brain Injury Overall scale (QOLIBRI-OS), and assessed retrospectively if the patients would have given their consent to the treatment. To verify the primary hypothesis that fibrinolytic treated ICH patients would still retrospectively consent to fibrinolytic therapy despite a relatively poor neurological outcome, we conducted a chi-square test to compare good versus poor outcome (mRS) between consenters and non-consenters. To investigate the association between hrQoL (QOLIBRI-OS) and consent, we conducted a Mann-Whitney U-test. Moreover, we did a Spearman correlation to investigate the correlation between functional outcome (mRS) and hrQoL (QOLIBRI-OS). The analysis comprised 63 data sets (35 men, mean age: 66.9 ± 11.8 years, median Hemphill score: 3 [2-3]). Good neurological outcome (mRS 0–3) was achieved in 52% (33/63) of the patients. Patients would have given their consent to surgery retrospectively in 89.7% (52/58). These 52 consenting patients comprised all 33 patients (100%) who achieved good functional outcome and 19 of the 25 patients (76%) who achieved poor neurological outcome (mRS 4–6). The mean QOLIBRI-OS value was 49.55 ± 27.75. A significant association between hrQoL and retrospective consent was found (p = 0.004). This study supports fibrinolytic treatment of ICH even in cases when poor neurological outcome would have to be assumed since subjective perception of deficits could be in contrast with the objectively measured neurological outcome. HrQoL serves as a criterion for success of rtPa lysis therapy in ICH.

Mechanical circulatory support in high-risk PE for more than a decade

Abstract Funding Acknowledgements None. Background/Introduction Absence of solid evidence in clinical practice guidelines on the management of patients with a severe pulmonary thromboembolism (PTE) in a situation of cardiogenic shock requiring mechanical circulatory support (veno-arterial ECMO). A registry has been carried out in a tertiary hospital of patients admitted to the Cardiological Critical Care Unit (CCCU) with a diagnosis of high-risk PTE and V-A ECMO implantation. Purpose The objective is to describe the experience of our center due to the paucity of evidence from current guidelines in this area iin terms of morbimortality and expected outcomes. Methods Data were collected from all patients admitted with a diagnosis of high-risk PE in the CCCU from 05/01/2010 to 05/01/2023. Of these, only those in whom V-A ECMO was implemented during admission were analyzed and described below. Clinical, analytical and survival variables were explored. Results A total of 11 patients were included, 3 (27.27%) being women. The mean age was 53 years (SD 10.64). Every V-A ECMO cannulation was performed in a femoro-femoral configuration by a surgical approach. The mean length of stay in the Critical Care Unit, total hospital stay length and circulatory support time were respectively: 8 days (SD 5.5); 20.7 days (DS 16.5) and 3 days (DS 1.9). The indication for the implantation of V-A ECMO was in a situation of SCAI-E in 7 patients (in 2 of them, V-A ECMO was implanted during cardiac arrest, and a 100% of mortality was described in the first 24 hours). On the other hand, in the remaining 4 patients, the indication for support was a deteriorating evolution despite amines. Of these, in 2 of them, there was a formal contraindication for the administration of systemic fibrinolytic treatment (recent major surgery, in one of them oncology). It should be noted that VA ECMO without adjuvant fibrinolysis was used in 6 of the patients (54.5%), and in 1 of them (16%) of them died (anoxic encephalopathy). However, the remaining 5 patients received combined VA ECMO therapy and systemic fibrinolysis (45.5%), with 2 deaths reported in this subgroup (40%). Those deceases happened both due to adequacy of the therapeutic effort in the context of multiple organ failure. No major bleeding was reported, even in the combination therapy group. Conclusions Support with V-A ECMO has allowed survival >70% in patients diagnosed with high-risk pulmonary embolism, including in those cases with absolute contraindication for systemic fibrinolysis. High safety profile in terms of bleeding even in those patients with a combined approach.

