Hemorrhage In Adults Research Articles

G121(P) Service evaluation of management of term neonates with major perinatal blood loss

Aims Clear guidelines exist for the management of major haemorrhage in adults. These include a strong emphasis on early transfusion of Fresh Frozen Plasma (FFP) in conjunction with Packed Red Cells (PRC) in order to avoid/treat possible accompanying coagulopathy. Current practice within the local neonatal population is to await clotting profiles and administer FFP if coagulation is found to be abnormal. This practice may lead to a significant delay in treatment. The aim of this service evaulation was to identify whether term neonates with major haemorrhage around the time of delivery required support with coagulation factors. This may support the use of prophylactic FFP alongside RBC transfusion prior to results becoming available helping to stabilise the infant sooner. Methods Data was requested from our local blood transfusion laboratory for all requests for blood products made for patients on the neonatal unit between April 2011 to December 2013. Further details regarding antenatal and neonatal course were then taken from the Badger database on all babies that were identified to have received blood products on their date of birth or following day. Babies born at less than 37 weeks were excluded. Results We identified 7 term babies with a clear history of major perinatal blood loss. 5/7 (71%) required transfusion of FFP in addition to PRC on the basis of abnormal clotting profile. All babies receiving FFP needed extensive resuscitation at birth followed by intensive care support, whereas the 2 babies that were not transfused were clinically stable. One of the babies not receiving FFP did not have their clotting profile checked. All babies received Vitamin K post delivery as standard. Conclusion Term infants with a clear history of perinatal blood loss who are compromised at delivery and require packed red cell transfusion should be considered for early transfusion of FFP without awaiting coagulation profiles.

PT-03 * PROLONGED VASOSPASM FOLLOWING POSTERIOR FOSSA TUMOR RESECTION- A CASE REPORT

Cerebral Vasospasm Syndrome after tumor resection has not been well described in the pediatric population. It is a frequent complication after subarachnoid hemorrhage in adults and few case reports have discussed it following resection of pituitary/sellar tumors. There are only 3 reported pediatric cases in the literature. Usual onset of symptoms occurs at a mean of 8 days postoperatively involving mainly the anterior circulation. We report our experience of a 17-year-old boy who developed recurrent diffuse cerebral vasospasm that lasted 6 weeks after surgery. The patient was diagnosed with a left cerebellar grade IV medulloblastoma and underwent subtotal resection with no major operative complications. 2 weeks after surgery, he developed worsening of focal weakness and expressive aphasia that progressed to lethargy, bradycardia and decreased brainstem reflexes. Magnetic resonance imaging (MRI) showed acute ischemia in the frontoparietal, right occipital, and right medial temporal lobe. Subsequent magnetic resonance angiography two days later showed narrowing of left internal carotid and basilar artery with beading. The spasm progressed the following day to involve the Circle of Willis territories bilaterally. An external ventricular drain was placed and steroids, triple therapeutic hypervolemia, hypertension, and hemodilution therapy, and intrathecal nicardipine were started. His vasospasm improved 10 days later but he developed posterior reversible encephalopathy syndrome secondary to the treatment. As he was weaned off therapy, he became symptomatic again and was found to have a recurrence of vasospasm. His symptoms and MRI vasospasm gradually resolved and at 8 weeks after surgery he was discharged with stable initial postoperative deficits. This is one of the first pediatric cases to describe vasospasm lasting 6 weeks following a posterior fossa tumor resection. The prolonged course of this patient's symptoms shows the importance of early recognition with a high index of suspicion and aggressive treatment of vasospasm in the initial phase.

Tranexamic acid - a useful drug in ENT surgery?

Tranexamic acid is a synthetic antifibrinolytic drug. It has been widely available for over 40 years, but only recently has it started to be used routinely in many surgical disciplines. For ENT surgeons, epistaxis and post-tonsillectomy bleeding contribute a significant proportion of the morbidity and emergency workload in a general ENT department. Published evidence indicates a potentially helpful role for tranexamic acid in managing epistaxis. To date, the benefits of tranexamic acid as a prophylactic treatment to reduce the rate and severity of post-tonsillectomy bleeding are less certain. Two recently published pilot studies looking at primary haemorrhage in children and secondary haemorrhage in adults following tonsillectomy suggest that further large, randomised trials should explore the efficacy of tranexamic acid in routine ENT surgery. There are potential reductions in patient morbidity and cost savings if tranexamic acid is found to be efficacious in larger trials.

