Higher Rates Of Intracranial Hemorrhage Research Articles

Systematic vitamin K antagonist reversal with prothrombin complex concentrate in patients with mild traumatic brain injury: randomized controlled trial.

Traumatic brain injury (TBI) in patients on vitamin K antagonists (VKAs) is linked to a high rate of intracranial hemorrhage (ICH). Rapid reversal can reduce ICH progression and mortality, but its effectiveness depends on the time between bleeding onset and coagulation normalization. The PREVACT study aimed to assess the efficacy and safety of prompt systematic reversal of anticoagulation in patients presenting to emergency departments (EDs) for recent mild-TBI while receiving a VKA. A randomized, open-label, blinded-endpoint clinical trial was conducted in 21 French EDs. Patients receiving a VKA, having experienced a TBI within the last 6 h, and presenting a Glasgow Coma Score ≥13 were included. Patients were randomized to systematic immediate VKA reversal with 25 IU/kg of four-factor prothrombin complex concentrate (4f-PCC) before any investigation (intervention group) or standard-of-care signifying reversal only if the initial cranial computed tomography (CT) scan indicated ICH (control group). The primary outcome was the rate of ICH detected on a cranial CT scan 24 h post-inclusion. The study was prematurely stopped for logistic reasons after the randomization of 202 patients (101 and 101 in the intervention and control groups, respectively, mean age 90; 51.8% female). On the 24-h cranial CT scan, 6 of 98 patients (6.1%) in the intervention group manifested ICH vs. 12 of 99 patients (12.1%) in the control group [odds ratio: 0.47 (95% confidence interval: 0.14-1.44); P = 0.215]. In patients with recent mild-TBI receiving a VKA, systematic prompt reversal with 4f-PCC did not statistically significantly reduce ICH rate at 24 h. However, the study was prematurely stopped and does not exclude a clinically relevant benefit of the strategy tested. Clinicaltrials.gov (NCT01961804).

Endovascular thrombectomy versus medical management for acute basilar artery occlusion stroke in the elderly.

The efficacy and safety of endovascular thrombectomy (EVT) for elderly basilar artery occlusion (BAO) stroke patients is unclear. This was an explorative retrospective analysis of the 2016-21 National Inpatient Sample in the United States. Elderly BAO stroke patients (80 years or older) with NIH stroke scale of at least 5 were included. Primary outcome was discharge to home. Secondary outcomes include in-hospital mortality and intracranial hemorrhage (ICH). Outcomes were compared between patients treated with EVT and those treated with medical management (MM) alone. Propensity score matching (PSM) was performed to control for confounders. Subgroup analyses were conducted for patients who did and did not receive intravenous thrombolysis (IVT). 2,520 elderly BAO patients were identified; 830 received EVT, and 1,690 received MM alone. After PSM, 1,115 patients and 715 patients remained in the MM and EVT groups, respectively. Compared to PSM controls, EVT was not significantly associated with different rates of home discharge (17.5% vs. 12.2%, OR 1.36 [95%CI 0.76-2.44], p=0.30) or in-hospital mortality (31.5% vs. 32.9%, OR 1.00 [95%CI 0.63-1.60], p=0.99), but it was significantly associated with higher rates of ICH (18.2% vs. 7.3%, OR 2.69 [95%CI 1.41- 5.15], p=0.003). Among patients who did not receive IVT, EVT was significantly associated with higher rates of home discharge (21.5% vs. 11.5%, OR 1.93 [95%CI 1.02-3.66], p=0.044), whereas EVT was not significantly associated with the same among those treated with IVT (5.6% vs. 15.0%, OR 0.28 [95%CI 0.05-1.46], p=0.13). Interaction analysis revealed that IVT was a negative modulator of EVT's positive association with home discharge (interaction p=0.031). EVT was not significantly associated with more favorable hospitalization outcomes for elderly BAO stroke patients, and it was significantly associated with increased risk of ICH. EVT may be an effective treatment for patients who did not receive IVT. EVT = endovascular thrombectomy; BAO = basilar artery occlusion; ICH = intracranial hemorrhage; MM = medical management; PSM = propensity score matching; IVT = intravenous thrombolysis.

Endovascular thrombectomy versus medical management for moderate-to-severe anterior cerebral artery occlusion stroke.

