Hemorrhage In Adults Research Articles

Use of an Irrigating External Ventricular Drain in an Infant: Proof-Of-Concept Technical Note

This report describes the procedural nuances for use of an irrigating external ventricular drain (EVD) in an infant patient. Intraventricular hemorrhage (IVH) and other intraventricular pathologies, such as infection, can occur in a variety of situations and patient populations, with few interventions available for immediate resolution. While manual endoscopic surgical irrigation has been trialed in both adult and pediatric patient populations to clear blood products or debris, this concept has recently been further extrapolated to the use of a continuous irrigating EVD over a more extended period. While this technique has been more commonly used for subarachnoid hemorrhage in adults, study of its use in pediatric patients, particularly in infants, is lacking. In this single case technical note of proof of feasibility, a continuous irrigating EVD was used in an infant to help clear an iatrogenic IVH. Utilization of an irrigating EVD was successfully completed in a 9kg infant without associated complications. Clearance of IVH was noted after 9days of irrigation. Use of irrigating EVD catheters should not be limited to the adult population. Indications for use are broad in the pediatric population and warrant further exploration.

Blunt Trauma in Children: Efficacy and Safety of Transarterial Embolization, 10-Year Experiences in a Single Trauma Center.

Transcatheter arterial embolization (TAE) is an established approach for controlling hemorrhage in adults with acute abdominal and pelvic trauma. However, its application in pediatric trauma is not well established. This study aimed to evaluate the safety and effectiveness of TAE in a population of pediatric patients with blunt trauma. This retrospective study was conducted in pediatric patients (<18 years) who underwent TAE for blunt trauma between February 2014 and July 2022. The patients were categorized into subgroups based on age and body weight. Patient demographics, injury severity, transfusion requirements, and clinical outcomes were analyzed. Exactly 73 patients underwent TAE. Technical success was achieved in all patients (100%), and clinical success was achieved in 83.6%. The mortality and complication rates were 4.1% and 1.4%, respectively. The mean duration of hospitalization was 19.3 days. Subgroup analysis showed that age, body weight, and sex did not significantly affect clinical success. The injury severity score and transfusion requirement were predictors of clinical success, with lower values associated with better outcomes. TAE is effective and safe for managing blunt pediatric trauma in younger and lighter patients. Injury severity and transfusion requirement are predictors of clinical success.

1210 Network Meta-Analysis of Associated Mortality with Transfusion Strategies for Major Haemorrhage in Adults

Abstract Aim The aetiology of a large proportion of mortality in trauma patients is attributed to acute major haemorrhage. Damage control resuscitation and surgery have been developed as part of management, which often includes large volume blood product transfusion. The aim of this meta-analysis was to investigate differences in mortality between transfusion strategies used in major haemorrhage in adults (18+ years). Method A frequentist random effects network meta-analysis (NMA) using the netmeta package in R 4.0.5 of the eligible papers in the systematic review “Optimal dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a systematic review” compared a 1:1:1 ratio of red blood cells (RBC), fresh frozen plasma (FFP) and platelets (P) to a ratio of 2:1:1, whole blood, and laboratory-guided replacement. Homogeneity and heterogeneity were assessed with Cochran’s Q. Results Mortality at one month by group was 21.8% (12/55) for whole blood, 17.0% (58/342) for 2RBC:1FFP:1P, 14.3% (5/35) for laboratory-guided transfusion and 22.3% (96/43) for standard 1RBC:1FFP:1P ratio. The NMA showed no significant differences between groups, with relative risk of death when compared to 1RBC:1FFP:1P by one month of 1.42 (0.631; 3.19, p = 0.398) for whole blood, 0.7643 (0.562; 1.04, p = 0.0871) for 2RBC:1FFP:1P and 0.4396 (0.1741; 1.1099, p = 0.0820) for laboratory-guided transfusion. Conclusions The results demonstrated no significant differences in mortality between transfusion strategies in major haemorrhage - however, some arms of the NMA contain few patients and so may be underpowered to detect differences between groups. On this evidence, current use of component therapy is not inferior to another transfusion strategy.

