Hemorrhagic Presentation Research Articles

Bullous skin signs and laboratory surgical indicators can quickly and effectively differentiate necrotizing fasciitis from cellulitis

ObjectivesThe purpose of this prospective study was to investigate the different microorganisms associated with mortality, to evaluate the bullous skin sign, and to identify the positive predictive factors for differentiating necrotizing fasciitis (NF) from cellulitis on initial onset at the emergency department. MethodsThis prospective study was conducted in 145 consecutive patients with NF and 159 patients with cellulitis. Age, sex, comorbidities, infection site, microbiological results, condition of skin lesions, laboratory findings, vital signs, and clinical outcomes were compared between the two groups at the time of admission to the emergency room. ResultsA total of 15 patients in the NF group and two patients in the cellulitis group died, resulting in a mortality rate of 10.3% and 1.3%, respectively. The NF group had a significantly higher incidence of white blood cell counts, band form neutrophil, and C-reactive protein than the patients in the cellulitis group. Hemorrhagic bullae presentation appeared to have significantly associated with NF and death. ConclusionThe following diagnostic indicators can be effectively used to differentiate NF from cellulitis at the initial onset: presence of hemorrhagic bullae, white blood cell counts >11,000 cells/mm3, band forms >0%, C-reactive protein >100 mg/l, and systolic blood pressure ≤90 mm Hg at the time of consultation.

Prediction of new cerebral ischemic lesion after carotid artery stenting: a high-resolution vessel wall MRI-based radiomics analysis.

Carotid artery stenting (CAS) is an established treatment for local stenosis. The most common complication is new ipsilateral ischemic lesions (NIILs). This study aimed to develop models considering lesion morphological and compositional features, and radiomics to predict NIILs. One hundred and forty-six patients who underwent brain MRI and high-resolution vessel wall MR imaging (hrVWI) before and after CAS were retrospectively recruited. Lumen and outer wall boundaries were segmented on hrVWI as well as atherosclerotic components. A traditional model was constructed with patient clinical information, and lesion morphological and compositional features. Least absolute shrinkage and selection operator algorithm was performed to determine key radiomics features for reconstructing a radiomics model. The model in predicting NIILs was trained and its performance was tested. Sixty-one patients were NIIL-positive and eighty-five negative. Volume percentage of intraplaque hemorrhage (IPH) and patients' clinical presentation (symptomatic/asymptomatic) were risk factors of NIILs. The traditional model considering these two features achieved an area under the curve (AUC) of 0.778 and 0.777 in the training and test cohorts, respectively. Twenty-two key radiomics features were identified and the model based on these features achieved an AUC of 0.885 and 0.801 in the two cohorts. The AUCs of the combined model considering IPH volume percentage, clinical presentation, and radiomics features were 0.893 and 0.842 in the training and test cohort respectively. Compared with traditional features (clinical and compositional features), the combination of traditional and radiomics features improved the power in predicting NIILs after CAS. • Volume percentage of IPH and symptomatic events were independent risk factors of new ipsilateral ischemic lesions (NIILs). • Radiomics features derived from carotid artery high-resolution vessel wall imaging had great potential in predicting NIILs after CAS. • The combination model with radiomics and traditional features further improved the diagnostic performance than traditional features alone.

Clinical significance of “periventricular collateral enhancement sign” in symptomatic moyamoya disease: A vessel wall imaging study