There are no established patient selection criteria for endovascular thrombectomy (EVT) for anterior cerebral artery (ACA) stroke. This was a retrospective cohort study of the 2016-2020 National Inpatient Sample in the United States. Isolated ACA-occlusion stroke patients with moderate-to-severe stroke symptoms (NIH stroke scale [NIHSS] ≥ 6) were included. Primary outcome was hospital discharge to home with self-care. Secondary outcomes include in-hospital mortality and intracranial hemorrhage (ICH). Confounders were accounted for by multivariable logistic regression. 6685 patients were included; 335 received EVT. Compared to medical management (MM), EVT patients were younger (mean 67.2 versus 72.2years; p = 0.014) and had higher NIHSS (mean 16.0 versus 12.5; p < 0.001). EVT was numerically but not statistically significantly associated with higher odds of home discharge compared to MM (aOR 2.26 [95%CI 0.99-5.17], p = 0.053). EVT was significantly associated with higher odds of home discharge among patients with NIHSS 10 or greater (aOR 3.35 [95%CI 1.06-10.58], p = 0.039), those who did not receive prior thrombolysis (aOR 3.96 [95%CI 1.53-10.23], p = 0.005), and those with embolic stroke etiology (aOR 4.03 [95%CI 1.21-13.47], p = 0.024). EVT was not significantly associated with higher rates of mortality (aOR 1.93 [95%CI 0.80-4.63], p = 0.14); however, it was significantly associated with higher rates of ICH (22.4% vs. 8.5%, p < 0.001). EVT was associated with higher odds of favorable short-term outcomes for moderate-to-severe ACA-occlusion stroke in select patients. Future studies are needed to confirm the efficacy of EVT in terms of longer term neurological outcomes.

Short-Term Neurologic Complications in Patients Undergoing Extracorporeal Membrane Oxygenation Support: A Review on Pathophysiology, Incidence, Risk Factors, and Outcomes.

Regardless of the type, extracorporeal membrane oxygenation (ECMO) requires the use of large intravascular cannulas and results in multiple abnormalities including non-physiologic blood flow, hemodynamic perturbation, rapid changes in blood oxygen and carbon dioxide levels, coagulation abnormalities, and a significant systemic inflammatory response. Among other sequelae, neurologic complications are an important source of mortality and long-term morbidity. The frequency of neurologic complications varies and is likely underreported due to the high mortality rate. Neurologic complications in patients supported by ECMO include ischemic and hemorrhagic stroke, hypoxic brain injury, intracranial hemorrhage, and brain death. In addition to the disease process that necessitates ECMO, cannulation strategies and physiologic disturbances influence neurologic outcomes in this high-risk population. For example, the overall documented rate of neurologic complications in the venovenous ECMO population is lower, but a higher rate of intracranial hemorrhage exists. Meanwhile, in the venoarterial ECMO population, ischemia and global hypoperfusion seem to compose a higher percentage of neurologic complications. In what follows, the literature is reviewed to discuss the pathophysiology, incidence, risk factors, and outcomes related to short-term neurologic complications in patients supported by ECMO.

Abstract WP31: Real World Comparison of Outcomes of IV Tenecteplase versus IV Alteplase for Acute Ischemic Stroke

Background: Tenecteplase (TNK) has been reported to be non-inferior to alteplase from a clinical outcome and safety standpoint according to recent studies. In our study, we compare the outcomes of IV TNK &amp; IV alteplase for acute ischemic stroke patients. Materials and Methods: We evaluated acute AIS patients treated with IVT between10/2020-03/2023 at theDepartment of Neurology, Hackensack MeridianHealth, JFKMedical Center. All analyses was done using SPSS version 29 software. Results: Among the total 270 patients, 150(55.6%) received IV alteplase and 120(44.4%) received IV TNK. Major neurological improvement (defined as improvement in NIHSS score by 8 or more points at 24hours) was observed with TNK. Any intracranial hemorrhage was higher among patients treated with IV TNK compared to alteplase (25% versus 14.7%, p=0.024). Symptomatic intracranial hemorrhage(sICH) was higher inTNK group (8.3% versus3.3%, p=0.075). The proportion of routine discharge was higher among alteplase patients, while non-routine discharge was higher among TNK patients (51.7% vs. 28%, p&lt;0.001). In the logistic regression analysis, patients treated with IV TNK were at a significantly higher risk of any intracranial hemorrhage(odds ratio[OR], 1.93, 95% confidence interval [CI]1.051-3.57, p=0.034). After adjusting for age, gender, NIHSS, thrombectomy, hypertension, diabetes, hyperlipidemia, CHF, previous TIA and previous stroke, there was anon-significant higher rate of intracranial hemorrhage. A nonsignificant decrease in the odds of symptomatic intracranial hemorrhage (sICH) was seen with TNK. There were significantly higher rates of non-routine discharge (OR, 3.078, 95% CI 1.8-5.19, p&lt;0.001) and death (OR, 4.84, 95% CI1.20-19.66, p=0.002) inpatients treated with IV TNK. After adjusting for the above-mentioned factors, there was a significantly higher rate of non-routine discharge in the TNK group and a higher trend of death in the TNK group. Conclusions: We found that IV TNK was associated with higher rates of intracranial hemorrhage compared to IV alteplase in patients with acute ischemic stroke.