Analysis of real-time data gathered using a mobile application from patients treated after code stroke activation in Alicante

IntroductionManagement of code stroke (CS) is complex, and the collection of information for subsequent evaluation is crucial. We present data obtained using a mobile application on the management of CS between 2020 and 2021 at the Hospital General Universitario Dr. Balmis (HGUB), a tertiary-level hospital that is the reference centre for endovascular treatment (EVT) in the province of Alicante. Material and methodsWe conducted a prospective, observational study of all patients attended after CS activation at the HGUB in 1 year. Data were collected using a specifically designed mobile application (CODICT). We present a descriptive analysis of patients' baseline characteristics, call flow, acute phase care, treatment rates, and mortality and functional outcomes at discharge and at 3 months in patients receiving EVT. ResultsA total of 1018 CS activations were recorded. Revascularisation treatment (intravenous fibrinolytic treatment [IVT], EVT, or EVT+IVT) was performed in 252 patients (24.75%), of whom 177 (17.38%) received EVT, amounting to a mean rate of 9.43 per 100 000 population. By healthcare district, the lowest rate was 3.16 and the highest was 16.40. A total of 49.32% of patients receiving EVT presented favourable functional status (mRS≤2) at 90 days. ConclusionThe data collected during IC care can be traced in real time through mobile applications. The potential of this approach is demonstrated by the volume of data collected during 1 year. These data show considerable disparities in access to EVT in the province of Alicante, which could be suggested as an area for improvement.

Leptomeningeal collaterals regulate reperfusion in ischemic stroke and rescue the brain from futile recanalization

Recanalization is the mainstay of ischemic stroke treatment. However, even with timely clot removal, many stroke patients recover poorly. Leptomeningeal collaterals (LMCs) are pial anastomotic vessels with yet-unknown functions. We applied laser speckle imaging, ultrafast ultrasound, and two-photon microscopy in a thrombin-based mouse model of stroke and fibrinolytic treatment to show that LMCs maintain cerebral autoregulation and allow for gradual reperfusion, resulting in small infarcts. In mice with poor LMCs, distal arterial segments collapse, and deleterious hyperemia causes hemorrhage and mortality after recanalization. In silico analyses confirm the relevance of LMCs for preserving perfusion in the ischemic region. Accordingly, in stroke patients with poor collaterals undergoing thrombectomy, rapid reperfusion resulted in hemorrhagic transformation and unfavorable recovery. Thus, we identify LMCs as key components regulating reperfusion and preventing futile recanalization after stroke. Future therapeutic interventions should aim to enhance collateral function, allowing for beneficial reperfusion after stroke.

Safety and Effectiveness of Fibrin Sheath Stripping of Pediatric Chest Ports

PurposeTo report the safety and effectiveness of fibrin sheath stripping of pediatric chest ports. Materials and MethodsFibrin sheath stripping procedures for pediatric chest ports between 2018 and 2023 were retrospectively reviewed. The treatment indication was the inability to aspirate blood from the port. The technical success, adverse events, days of primary and secondary service intervals, fluoroscopy time, and fluoroscopy dose were recorded. ResultsFibrin sheath stripping procedures were performed in 15 patients for a total of 18 procedures. All patients treated with fibrin sheath stripping had failed fibrinolytic treatment and a preprocedural fluoroscopy examination suggestive of fibrin sheath before attempting stripping. All fibrin sheath stripping procedures were technically successful. The median and mean total days of primary service interval from the date of port placement to the date of suspected fibrin sheath were 666 and 617 days, respectively. The median and mean total number of days of secondary service interval were 385 and 561 days, respectively. The mean fluoroscopy time was 16.9 minutes. The mean fluoroscopy air kerma was 29.8 mGy. No adverse events were observed. ConclusionsFibrin sheath stripping is a safe and effective minimally invasive option to maintain the function of pediatric chest ports.

