Hemorrhagic Presentation Research Articles

Is there an Influence of Match and Mismatch of Venous Drainage Pattern on AVM Hemorrhagic Presentation?

To analyze whether there is an influence of match and mismatch of venous drainage patterns on arteriovenous malformation (AVM) hemorrhagic presentation. Consecutive 161 patients of AVM between 2014 and 2017 were retrospectively reviewed. Venous drainage was considered deep or superficial. Match of venous drainage pattern was defined as a superficial AVM with only superficial venous drainage or a deep AVM with deep venous drainage. Mismatch of venous drainage pattern was defined as a superficial AVM involving a deep venous drainage. Univariate analysis was used to assess the influence of match and mismatch of venous drainage pattern on AVM hemorrhagic presentation. AVM location and venous drainage were matched in 116 patients, including superficial location with superficial venous drainage or deep location with deep venous drainage, and were mismatched in 45 patients, including superficial location with deep venous drainage. The rupture proportion of mismatch venous drainage pattern was statistically comparable to that of deep location with deep drainage (P = 0.819). However, superficial location with deep venous drainage was statistically associated with a higher rupture percentage than that of superficial location with superficial venous drainage (P = 0.003). Mismatch venous drainage pattern or an exclusively deep venous drainage is associated with an initial clinical presentation with an AVM hemorrhage.

Clinical Presentation of Legionella pneumophila Serogroup 1-Associated Pneumonia and Diffuse Alveolar Hemorrhage: A Case Report and Literature Review

Patient: Female, 44-year-old Final Diagnosis: Legionella pneumophila serogroup 1-associated pneumonia and diffuse alveolar hemorrhage Symptoms: Dyspnea Medication:— Clinical Procedure: Bronchoalveolar lavage Specialty: Infectious Diseases Objective: Rare disease Background:We report a case of diffuse alveolar hemorrhage (DAH) caused by Legionella pneumophila serogroup (SG) 1 and review the existing literature to identify risk factors and determine the prognosis of patients with Legionella pneumonia-associated DAH.Case Report:A 44-year-old woman was admitted to our hospital following the presentation of dyspnea for a few days. Chest computed tomography (CT) findings revealed “crazy-paving” pattern in the right upper lobe implicating DAH and consolidation in the lower lobe. Analysis of the bronchoalveolar lavage (BAL) fluid revealed DAH, with further analyses identifying L. pneumophila SG 1 as the causative agent. The patient was successfully treated with levofloxacin and a red blood cell transfusion and discharged on the 32nd day of hospitalization. A literature review of 6 reported cases (including our case) of Legionella pneumonia-associated DAH revealed that the median age of patients with DAH was 59 years (range, 44–75 years), involving female patients in 4 cases (67%) and the use of immunosuppressive drugs in 2 cases (33%). Three cases were BAL Legionella polymerase chain reaction (PCR)-positive and 4 cases were diagnosed using a urinary Legionella antigen test (one case was simultaneously PCR-positive). These infections were caused by L. pneumophila SG 1 in three cases and SG 3 in one case. Mechanical ventilation was used in 5 cases (83%) and one patient had an unfavorable prognosis. Steroids for DAH were used in 5 cases (83%), and 2 cases responded to this treatment.Conclusions:Our case highlights that clinicians should be aware of Legionella spp. as a cause of DAH in an immunocompe-tent host with “crazy-paving” pattern on chest CT, and perform a urinary antigen test and BAL PCR for diagnosis.

Five-year symptomatic hemorrhage risk of untreated brainstem cavernous malformations in a prospective cohort.