Perioperative ketorolac increases post‐tonsillectomy hemorrhage in adults but not children

To evaluate the risk of post-tonsillectomy hemorrhage associated with perioperative ketorolac use. Systematic review and meta-analysis of primary articles reporting individual-level post-tonsillectomy hemorrhage rates in subjects receiving perioperative ketorolac and matched controls. Retrospective and prospective studies were both included. PubMed search was performed for "[ketorolac OR toradol] AND tonsillectomy." Articles fulfilling inclusion criteria were subjected to meta-analysis to determine summary relative risk (RR). Adults are at five times increased risk for post-tonsillectomy hemorrhage with ketorolac use (RR: 5.64; 95% confidence interval [CI]: 2.08-15.27; P < .001). In contrast, children under 18 are not at statistically significantly increased risk (RR: 1.39; 95% CI: 0.84-2.30; P = .20). Both retrospective and prospective studies yield consistent findings. There is no association of RR with pre- or postoperative administration of ketorolac. Ketorolac can be used safely in children, but is associated with a five-fold increased bleeding risk in adults.

A risk factor analysis of prospective symptomatic haemorrhage in adult patients with cerebral cavernous malformation

ObjectiveThe purpose of this study was to assess the risk factors of prospective symptomatic haemorrhage in a large series of adult patients with cerebral cavernous malformation (CM).MethodsThree hundred twenty-six patients...

Poor Long-Term Functional Outcome After Stroke Among Adults Aged 18 to 50 Years

Stroke in young adults has a dramatic effect on life; therefore, we investigated the long-term functional outcome after transient ischemic attack, ischemic stroke, or intracerebral hemorrhage in adults aged 18 to 50 years. We studied 722 young patients with first-ever stroke admitted between January 1, 1980, and November 1, 2010. Functional outcome was assessed by stroke subtype with the modified Rankin Scale and Instrumental Activities of Daily Living scale. After a mean follow-up of 9.1 (SD, 8.2) years, 32.0% of all patients had a poor functional outcome (modified Rankin Scale, >2); for ischemic stroke, this was 36.5%, for intracerebral hemorrhage 49.3%, and for transient ischemic attack 16.8%. At follow-up, 10.8% of transient ischemic attack, 14.6% of ischemic stroke, and 18.2% of intracerebral hemorrhage patients had a poor outcome as assessed by Instrumental Activities of Daily Living (<8). Ten years after ischemic stroke or intracerebral hemorrhage in young adults, 1 of 8 survivors is still dependent in daily life.

Abstract No. 385 - Endovascular treatment of spontaneous adrenal hemorrhage in adults

Abstract No. 385 - Endovascular treatment of spontaneous adrenal hemorrhage in adults

The use of handheld near-infrared device (Infrascanner) for detecting intracranial haemorrhages in children with minor head injury.

A handheld device using near-infrared technology (Infrascanner) has shown good accuracy for detection of traumatic intracranial haemorrhages in adults. This study aims to determine the feasibility of use of Infrascanner in children with minor head injury (MHI) in the Emergency Department (ED). Secondary aim was to assess its potential usefulness to reduce CT scan rate. Prospective pilot study conducted in two paediatric EDs, including children at high or intermediate risk for clinically important traumatic brain injury (ciTBI) according to the adapted PECARN rule in use. Completion of Infrascanner measurements and time to completion were recorded. Decision on CT scan and CT scan reporting were performed independently and blinded to Infrascanner results. Completion of the Infrascanner measurement was successfully achieved in 103 (94%) of 110 patients enrolled, after a mean of 4.4 ± 2.9min. A CT scan was performed in 18 (17.5%) children. Only one had an intracranial haemorrhage that was correctly identified by the Infrascanner. The exploratory analysis showed a specificity of 93% (95% CI, 86.5-96.6) and a negative predictive value of 100% (95% CI, 81.6-100) for ciTBI. The use of Infrascanner would have led to avoid ten CT scan, reducing the CT scan rate by 58.8%. Infrascanner seems an easy-to-use tool for children presenting to the ED following a MHI, given the high completion rate and short time to completion. Our preliminary results suggest that Infrascanner is worthy of further investigation as a potential tool to decrease the CT scan rate in children with MHI.

Gastrointestinal Hemorrhage in Adults Requiring Extracorporeal Membrane Oxygenation: Incidence, Clinical Predictors, and Impact on Outcomes

Gastrointestinal Hemorrhage in Adults Requiring Extracorporeal Membrane Oxygenation: Incidence, Clinical Predictors, and Impact on Outcomes

Intracerebral Hemorrhages in Adults with Community Associated Bacterial Meningitis in Adults: Should We Reconsider Anticoagulant Therapy?