BackgroundPeriventricular collaterals are associated with high risk of hemorrhagic stroke in adult moyamoya disease (MMD). However, the clinical significance of the periventricular collateral enhancement sign (PCES), which indicates wall enhancement of periventricular collaterals on contrast-enhanced vessel wall imaging (VWI), has yet to be determined. MethodsThirty-seven patients with MMD with acute neurological symptoms were consecutively recruited. Periventricular collaterals including lenticulostriatal artery, thalamic artery, and choroidal artery collaterals were evaluated on digital subtraction angiography, and then PCES was detected on pre- and postcontrast VWI. First, the association between PCES and hemorrhagic presentation was evaluated using multivariate analyses. Second, two raters investigated the culprit vessels responsible for bleeding in hemorrhagic MMD using the Cohen kappa statistic. ResultsFifteen sites of PCES on postcontrast VWI were observed in 15 patients. Multivariate analysis revealed that hemorrhagic presentation was the only independent factor for PCES (OR = 37.3, 95%CI = 3.9–113, p =.002). In patients with hemorrhagic presentation (n = 20), the identification rate of the ruptured vessel was 80% by rater 1, with excellent agreement. (inter-rater, κ = 0.86, 95%CI = 0.59–1.00; intra-rater, κ = 0.83, 95%CI = 0.50–1.00). Choroidal (50%) and thalamic artery collaterals (15%) were the most common and the second most common types of culprit vessels. Inter-rater and intra-rater reliabilities for the classification of culprit vessels were also excellent (intra-rater, κ = 0.86, 95%CI = 0.67–1.00; inter-rater, κ = 0.93, 95%CI = 0.79–1). ConclusionAcute hemorrhagic stroke in MMD is independently associated with PCES on postcontrast VWI. PCES can help to detect the culprit vessels that are responsible for hemorrhage in patients with MMD.

Pseudoaneurysm as a differential for the computed tomography angiography "spot sign" in atypical presentations of intracerebral hemorrhage: illustrative case.

The computed tomography angiography (CTA) "spot sign" is a well-recognized radiographic marker in primary intracerebral hemorrhage (ICH). Although it has been demonstrated to represent an area of active hemorrhage or contrast extravasation, the exact pathophysiology remains unclear. Vascular mimics of the spot sign have been identified; however, those representing pseudoaneurysm and small vessel aneurysm have rarely been reported. A 57-year-old female with a past medical history of hypertension and diabetes mellitus presented with 2 weeks of acute-onset, worsening headache. Computed tomography scanning showed a right interior frontal lobe intraparenchymal hemorrhage. CTA demonstrated a punctate focus of hyperattenuation within the hematoma, consistent with a spot sign, which corresponded to a distal anterior cerebral artery pseudoaneurysm on a cerebral angiogram. The patient subsequently underwent emergent resection of the pseudoaneurysm and hematoma evacuation without complications. Her postoperative course was unremarkable without acute concerns or residual symptoms at the 4-month follow-up. The authors present a unique case of a distal anterior cerebral artery pseudoaneurysm presenting as a spot sign in a relatively young patient without underlying vascular disease. Given the need for emergent intervention, intracranial pseudoaneurysm is an important diagnosis to consider in the presence of a spot sign in atypical clinical presentations of primary ICH.

Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients.

Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children. This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed. Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae. Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.

PSAT038 A Case of Spontaneous Atraumatic Unilateral Adrenal Hemorrhage

Abstract Background Adrenal hemorrhage is a rare disorder with an incidence of 0.1 to 1% for which a cause is identified in most cases. It is usually classified as traumatic or atraumatic, unilateral or bilateral and can result in serious consequences such as adrenal crisis and death if not diagnosed and treated properly. We describe a patient with an atraumatic unilateral adrenal hemorrhage without a known coagulopathy Case presentation: A 51-year-old man with history of COPD and Reynaud's phenomenon presented to the hospital for severe right upper quadrant pain. CT of the abdomen demonstrated a right adrenal hemorrhage of 5.2×4.0×2.6 cm in size, for which Endocrinology was consulted. The patient denied recent trauma or anticoagulation use. Physical examination exhibited generalized abdominal tenderness, without hypotension, or symptoms of acute adrenal insufficiency. Biochemical evaluation showed an AM Cortisol level of 14.3 ug/dL (4.2 - 22.4 ug/dL) and ACTH 67.1 pg/mL (7.2 - 63.3 pg/mL). MRI abdomen showed a decrease in size of the hemorrhage measuring 3.1×1.7×5.2 cm. He was referred to Hematology/Oncology to evaluate for coagulopathy which was unrevealing. About one month from hospital discharge, the patient reported voice hoarseness and was diagnosed with moderately differentiated keratinizing squamous cell carcinoma of larynx. Ten months later PET-CT scan showed hypermetabolic laryngeal mass with bilateral cervical lymphadenopathy without evidence of adrenal gland metastasis with resolution of adrenal hemorrhage, indicative that the hemorrhagic episode is unrelated to this newly diagnosed malignancy. Discussion Adrenal hemorrhage is a rare disorder that overall is associated with a 10-20% mortality rate, it is usually classified as traumatic and no traumatic. Most times it is caused by secondary disorders such as trauma, surgery, anticoagulants, infections, but in rare instances is idiopathic. Clinical manifestations of adrenal hemorrhages vary depending on extension of the hemorrhage and early diagnosis is crucial for better outcomes. As per current guidelines, assessment for adrenal insufficiency including hemodynamics, biochemical evaluation and imaging is paramount. To date, clear etiology of primary adrenal hemorrhage is lacking. This case demonstrated an unusual presentation of idiopathic unilateral adrenal hemorrhage without evidence of adrenal insufficiency. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Cystic artery pseudoaneurysm: an uncommon complication of a common disease