Endovascular thrombectomy for posterior cerebral artery strokes in the national inpatient sample (EaT PeCANpIeS) study.

Posterior cerebral arteries with acute ischemic strokes (PCA-AISs) comprise around 2% of all acute ischemic strokes and may result in significant long-term deficits. Current guidance regarding endovascular thrombectomy (EVT) for PCA-AIS is insufficient as no published randomized trials exist. An analysis of the National Inpatient Sample database compared medical management versus EVT for PCA-AIS. Propensity score matching was applied to adjust for nonrandomization. The study included 19,655 patients. Before matching, the EVT cohort had significantly higher National Institutes of Health Stroke Scale (NIHSS) (10.21 vs. 4.67, p < 0.001), had lower rates of favorable functional outcomes, functional independence, and higher rates of intracranial hemorrhage (ICH) and inpatient mortality. After matching, no differences in functional outcomes were identified, but revealed a higher proportion of ICH in the EVT group (17.45% vs. 8.98%, p < 0.001). However, NIHSS subgroup analysis identified improved functional outcomes associated with the EVT group who presented with an NIHSS between 10 and 19 both in terms of rates of favorable functional outcomes (35.56% vs. 12.09%, p < 0.001) and rates of functional independence (26.67% vs. 9.34%, p < 0.01). On further investigation, the clinical benefit, in the NIHSS 10-19 subgroup, was driven by patients receiving EVT in combination with intravenous thrombolysis (IVT). This analysis shows that current national practices utilize EVT for more severe PCA strokes. Clinical benefit was only detected in patients with moderate stroke severity (NIHSS 10-19) who were treated with combined EVT and IVT. Further work is needed to investigate the features of PCA-AIS that might benefit from EVT the most.

Associations between NIHSS sub-item scores and prognosis and intracranial hemorrhage after endovascular therapy for acute anterior circulation ischemic stroke.

The relationship between sub-item scores on the National Institutes of Health Stroke Scale (NIHSS) scores and prognosis and intracranial hemorrhage in patients with acute ischemic stroke undergoing endovascular treatment (EVT) has been insufficiently studied. The aim of this study was to investigate the correlation between NIHSS sub-item scores, prognosis, and intracranial hemorrhage. This study included patients with acute anterior circulation ischemic stroke undergoing EVT between February 2019 and April 2022. The outcomes included functional independence, defined as a modified Rankin Scale (mRS) score ≤ 2 at 3 months after EVT, intracranial hemorrhage within 24 h after EVT, and mortality within 3 months. A multivariate regression analysis was performed, including NIHSS sub-item scores and other adjusted variables. A total of 568 patients were enrolled. Of the 568 patients, 239 (45%) achieved functional independence at 3 months after EVT. The median age in this group was 63 years (IQR 52-69) and 176 (73.6%) were male patients. Intracranial hemorrhage within 24 h after EVT occurred in 170 (30%) patients. The median age in this group was 65 years (IQR 56-71) and 105 (61.8%) were male patients. In a multivariate analysis adjusted for age, gender, and factors with a value of p of <0.05, the NIHSS limb movement sub-item score was strongly associated with prognosis at 3 months (OR 0.833, 95% CI 0.758-0.915) and intracranial hemorrhage within 24 h after EVT (OR 1.161, 95% CI 1.037-1.300). Higher limb movement sub-item scores on the NIHSS were independently associated with a poorer prognosis at 3 months and a higher rate of intracranial hemorrhage within 24 h after EVT among patients with acute anterior circulation ischemic stroke.

Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma

BackgroundAlthough clinical decision rules exist for patients with head injuries, no tool assesses patients with unknown trauma events. Patients with uncertain trauma may have unnecessary brain imaging. ObjectiveThis study evaluated risk factors and outcomes of geriatric patients with uncertain head injury. MethodsThis prospective cohort study included geriatric patients with definite or uncertain head injury presenting to two emergency departments (EDs). Patients were grouped as definite or uncertain head trauma based on history and physical examination. Outcomes were intracranial hemorrhage (ICH) on head computed tomography (CT), need for neurosurgical intervention, and mortality. Risk factors assessed included gender, alcohol use, tobacco use, history of dementia, anticoagulant use, antiplatelet use, and Glasgow Coma Scale (GCS) score < 15. ResultsWe enrolled 2905 patients with definite head trauma and 950 with uncertain head trauma. Rates of acute ICH (10.7% vs. 1.5%; odds ratio [OR] 8.02; 95% confidence interval [CI] 4.67–13.76), delayed ICH (0.7% vs. 0.1%; OR 6.58; 95% CI 4.67–13.76), and neurosurgical intervention (1.2% vs. 0.3%; OR 3.74; 95% CI 1.15–12.20) were all higher in definite vs. uncertain head injuries. There were no differences in mortality. Patients with definite trauma had higher rates of ICH with male gender (OR 1.58; 95% CI 1.24–1.99), alcohol use (OR 1.62; 95% CI 1.25–2.09), antiplatelet use (OR 1.84; 95% CI 1.46–2.31), and GCS score < 15 (OR 3.24; 95% CI 2.54–4.13). Patients with uncertain trauma had no characteristics associated with increased ICH. ConclusionsAlthough ICH rates among patients with uncertain head trauma was eight times lower than those with definite head trauma, the risk of ICH is high enough to warrant CT imaging of all geriatric patients with uncertain head injury.

Sex disparity in stroke outcomes in a multicenter prospective stroke registry in Viet Nam.

Although men have a higher rate of stroke than women, it is not clear whether women have a worse outcome after adjusting for confounders such as vascular risk factors, age, stroke severity, and reperfusion therapy. We evaluated sex differences on 90-day functional outcomes after stroke in a multicenter study in Vietnam. We recruited patients presenting with ischemic or hemorrhagic stroke at 10 stroke centers in Vietnam for a period of 1 month from August 1, 2022, to August 31, 2022. We reviewed the patient's clinical demographics, time from symptom onset to hospital admission, stroke classification, stroke subtype, stroke severity, characteristics of reperfusion therapy, and 90-day clinical outcome. We compared functional outcomes and predisposing factors at day 90 between men and women after an ischemic and hemorrhagic stroke. Poor outcome was defined as mRS 3-6. There were 2,300 stroke patients included. Men accounted for 61.3% (1,410) of participants. Compared with men, women were older (67.7±13.9 vs. 63.7±13.3, P<0.001), had a higher rate of diabetes mellitus (21.1% vs.15.3%, P<0.001), a lower rate of smoking (1.0 % vs. 23.6%, P<0.001), and a lower BMI (21.4 ± 2.70 vs. 22.0 ± 2.72, P<0.001). There was a higher rate of ICH in men (21.3% vs.15.6%, P=0.001), whereas the rate of subarachnoid hemorrhage was higher in women (6.2% vs.3.0%, P<0.001). For ischemic stroke, door-to-needle time (36.9±17.6 vs. 47.8±35.2 minutes, P=0.04) and door-to-recanalization time (113.6±51.1 vs.134.2±48.2, p=0.03) were shorter in women.There was no difference in 90-day functional outcomes between sexes. Factors associated with poor outcomes included age ≥ 50 years (adjusted OR, aOR 1.75; 95% CI, 1.16 to 2.66), history of stroke (aOR 1.50; 95% CI, 1.15 to 1.96), large artery atherosclerosis (aOR 5.19; 95% CI, 3.90 to 6.90), and cardioembolism (aOR 3.21; 95% CI, 1.68 to 6.16). Factors associated with mortality in patients with acute ischemic stroke included a history of coronary artery disease (aOR 3.04; 95% CI, 1.03 to 8.92), large artery atherosclerosis (aOR 3.37; 95% CI, 2.11 to 5.37), and cardioembolism (aOR 3.15; 95%CI, 1.20 to 8.27). There were no sex differences in the clinical outcome of stroke and ischemic stroke in this prospective cohort of hospitalized Vietnamese patients.