Current treatment of acute coronary syndromes in cancer patients: the need for improvement

Abstract Background Cancer patients can develop acute coronary syndromes (ACS) due to their oncological therapy exposure or shared risk factors between cancer and cardiovascular disease. Cancer patients have been reported to receive suboptimal treatment in this setting, with lower rates of coronary angiography and or primary percutaneous intervention, despite the clear benefit of these therapies in ACS. This disparity in the care of cancer patients can lead to worse cardiovascular outcomes. Purpose To describe the contemporary therapeutic approach in patients with a history of cancer or current cancer presenting with an acute coronary syndrome to a tertiary care cardiology hospital. Methods We performed an electronic chart review of patients admitted to the cardiac intensive coronary unit of a tertiary care Cardiology hospital in our city, from May 2021 to February 2023. Patients with a current or historical diagnosis of cancer and acute coronary syndrome (with and without ST segment elevation) were identified. We collected the following information: demographic data, oncological diagnosis, cancer treatment history, ACS type, and ACS management. Results Seventy-five patients had diagnosis of current or historical cancer in the selected period. Of them, 40 patients were admitted with diagnosis of acute coronary syndrome. Mean age was 69.8 + 10.0 years. Twenty-one patients (52.5%) had a historical diagnosis of cancer and nineteen patients had diagnosis of current cancer. Of patients with historical cancer the most common type was hematological, followed by prostate and renal cancer. The most common types of active malignancies were prostate, colon, and renal cancer. ST-segment elevation myocardial infarction (STEMI) was the most common type of ACS (27 patients). Notably, only half of the patients presenting with STEMI underwent primary percutaneous coronary intervention, four patients received fibrinolytic treatment, and one third of patients with STEMI did not receive reperfusion therapy. Among patients with STEMI, mean time from symptom onset to reperfusion therapy was 495 minutes. Regarding the 13 patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI), eight underwent an invasive strategy (coronary angiography) in the first 48 hours, of whom six had percutaneous coronary intervention, and one underwent coronary artery bypass graft surgery. Five patients with NSTEMI (38.4%) did not undergo coronary angiography during their hospitalization. Conclusions Patients with active or historical cancer presenting with STEMI receive late reperfusion treatment and up to one out of three do not receive reperfusion therapy. An important proportion of cancer patients presenting with NSTEMI do not even undergo invasive strategy. It is imperative to provide optimal care of cancer patients presenting with ACS.

Does Emergency Medical Services Blood Collection Shorten Time to Tissue Plasminogen Activator in Ischemic Stroke?

Background: Ischemic stroke is the leading cause of long-term disability in the United States. To reduce the likelihood of debilitating outcomes, early treatment with fibrinolytics is necessary; however, many struggle to identify strategies that limit time to treatment. The purpose of this study is to identify if implementing a process for obtaining laboratory blood draws by emergency medical services (EMS) prior to patient arrival at the hospital will reduce the door-to-needle time for patients arriving with acute ischemic stroke. Objectives: To compare the door-to-needle time for patients with acute ischemic stroke who had blood drawn via EMS versus in hospital. Methods: This single-center, retrospective cohort study was conducted from 2015 to 2017 at a 433-bed designated Level II Trauma Center and Comprehensive Stroke Center community hospital. A comprehensive chart review was done via stroke coordinator binders and electronic medical record. Adult patients ≥18 years of age with an acute ischemic stroke diagnosis who met criteria for and received alteplase were included in the study. Patients were excluded if they did not arrive via EMS. The primary end point assessed time to fibrinolytic treatment via door-to-needle times. Results: A total of 66 patients were included with 28 in the EMS laboratory drawn group and 38 in the usual group. Median door-to-needle time was 57.5 ± 19.0 minutes in the EMS group and 55.0 ± 31.9 minutes in the usual care group (p = 0.818). Conclusions: Collection of blood for laboratories by EMS personnel did not significantly shorten door-to-needle time.

Post COVID-19 Pediatric Acute Myocardial Infarction In a Known Case of Acute Lymphoblastic Leukemia (A case Report)

A known case of acute lymphoblastic leukemia presented with short history of COVID-19 infection complicated by mucormycosis, admitted to emergency department complaining from irritability, sweating and central cyanosis. After providing a detailed history, clinical examination and laboratory work up; he was diagnosed as acute myocardial infarction that needs fibrinolytic treatment in PICU and then discharged well.