Cystic artery pseudoaneurysm, though rare, is a notable cause of upper GI bleed. Here, we report an unusual presentation of upper gastrointestinal haemorrhage due to a cystic artery pseudoaneurysm secondary to acute cholecystitis in a 54-year-old male. Initial imaging revealed cholelithiasis with evidence of acute cholecystitis. Further investigations with Doppler ultrasound and CT suggested evidence of a cystic artery pseudoaneurysm with hyperdense contents in the gall bladder suggesting blood products. Taking into consideration the risk of hemorrhage during the procedure, the patient was taken up for open cholecystectomy. This case emphasizes the need for a high level of awareness of pseudo-aneurysmal disease and inclusion of cystic artery pseudoaneurysm as one of the differential diagnosis for a patient presenting with recurrent upper quadrant pain, jaundice and melena or hemobilia.

Rational Use of Ceftriaxone in Necrotizing Fasciitis and Mortality Associated with Bloodstream Infection and Hemorrhagic Bullous Lesions.

Necrotizing fasciitis (NF) is an uncommon life-threatening necrotizing skin and soft tissue infection. The formation of hemorrhagic bullae is a special skin sign of NF. The purposes of this study were to investigate the incidence of hemorrhagic bullae formation and bacteremia associated with different organisms, to appraise the appropriate use of ceftriaxone, and to compare the clinical and laboratory risk indicators of NF patients with Gram-positive and Gram-negative infections on the initial examination. Methods: From March 2018 to December 2020, there were seventy-four NF patients with positive monomicrobial bacterial cultures enrolled based on surgical confirmation, and were categorized into two groups: the Gram-positive group and the Gram-negative group. Ceftriaxone susceptibility tests were carried out using the standard disk diffusion technique. Data, such as demographics, clinical outcomes, microbiological results, presentations of hemorrhagic bullae, and laboratory findings, were compared among these two groups. Results: The Gram-negative group included 52 patients, of whom 6 patients died, resulting in a mortality rate of 11.5%. The Gram-positive group included 22 patients and none died. Patients with bacteremia, hemorrhagic bullae, shock, fever, higher segmented forms and banded forms, and lower platelet counts constituted higher proportions in the Gram-negative group than in the Gram-positive group. The multivariate analysis identified six variables for the differentiation of Gram-negative and Gram-positive NF: the presentation of bacteremia, hemorrhagic bullae, shock at first consultation, fever with body temperature > 38.5 °C, band forms > 0%, and segmented forms ≦ 74%. A total of 66 isolates (89.2%) was susceptible to ceftriaxone. Conclusions: Gram-negative NF patients were significantly associated with hemorrhagic bullae presentation, blood stream infection, and mortality. Physicians should be alert to NF patients with the appearance of bacteremia, shock, fever, higher WBC banded and segmented forms, and lower platelet counts at the emergency department, with patients revealed to more likely have Gram-negative infections. Ceftriaxone with/without other appropriate antibiotics under the supervision of infectious doctors appeared to be clinically effective for the treatment of NF and blood stream infections.