Early venous filling after mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion in anterior circulation

BackgroundThe significance of early venous filling (EVF) after mechanical thrombectomy (MT) in acute ischemic stroke (AIS) is not fully understood. In this study, we aimed to investigate the impact of...

Impact of Cerebral Microbleeds in Stroke Patients with Atrial Fibrillation.

Cerebral microbleeds are associated with the risks of ischemic stroke and intracranial hemorrhage, causing clinical dilemmas for antithrombotic treatment decisions. We aimed to evaluate the risks of intracranial hemorrhage and ischemic stroke associated with microbleeds in patients with atrial fibrillation treated with vitamin K antagonists, direct oral anticoagulants, antiplatelets, and combination therapy (i.e. concurrent oral anticoagulant and antiplatelet). We included patients with documented atrial fibrillation from the pooled individual patient data analysis by the Microbleeds International Collaborative Network. Risks of subsequent intracranial hemorrhage and ischemic stroke were compared between patients with and without microbleeds, stratified by antithrombotic use. A total of 7,839 patients were included. The presence of microbleeds was associated with an increased relative risk of intracranial hemorrhage (adjusted hazard ratio [aHR] = 2.74, 95% confidence interval = 1.76-4.26) and ischemic stroke (aHR = 1.29, 95% confidence interval = 1.04-1.59). For the entire cohort, the absolute incidence of ischemic stroke was higher than intracranial hemorrhage regardless of microbleed burden. However, for the subgroup of patients taking combination of anticoagulant and antiplatelet therapy, the absolute risk of intracranial hemorrhage exceeded that of ischemic stroke in those with 2 to 4 microbleeds (25 vs 12 per 1,000 patient-years) and ≥ 11 microbleeds (94 vs 48 per 1,000 patient-years). Patients with atrial fibrillation and high burden of microbleeds receiving combination therapy have a tendency of higher rate of intracranial hemorrhage than ischemic stroke, with potential for net harm. Further studies are needed to help optimize stroke preventive strategies in this high-risk group. ANN NEUROL 2023;94:61-74.

Abstract WP11: Outcomes Associated With Iv Tenecteplase And Iv Alteplase For Acute Ischemic Stroke With Or Without Thrombectomy In Real-world Settings In The United States

Background and Purpose: Although many stroke centers in United States are using intravenous (IV) tenecteplase (TNK) for acute ischemic stroke patients, there is paucity of comparative data between IV TNK and IV alteplase from real-world settings. Materials and Methods: We analyzed the data from 122 healthcare facilities to determine the effect of IV TNK (compared with IV alteplase) on occurrence of two outcomes in acute ischemic stroke patients stratified by use of thrombectomy: non-routine discharge or death, and intracranial hemorrhage after adjusting for potential confounders. Results: Among 30,643 acute ischemic stroke patients analyzed, 29,480 (96.2%) and 1,163 (3.8%) patients received IV alteplase and IV TNK, respectively. The proportion of patients who received thrombectomy was significantly higher among patients who received IV TNK compared with those who received IV alteplase (16.7% versus 11.0%, p&lt;0.001). Occurrence of intracranial hemorrhage was higher more common among patients treated with IV TNK among acute ischemic stroke patients who received thrombectomy (20.1% versus 16.8%, p=0.234) or did not receive thrombectomy (7.9% versus 5.1%, p&lt;0.001). In the logistic regression analysis, patients treated with IV TNK who did not receive thrombectomy were at higher risk of intracranial hemorrhage (OR, 1.34, 95% CI 1.05-1.72, p=0.02) after adjusting for potential confounders. There was no difference in the rate of non-routine discharge or death between patients treated with IV TNK and those treated with IV alteplase in the multivariate analyses. Conclusions: In an analysis of real-world data, IV TNK was associated with higher rates of intracranial hemorrhage compared with IV alteplase in patients with acute ischemic stroke.