Hemorrhage of brainstem cavernous malformation (CM) would cause various symptoms and severe disability. The study aimed to elaborate on the 5-year actuarial cumulative hazard of symptomatic hemorrhage. Patients diagnosed in our institute between 2009 and 2013 were prospectively registered. All clinical data were obtained, follow-up was performed, and risk factors were evaluated. Four hundred sixty-eight patients (217 female, 46.4%) were included in the study with a median follow-up duration of 79.0months. A total of 137 prospective hemorrhages occurred in 107 patients (22.9%) during 1854.0 patient-years. Multivariate Cox analysis found age ≥ 55years (hazard ratio (HR) 2.166, p = 0.002), DVA (HR 1.576, p = 0.026), superficial-seated location (HR 1.530, p = 0.047), and hemorrhage on admission (HR 2.419, p = 0.026) as independent risk factors for hemorrhage. The 5-year cumulative hazard of hemorrhage was 30.8% for the overall cohort, 47.8% for 60 patients with age ≥ 55years, 43.7% for 146 patients with DVA, 37.9% for 272 patients with superficial-seated lesions, and 37.2% for 341 patients with hemorrhage on admission. As a stratified analysis, within subcohort of 341 patients with a hemorrhagic presentation, age ≥ 55years (HR 3.005, p < 0.001), DVA (HR 1.801, p = 0.010), and superficial-seated location (HR 2.276, p = 0.001) remained independently significant. The 5-year cumulative hazard of hemorrhage was 52.0% for 119 patients with both DVA and hemorrhagic presentation. The 5-year cumulative hemorrhagic risk was 30.8% and was higher in subgroups if harboring risk factors that helped to predict potential hemorrhagic candidates and were useful for treatment decision-making.Clinical Trial Registration-URL: http://www.chictr.org.cn Unique identifier: ChiCTR-POC-17011575.

Adrenal hemorrhage presenting as severe indirect hyperbilirubinemia in a neonate

The Sri Lanka Journal of Perinatal Medicine (SLJPM) was launched in 2019 as the official journal of the Perinatal Society of Sri Lanka. This journal is unique in the fact that it brings together three core specialties of perinatal medicine - obstetrics, neonatology and community medicine. It is an open access peer reviewed journal containing original research articles, expert reviews, current practices and other articles of interest to all involved in perinatal medicine.

Arterio-Venous Brain Malformation Rupture during Pregnancy, About a Case

AVMs are abnormalities of the intracranial vessels that constitute a connection between the arterial and venous systems and lack an intervening capillary bed. Hemorrhagic presentation of AVM is associated with significant morbidity and mortality; it is an independent predictor of future hemorrhage. AVM rupture is one of the most frequent and important causes of hemorrhagic stroke during pregnancy and puerperium. Whether the risks of AVM rupture increases during pregnancy and puerperium is controversial, but maternal physiological changes in hemodynamics, blood volume, and hormonal effects on the vessel walls could potentially increase the risk of hemorrhage from AVMs during pregnancy and in the postpartum period. For AVM during pregnancy and puerperium, previous studies have demonstrated histologic changes in arteries and arterioles of pregnant women, thought to be mediated by progesterone; the changes included fragmentation of reticular fibers and loss of normal corrugation of elastic fibers, which might play a role in the increased risk for AVM hemorrhage during pregnancy. However, there is insufficient evidence to guide management decisions for ruptured AVMs during pregnancy, and further well-designed, multicenter, perspective clinical trials are needed. We report the case of a young woman, who had an emergency ceasarean surgery for a headeck and consciousness disorder witch evoked eclampsia, while in fact; she had a rupture of arteriovenous malformation following the rupture of a cerebral Arterio-venous malformation in cerebral imaging.

Intracranial aspergillosis in immunocompetent adult patients without risk factors: a systematic review.