Urokinase administration for intraventricular hemorrhage in adults: A retrospective analysis of hemorrhage volume reduction and clinical outcomes.

Intraventricular hemorrhage (IVH) is a type of ventricular bleeding that results in significant morbidity and mortality. Multiple studies have investigated the use of urokinase in IVH treatment. The use of urokinase may lead to higher rates of hematoma resolution and lower mortality rates. However, further studies are required to determine efficacy of urokinase administration. This study examined the association between urokinase use, IVH volume reduction, and clinical outcomes. In total, 94 adult patients with hypertensive intracerebral hemorrhage with ventricular extension or primary IVH were enrolled between 2015 and 2021. Participants were categorized into two groups: "EVD combined with fibrinolysis" and "EVD only." The primary objective was to assess the reduction of IVH severity. Additionally, the study evaluated the functional outcomes and shunt dependency rate as secondary outcomes. Non-contrast computed tomography scans were obtained to measure the severity of IVH using the mGRAEB score. The main outcomes were the association among urokinase administration, reduced IVH severity, and functional outcomes. There were no significant differences in the reduction rate of mGRAEB scores within a 7-day period (-50.0 [-64.4 to -32.5] % vs -44.2 [-59.3 to -7.9] %; p = 0.489). In addition, investigation of the third and fourth ventricles showed similar findings between the two groups. Urokinase treatment was not associated with significant differences in the modified Rankin Scale (5.0 (4.0-5.0) vs. 4.5 (4.0-5.0), p = 0.674) or shunt dependency rate (33.3% vs 39.3%, p = 0.58). This study found that intraventricular urokinase use in patients with IVH was not associated with reduced IVH severity. In addition, urokinase use was not associated with better functional outcomes or minor shunt dependency rates.

Analysis of Clinical Characteristic and Risk Factors for Short-Term Prognosis of Moyamoya Disease with Intraventricular Hemorrhage in Adults

Intraventricular hemorrhage (IVH) is the most common type of hemorrhage in moyamoya disease (MMD) with intracerebral hemorrhage (ICH), but the risk factors affecting the short-term prognosis of MMD with IVH in adults are still unclear. We retrospectively analyzed patients of MMD with IVH between January 1, 2018 and January 31, 2020 in the First Affiliated Hospital of Zhengzhou University. According to the modified Rankin Scale (mRS) score at 3 months after discharge, the patients were divided into mRS score ≤2 (good prognosis) group and mRS score >2 (poor prognosis) groups. Univariate and multivariate logistics regression analysis was used to analyze the risk factors affecting the short-term prognosis of adult MMD with IVH. Univariable analyses showed that patients in the poor prognosis group had a significantly older age of onset (48.48 ± 8.34 vs. 43.74 ± 5.44 years; P= 0.002), ahigher percentage of hypertension (57.97% vs. 33.33%; P= 0.014), a higher percentage of tracheotomy (23.19% vs. 2.56%; P= 0.005), a lower Glasgow Coma Scale (GCS) score (7.90 ± 3.58 vs. 11.19 ± 2.56; P= 0.000), a higher Graeb score (7.46 ± 4.04 vs. 5.23 ± 1.93; P= 0.002), and treatment methods (P= 0.000). Multiple logistic regression analysis showed that the lower GCS score (odds ratio [OR],1.761; P= 0.001) and higher Graeb score (OR, 1.767; P= 0.002) were independently associated with the poor prognosis of MMD with IVH, and surgery treatment (OR,0.032; P= 0.000) was independently related to the good prognosis of MMD with IVH. Among patients with MMD with IVH, the lower GCS score and higher Graeb score are independent risk factors for poor prognosis, whereas in patients with MMD with IVH, surgery treatment acts as a protective factor.

Abstract 11161: Thymic Hemorrhage – A Cause for Cardiac Arrest?