Asymptomatic Postoperative Cerebral Venous Sinus Thrombosis After Posterior Fossa Tumor Surgery: Incidence, Risk Factors, and Therapeutic Options.

Cerebral venous sinus thrombosis (CVST) is a known complication of posterior fossa surgery near the sigmoid and transverse sinus. The incidence and treatment of postoperative asymptomatic CVST are controversial. To analyze incidence, risk factors, and management of asymptomatic postoperative CVST after posterior fossa tumor surgery. In this retrospective, single-center study, we included all patients who underwent posterior fossa tumor surgery in the semisitting position between January 2013 and December 2020. All patients underwent preoperative and postoperative imaging using MRI with/without additional computed tomography angiography. We analyzed the effect of demographic and surgical data on the incidence of postoperative CVST. Furthermore, therapeutic anticoagulation or conservative treatment for postoperative CVST and the incidence of intracranial hemorrhage were investigated. In total, 266 patients were included. Thirty-three of 266 (12.4%) patients developed postoperative CVST. All patients were asymptomatic. Thirteen of 33 patients received therapeutic anticoagulation, and 20 patients did not. Univariate analysis showed that age ( P = .56), sex ( P = .20), American Society of Anesthesiology status ( P = .13), body mass index ( P = .60), and length of surgery ( P = .176) were not statistically correlated with postoperative CVST. Multivariate analysis revealed that meningioma ( P < .001, odds ratio 11.3, CI 95% 4.1-31.2) and vestibular schwannoma ( P = .013, odds ratio 4.4, CI 95% 1.3-16.3) are risk factors for the development of new postoperative CVST. The use of therapeutic anticoagulation to treat postoperative CVST was associated with a higher rate of intracranial hemorrhage (n = 4, P = .017). Tumor entity influences the incidence of postoperative CVST. In clinically asymptomatic patients, careful decision making is necessary whether to initiate therapeutic anticoagulation or not.

Outcomes with IV tenecteplase and IV alteplase for acute ischemic stroke with or without thrombectomy in real-world settings in the United States

Background and PurposeAlthough many stroke centers in United States are using intravenous (IV) tenecteplase (TNK) for acute ischemic stroke patients, there is paucity of comparative data between IV TNK and IV alteplase from real-world settings. Materials and MethodsWe analyzed the data from 122 healthcare facilities in Cerner Real World Data and included patients admitted between February 2016 to April 2022 to determine the effect of IV TNK (compared with IV alteplase) on occurrence of two outcomes in acute ischemic stroke patients stratified by use of thrombectomy: non-routine discharge or death, and intracranial hemorrhage after adjusting for potential confounders. ResultsAmong 30,643 acute ischemic stroke patients analyzed, 29,480 (96.2%) and 1,163 (3.8%) patients received IV alteplase and IV TNK, respectively. The proportion of patients who received thrombectomy was significantly higher among patients who received IV TNK compared with those who received IV alteplase (16.7% versus 11.0%, p<0.001). Occurrence of intracranial hemorrhage was more common among patients treated with IV TNK in acute ischemic stroke patients who did not receive thrombectomy (7.9% versus 5.1%, p<0.001) but not in those who received thrombectomy (20.1% versus 16.8%, p = 0.234). In the logistic regression analysis, patients treated with IV TNK who did not receive thrombectomy were at higher risk of intracranial hemorrhage (OR, 1.34, 95% CI 1.05-1.72, p = 0.02) after adjusting for age (age strata), gender, race/ethnicity, hypertension, diabetes mellitus, atrial fibrillation, hyperlipidemia, malignancy, nicotine dependence, previous ischemic stroke, previous transient ischemic attack, previous intracerebral hemorrhage, previous subarachnoid hemorrhage, previous acute myocardial infarction, atherosclerosis of aorta, previous AKI, congestive heart failure, peripheral vascular disease, and hospital type, aphasia, hemiplegia, neglect, somnolence, stupor and coma, dysphagia, and homonymous hemianopsia. There was no difference in the rate of non-routine discharge or death between patients treated with IV TNK and those treated with IV alteplase in the multivariate analyses. ConclusionsIn an analysis of real-world data, IV TNK was associated with higher rates of intracranial hemorrhage compared with IV alteplase in patients with acute ischemic stroke who did not undergo thrombectomy.