The clinical features and prognostic factors of intracranial aspergillosis in immunocompetent patients without risk factors are not well known. PubMed, Scopus, Google Scholar, and Web of Science were searched for all relevant case reports/series on adult patient (≥ 18years) with aspergillosis published from 1976 to 2018. One hundred eighty-two patients (median age, 40years; range, 18-83years; male:female, 115:67) were identified. Types of intracranial aspergillosis included intracranial mass from the skull base (54.9%), pure intraparenchymal disease (23.6%), meningoencephalitis (13.2%), and dural-based mass (8.2%). Vascular complications occurred in 44 patients (26.3%). Eighty-one patients (44.5%) had favourable final clinical outcomes without any deficits, whereas 58 (31.9%) died. Disease-related mortality improved significantly over time (43.1% [28/65] before 2000, 25.9% [30/116] after 2001; p = 0.021). Patients with meningoencephalitis demonstrated the highest mortality rate (79.2%, 19/24). Medical non-responders (patients whose disease course worsened after receiving the initial medication regimen) and vascular complications (the presentation of subarachnoid haemorrhage, intracerebral haemorrhage, or infarction related to the rupture or occlusion of intracranial vessels) were significantly associated with mortality (p < 0.001). Findings from the current review may help predict patient prognosis at the initial assessment and determine potential prognostic factors.

Ganglioglioma revealed by spontaneous intracerebral hematoma: A cohort study

BackgroundGangliogliomas are rare tumors of the central nervous system. Intracerebral hemorrhage (ICH) is a frequent pathological event, rarely related to intracranial tumor. Here we report a cohort of 14 gangliogliomas, 3 of which were revealed by ICH. We also performed a systematic review of the literature on gangliogliomas revealed by ICH. Patients and methodsWe retrospectively collected data for all gangliogliomas operated on in our department between January 2015 and December 2019: clinical history, radiological data and outcome, with a special focus on gangliogliomas revealed by spontaneous ICH. All cases had pathological validation. For the systematic review, relevant studies were identified by systematic search of the scientific literature in PubMed. ResultsFifteen patients underwent surgery for ganglioglioma during the study period. Six cases were revealed by seizures, 3 by headache, 1 by hydrocephaly and 1 by developmental disorder. Three patients (21%) had hemorrhagic presentation. All patients were male, aged 30 to 48 years, diagnosed with atypical ICH without vascular abnormality on cerebral angiogram. Conservative management was first decided. Diagnosis of ganglioglioma was made within 3 months for 2 patients and 9 years later for 1, after surgical removal and histological analysis. All hemorrhagic gangliogliomas were BRAF wild type. The systematic review of the literature identified 8 other cases of ganglioglioma revealed by ICH. ConclusionICH may be a mode of revelation of ganglioglioma, and ganglioglioma is a possible etiology of atypical ICH in young patients. Long-term imaging follow-up is mandatory in patients with unexplained ICH.

Multimodality Treatment of Brain Arteriovenous Malformations with One-Staged Hybrid Operation: Clinical Characteristics and Long-Term Prognosis.

Objective We aimed to evaluate the clinical characteristics and long-term prognosis of brain arteriovenous malformations (bAVMs) treated with multimodality management of one-staged hybrid operation. Methods We identified bAVM patients treated with one-staged hybrid operation from a multicenter prospective cohort study (NCT03774017) between January 2016 and June 2020. Patients were divided into unruptured and ruptured groups by the hemorrhagic presentation. Long-term (>12 months) neurological disability, postoperative complications of stroke, and nidus obliteration were evaluated and compared between groups. Prognostic predictors associated with outcomes were analyzed. Results A total of 130 patients were identified in the study receiving one-staged hybrid operations, including 61 unruptured cases and 69 ruptured cases. Mean age was 29.1 years old, with 78 (60.0%) being male. Patients included in the study were followed up for a mean period of 37.4 (11.07) months. The annual hemorrhagic risk was 4.2% per year. Thirteen postoperative stroke events were detected in 11 patients (8.5%). Long-term disability occurred in 6.9% of cases, and 86.2% of patients experienced an unchanged or improved neurological status at the last follow-up. All patients achieved complete obliteration on follow-up angiographies. Increased AVM volume was associated with a higher risk of postoperative stroke (odds ratio (OR) 1.021, 95% confidence interval (CI) 1.006-1.037, and P = 0.006). Poor neurological status (OR 6.461, 95% CI 1.309-31.889, and P = 0.022) and infratentorial location (OR 5.618, 95% CI 1.158-27.246, and P = 0.032) were independent predictors for long-term disability. Conclusions One-staged hybrid operation of embolization combined microsurgical resection can be performed as a safe and effective strategy for bAVM treatments. Long-term prognosis of complete obliteration with low rates of morbidity and mortality can be achieved. Unruptured and ruptured bAVMs acquired similar favorable outcomes after the multimodality treatment.