ObjectiveTo study the incidence, clinical presentation and outcome of intracranial hemorrhagic complications in adult patients with community associated bacterial meningitis.MethodsNationwide prospective cohort study from all hospitals in the Netherlands, from 1 March 2006, through 31 December 2010.ResultsOf the 860 episodes of bacterial meningitis that were included, 24 were diagnosed with intracranial hemorrhagic complications: 8 upon presentation and 16 during clinical course. Clinical presentation between patients with or without intracranial hemorrhage was similar. Causative bacteria were Streptococcus pneumoniae in 16 patients (67%), Staphylococcus aureus in 5 (21%), Pseudomonas aeruginosa and Listeria monocytogenes both in 1 patient (4%). Occurrence of intracranial hemorrhage was associated with death (63% vs. 15%, P<0.001) and unfavorable outcome (94% vs. 34%, P<0.001). The use of anticoagulants on admission was associated with a higher incidence of intracranial hemorrhages (odds ratio 5.84, 95% confidence interval 2.17–15.76).ConclusionIntracranial hemorrhage is a rare but devastating complication in patients with community-associated bacterial meningitis. Since anticoagulant therapy use is associated with increased risk for intracranial hemorrhage, physicians may consider reversing or temporarily discontinuing anticoagulation in patients with bacterial meningitis.

Use of Recreational Drug 1,3-Dimethylethylamine (DMAA) Associated With Cerebral Hemorrhage

Dimethylamylamine (DMAA) was a forgotten pharmaceutical that was patented in 1944 as a nasal decongestant. DMAA has recently gained popularity as a dietary supplement, with claims of effectiveness as an athletic performance enhancer and weight loss aid. It is also sold as a recreational stimulant drug. DMAA is a sympathomimetic and potent pressor agent. This report describes 3 cases of cerebral hemorrhage in adults after the use of DMAA. The status of this substance as a synthetic or naturally occurring compound is also discussed.

Moyamoya Disease in China

Here we describe the clinical features and outcomes of patients with moyamoya disease who were surgically treated at a single institution in China. Our cohort included 802 patients with moyamoya disease. Demographic and clinical characteristics were obtained by retrospective chart review; follow-up information and outcome were obtained through clinical visits, telephone, or letter interview. We used the Kaplan-Meier methods to estimate stroke risk by treatment status. The median age for the onset of symptoms was 28 (range, 0.5-77) years. Two definite peaks in age distribution were found. The ratio of women to men was 1:1 (398/404). Familial occurrence of moyamoya disease was 5.2%. The initial symptom was ischemia, hemorrhage, or others in 564, 113, and 125 patients, respectively. Twenty-nine of the 802 patients (3.6%) received conservative management. The remaining 773 patients (96.4%) underwent neurosurgical revascularization procedures, and 502 of these were bilateral. The median follow-up after surgery (n=773) or conservative management (n=26) was 26.3 months (range, 6.0-101.9 months). Most subsequent ischemic events appeared in the first 2 years after surgery. The Kaplan-Meier estimated stroke risk was 10.1% in the first 2 years, and the 5-year-Kaplan-Meier risk of stroke was 12.7% after surgery for all patients treated with surgical revascularization. This study on the clinical features of moyamoya disease in mainland China indicated bimodal incidence distribution with women-to-men ratios of 1:1 and lower rate of hemorrhages in adults compared with in children. Patients had low rates of postoperative ischemic or hemorrhagic strokes, and the majority of patients had preserved functional status after revascularization.

Hemorrhagic moyamoya disease in children: clinical features and surgical outcome

The clinical presentation of moyamoya disease (MMD) typically includes cerebral ischemia in children and intracranial hemorrhage in adults. Because of its rarity, the benefit of surgery in the hemorrhagic type of pediatric MMD has not been clearly established. The purpose of this study was to delineate the clinical features and surgical outcome of hemorrhagic MMD in children. Thirteen patients (six boys and seven girls with a combined mean age of 11.1years and a range of 4-18years) were retrospectively confirmed as having MMD with intracranial hemorrhage between 1988 and 2009. All of the patients underwent indirect bypass surgery that followed a relatively uniform scheme at a single institution. We retrospectively reviewed their clinical features and surgical outcome. The mean time of follow-up was 50.3months (with a range of 3-99months). Six of the patients presented with intracerebral hemorrhage (ICH), and six others presented with intraventricular hemorrhage (IVH); the remaining patient presented with both ICH and IVH. Preoperative angiography demonstrated that the patients were in various stages of the disease, but the majority of the patients (i.e., 16 of the 26 hemispheres) were in stage 3 with abundant moyamoya vessels (MMV). Three of four patients who presented with a history of prior hemorrhage or infarct exhibited a poor clinical outcome. Five patients with good revascularization had a decreased degree of MMV in their follow-up angiogram and showed good clinical outcome. Recurrent bleeding occurred after surgery in one patient. Revascularization surgery may have a role for prevention of rebleeding and cerebral infarction in pediatric MMD patients who present with intracranial hemorrhage.