WHEN PERCUTANEOUS CORONARY INTERVENTION (PCI) IS NOT AN OPTION - CONSERVATIVE TREATMENT OF STEMI DUE TO THE CONTRAINDICATIONS AND SEVERE COVID-19 INFECTION

Objective: The case report presents patient with the history of ST-segment elevation myocardial infarction (STEMI) and COVID-19 infection. STEMI is one of the acute coronary syndromes, defined as sudden ischaemia of the heart muscle. The most common cause of STEMI is the abrupt cessation in coronary artery blood flow based on pre-existing atherosclerosis. Percutaneous coronary intervention (PCI) remains the gold standard for patients with STEMI. In some cases, due to contraindications, only conservative treatment is possible. Design and method: Case report presentation of the patient admitted to the hospital due to the shortness of breath, cough and chest pain as well as analysis of symptoms, additional tests, diagnosis and treatment options. Results: A 78-year-old woman with the history of heart failure, type 2 diabetes mellitus, obesity, hypertension, chronic kidney disease, several myocardial infarctions, anaemia and thrombocytopenia in the course of myelodysplastic syndrome was admitted to Department of Internal Medicine and Hypertension because of compressive chest pain, deteriorating shortness of breath and cough. In the Emergency Unit COVID-19 infection was confirmed, as well as STEMI was diagnosed. An invasive cardiologist, due to severe thrombocytopenia, qualified the patient for conservative treatment, including fondaparinux, statin, nitroglycerin infusion and beta blocker. Due to the severe course of COVID-19 infection oxygen therapy and pharmacotherapy were implemented. During hospitalization, an attack of atrial fibrillation occurred. Considering the risk of haemorrhage an apixaban was recommended, without antiplatelet agent. The patient was discharged home in general good condition. Conclusions: Reperfusion treatment involves PCI, which should be performed within 120 minutes from the diagnosis of STEMI. Other methods include coronary artery bypass grafting and fibrinolytic treatment. Due to the increased risk of complications, particularly the high bleeding risk, conservative treatment was applied, resulting in a significant improvement of the patient's condition, despite unexpected new incidents.

Treatment of Parapneumonic Effusion in Children.

To the Editors: We read the article by Lohuis et al1 regarding conservative treatment of parapneumonic effusion in children. In their article, the authors stated that the greater amount of children with parapneumonic effusion (PPE) could be treated conservatively with antibiotics only, especially in the absence of mediastinal shift, pleural septations/pockets, pleural thickening or extensive effusions. In a cohort of 136 patients, 117 patients (86%) were treated conservatively and 19 (14%) underwent pleural drainage. They found patients undergoing pleural drainage had mediastinal shift more frequently compared with conservatively treated patients (58% vs. 3%, difference 55%; 95% confidence interval: 32%–77%). In the study patients treated conservatively, median duration of hospitalization was 5 days (Interquartile range: 4–112) compared with 19 days (Interquartile range: 15–24) in the drainage group (P < 0.001), without significant difference in readmission rate (11% vs. 4%). Children with pneumonia can admit initially with an effusion that is in any one of the stages of evolution. The stage of evolution of the parapneumonic process and what therapy has already been provided is the key point for treatment. As in the study of Lohuis et al1 not all the patients were evaluated with ultrasonography, it is not possible to state how benign or complicated were PPE in the initial phase, since the cohort is not large enough to generalize to whole population and it is not easy to say PPE could be treated conservatively with antibiotics only, this statement might change due to geographic location, immunization schedules or surveillance data. For patients with parapneumonic effusions, clinicians can use ultrasound to quantify and characterize pleural fluid to determine whether diagnostic or therapeutic drainage is indicated, as well as to guide whether intrapleural fibrinolytics or surgical treatment is needed.2 In our center, 48 patients between 1 and 17 years of age from January 2011 to December 2016 were diagnosed with PPE, tube thoracostomy was performed in 43 of 48 (89.6%). Patients treated with fibrinolytic therapy was 22 (45.8%) and the mean dose was 5.18 ± 2.59 (1–9) in total. Fibrinolytic therapy was significantly higher in PE stage (II) than the other stages (P = 0.001). Intensive care need was 20.8% (n = 10), while total hospital stay was 23.58 ± 8.69 (3–47) days. Thoracotomy/decortication or Video assisted thoracoscopic surgery were required in 5 (10.4%) patients. There was no significant relationship between the operation and fibrinolytic treatment status of patients. The complication rate was 41.6% in total.3 Similarly, Lohuis et al1 also discussed that thoracic ultrasound could play a more important role in the decision making for the favorable treatment option with either conservative management or pleural drainage. Their study suggests that a Computed tomography scan does not play a major role in the diagnosis and treatment of PPE in children. These studies highlighting therapy of parapneumonic effusion in children are very helpful to guide clinicians and more randomized controlled trails are warranted.