Quantified flow and angioarchitecture show similar associations with hemorrhagic presentation of brain arteriovenous malformations

IntroductionThe purpose of our study was to elucidate the impact of brain arteriovenous malformation (BAVM) flow and wall shear stress (WSS) on angioarchitecture and to evaluate their association with hemorrhagic presentations. Materials and methodsForty-one patients with BAVMs were evaluated by phase-contrast MR angiography. Volume flow rate and WSS were quantified. Angioarchitectural features such as location, angiogenesis, venous stenosis, venous ectasia, venous phlebitis, venous rerouting, exclusive deep vein and venous sac were evaluated by two neuroradiologists. The correlation between BAVM flow and size was evaluated with Spearman correlation coefficients. Differences of size, flow, and WSS between the hemorrhagic and non-hemorrhagic groups, the seizure and non-seizure groups, and between the different groups based on angioarchitecture were evaluated with Mann-Whitney U tests. Accuracy in predicting hemorrhage was evaluated with receiver operating characteristic curves. ResultBAVM flow was highly correlated with volume (ρ = 0.77). Higher flow was more commonly associated with angiogenesis, venous ectasia, venous rerouting, and venous phlebitis. Flow and angioarchitecture showed similar efficacy in differentiating hemorrhagic from non-hemorrhagic BAVMs. WSS did not demonstrate differences across any clinical groups. ConclusionFlow quantification and angioarchitecture analysis of BAVMs showed similar efficacy as evaluated by associations with hemorrhagic presentation. High flow affects both arterial and venous angioarchitecture, reflecting the nature of low vascular resistance in BAVMs.

The effect of early tranexamic acid on bleeding, blood product consumption, mortality and length of hospital stay in trauma cases with hemorrhagic shock: a randomized clinical trial

SummaryIntroductionBecause no medication has been approved for coagulation support in trauma, the current study was aimed to evaluate the effectiveness of intravenous injection of Tranexamic acid (TXA) in patients with acute traumatic bleeding.MethodsIn the current randomized controlled clinical trial, 68 patients with acute bleeding and hemorrhagic shock presentation due to blunt trauma of the abdomen, pelvis, and thorax, randomly assigned into two groups of TXA and placebo.ResultsThere was no statistically significant difference between the two groups in terms of Systolic blood pressure, pulse rate, Base excess, serum hemoglobin changes, bleeding volume, the incidence of thrombotic events, and the number of deaths (p > 0.05). But Systolic blood pressure, pulse rate, base excess, and serum hemoglobin, changed significantly within each group over time(p < 0.05). The median time for the length of hospital stay among the TXA group was lower than the Placebo group (6 days vs 10 days, p = 0.004). Also, there was a significant difference between the two groups about the median of pack cell, Platelet consumption, and bleeding Volume (p < 0.05).ConclusionThe use of TXA is associated with lower use of blood production and reduced length of hospital stay, however, thrombotic events incidence and mortality rates between the TXA and placebo groups were not different.

The burden and risks factors for intracerebral hemorrhage in a Southeast Asian population