Introduction: Thymic hemorrhage is a rare cause of sudden cardiac death, particularly in adults. We present a 35- year- old with sudden “cardiac” death secondary to thymic hemorrhage. Case: A 35-year-old healthy man presented following witnessed cardiac arrest. CPR was initiated immediately. The initial rhythm was shockable, he was defibrillated, and ROSC was achieved. He was intubated on site and transferred to the hospital. Initial labs were negative for electrolyte derangements and drugs of abuse. His high-sensitivity troponin T was 238 ng/L (nl&lt;23 ng/L) and subsequently trended downward. His electrocardiogram showed non-specific ST-T abnormalities. His echocardiogram showed an ejection fraction of 25 to 29% with global hypokinesis. He was extubated on day 4 and scheduled for coronary angiography. On day 5, when he attempted to get out of bed, he lost consciousness and became pulseless. His initial rhythm was PEA, but with episodes of ventricular fibrillation during CPR, he was shocked accordingly. He had prolonged CPR, therefore, obviating advanced therapies. His autopsy showed only thymic hemorrhage. His coronary arteries were normal, with no signs of myocardial injury or myocarditis. Conclusion: Massive acute thymic hemorrhage is extremely rare in adults but is a rare but recognized cause of sudden death in utero and infants. There are only two reported cases of thymic hemorrhage in adults in the literature. Both the patients were nearly 40-year-old men who presented with chest pain. Initial imaging was consistent with mediastinal widening requiring thoracotomy that demonstrated hemorrhagic thymus. Similar to our patient, the reported cases were young men with no prior history of trauma. In contrast, our patient presented with cardiac arrest, and initial imaging was negative for mediastinal widening. The underlying etiology of cardiac arrest from thymic hemorrhage is poorly understood. Right atrial compression from acute hemorrhage of a benign thymic tumor was postulated as the cause of sudden death in a previously healthy 15-year-old boy. Our patient is a rare case since there are, to our knowledge, no reported cases in the literature of thymic hemorrhage as the cause of death in adults.

Analysis of risk factors for post-tonsillectomy hemorrhage in adults

ObjectivesTo identify the risk factors for post-tonsillectomy hemorrhage (PTH) in adult patients (>19 years). Methods275 adult patients who underwent tonsillectomy between 2009 and 2019 were retrospectively analyzed. Possible risk factors associated with PTH were investigated by univariate and multivariate logistic regression analyses. ResultsPTH occurred in 39 of 275 patients (14.2%). Regarding underlying diseases, PTH occurred more frequently in focal infection of IgA nephropathy. Furthermore, bipolar electrocautery was the other risk factor for PTH on multivariate analysis. ConclusionFocal infection of IgA nephropathy and bipolar electrocautery were identified as the risk factors for PTH.

Propranolol therapy for cerebral cavernous malformations

Cerebral cavernous malformations (CCMs) are vascular malformations characterized by the abnormal growth of vascular structures in the central nervous system. However, the precise mechanism(s) responsible for the development of CCM vascular abnormalities remain poorly understood. Although the mechanisms of action of propranolol in CCM have not yet been fully explored it is not commonly prescribed, it has been shown to be effective in children and appears to play a protective role in the prevention of CCM‑derived hemorrhage in adults. The present study performed <em>in vitro</em> and <em>ex vivo</em> assays in order to examine the effects of propranolol on endothelial cells (ECs). The percentage of CD14⁺/CD31⁺ cells and the levels of VEGF in the peripheral blood (PB) of a child patient with CCM, with recurrent seizures and hemorrhages, who was maintained under propranolol therapy, were also analyzed. In addition to the effects of propranolol on differentiated ECs, and the decrease angiogenic‑related features <em>in vitro</em> and <em>ex vivo</em>, it was observed that in the PB of this patient, propranolol administration decreased the percentage of circulating cells sharing monocytic and EC features (CD14⁺/CD31⁺ cells), as well as the VEGF levels; this was concomitant with a good prognosis and with the reversion of CCM lesions. A decrease in VEGF levels by propranolol may also be involved in the impairment of the recruitment of CD14⁺/CD31⁺ monocytes functioning as endothelial progenitor cells to sustain the vascular lesion. On the whole, the present study demonstrates that propranolol impairs angiogenesis <em>in vitro</em> and may thus be a useful tool for the clinical management of CCM. Moreover, the present study highlights the monitorization of the levels of CD14⁺/CD31⁺ monocytes and VEGF levels as a useful tool for predicting the clinical efficacy of propranolol in patients with CCM.