Effect of atrial fibrillation on outcomes after mechanical thrombectomy and long-term ischemic recurrence in patients with acute basilar artery occlusion.

IntroductionAccording to the literature on anterior circulation, comorbid atrial fibrillation (AF) is not associated with a worse functional outcome, lower reperfusion rates, or higher rates of intracranial hemorrhage after mechanical thrombectomy (MT) compared to intravenous thrombolysis (IVT) or treatment with supportive care. However, data are limited for the effect of comorbid AF on procedural and clinical outcomes of acute basilar artery occlusion (ABAO) after MT. This study aimed to investigate the effect of atrial fibrillation on outcomes after MT and long-term ischemic recurrence in patients with ABAO.MethodsWe performed a registered study of the Endovascular Treatment for Acute Basilar Artery Occlusion Study (BASILAR, which is registered in the Chinese Clinical Trial Registry, http://www.chictr.org.cn; ChiCTR1800014759) from January 2014 to May 2019, which included 647 patients who underwent MT for ABAO, 136 of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared.ResultsOn multivariate analysis, AF predicted a shorter puncture-to-recanalization time, higher first-pass effect rate, and lower incidence of angioplasty and/or stenting (p < 0.01). AF had no effect on intracranial hemorrhage incidence [adjusted odds ratio (aOR), 1.093; 95% confidence interval (CI), 0.451–2.652], 90-day functional outcomes (adjusted common odds ratio, 0.915; 95% CI, 0.588–1.424), or mortality (aOR, 0.851; 95% CI, 0.491–1.475) after MT. The main findings were robust in the subgroup and 1-year follow-up analyses. Comorbid AF was the remaining predictor of ischemic recurrence (aOR, 4.076; 95% CI, 1.137–14.612).ConclusionsThe study revealed no significant difference in the safety and efficacy of MT for ABAO regardless of whether patients had comorbid AF. However, a higher proportion of patients with AF experienced ischemic recurrence within 1 year after MT.

Endovascular thrombectomy with and without preceding intravenous thrombolysis for treatment of large vessel anterior circulation stroke: A cross-sectional analysis of 50,000 patients

IntroductionThe safety and efficacy of intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) for large vessel occlusion stroke remains a highly contested and unanswered clinical question. We aim to characterize the clinical profile, complications, and discharge disposition of EVT patients treated with and without preceding IVT using a large, nationally-representative sample. MethodsThe National Inpatient Sample was queried from 2015 to 2018 to identify adult patients with anterior circulation stroke treated with EVT with and without preceding IVT. Multivariable logistic regression analysis and propensity-score matching were employed to assess adjusted associations with clinical endpoints and to address confounding by indication for IVT, respectively. ResultsAmong 48,525 patients identified, 40.7% (n = 19,735) received IVT prior to EVT. On unadjusted analysis, patients treated with IVT bridging therapy experienced higher rates of intracranial hemorrhage (26% vs. 24%, p = 0.003) and routine discharge to home with or without services (33% vs. 27%, p < 0.001), a lower frequency of thromboembolic complications (3% vs. 5%, p < 0.001), and lower rates of extended hospital stays (eLOS) (20% vs. 24%, p < 0.001). Multivariable logistic regression analysis adjusting for demographic and baseline clinical characteristics demonstrated independent associations of IVT bridging therapy with intracranial hemorrhage (aOR 1.28, 95% CI 1.15, 1.43; p < 0.001), thromboembolic complications (aOR 0.66, 95% CI 0.53, 0.83; p < 0.001), routine discharge (aOR 1.27, 95% CI 1.15, 1.40; p < 0.001), and eLOS (aOR 0.76, 95% CI 0.68, 0.85; p < 0.001). Sensitivity testing confirmed these findings. ConclusionPreceding IVT was associated with favorable functional outcomes following endovascular therapy. Prospective randomized clinical trials are warranted for further evaluation.