ObjectiveThe characteristics of intracerebral hemorrhage in Southeast Asian countries are insufficiently represented in the literature despite a large proportion of new stroke cases and deaths. This study aims to report the epidemiological and clinical presentation of intracerebral hemorrhage in Brunei Darussalam and investigate its incidence according to sex and age, as well as in relation to clinical presentation, radiological findings, and prognostic factors. MethodsThis retrospective study of intracerebral hemorrhage admissions was conducted from 1 January 2016–31 December 2019. Crude incidence rates were calculated by age and sex. Patient characteristics/demographics, mortality and functional outcomes were analyzed. Multivariate Cox regression models were used for investigating predictors of mortality. ResultsThe study cohort consisted of 255 patients (median age, 52 years); most were men (64.3% [164/255]) and had hypertension (76.9% [196/255]). The annual incidence rate was 14.6 per 100,000 (95% confidence interval, 12.9–16.5), and incidence rates were higher in men than in women for all age groups. A 7-day and 30-day mortality rate of 22.7% and 31.4%, respectively, was reported. Increased 30-day mortality was associated with patients on dialysis, diabetes mellitus, Glasgow Coma Scale score ≤ 8, bilateral dilated pupils, higher international normalized ratio, hematoma in the cerebellum or brainstem, hematoma volume, and presence of intraventricular hematoma. ConclusionsThis study provided insight into several aspects of the burden of intracerebral hemorrhage in Brunei Darussalam where an increasing incidence trend in men was observed. Intracerebral hemorrhage is associated with significant mortality and severe disability, and hypertension remains a significant risk factor.

Correlation between angioarchitectural characteristics of brain arteriovenous malformations and clinical presentation of 183 patients.

The correlation between angioarchitecture and clinical presentation of brain arteriovenous malformation (bAVM) remains a subject of debate. The main purpose of the present study was to assess the correlation between angioarchitectural characteristics of bAVM and clinical presentation. A retrospective review of all consecutive patients presenting a bAVM who underwent a cerebral angiography at Beneficencia Portuguesa Hospital in São Paulo between January 2006 and October 2016 was carried out. Patients were divided in five groups: group 1 - hemorrhage; group 2 - seizure; group 3 - headache; group 4 - progressive neurological deficits (PND); group 5 - incidental). A total of 183 patients were included, with group 1 comprising 56 cases, group 2 49 cases, group 3 41 cases, group 4 28 cases, and group 5 9 cases. Regarding hemorrhage presentation, a statistical correlation was observed with female gender (P < 0.02), Spetzler-Martin 3B (P < .0015), and lesions with low flow (P < 0.04). A positive association was found between group 2 and age less than 36 years (P < 0.001), male sex (P < 0.018), presence of superficial lesions not classified as SM 3B (P < 0.002), presence of venous ectasia (p <0.03), and arterial steal phenomenon (P < 0.03). Group 4 was associated with older age (P < 0.01). Angioarchitectural characteristics can be correlated with some clinical presentations as well as with some clinical data, making it possible to create predictive models to differentiate clinical presentations.

A Rare Case of Severe Post Adenoidectomy Secondary Haemorrhage

Tonsillectomy and adenoidectomy are amongst the most common surgeries performed in children. Haemorrhage, after and during these procedures, is a major and known complication. Most commonly, the haemorrhage presents intraoperatively or in the immediate postoperative period and is self-limiting. However, secondary haemorrhage presenting after adenoidectomy where adenoidectomy alone was performed have been reported in very few patients. In this case, a 10-year-old male presented with history of upper airway obstruction including sleep apnoea, adenoid facies, and bilateral moderate conductive hearing loss since four years. He had no co-morbidities, history of bleeding diathesis. The pre-operative evaluation of the adenoids (clinically and radiologically) revealed no abnormal vasculature or anatomical variations. Conventional adenoidectomy and bilateral grommet insertion was performed under General Anaesthesia (GA). The postoperative period was entirely uneventful, and the patient was discharged on postoperative day 3. Despite having no risk factors, he presented with profuse posterior epistaxis after conventional adenoidectomy on postoperative day 5. Immediate management was done by posterior nasal packing and intravenous amoxicillinclavulanate Definitive treatment was done by re-exploration and debridement of the remnant adenoid tissue using a microdebrider under GA the next day. The patients had no complaints postoperatively or at 6 months follow-up. The rarity of complications makes adenoidectomy a fairly safe procedure. However, despite being uncommon, secondary complications of adenoidectomy should be anticipated by surgeons to avoid dire consequences for the patient.