Dynamic Changes of Collateral Vessels After Encephaloduroarteriosynangiosis in Moyamoya Disease: Childhood to Adulthood

Moyamoya disease (MMD) often presents as ischemic stroke in pediatric patients and hemorrhage in adults. This situation raises questions as to whether the phenotype of moyamoya disease changes with age. We performed self-precontrol and postcontrol observation monitoring until adulthood on abnormal collateral vessels (ACVs) with the potential risk of bleeding to evaluate the chance of further hemorrhage. Fifteen pediatric patients with >10 years angiography-based follow-up were analyzed. The Matsushima grades were divided into 2 groups (good group, representing Matsushima stage A; and mild group, representing Matsushima stages B and C) to investigate the relationship between Matsushima grades and ACVs derived from vessels likely to cause intracranial hemorrhage. Four patients (26.7%) had infarction type and 11 (73.3%) patients had transient ischemic attack type. No patient experienced late-onset cerebral hemorrhagic events. One patient experienced recurrent ischemic stroke 6 months after the second surgery and recovered completely after the third surgery. The angiography-based follow-up was conducted at least 10 years after theencephaloduroarteriosynangiosis (EDAS). The good Matsushima group showed a significant positive correlation with the reduction of the anterior choroidal artery (odds ratio, 56.00; P= 0.003), whereas the posterior communicating artery showed no significant decrease before and after the EDAS procedure (odds ratio, 2.00; P= 1.00). The EDAS procedure can effectively attenuate the dilation and ACVs of the anterior choroidal artery, which may reduce the incidence of further hemorrhage in adulthood.

Clinical profile and surgical outcome of pars plana vitrectomy in non-diabetic vitreous hemorrhage.

Background:Spontaneous vitreous hemorrhage is one of the common causes of ocular emergency. There are very few prospective studies on the clinical profile and surgical outcomes for patients with dense vitreous hemorrhage caused by non-diabetic and non-traumatic till date to our knowledge.Objectives:This study was conducted to better understand the etiologies, clinical profile, surgical outcome, and visual prognosis following pars plana vitrectomy for dense vitreous hemorrhage in adults with non-traumatic and non-diabetic retinopathy.Design:This was a prospective interventional study.Methods:This study was conducted in Mechi Eye Hospital (Birtamod, Nepal) from October 2018 to September 2019. All consecutive cases, 46 eyes of 46 patients, with vitreous hemorrhage that underwent vitrectomy were included in our study. There were 14 (30.4%) female and 32 (69.6%) male patients, and the average age at presentation was 43.74 ± 16.19 (17–84) years. The success rate of surgery in terms of visual outcome was evaluated.Results:The most common cause of vitreous hemorrhage was retinal vasculitis with fibrovascular changes and vascular sheathing 19 (41%). The indication of vitrectomy on patient demand was 20 (43.5%). Success rate of surgery in terms of visual outcome (functional outcome) was defined as final visual acuity of >6/60 which was 86.9%.Conclusion:The most common cause of spontaneous vitreous hemorrhage in our study was retinal vasculitis with fibrovascular changes and vascular sheathing. Vitrectomy has a good surgical outcome for spontaneous vitreous hemorrhage in terms of visual outcome (functional outcome) unless guarded by other factors like chorioretinal atrophy followed by optic atrophy and epiretinal membrane.

Clinical Features and Risk Factors Analysis for Hemorrhage in Adults on ECMO.