D-dimer Release From Livers During Ex Situ Normothermic Perfusion and After In Situ Normothermic Regional Perfusion: Evidence for Occult Fibrin Burden Associated With Adverse Transplant Outcomes and Cholangiopathy.

Deceased donor livers are prone to biliary complications, which may necessitate retransplantation, and we, and others, have suggested that these complications are because of peribiliary vascular fibrin microthrombi. We sought to determine the prevalence and consequence of occult fibrin within deceased donor livers undergoing normothermic ex situ perfusion (NESLiP) and evaluate a role for fibrinolysis. D-dimer concentrations, products of fibrin degradation, were assayed in the perfusate of 163 livers taken after 2 h of NESLiP, including 91 that were transplanted. These were related to posttransplant outcomes. Five different fibrinolytic protocols during NESLiP using alteplase were evaluated, and the transplant outcomes of these alteplase-treated livers were reviewed. Perfusate D-dimer concentrations were lowest in livers recovered using in situ normothermic regional perfusion and highest in alteplase-treated livers. D-dimer release from donation after brain death livers was significantly correlated with the duration of cold ischemia. In non-alteplase-treated livers, Cox proportional hazards regression analysis showed that D-dimer levels were associated with transplant survival ( P = 0.005). Treatment with alteplase and fresh frozen plasma during NESLiP was associated with significantly more D-dimer release into the perfusate and was not associated with excess bleeding postimplantation; 8 of the 9 treated livers were free of cholangiopathy, whereas the ninth had a proximal duct stricture. Fibrin is present in many livers during cold storage and is associated with poor posttransplant outcomes. The amount of D-dimer released after fibrinolytic treatment indicates a significant occult fibrin burden and suggests that fibrinolytic therapy during NESLiP may be a promising therapeutic intervention.

Outcomes of Combined Endoscopic Surgery and Fibrinolytic Treatment Protocol for Intraventricular Hemorrhage: A Randomized Controlled Trial.

Intraventricular fibrinolysis (IVF) and endoscopic surgery (ES) are the new promising treatment strategies to enhance the rate of hematoma clearance, which might improve functional outcome. This study investigated and compared the outcomes among these interventions. A randomized (1:1) double-blinded trial was carried out between August 2018 and December 2021. The intervention and control groups comprised patients receiving IVF and/or ES and external ventricular drainage (EVD), respectively. All participants had experienced primary or secondary intraventricular hemorrhage (IVH) from spontaneous intracerebral hemorrhage with obstructive hydrocephalus complications. The primary outcome was modified Rankin Scale score 180 days post treatment. Interim assessments were planned for every 50 participants enrolled to ensure safety and efficacy. After enrollment of 110 participants (55 participants in each group), there was a difference in 30-day mortality (2 [3.6%] vs. 13 [32.7%] in the EVD group, P= 0.002), reaching the predetermined boundaries for termination of the trial. We demonstrated a better favorable outcome (modified Rankin Scale score 0-3) at 180 days in the intervention group, compared with the control group (35 [63.6%] vs. 24 [43.6%], P= 0.04). Participants in the intervention group experienced a higher IVH removal rate (91% [9.0] vs. 69.5% [38.0], P < 0.01) and had lower shunt conversion (1 [1.8%] vs. 16 [29.3%], P < 0.01). Treatment complications were comparable between the two groups. This study demonstrated that combined ES and IVF is safe and effective for the treatment of IVH. In addition, it concluded that aggressive but safe procedures used to remove IVH could improve clinical outcome in patients with IVH.

Significance of pleural effusion detected by metagenomic next-generation sequencing in the diagnosis of aspiration pneumonia.