Prognostic Factors For Functional Outcome in Patients with Mesencephalic Hemorrhage.

Mesencephalic hemorrhage (MH) is a rare presentation of spontaneous intraparenchymal hemorrhage. This study aims to evaluate prognostic parameters of the MH outcome. We conducted an extensive search in the literature for cases with spontaneous, isolated mesencephalic hemorrhage. The study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Sixty-two eligible cases have been reported in the literature as proven by CT or MRI, and to these, we added six cases confirmed by MRI. The modified Rankin Scale (mRS) was dichotomized into two groups as the favorable outcome (FO; score, 0-2) and unfavorable outcome (UO; score, 3-6). Of the 68 patients studied, 26 (38%) presented with normal consciousness, 22 (32%) with lethargy , and 20 (29%) with stupor or coma. There was no cause of hemorrhage in 26 (65%) patients with FO and 12 (43%) with UO (p=0.059). In univariate analyses, neither arteriovenous malformations (p=0.33) nor cavernomas (p=0.19) were associated with outcome. Multiple logistic regression analysis revealed that hypertension (OR, 51.22; CI95%, 1.92-1370.24; P=0.019), consciousness (OR, 133.54; CI95%, 1.61-1113.3; P=0.03), NIHSS at admission (OR, 57.23; CI95%, 2.87-1141.2; p=0.008), and ventrodorsal hemorrhage size (≥1 cm) (OR, 61.83; CI95%, 2.15-1779.2; p=0.016) were significantly associated with UO. Three months after stroke, 40 patients (59%) had FO, 28 (41%) had UO, and 8 (12%) died. These results suggest that ventrodorsal size of hemorrhage and clinical severity at stroke onset are possible predictors of functional outcome after mesencephalic hemorrhage.

Adrenal gland hematoma presenting as an acute scrotum in a neonate

The acute scrotum in a neonatal patients is an emergency. Its'etiology is variable, mostly represented by testicular torsion, trauma or adrenal hemorrhage. Previously, immediate scrotal exploration was considered imperative for diagnosis and treatment. With good imaging studies, some patients are conservatively managed. We report two cases of neonatal adrenal hemorrhage presenting as acute scrotum misguiding the clinician to rule out a local scrotal pathology. As the clinical examination is not reliable in a new-born, it definitely requires an imaging evaluation to establish the diagnosis. This case report tries to outline the importance of the correlation between acute adrenal hemorrhage and acute scrotum and the role of ultrasonography as a useful tool for differential diagnosis. A well performed ultrasound examination helps to identify an abdominal pathology as the cause of an acute scrotum and to specifically diagnose an adrenal hemorrhage in order to avoid unnecessary surgical exploration.

Idiopathic bilateral adrenal hemorrhage presenting as acute abdomen in a 61-year-old male: A case report with review of literature

Introduction: Adrenal haemorrhage (AH) is a rare, life-threatening condition that requires prompt diagnosis and management. Case Report: A 61-year-old male presented with sudden-onset central abdominal pain, distended abdomen, and nausea. There was no history of trauma or any other predisposing factor for AH. The blood pressure was raised, while other vitals were normal. The patient was managed with intravenous Diclofenac, Tablet Amlodipine, and Ryle's tube insertion. Initial abdominal ultrasound revealed bilateral adrenal enlargement. However, non-contrast computed tomography of abdomen revealed changes suggestive of bilateral AH. These findings were confirmed on magnetic resonance imaging of abdomen. Though the serum cortisol and adrenocorticotropic hormone levels were normal, and the patients were not symptomatic of adrenal insufficiency, intravenous Methylprednisolone was initiated to prevent deterioration of adrenal function. All the known causes of AH were excluded, and a diagnosis of idiopathic bilateral AH was reached. On Day 7, an abdominal ultrasound revealed a non-progressive size of the bilateral adrenal lesions and the patient was discharged with well-controlled blood pressure. Conclusion: Idiopathic AH, in patients without any predisposing factors, should be included in the differential diagnosis of a patient with vague abdominal pain.