Background: The use of extracorporeal membrane oxygenation (ECMO) to support critically ill patients with cardiorespiratory dysfunction has increased over the last decades. However, hemorrhagic complications occur frequently during ECMO support, and this has a significant impact on morbidity and mortality. Thus, this study aimed to identify the risk factors for hemorrhage in patients receiving ECMO.Methods: Our retrospective study included 60 patients, who were admitted to the Taihe Hospital in Shiyan City, Hubei Province, China from February 2017 to October 2020. About 18 patients developed hemorrhagic complications, and 42 patients did not demonstrate such complications. Data regarding patient demography, laboratory tests, and clinical manifestations prior to ECMO were collected to analyze their clinical features. Univariable and multivariable logistic analyses were used to explore the risk factors for hemorrhage in adults on ECMO. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of the binary logistic model. The amount of blood transfusions was compared between the two groups, and the activated partial thromboplastin time (APTT), platelet count, and hemoglobin level before the initiation of ECMO.Results: Logistic analysis showed that a longer duration of ECMO support, higher APTT, and lower platelet count prior to ECMO were independent risk factors for hemorrhage in adults on ECMO. In addition, we found that the cannula site was the most common bleeding site. Most bleeding events occurred within the first 3 days of ECMO therapy. After the ECMO initiation, APTT was prolonged while the platelet count and hemoglobin levels were decreased. The amount of blood transfusion was significantly higher in the hemorrhage group than in the non-hemorrhage group.Conclusions: Clinicians should evaluate the risk of hemorrhage based on the coagulation function of patients, underlying disease, and the duration of ECMO support. In the first 3 days during ECMO support, special attention should be given to the cannula site, mucosal, and dermal regions, and digestive tract to detect any signs of hemorrhage. Moreover, increasing the platelet count transfusion threshold and accurately determining the amount of blood transfusion required may prevent bleeding events.

Risk factors for intracranial hemorrhage in adults with acute leukemia.

Intracranial hemorrhage (ICH) is a rare, but serious complication in patients with acute leukemia. Little is known about why some patients experience serious bleeding, including ICH, while others do not. Adults between 18 and 80 years old with acute leukemia and ICH between January 1, 2009 and December 31, 2016 were included. Matched controls were identified using the propensity score matching method. Clinical and laboratory characteristics and outcome data were collected to identify variables associated with ICH. Of 2578 patients diagnosed with acute leukemia during the study period, 55 cases and 161 matched controls were included. Patients who experienced ICH were older (62 vs. 55 years, p=.004) and more likely to have diabetes mellitus (p=.04). Patients with ICH had a higher baseline white blood cell count (mean 84.5 ± 115.8 vs. 28.7 ± 58.5 × 109 /L, p=.001), peripheral blast count (61.3 ± 96.5 vs. 21.2 ± 50.8 × 109 /L, p=.004), and a longer PT (16.5 ± 2.06 vs. 15.3 ± 3.2 s, p=.002). Neither the platelet count at diagnosis, the platelet nadir, the number of days with a platelet count of less than 10 × 109 /L, or a diagnosis of platelet refractoriness were associated with ICH. Older age and more proliferative disease appear to be associated with ICH, whereas thrombocytopenia alone does not. In patients with newly diagnosed acute leukemia, aggressive cytoreduction in those with leukocytosis may help mitigate the risk of ICH.

COMPUTER HYBRID SYSTEM OF HEMORRHAGE (HES) DETECTION USED FOR AIDED DIAGNOSIS OF DIABETIC RETINOPATHY

Diabetes cause’s metabolic and physiological abnormalities in the retina and the changes suggest a role for inflammation in the development of diabetic retinopathy. Abnormal blood vessels can form in the back of the eye of a person with diabetes. These new blood vessels are weaker and prone to breaking and causing hemorrhage (HEs). Diabetic retinopathy (DR) accounts for 31.5–54% of all cases of vitreous hemorrhage in adults in the world. Therefore, detection of HEs is still a challenging factor task for computer-aided diagnostics of DR. Many researchers have developed advanced algorithms of hemorrhages detection using fundus images. In this paper, a robust and computationally efficient approach for HEs with different shape and size detection and classification is presented. First, brightness correction and contrast enhancement are applied to fundus images. Second, candidate hemorrhages are extracted by using an unsupervised classification algorithm. Third, an approach based on mathematical morphology is carried out for vascular network and macula segmentation. Finally, a total of 13 HEs features are considered in this study and selected for classification. The proposed method is evaluated on 419 fundus images of DIARETDB0, DIARETDB1 and MESSIDOR databases. Experimental results show that overall average sensitivity, specificity, predictive value and accuracy for hemorrhage in lesion level are 98.90%, 99.66%, 97.63% and 99.56%, respectively. The results show that the proposed method outperforms other state-of-the-art methods in detection of hemorrhages. These results indicate that this new method may improve the performance of diagnosis of DR system.