Using metagenomic next-generation sequencing (mNGS) to profile the bacterial pathogen of pleural infection in aspiration pneumonia for therapeutic decision-making. Collection and analysis of the clinical and laboratory data of aspiration pneumonia patients who underwent mNGS detection of pleural effusion at the Second Hospital of Jilin University from November 2020 and March 2022. Nine males and one female were included, aged 33 to 69 years. All patients had chest pain, fever, cough, and hypoxemia symptoms; 90% had expectoration. The laboratory tests revealed that all patients had elevated white blood cell, neutrophil, and C-reactive protein (CRP) levels. Furthermore, erythrocyte sedimentation rate (ESR) increased in 8 patients, and procalcitonin increased in only one patient. Chest CT indicated different degrees of lobar pneumonia and pleural effusion in all patients, and biochemical results implied exudative effusion according to Light criteria. Most routine culture results were negative. Among bacteria identified by mNGS, Fusobacterium nucleatum (n=9) was the most common, followed by Parvimonas micra (n=7) and Filifactor alocis (n=6). Three patients underwent surgical treatment after applying targeted antibiotics, thoracic puncture and drainage, and fibrinolytic septum treatment. After the adjusted treatment, the number of white blood cells, neutrophils, and lymphocytes decreased significantly, indicating the eradication of the infection. Improving the vigilance of atypical people suffering from aspiration pneumonia is essential. The mNGS detection of pleural effusion clarified the microbial spectrum of aspiration pneumonia, allowing targeted antibiotic administration.

Impact of Metabolic Syndrome in Patients With Acute Myocardial Infarction After Thrombolytic Therapy

Background: Metabolic syndrome (MetS) comprises a group of conditions that happen together and increase the risk of heart disorders. MetS has known characteristic diagnostic criteria and is diagnosed through physical examination and blood tests. This syndrome is extremely prevalent in patients with acute myocardial infarction. We aimed to determine the prevalence of MetS and its relationship with myocardial infarction and response to treatment in patients suffering from acute myocardial infarction under fibrinolytic treatment. Methods: In this cross-sectional study, 145 patients with acute ST-elevation myocardial infarction (STEMI) were enrolled. They were referred to Bu-Ali Sina Hospital in Qazvin, Iran, between January 2018 and January 2019 and were candidates for thrombolytic therapy. The patients were divided into two groups with and without MetS according to the NCEP ATP III definition (the National Cholesterol Education Program-Adult Treatment Panel III). In each group, the ST resolution of more than 50% in electrocardiogram was evaluated 90 minutes after thrombolytic administration. In addition, angiographic information and left ventricular ejection fraction (LVEF) were compared between the two groups. Results: Overall, the prevalence of MetS was 57.2% in the study population. After treatment, ST-segment resolution of more than 50%, the number of involved coronary vessels, the thrombolysis in myocardial infarction flow grade, mean LVEF, and type of myocardial infarction were similar in both study groups. Conclusion: Our study indicates that MetS does not affect the response rate to thrombolytic treatment.

Minimally invasive fibrinolytic treatment and drainage in patients with acute subdural hemorrhage and underlying comorbidities.

The incidence of acute subdural hemorrhage (ASDH), which is often caused by head trauma, is steadily increasing due to an increase in the elderly population and the use of anticoagulants. Urgent surgical treatment is recommended if the patient has impaired consciousness, worsening neurological symptoms, or brain midline shift (MLS) due to large hematomas on brain computed tomography (CT). Although large craniotomy is traditionally recommended for ASDH removal, old age, comorbidities, and antiplatelet drugs are considered risk factors for surgical complications, many neurosurgeons hesitate to perform aggressive surgical procedures in these patients. In this study, we introduced a method that can quickly and effectively remove ASDH without general anesthesia. We retrospectively reviewed 11 cases of patients with ASDH who underwent hematoma drainage between June 2019 and December 2020. We measured the maximum subdural hematoma thickness and MLS on brain CT of patients and recorded the Glasgow Coma Scale scores before and after the surgical procedure. All patients had multiple comorbidities, and seven patients received anticoagulant or antiplatelet therapy. On initial brain CT, the median subdural hemorrhage thickness was 21.36 mm, median MLS was 10.09 mm, and mean volume of the subdural hematoma was 163.64 mL. The mean evacuation rate of the subdural hematoma after drainage was 83.57%. There was no rebleeding or operation-related infection during the aspiration procedure, and the median MLS correction after the procedure was 7.0 mm. Our treatment strategies can be a reliable, less invasive, and alternative treatment option for patients at high risk of complications due to general anesthesia or patients who are reluctant to undergo a large craniotomy due to a high bleeding tendency.