Incidence, Presentation, and Natural History of Adrenal Hemorrhage

INTRODUCTION: Adrenal hemorrhage (AH) occurring within a normal gland or an adrenal tumor can be indistinguishable on imaging. Guidelines regarding appropriate follow-up of AH are lacking. METHODS: We identified patients with AH found on chest, abdominal, or spinal CT at our tertiary medical center from January 1, 2006, to October 5, 2021, and performed a retrospective cohort analysis. Follow-up imaging of patients without documented resolution of hemorrhage underwent dedicated review by an attending radiologist for evidence of underlying mass. RESULTS: Of 490,301 scans, 550 (0.11%) had evidence of AH. Mean age of patients with AH was 36.8 years and 34.7% were women. Most scans (n = 493, 89.6%) were performed during trauma evaluation. Two patients underwent intervention at the time of presentation: 1 embolization and 1 aspiration of hemorrhagic cyst. Of 126 (22.9%) patients with follow-up imaging at our institution, 92 (73.0%) demonstrated resolution of hemorrhage and 19 (15.1%) showed decreased size at medians of 8.1 and 1.6 months after index scan, respectively. Ten patients (7.8%) had evidence of an adrenal mass, confirmed on follow-up imaging (n = 7) and/or at adrenalectomy (n = 3), with 1 adrenal cortical carcinoma confirmed on pathology. Nontrauma scans with AH were significantly more likely to have an underlying mass (n = 7/35 [20%] nontrauma vs n = 3/96 [3.1%] trauma, p < 0.01). CONCLUSION: AH is a rare finding on CT imaging that may indicate the presence of an underlying mass, particularly when unrelated to trauma. Interval imaging follow-up at 6 months to 1 year should be considered to assess for resolution of hemorrhage and exclude underlying mass.

Intracranial Corkscrew Angiopathy.

The objective of this case report was to describe a rare presentation of corkscrew cerebral angiopathy presenting as subarachnoid hemorrhage (SAH). We present a young woman who presented with a thunderclap headache, found to have a nonaneurysmal SAH. Cerebral angiogram revealed corkscrew angiopathy in medium-sized vessels and multiple micro-occlusions with collateralization. No intracranial aneurysm was detected. Extensive workup for vasculitis and genetic causes for vasculopathy was unrevealing. The patient had no neurologic deficits, and her symptoms resolved. This is an extremely rare presentation of subarachnoid hemorrhage due to corkscrew angiopathy.

S2684 A Rare Case of Helicobacter pylori Gastric Ulcer Causing Left Gastric Artery Pseudoaneurysm and Upper GI Bleed: A Case Report and Scoping Review of Human Cases

Introduction: Pseudoaneurysm is an uncommon but lethal presentation of upper gastrointestinal hemorrhage, as a rupture is associated with a 40-80% mortality rate. Here, we report a rare case of left gastric artery pseudoaneurysm secondary to Helicobacter pylori (HP) infection-associated peptic ulcer disease presenting as upper gastrointestinal hemorrhage. Case Description/Methods: A 62-year-old male with a history of oral cancer status post resection in 2015, polysubstance use disorder (cocaine, heroin, and methamphetamine), hypertension, and gastroesophageal reflux disease presented to the hospital with chest and epigastric pain and melena. Admission laboratory findings were notable for acute kidney injury, leukocytosis, and normocytic anemia. Computed tomography angiography (CT-A) demonstrated a small pseudoaneurysm arising from the left gastric artery projecting into the stomach wall, heterogeneous material within the stomach, and a prominent left gastric artery. These findings were concerning for intraluminal hemorrhage (Figure). The patient underwent emergent embolization of the left gastric artery pseudoaneurysm, followed by esophagogastroduodenoscopy (EGD). This revealed a 2.5 cm ulceration over the lesser curvature of the stomach, and biopsies were positive for HP infection. A systematic review in PubMed and Embase for gastric artery pseudoaneurysm due to gastric ulcer only resulted in one other case report. Though also rare, splenic artery pseudoaneurysm due to gastric ulceration is more common, as our search yielded 5 case reports. Discussion: Acute upper gastrointestinal bleeds presenting to the emergency department are most commonly secondary to variceal hemorrhage or peptic ulcer disease. Peptic ulcer disease can result in gastric artery pseudoaneurysm, however as we only found only one other case report documenting this presentation, it appears to be extremely rare. Recognition of gastric pseudoaneurysm on the CT-A should prompt endoscopic exploration and biopsy with HP testing, with close follow-up for a test of cure.Figure 1.: Computed tomography angiography. (a) Sagittal plane, (b) Transverse plane.