Associated Aneurysms in Pediatric Arteriovenous Malformations and the Implications for Treatment

Arteriovenous malformations (AVM) with associated aneurysms (AA) increase the risk of hemorrhage in adults. Associated aneurysms are thought to develop over time, and the incidence in children, therefore, has been thought to be minimal, although this has not yet been studied. To define the incidence and morbidity of AA in children and to assess the results of our treatment strategy. Patients younger than 18 years of age with pial AVM seen from 2000 to 2009 were reviewed. Demographics, presentation, hemorrhage, AAs, treatment method, and outcome were analyzed. Of 144 patients with AVM, 30 were younger than 18 years of age. AA was identified in 5 of 30 children (16.7%) and 33 of 114 adults (28.9%; P = .25). Mean age at presentation in children was 11.67 years (range, 6 months to 17 years), and mean follow-up was 28.8 months (range, 1-75 months). Hemorrhage at presentation was seen in 80% of patients with AA and 72% with AVM alone. Emergent therapy was required in 60% of patients with AA and 40% with AVM alone (P = .63). Time to treatment was 4.3 days with AA and 27.3 days without (P = .42). There was no difference in outcome between patients with AA and those with AVM alone. The incidence of pediatric AA was higher in our series than projected in the current literature. Time to treatment was shorter in children with AA compared with those with AVM alone, although there was no difference in clinical outcome. Although hemorrhage rates were similar, emergent therapy was required more often in patients with AA. Our findings support the need for early diagnosis and treatment of associated aneurysms in children.

Could Intra-alveolar Hemosiderin Deposition in Adults be Used as a Marker for Previous Asphyxial Episodes in Cases of Autoerotic Death?

Intra-alveolar hemorrhage and hemosiderin have been cited as possible markers of recent and remote asphyxial events. Little study has been undertaken of the potential significance of intra-alveolar hemosiderin in adults as a potential marker of previous sublethal asphyxial episodes. Ten cases of lethal sexual asphyxia (an entity known to be associated with repetitive sublethal asphyxial episodes) and 20 randomly selected, age- and sex-matched controls had sections of lung stained for hemosiderin. Subsequently, intra-alveolar, iron-containing macrophages were counted. All cases were men (ages 15-50 years; mean 31.8). No significant increase in hemosiderin was found in victims of sexual asphyxia, indicating that asphyxial episodes in sublethal sexual asphyxial activities may not be sufficiently intense or prolonged to cause intra-alveolar hemorrhage or that intra-alveolar hemorrhage in adults is a relatively nonspecific finding. These results do not support intra-alveolar hemosiderin deposition as a marker for previous sublethal asphyxial events in autoerotic asphyxia.

Cerebellar Pilocytic Astrocytomas with Spontaneous Intratumoral Hemorrhage in Adult

Cerebellar pilocytic astrocytomas (PAs) are benign gliomas predominantly found in the pediatric population. Intracranial hemorrhages are extremely rare in initial presentations of cerebellar PAs. There are no reports in the medical literature of adult cerebellar PA cases presenting with intratumoral hemorrhage. We report 2 cases of adult cerebellar pilocytic astrocytomas with intratumoral hemorrhage. The first case is a 37-year-old woman presenting with severe headache, nausea, and vomitting. Computed tomography demonstrated an acute hemorrhage adjacent to the right cerebellar hemisphere and hydrocephalus. Magnetic resonance imaging (MRI) revealed a cerebellar vermian tumor with the hemorrhage as a mixed isointense area in the T2-weighted image, and as a mixed hyperintense area in the contrast-enhanced T1-weighted image. The second case is a 53-year-old man presenting with headache for 3 weeks. MRI revealed a cerebellar hemispheric tumor with the hemorrhage as a mixed hyperintense area. It had a cystic mass with a heterogeneous enhanced mural nodule in the gadolinium-enhanced T1-weighted image and a fluid-fluid level within the cyst in the T2-weighted image. Both of them underwent radical resections of their respective lesions. Histological examination of the specimens revealed typical astrocytoma, including a hemorrhagic portion. Both patients recovered postoperatively and continue to do well at present. The medical literature on hemorrhagic cerebellar PAs is also reviewed.