Interest of Tenecteplase in Thrombolysis of Pulmonary Embolism: A Case Report

Pulmonary embolism is one of the most common and serious symptoms of venous thromboembolic disease. It is a potentially fatal condition associated with significant morbidity and mortality, and because of that, rapid and effective management is very important. Fibrinolytic treatment is a major step in the therapeutic process, principally in intermediate to high-risk forms. Through this case and a review of the literature, we will discuss the interest in thrombolysis by tenecteplase in intermediate-high-risk pulmonary embolism. A 42 years old, taxi driver, chronic smoker, with a family history of treated deep vein thrombosis, was admitted with acute respiratory distress leading to the discovery of a high intermediate-risk pulmonary embolism. sPESI score was 4 points. High-sensitive cardiac troponin I was elevated to 23 times the normal value. Echocardiography revealed an acute pulmonary heart with low cardiac output at 2,24 l/min and a cardiac index of 1,25 L/min/m2, with no visualizable thrombus. The patient underwent urgent thrombolysis with tenecteplase with a very good clinical evolution. No precipitating factors were identified. Etiological investigation revealed a protein C deficiency. The patient is put on vitamin K antagonist for life with close monitoring of the INR. This case demonstrates that even though tenecteplase is not currently approved for the treatment of acute pulmonary embolism according to current guidelines, it is a promising treatment for patients with intermediate or high- risk forms with remarkable efficacy and safety.

Schwere ambulant erworbene Pneumonie im Kindes- und Jugendalter

BackgroundApproximately 20% of children and adolescents with pediatric community-acquired pneumonia (pCAP) experience severe disease courses. These are characterized by hospitalization and/or occurrence of complications, such as pleural effusion, empyema and lung abscesses.ObjectiveThis article summarizes the data on clinical features, diagnostics and treatment of severe pCAP.Material and methodsThis article is based on national and international guidelines for the treatment of pCAP, especially the current guidelines of the Association of the Scientific Medical Societies in Germany (AWMF), as well as further literature from PubMed.ResultsPersistent fever (> 38.5 °C), hypoxemia, respiratory distress or lack of improvement in the child’s clinical condition after initiation of appropriate antibiotic therapy can be a reflection of a severe disease course. In cases of unequal bilateral breathing sounds, chest pain and weight loss, local complications must also be considered. In severe pCAP, the pathogens causing the disease should always be confirmed and comprehensive laboratory testing for infections can be helpful in the estimation of the severity and also assessment of the course. Important diagnostic methods include X‑ray imaging, sonography and multislice imaging procedures. The basis of treatment is usually antibiotic therapy, which is mostly chosen empirically according to the epidemiological conditions and resistance; however, in cases of a confirmed viral etiology, antibiotic treatment can be omitted. Interventional procedures, sometimes with the use of fibrinolytic treatment, are of importance in complicated courses of disease. Surgical treatment is only necessary in exceptional cases with failure of conservative treatment.PrognosisWith adequate treatment the prognosis of severe pCAP in children is good.

Fibrin-Targeted Nanoparticles for Finding, Visualizing and Characterizing Blood Clots in Acute Ischemic Stroke.