Safety and Effectiveness of Lower Alteplase Dose Driven by Impending Clinical Deterioration Factors in very Elderly Submassive Pulmonary Embolism Patients. Case Series

Although thrombolysis improves the outcome and mortality in submassive (SM) and massive PE, its role is controversial because of the high rate of intracranial hemorrhage. In addition, safety and efficacy are unclear since randomized controlled studies have excluded very elderly patients because of frailty, multiple comorbidities, and a higher risk of bleeding. Therefore, the best thrombolytic regimen is unknown. Furthermore, it is unclear whether the decision-making for thrombolysis is performed according to the guidelines or based on clinical risk factors associated with poor outcomes. We report three very elderly SMPE associated with several impending clinical deterioration factors (ICDF) (in-transit thrombus, saddle thrombus, etc.). Therefore, we decided on 25 mg alteplase in one- or two-hour continuous infusion based on ICDF rather than clinical instability and systolic hypotension. In addition, we initiate DOACs around 48 hours after stopping unfractionated heparin (UFH). As a result, all patients improve right ventricular performance without bleeding complications. Our results suggest that the lower alteplase dose in one- or two-hour continuous infusion, followed by weight-adjusted UFH, was effective and safe, involving a complicated scenario as an intransit thrombus. Also, DOACs standard doses driven by the patient´s characteristics were unrelated to bleeding complications avoiding recurrence in very elderly SMPE.

Use of Magnetic Resonance Imaging in Acute Traumatic Brain Injury Patients is Associated with Lower Inpatient Mortality.

Objectives:While magnetic resonance imaging (MRI) has higher sensitivity than computed tomography for certain types of traumatic brain injury (TBI), it remains unknown whether the increased detection of intracranial injuries leads to improved clinical outcomes in acute TBI patients, especially given the resource requirements involved in performing MRI. We leveraged a large national patient database to examine associations between brain MRI utilization and inpatient clinical outcomes in hospitalized TBI patients.Material and Methods:The National Inpatient Sample database was queried to find 3,075 and 340,090 hospitalized TBI patients with and without brain MRI, respectively, between 2012 and 2014 in the United States. Multivariate regression analysis was performed to independently evaluate the association between brain MRI utilization and inpatient mortality rate, complications, and resource requirements.Results:The MRI group had a lower unadjusted mortality rate of 0.75% compared to 2.54% in the non-MRI group. On multivariate regression analysis, inpatient brain MRI was independently associated with lower mortality (adjusted OR 0.32, 95% CI 0.12–0.86), as well as higher rates of intracranial hemorrhage (adjusted OR 2.20, 95% CI 1.27–3.81) and non-home discharge (adjusted OR 1.33, 95% CI 1.07–1.67). Brain MRI was independently associated with 3.4 days (P < 0.001) and $8,934 (P < 0.001) increase in the total length and cost of hospital stay, respectively.Conclusion:We present the first evidence that inpatient brain MRI in TBI patients is associated with lower inpatient mortality, but with increased hospital resource utilization and likelihood of non-home discharge.

Endovascular treatment experience in acute ischemic stroke

Background and Objective: Thrombolytic and mechanical thrombectomy therapies are proven treatment methods in patients with acute stroke. Aim is to share our experience in acute stroke therapy with colleagues. Material and methods: In this study we evaluated the patients who underwent MT or MT + IV-tPA between 2018-2019 retrospectively. Demographic features, comorbid diseases of patients, symptom onset-to-gate and symptom gate-to-puncture durations, mRS (Modified Rankin Score) and NIHSS (National Institutes of Health Stroke Scale) score, treatment method and degree of recanalization were listed. Results: MT was applied to 29 patients, MT + bolus IV-tPA was applied to 12 patients and MT + full dose IV-tPA was applied to 7 patients. The mean age was 66 ± 15 years, arrival mRS was 2 ± 2, arrival NIHSS score was 14 ± 5, onset-to-gate duration was 185 minutes and gate-to-puncture duration was 118 minutes. Conclusion: The rate of recanalization, functional independence and mortality were similar to the HERMES study. It was observed a higher rate of intracranial hemorrhage in patients who received bolus or full dose IV-Tpa compared to patients who underwent MT. These results have led us to question the necessity of giving bolus or full dose IV-tPA before MT. Onset-to-gate and gate-to-puncture durations were found longer than the recommended durations. Rapid and effective management of AIS patients will provide good clinical results.

Dual antiplatelet therapy after carotid artery stenting: trends and outcomes in a large national database

BackgroundWhile dual antiplatelet therapy (dAPT) is standard of care following carotid artery stenting (CAS), the optimal dAPT regimen and duration has not been established.MethodsWe canvassed a large national database (IBM...