Appropriate Tourniquet Types in the Pediatric Population: A Systematic Review.

Trauma is the leading cause of mortality in those aged 1-19, with hemorrhage accounting for up to 40% of all trauma deaths. Manufactured tourniquets are recommended for the control of life-threatening extremity hemorrhage in adults but their use in the pediatric population requires further investigation. We performed a systematic review to evaluate the most appropriate tourniquet design for use in the pediatric population. A literature search of Embase and the Cochran databases of trials and systematic reviews on October 1, 2020 identified 454 unique references, of which 15 were included for full-text screening. Two single-arm observational studies with a high risk of bias evaluated the use of windlass tourniquets in the pediatric population (73 patients, age 2-16 years). The certainty of the evidence was very low. In both studies, conducted on uninjured extremities, the use of a manufactured windlass tourniquet, specifically the Combat Application Tourniquet (C-A-T®) Generation 7, led to the cessation of Doppler detected pulses in 71/71 (100%) of upper extremities and 69/73 (94.5%) of lower extremities. Of the four failures, one participant withdrew due to pain and three tourniquet applications failed to occlude pulses after three turns of the windlass. No controls were used for comparison. In conclusion, two observational studies demonstrated that windlass tourniquets were able to abolish distal pulses in children as young as two years of age and with a minimum limb circumference of 13 cm. These preliminary findings may be helpful for organizations in the creation of guidelines for the management of life-threatening extremity bleeding in children.

Pharmacological Management of Spontaneous Intracerebral Hemorrhage in Older Adults

Pharmacological management of intracerebral hemorrhage in adult patients over 65 years of age requires special considerations due to differing clinical presentations, underlying organ dysfunction, and more complex medical histories and medication profiles. A literature review of articles focusing on the age-specific pharmacological management of intracerebral hemorrhage was conducted. Treatment approaches and clinical outcomes specific to older adults were evaluated and therapeutic considerations for this population are summarized. Older adults were commonly included in trials regarding reversal of anticoagulants and antiplatelet agents and these results are generalizable to older adults. Underlying organ dysfunction should frequently be considered throughout the treatment of intracerebral hemorrhage in older adults. Older adults with intracerebral hemorrhage should be managed similarly to younger adult patients; however, consideration of age-related comorbidities and physiological differences is critically important for optimizing patient care.

Multimodality Management in bAVM Surgery - Recent Experience from International Cerebrovascular Fellowship.