Association of Risk Factors with Maternal Outcomes In Abruptio Placenta at Tertiary Care Hospital

Introduction: Abruptio placenta is a serious condition that increases maternal and neonatal morbidity and mortality. The incidence of abruption placenta is between 0.49% -1.8%. Primary cause of abruption is not known but the main precipitating and predisposing factors of abruption are age, parity, anemia, poor nutrition, pregnancy induced hypertension, eclampsia, gestational diabetes mellitus, preterm premature rupture of membrane, and previous medical termination of pregnancy. Methodology: It is a retrospective observational study done by analyzing the case sheets of abruption placenta in tertiary care hospital from January 2020 to December 2020. All those patients of antepartum hemorrhage presenting directly as typical cases of abruption placenta were included. Also, those cases in which placenta previa and other causes were ruled out after clinical, per speculum examination and/or USG examination were ruled out. Result: The total number of abruption placenta collected during this period was 21. We found 38% patients with chronic hypertension, 33 % of patients with severe preeclampsia, 14% with eclampsia, 15% were normotensive. Advanced maternal age and multiparity were also the risk factors of abruption placenta. Conclusion: Antenatal care which identifies the risk factors like PIH plays an important role in decreasing the incidence of abruption placenta. Early detection and active management will reduce morbidity.

Risk Factors of Aggressive Clinical Presentation in Patients with Angiographically Aggressive Cranial Dural Arteriovenous Fistulas.

Compared to nonaggressive cranial dural arteriovenous fistulae (cDAVF), aggressive cDAVF carries leptomeningeal venous drainage (LVD) and has approximately 15% annual risk of hemorrhagic and non-hemorrhagic aggressive neurological presentations. In terms of aggressive clinical presentations, the previous classification does not adequately differentiate the higher risk group from the lower risk group. Herein, we retrospectively collected a series of patients with aggressive cDAVF and explored the risk factors for differentiating the higher-risk group from the lower-risk group with aggressive clinical presentations. We retrospectively collected patients with aggressive cDAVF from March 2011 to March 2019. The risk of aggressive clinical presentation was recorded. Risk factors were included in the analysis for aggressive clinical presentations. From March 2011 to March 2019, 37 patients had aggressive cDAVF. Among them, 24 presented with aggressive clinical presentation (20, hemorrhagic presentation; four, non-hemorrhagic presentation). In patients presenting with hemorrhage, four patients experienced early rebleeding after diagnosis. In the univariate analysis, risk location, directness of LVD, exclusiveness of LVD, and venous strain were significantly different in patients with aggressive clinical presentation. In the multivariate analysis, exclusiveness of LVD and venous strain were observed, with a significant difference between patients with aggressive clinical presentation and those with benign clinical presentation. Among patients with angiographically aggressive cDAVFs, approximately 65% presented with aggressive clinical presentations in our series. Among all potential risk factors, patients with exclusiveness of LVD and venous strain have even higher risk and should be treated aggressively and urgently.

Intracranial Hemorrhage from Dural Arteriovenous Fistulas: What Can We Find with CT Angiography?

(1) Background: Dural arteriovenous fistulas (DAVF) represent a rare acquired intracranial vascular malformation, with a variety of clinical signs and symptoms, which make their diagnosis difficult. Intracranial hemorrhage is one of the most serious clinical manifestations. In this paper the authors’ goal was to verify the accuracy and utility of contrast-enhanced brain CT angiography (CTA) for the identification and the characterization of dural arteriovenous fistulas (DAVFs) in patients who presented with brain hemorrhage compared to 3D digital subtraction angiography (3D DSA); (2) a retrospective study of 26 patients with DAVFs who presented with intracranial hemorrhage to our institution was performed. The information reviewed included clinical presentation, location and size of hemorrhage, brain CTA and 3D DSA findings; (3) results: 61% (16/26) of DAVFs were identified by CTA. The vast majority of patients were male (69%, 18/26) and the most common presenting symptom was sudden onset headache. All DAVFs had cortical venous drainage and about one-third were associated with a venous varix. The most common location was tentorial (73%, 19/26); (4) conclusions: CTA can represent a valid alternative diagnostic method to 3D DSA for the study of DAVF in the initial and preliminary diagnostic approach, especially in emergency situations. In fact, it represents a fast, inexpensive, non-invasive and above all, easily accessible and available diagnostic technique, unlike DSA or MRI, allowing to provide information necessary for the identification, classification and treatment planning of DAVFs.