Adult onset moyamoya disease: Institutional experience

Moyamoya disease is a progressive steno-occlusive disease of bilateral carotid forks with the formation of fine collateral vascular network and is an angiographic diagnosis. We analyzed case records of 11 patients with "adult-onset moyamoya disease." Six patients presented with intracranial hemorrhage (intracerebral and/or intraventricular) and 5 with focal ischemia. Angiography revealed bilateral Internal carotid artery involvement in 8 patients and unilateral involvement in 3. Posterior cerebral artery involvement was seen in 3 patients. Saccular aneurysm involving posterior circulation was seen in only 1 patient. Although rare, adult-onset moyamoya disease should be considered as one of the causes for intracerebral and intraventricular hemorrhage in adults.

Postoperative Complications of Powered Intracapsular Tonsillectomy and Monopolar Electrocautery Tonsillectomy in Teens versus Adults

This study was performed to determine whether teens have different rates of posttonsillectomy hemorrhage, admission for dehydration, or recurrent tonsillitis compared to adults. Specifically, these parameters were compared within two groups: patients who underwent powered intracapsular tonsillectomy (PIT) and those who underwent monopolar electrocautery tonsillectomy (MET). In a retrospective review of 579 patients at least 12 years of age from January 2000 to July 2006 in a tertiary referral center, outcome measures of reoperation for hemorrhage, readmission or emergency room visit for dehydration, and postoperative tonsillitis were compared for 200 patients 12 to 19 years of age and 379 patients more than 19 years of age. These outcome measures in teens were compared to those in adults who had tonsillectomy by the same technique (101 teens who underwent PIT compared to 117 adults who underwent PIT, and 99 teens who underwent MET compared to 262 adults who underwent MET). Outcome measures were also compared within the PIT and MET groups based on the indication for surgery (chronic tonsillitis, tonsillar hypertrophy, or both). In comparing teens to adults who underwent the same technique (PIT versus PIT, or MET versus MET), no statistically significant differences existed in the incidence of hemorrhage, dehydration, or postoperative tonsillitis. Greater hemorrhage rates for adults who underwent MET compared to teens, however, almost met statistical significance (p = 0.053). Analyzing complication rates by indication within the PIT and MET groups exclusively revealed higher rates of hemorrhage in adults who underwent the MET technique for the indication of chronic tonsillitis. Within the PIT comparison, no significant differences were found on the basis of indication for surgery. Teenage patients who undergo tonsillectomy should be considered unique as far as complication rates are concerned. Comparison of technique-specific complication rates between adults and teens showed no significant differences in either the PIT or MET groups, although adults who underwent MET had greater hemorrhage rates that almost met significance (p = 0.053). Adults who were undergoing tonsillectomy for chronic tonsillitis were more likely than teens to encounter postoperative hemorrhage if they underwent the MET technique.

Transplacental transfer of postpartum inhibitors to factor VIII

Acquired haemophilia due to antibodies directed against coagulation factor VIII is a well-recognized cause of severe haemorrhage in adults but an uncommon cause of bleeding in children. We present the cases of a mother with a life-threatening postpartum haemorrhage due to an autoantibody to factor VIII and her newborn who developed symptomatic bleeding after a minor surgical intervention as a result of transplacental transfer of the autoantibody. Both patients were treated with infusions of recombinant factor VIIa to control bleeding. The mother required immunosuppressive therapy to decrease inhibitor levels and the infant's levels decreased over time without specific treatment. We also provide a concise review of postpartum haemophilia and transplacental transmission of factor VIII autoantibodies to the neonate--a rare but potentially life-threatening complication of acquired haemophilia in women of childbearing age.

Hemorrhagic Meckel's diverticulum in an older woman diagnosed by repeated angiographies

Meckel's diverticulum is a remnant of the vitelline duct and a congenital anomaly of the gastrointestinal tract. Hemorrhage from a Meckel's diverticulum is common in children but extremely rare in adults over 50 years of age. Very few cases have been reported to date and all prior cases were in men. Meckel's diverticulum is commonly overlooked as a possible cause of a lower gastrointestinal hemorrhage in adults. Here, we present the rare case of a 58-year-old woman with massive hemorrhage from a Meckel's diverticulum that was diagnosed by repeated emergency angiographies and treated with elective laparoscopic surgery.