Background:Arteriovenous malformation (bAVM) presents maldevelopment of the brain’s vessels with a direct connection between cerebral arteries and veins. By current data, patients from Spetzler Ponce A (SP) are found to benefit from the treatment. Considering the outcome, most of SP C and some of the SP B are the most debatable.Objective:Arteriovenous malformation presents maldevelopment of the brain’s vessels with a consequent direct connection between cerebral arteries and veins. The annual risk of hemorrhage in adults is reported for 2-3 %. They usually present with unilateral headaches seizures and intracranial hemorrhage. By current data, patients from Spetzler Ponce A (SP) are found to benefit from the treatment. Considering the outcome, most of SP C and some of the SP B are the most debatable.Methods:The study included a cohort of bAVM patients referred to Fujita Health University Bantane Hotokukai Hospital, Nagoya, Aichi, Japan where the main author (AA) has completed an international cerebrovascular fellowship under the mentorship of Professor Yoko Kato. Japanese Stroke Guidelines (JSG) were used for the treatment decision. Patients were graded according to the Spetzler Ponce (SP) system. Considering American Heart Association criteria (AHA), embolization was used as a part of multimodal treatment. Intraoperative microscopic video tools included Indocyanine green ICG, FLOW 800 and dual image video angiography DIVA. Clinical outcomes were measured using Modified Ranking Score (mRs).Results:A total of eleven patients with brain bAVM were studied with a median age of 32 years [IQR = 22-52]. There were ten patients presented with supratentorial and a single patient with infratentorial AVM. Patients were graded according to the Spetzler Ponce (SP) system. There were eight patients in SP A (72,7%), one in group B (9 %) while the rest of them were in C (18 %). Two patients had associated aneurysms that required treatment. The median size of the AVM nidus was 3,50 cm [IQR= 2-5]. Deep venous drainage was found in six patients while three were located in eloquent zones. Clinical outcomes were considered good by mRs <2 in eight patients, seven from the surgically treated group (72,7 % respectively). Surgery median length time was 427, 5 minutes; [IQR =320 - 463] with complete AVM resection in all patients and no mortality recorded in this cohort with the median follow up of 39,5 months [IQR = 19-59].Conclusion:Ideal management of bAVM is still controversial. Those complex vascular lesions require multimodal treatment in a majority of cases in highly specialized centers. In SP A patients, surgery provides the best results with a positive outcome and a small number of complications. With the improvement of endovascular feeder occlusion SP B patients become prone to a more positive outcome. Nowadays, intraoperative microscopic tools such as FLOW 800, ICG and DIVA are irreplaceable while improving safety to deal with bAVM. For SP C patients, a combination of endovascular and stereotactic radiosurgery was found to be a good option in the present time.

Risk factors of post-tonsillectomy hemorrhage in adults.

ObjectiveTonsillectomy is an essential surgery and is conducted on both children and adults. However, the risk factors of post‐tonsillectomy hemorrhage for adult patients remain unclear. In this study, we analyzed post‐tonsillectomy hemorrhage in adult patients.MethodsWe retrospectively analyzed 325 adult patients who underwent a tonsillectomy between 2014 and 2018 in our facilities.ResultsThe average age of this study's population was 31.7 ± 10.5 years (range: 19‐70 years), and 250 (76.9%) patients were male. Overall, post‐tonsillectomy hemorrhage occurred in 71 (21.8%) patients and 5 (1.5%) patients required a second surgery for hemostasis. Post‐tonsillectomy hemorrhage often occurred on postoperative day zero or six. Using multiple logistic regression analysis, current smoking status (odds ratio 3.491; 95% confidence interval 1.813‐6.723), male sex (odds ratio 3.924; 95% confidence interval 1.548‐9.944), and perioperative non‐steroidal anti‐inflammatory drug administration (odds ratio 7.930; 95% confidence interval 1.004‐62.64) were revealed as overall post‐tonsillectomy hemorrhage risk factors. To analyze the hemorrhage period after tonsillectomy, we categorized the post‐tonsillectomy hemorrhage patients into the primary (bleeding within postoperative day one) and secondary hemorrhage (bleeding on or after postoperative day two) groups. The current smoking status and older age were risk factors for primary hemorrhage and the current smoking status and sex (male) were risk factors for secondary hemorrhage.ConclusionsIn this study, smoking status, sex, and perioperative non‐steroidal anti‐inflammatory drug administration were the clinical risk factors for adult post‐tonsillectomy hemorrhage. Thus, smoking cessation is, at least, mandatory for patients who receive tonsillectomy to avoid post‐tonsillectomy hemorrhage.Level of Evidence4

Moyamoya disease with hemorrhagic stroke in a Nepalese woman

The authors report a case of Moyamoya disease in a middle aged Nepali female. Though the disease is common in other parts of Asia only one case has been reported previously from Nepal. It should be suspected as a rare cause for spontaneous intracerebral hemorrhage in adults.