S2328 Gurvit Syndrome: An Unusual Presentation of Upper Gastrointestinal Hemorrhage in a Case of Hypovolemic Shock

S2328 Gurvit Syndrome: An Unusual Presentation of Upper Gastrointestinal Hemorrhage in a Case of Hypovolemic Shock

Perinatal Outcome of Subchorionic Hemorrhage in Early Pregnancy Vaginal Bleeding

Introduction: First-trimester vaginal bleeding is an early indicator of underlying placental pathology and is a causative factor for adverse perinatal outcome. Although subchorionic hemorrhage is quite prevalent, but outcomes have not been studied in the ongoing pregnancies. Hence, we aimed to study the outcome in pregnancies with subchorionic hemorrhage presenting with vaginal bleeding in up to 20 weeks of pregnancy. Methodology: The present study was an observational study conducted over a period of 1 year. A sample size of 230 patients presenting with threatened abortion within 20 weeks of gestation and who fulfilled the inclusion criteria were recruited in the study. A routine ultrasound examination was done to analyze the presence of subchorionic hemorrhage, and the outcomes of such pregnancies were studied. Results: Total 230 subjects presented with bleeding in early pregnancy with gestational age of &lt;20 weeks on ultrasound examination; 31 (13.4%) patients were found to have subchorionic hemorrhage. The present study showed that women with subchorionic hematoma had a significantly higher rate of complications. Conclusion: There is an increased risk of adverse outcome in pregnancy with subchorionic hemorrhage.

Clinical Characteristics and Multimodality Therapy Outcomes in 304 Pediatric Patients with Cerebral Arteriovenous Malformations

Clinical follow-up data of pediatric patients with cerebral arteriovenous malformations (AVMs) are limited. This study investigated the characteristics of AVMs in children and analyzed the clinical outcomes of multimodality therapy in pediatric patients with AVMs at a single center. This retrospective study included consecutive patients diagnosed with AVMs at our institution between August 2008 and June 2018. Data on demographic characteristics, AVM features, and clinical outcomes were collected. Patients aged <18years at admission were defined as children. Overall, 1009 patients with AVMs were included, with 304 (30.1%) patients aged <18years. AVMs in pediatric patients were more likely to present with intracranial hemorrhage, mostly located in deep areas of the brain. A small nidus, exclusively deep drainage, and deep AVM location were associated with hemorrhage in children; Kaplan-Meier analysis revealed that patients with ruptured AVMs had a higher risk of developing a follow-up hemorrhage than those with unruptured AVMs. Among 290 children who were followed up, the multivariate regression analysis showed that a higher pretreatment modified Rankin Scale score, deep AVM location, and conservative treatment were significantly associated with unfavorable outcomes. In pediatric patients, AVMs were more likely to present with intracranial hemorrhage than that in adults. Hemorrhagic presentation in children was associated with a small nidus, exclusively deep drainage, and deep AVM location. Pediatric patients with ruptured AVMs had significantly higher risks of follow-up hemorrhage than those with unruptured AVMs. Our clinical results suggest that nonconservative treatment is better for pediatric patients with AVMs.

33190 Acral hemorrhagic Darier disease: A case report of a rare variant and literature review

Introduction: Acral hemorrhagic Darier disease (DD) is an unusual variant of DD. It presents with acral irregular, jagged shaped hemorrhagic vesicles. A mutation in exon 15 of the ATP2A2 gene that encodes a sarco/endoplasmic reticulum calcium-ATPase pump (SERCA2) is found in 71% in patients with this variant, some with conflicting genetic results. We present 2 patients with this condition. Case: A 41-year-old man presented with several years of evolution of multiple black hemorrhagic vesicles with jagged borders on the dorsum and palms of hands and feet. A punch biopsy showed hemorrhage in the cornified layer with suprabasilar acantholysis and he was diagnosed with acral hemorrhagic DD. His mother had a similar rash affecting acral skin. Genetic testing revealed a p.N676S mutation in the ATP2A2 gene. He was started on acitretin 25 mg/day, increased later to 50 mg/day due to mild improvement. However, he developed facial and truncal lesions resembling classic DD and discontinued treatment. Discussion: 20 cases of this variant have been reported in the literature. In most cases, individuals first developed classic DD and were affected by the hemorrhagic presentation later in life or paradoxically after treatment with a systemic retinoid. It is thought that certain mutations in the ATP2A2 gene may disrupt SERCA2 function of the keratinocytes and vascular endothelium or may produce a mutant SERCA2 protein with a secondary effect in blood vessels. To the best of our knowledge this is the first case of acral hemorrhagic DD that has a p.N676S mutation in the ATP2A2 gene.