DIFFUSE ALVEOLAR HEMORRHAGE WITH LATE PRESENTING RIGHT VENTRICULAR THROMBI

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Diffuse alveolar hemorrhage is a life threatening emergency that can be caused by multiple etiologies. Pulmonary capillaritis, one common etiology, is particularly associated with autoimmune or inflammatory diseases. We present a challenging case of diffuse alveolar hemorrhage with associated acute hypoxic respiratory failure due to isolated pulmonary capillaritis with multiple late presenting intracardiac thrombi. CASE PRESENTATION: A 20 year-old woman presented with four days of myalgias, fever, and shortness of breath. Testing for pulmonary embolism and SARS-CoV2 was negative. She was diagnosed with pneumonia and treated with ceftriaxone and azithromycin. She then developed blood tinged mucous which was concerning for diffuse alveolar hemorrhage and received three days of pulse dose steroids. Seven days after initial presentation, she required escalation to intensive care. Her oxygen saturation was 96% on 70% FiO2 and 50 liters of pressure and subsequently required intubation for hypoxic respiratory failure. Imaging revealed diffuse bilateral infiltrates and bronchoscopy with lavage yielded mild endobronchial bleeding, but no overt hemorrhage. Pathology demonstrated neutrophilic capillaritis with diffuse alveolar damage. Prior outpatient autoimmune workup was significant only for mildly positive anti-nuclear antibody (speckled pattern 1:80). Transthoracic echocardiogram performed after intubation revealed two right ventricular thrombi that were not present on prior echocardiogram from admission. We initiated a heparin infusion in the setting of her alveolar bleeding and continued treatment with methylprednisolone. She then developed acute hemodynamic changes concerning for pulmonary embolism but stabilized without further intervention. The patient's oxygenation improved and she was successfully extubated. An antiphospholipid syndrome screen returned positive for a Dilute Russell Viper Venom Time (though notably value was 1.25 and upper limit of normal is 1.24) and anticoagulation was transitioned to warfarin prior to discharge home. DISCUSSION: Concurrent hemorrhage and hypercoagulability is a difficult management dilemma that many clinicians will face in the hospital setting. This case highlights the degree of suspicion required to evaluate for thromboembolic phenomena even in a patient with hemorrhage. In this young patient with no significant past medical history, autoimmune etiologies must be considered for her presentation of diffuse alveolar hemorrhage, which can also cause a concurrent hypercoagulable state. Despite mildly positive lupus anticoagulant screen, remainder of autoimmune workup was negative and suspicion low for systemic autoimmune disease. CONCLUSIONS: Bedside clinical judgement must drive decision making in the balance between worsening bleeding with anticoagulation or considering intervention for hemodynamically significant thromboembolic events. REFERENCE #1: Stoots SA, Lief L, Erkan D. Clinical Insights into Diffuse Alveolar Hemorrhage in Antiphospholipid Syndrome. Curr Rheumatol Rep. 2019;21(10):56. Published 2019 Sep 6. doi:10.1007/s11926-019-0852-7 REFERENCE #2: Park MS. Diffuse alveolar hemorrhage. Tuberc Respir Dis (Seoul). 2013;74(4):151-162. doi:10.4046/trd.2013.74.4.151 DISCLOSURES: No relevant relationships by Micah Fisher, source=Web Response No relevant relationships by David Wilhoite, source=Web Response