Incidence of early intra-cranial bleeding and ischaemia in adult veno-arterial extracorporeal membrane oxygenation and extracorporeal cardiopulmonary resuscitation patients: a retrospective analysis of risk factors.

Cerebral complications in veno-arterial extracorporeal membrane oxygenation are known to have a strong impact on mortality and morbidity. Aim of this study is to investigate the early incidence, risk factors and in-hospital mortality of intra-cranial ischaemia and haemorrhage in adults undergoing veno-arterial extracorporeal membrane oxygenation treatment. This study is a single-centre retrospective analysis on adult patients undergoing veno-arterial extracorporeal membrane oxygenation for different indications. The inclusion criterion included patients with early routine cerebral computed tomography imaging during extracorporeal membrane oxygenation, with no clinical evidence of cerebral pathology prior to cannulation. Cerebral complications were grouped by aetiology and the territories of the brain's supplying arteries. One hundred eighty-seven adult patients with a total of 190 veno-arterial extracorporeal membrane oxygenation treatments were included. A total of 16.3% (n = 31) had evidence of either cerebral ischaemia (11.1%) or haemorrhage (5.8%); one patient suffered from both. Cerebral computed tomography scans were performed early in median on the first day after extracorporeal membrane oxygenation cannulation; in-hospital mortality of intra-cranial ischaemia and haemorrhage was 71.4% and 45.5%, respectively. Associated with an increased risk for ischaemic lesions were cannulation of the ascending aorta, higher age, presence of an autoimmune disease and cardiac surgery prior to veno-arterial extracorporeal membrane oxygenation. An association with haemorrhagic lesions was found for a lower blood PaCO2 at 2 hours, lower blood flow through the extracorporeal membrane oxygenation device at 2 hours, higher international normalized ratio and constantly higher activated partial thromboplastin time values as well as higher mean arterial pressures until haemorrhagic lesions were evident. Cerebral complications are frequent in patients on veno-arterial extracorporeal membrane oxygenation and may be clinically silent events. Careful monitoring with routine neuroimaging seems to be the most appropriate diagnostic approach at present. Intra-cranial ischaemia occurs more frequent than haemorrhage and is associated with cannulation of the aorta ascendens.

Prevalence of Post-Tonsillectomy Hemorrhage in Adults and Children

Background and objectivesHemorrhage is the most common complication of tonsillectomy. However, the incidence of post-tonsillectomy hemorrhage may be affected by various factors including weight, age, medications, surgical technique, etc. This study was carried out to determine prevalence of post-tonsillectomy hemorrhage in patients undergoing tonsillectomy in a teaching hospital in Gorgan, Iran.MethodsThis descriptive study was conducted on 1,043 cases of tonsillectomy who were admitted to a referral teaching hospital in Gorgan (Iran) between 2016 and 2017. Data were collected from medical records. Demographics characteristics, the applied surgical technique (e.g., tonsillectomy, adenoidectomy and adenotonsillectomy), the time of bleeding onset, the results of coagulation tests and the method of post-tonsillectomy hemorrhage management were recorded.ResultsThe frequency of tonsillectomy was 19.2, 50.8, 18.6, 4, 2.1 and 5.3% in subjects aged 0-5, 5-10, 10-15, 15-20, 20-25 and more than 25 year old, respectively. The overall prevalence of post-tonsillectomy hemorrhage was 2.1%. The frequency of post-tonsillectomy hemorrhage was highest (13.6%) in patients aged 20-25 years. The incidence of post-tonsillectomy hemorrhage was zero in those aged ≤5 years. The rate of post-tonsillectomy hemorrhage was 54.5, 31.8 and 13.6% for those undergoing tonsillectomy, adenoidectomy and adenotonsillectomy, respectively. Secondary post-tonsillectomy hemorrhage (after 24 hours) was more common (81.8%). Moreover, the rate of re-admission for controlling the bleeding was 63.4% (14 cases).ConclusionThe incidence of post-tonsillectomy hemorrhage, the methods for its management and the need for re-admission are quite different in different age groups.