Quantitative evaluation of the hemodynamic differences between ruptured and unruptured cerebral arteriovenous malformations using angiographic parametric imaging-derived radiomics features.

Imaging features of cerebral arteriovenous malformations (AVMs) are mainly interpreted according to demographic and qualitative anatomical characteristics. This study aimed to use angiographic parametric imaging (API)-derived radiomics features to explore whether these features extracted from digital subtraction angiography (DSA) were associated with the hemorrhagic presentation of AVMs. Patients with AVM were retrospectively evaluated. Among them, 80% were randomly assigned to a training dataset, and the remaining 20% were assigned to an independent test dataset. Radiomics features were extracted from DSA by API. Then, informative features were selected from radiomics features and clinical features using the Least Absolute Shrinkage and Selection Operator (LASSO) algorithm. A model was constructed based on the selected features to classify the dichotomous hemorrhagic presentation in the training dataset. The model performance was evaluated in the test dataset with confusion matrix-related metrics. A total of 529 consecutive patients with AVMs between July 2011 and December 2020 were included in this study. After being selected by the LASSO algorithm and analyzed by multivariable logistic regression, three clinical features, namely, age (p = 0.01), nidus size (p < 0.001), and venous drainage patterns (p < 0.001), and four radiomics features were used to construct a model in the training dataset. On the independent test dataset, the model demonstrated a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 0.852, 0.844, 0.881, 0.809, and 0.849, respectively. The radiomics features extracted from DSA by API could be potential indicators for the hemorrhagic presentation of AVMs.

Machine learning for predicting hemorrhage in pediatric patients with brain arteriovenous malformation.

Ruptured brain arteriovenous malformations (bAVMs) in a child are associated with substantial morbidity and mortality. Prior studies investigating predictors of hemorrhagic presentation of a bAVM during childhood are limited. Machine learning (ML), which has high predictive accuracy when applied to large data sets, can be a useful adjunct for predicting hemorrhagic presentation. The goal of this study was to use ML in conjunction with a traditional regression approach to identify predictors of hemorrhagic presentation in pediatric patients based on a retrospective cohort study design. Using data obtained from 186 pediatric patients over a 19-year study period, the authors implemented three ML algorithms (random forest models, gradient boosted decision trees, and AdaBoost) to identify features that were most important for predicting hemorrhagic presentation. Additionally, logistic regression analysis was used to ascertain significant predictors of hemorrhagic presentation as a comparison. All three ML models were consistent in identifying bAVM size and patient age at presentation as the two most important factors for predicting hemorrhagic presentation. Age at presentation was not identified as a significant predictor of hemorrhagic presentation in multivariable logistic regression. Gradient boosted decision trees/AdaBoost and random forest models identified bAVM location and a concurrent arterial aneurysm as the third most important factors, respectively. Finally, logistic regression identified a left-sided bAVM, small bAVM size, and the presence of a concurrent arterial aneurysm as significant risk factors for hemorrhagic presentation. By using an ML approach, the authors found predictors of hemorrhagic presentation that were not identified using a conventional regression approach.

Hemorrhagic presentation of previously silent brain tumors

Introduction and objectivesAcute presentation with intracranial hemorrhage owing to a previously silent brain tumor (BT) is rare. Although any BT can bleed, the frequency and type of bleeding varies across tumor types. Materials and methodsWe aimed to retrospectively review our experience with 55 patients with BTs presenting with ICH. ResultsSigns of increased intracranial pressure were the most common symptoms. The temporal lobe was the most common lesion site (n=22). Hemorrhages were mainly confined to the tumor margins (HCTs) (n=34). Extensive intraparenchymal hemorrhages (EIHs) were mainly associated with moderately/severely decreased levels of consciousness (LOCs) (n=15/16). High-grade glioma (HGGT) (n=25) was the leading pathological diagnosis followed by metastasis (MBT) (n=16/55). The hemorrhage type was associated with the pathological diagnosis of the tumor. Patients with HGGT (n=19/25) and MBT (n=9/16) mainly presented with HCTs, whereas low-grade gliomas (LGGT) primarily caused EIHs (n=6/7). ConclusionsHemorrhagic presentation is a rare occurrence in BTs. Among all, MBT and HGGT are responsible for majority of the cases. Importantly, despite their relatively benign characteristics, LGGTs mainly result in extensive parenchymal destruction once they bleed. Maximum surgical resection of hemorrhagic BTs and decompression of the affected brain regions followed by histological confirmation of the diagnosis should be the main goals of treatment in cases with hemorrhagic BTs.