Recanalization of the occluded artery is the gold standard treatment for acute ischemic stroke, which includes enzymatic fibrinolytic treatment with the use of recombinant tissue plasminogen activators (rtPAs) to disrupt the occluding clot, the use of mechanical thrombectomy to physically remove the clot, or a combination of both. Fibrin is one of the main components of blood clots causing ischemic stroke and is the target of rtPA upon activation of plasminogen in the clot. In addition, fibrin content also influences the efficacy of mechanical thrombectomy. Current imaging methods can successfully identify occlusions in large vessels; however, there is still a need for contrast agents capable of visualizing small thrombi in ischemic stroke patients. In this work, we describe the synthesis and the in vitro characterization of a new diagnostic nanoparticle, as well as the in vivo evaluation in an animal model of thromboembolic stroke. Gd-labeled KCREKA peptides were synthesized and attached onto the surface of PEGylated superparamagnetic nanoparticles. Magnetic resonance imaging (MRI) of blood clots was performed in vitro and in vivo in animal models of thromboembolic stroke. KCREKA-NPs were synthesized by attaching the peptide to the amino (N) termini of the PEG-NPs. The sizes of the nanoparticles, measured via DLS, were similar for both KCREKA-NPs and PEG-NPs (23 ± 4 nm, PDI = 0.11 and 25 ± 8 nm, PDI = 0.24, respectively). In the same line, r2 relaxivities were also similar for the nanoparticles (149 ± 2 mM Fe s−1 and 151 ± 5 mM Fe s−1), whereas the r1 relaxivity was higher for KCREKA-NPs (1.68 ± 0.29 mM Fe s−1 vs. 0.69 ± 0.3 mM Fe s−1). In vitro studies showed that blood clots with low coagulation times were disrupted by rtPA, whereas aged clots were almost insensitive to the presence of rtPA. MRI in vitro studies showed a sharp decrease in the T1 × T2 signals measured for aged clots incubated with KCREKA-NPs compared with fresh clots (47% [22, 80] to 26% [15, 51]). Furthermore, the control blood showed a higher value of the T1 × T2 signal (39% [20, 61]), being the blood clots with low coagulation times the samples with the lowest values measured by MRI. In vivo studies showed a significant T1 × T2 signal loss in the clot region of 24% after i.v. injection of KCREKA-NPs. The thrombus age (2.5% ± 6.1% vs. 81.3% ± 19.8%, p < 0.01) confirmed our ability to identify in vivo fresh blood clots. In this study, we developed and tested a dual MRI nanoparticle, acting as T1 and T2 contrast agents in MRI analyses. The developed KCREKA-NPs showed affinity for the fibrin content of blood clots, and the MRI signals provided by the nanoparticles showed significant differences depending on the clot age. The developed KCREKA-NPs could be used as a tool to predict the efficacy of a recanalization treatment and improve the triage of ischemic stroke patients.

Fibrinolytic treatment with tissue plasminogen activator in a patient with massive pulmonary thromboembolism and bidirectional Glenn procedure

Fibrinolytic treatment with tissue plasminogen activator in a patient with massive pulmonary thromboembolism and bidirectional Glenn procedure

Associated factors with functional prognosis of patients with acute ischemic stroke undergoing thrombectomy

IntroductionMechanical thrombectomy (MT) has meant a change in natural history of acute ischemic stroke (AIS). Our aim is to assess the possible association between different factors and prognosis in patients treated with MT in a third degree Spanish hospital. MethodsCross-sectional study including 198 patients underwent MT because of AIS between 2012–2020. Sociodemographic, vascular risk factors (VRF) and clinical-radiologic factors were recorded. Functional outcome was evaluated based on modified Rankin Scale (mRS) at 90 days, being mRS ≤ 2 favourable and mRS ≥ 3 unfavourable outcome. ResultsMean age 67.7 ± 13.5 years, 50.5% women. Arterial hypertension was the most prevalent VRF (65.7%). National Institute of Health Stroke Scale (NIHSS) median value at admission was 17.0 (8.0; 22.0). 40.9% of cases also received fibrinolytic treatment. Conscious sedation was performed in 66.7% patients. Median passes of MT were 2, and median duration 41 min. Successful recanalization was achieved in 79.9% and mRS ≤ 2 at 90 days was registered at 59.5% cases. Age, type 2 diabetes (T2D), number of MT passes and procedure duration were associated with mRS ≥ 3. Successful recanalization was associated with mRS ≤ 2. Regression model confirmed these associations in age (OR: 1.56.IC%: 1.11; 2.20); T2D (OR: 3.51.IC%: 1.38; 8.97) and successful recanalization (OR: 0.07.IC%: 0.02; 0.28). ConclusionAge, T2D and failed recanalization increase risk for unfavorable outcome at 90 days in patients with AIS treated with MT. Procedure time duration should be considered as a possible determinant factor in functional outcome.