Brain dural arteriovenous fistulas in the COVID-19 Era: A warning and rationale for association

ObjectivesBrain dural arteriovenous fistulas(bDAVFs) are anomalous connections between dural arteries and cerebral veins or sinuses. Cerebral venous thrombosis(CVT) often precedes or coincides with bDAVFs and is considered a risk factor for these vascular malformations. Recently, vaccine-induced thrombotic thrombocytopenia causing CVTs has been associated with COVID-19 vaccines. Concurrently with the start of massive vaccination in our region, we have observed a fivefold increase in the average incidence of bDAVFs. Our objective is to raise awareness of the potential involvement of COVID-19 vaccines in the pathogenesis of bDAVF. MethodsA retrospective review of demographic, clinical, radiological, COVID-19 infection and vaccination data of patients diagnosed with bDAVFs between 2011 and 2021 was conducted. Patients were divided into two cohorts according to their belonging to pre- or post-COVID-19 vaccination times. Cohorts were compared for bDAVFs incidences and demographic and clinical features. ResultsTwenty-one bDAVFs were diagnosed between 2011 and 2021, 7 of which in 2021. The mean age was 57.7 years, and 62 % were males. All cases except one were treated; of them, 85 % exclusively managed with surgery. All treated cases were successfully occluded. The incidence in 2021 was significantly higher than that in the prevaccination period (1.72 vs 0.35/100,000/year;p = 0.036; 95 %Confidence Interval=0.09–2.66). Cohorts were not different in age, sex, hemorrhagic presentation, dural sinus thrombosis or presence of prothrombotic or cardiovascular risk factors. ConclusionThe significant increase in the incidence of bDAVF following general vaccination policies against COVID-19 observed in our region suggests a potential correlation between these two facts. Our findings need confirmation from larger cohorts and further pathogenic research.

Plasma Matrix Metalloproeteinase-9 Is Associated with Seizure and Angioarchitecture Changes in Brain Arteriovenous Malformations

Both angiogenesis and inflammation contribute to activation of matrix metalloproeteinase-9 (MMP-9), which dissolves the extracellular matrix, disrupts the blood-brain barrier, and plays an important role in the pathogenesis of brain arteriovenous malformations (BAVMs). The key common cytokine in both angiogenesis and inflammation is interleukin 6 (IL-6). Previous studies have shown elevated systemic MMP-9 and decreased systemic vascular endothelial growth factor (VEGF) in BAVM patients. However, the clinical utility of plasma cytokines is unclear. The purpose of this study is to explore the relationship between plasma cytokines and the clinical presentations of BAVMs. Prospectively, we recruited naive BAVM patients without hemorrhage as the experimental group and unruptured intracranial aneurysm (UIA) patients as the control group. All patients received digital subtraction angiography, and plasma cytokines were collected from the lesional common carotid artery. Plasma cytokine levels were determined using a commercially available, monoclonal antibody-based enzyme-linked immunosorbent assay. Subgroup analysis based on hemorrhagic presentation and angiograchitecture was done for the BAVM group. Pearson correlations were calculated for the covariates. Means and differences for continuous and categorical variables were compared using Student's t and χ2 tests respectively. Plasma MMP-9 levels were significantly higher in the BAVM group (42,945 ± 29,991pg/mL) than in the UIA group (28,270 ± 17,119pg/mL) (p < 0.001). Plasma MMP-9 levels in epileptic BAVMs (57,065 ± 35,732; n = 9) were higher than in non-epileptic BAVMs (35,032 ± 28,301; n = 19) (p = 0.049). Lower plasma MMP-9 levels were found in cases of BAVM with angiogenesis and with peudophlebitis. Plasma MMP-9 is a good biomarker reflecting ongoing vascular remodeling in BAVMs. Angiogenesis and pseudophlebitis are two angioarchitectural signs that reflect MMP-9 activities and can potentially serve as imaging biomarkers for epileptic BAVMs.