Intracranial Hemorrhage Research Articles

Patterns and Clinical Implications of Hemorrhagic Transformation After Thrombolysis in Acute Ischemic Stroke: Results From the ENCHANTED Study.

Hemorrhagic transformation may be a potentially devastating complication of IV thrombolysis (IVT) in acute ischemic stroke, but what degree of hemorrhage indicates the greatest negative effect is not known. We aimed to define the associations between hemorrhagic transformation patterns, classified according to clinical and imaging categories, and clinical outcomes after IVT. We conducted a post hoc analysis from the international Enhanced Control of Hypertension and Thrombolysis Stroke Study. Symptomatic intracerebral hemorrhage (sICH) was defined based on established criteria, such as the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria. Asymptomatic intracerebral hemorrhage (aICH) was defined as any intracerebral hemorrhage that did not meet the criteria for sICH. Imaging subtypes of hemorrhagic transformation were assessed using the Heidelberg Bleeding Classification system. The primary outcome was death or major disability, defined by modified Rankin scale (mRS) scores 3-6 at 90 days. Secondary outcomes included death, death or disability (mRS 2-6), and poor health-related quality of life (HRQoL), defined as an overall heath utility score ≤0.7 (mean). Of the 4,370 participants, 779 (17.8%) developed any intracranial hemorrhage (ICH), with a median time from randomization to hemorrhage of 23.5 hours (interquartile range 18.92-26.07). According to the SITS-MOST criteria, 62 patients (1.4% of 4,370) were classified as sICH, and 717 patients (16.4% of 4,370) were classified as aICH. sICH per SITS-MOST criteria was associated with death or major disability (odds ratio [OR] 23.05, 95% CI 8.97-59.23), death (OR 20.14, 95% CI 11.32-35.84), death or disability (OR 61.36, 95% CI 8.40-448.01), and poor HRQoL (OR 17.87, 95% CI 7.47-42.71). Similarly, aICH per SITS-MOST criteria was also associated with death or major disability (OR 2.23, 95% CI 1.84-2.70), death (OR 1.82, 95% CI 1.39-2.38), death or disability (OR 2.29, 95% CI 1.87-2.80), and poor HRQoL (OR 1.81, 95% CI 1.50-2.18). Comparable associations were observed for sICH and aICH defined by other criteria, as well as for imaging subtypes based on Heidelberg Bleeding Classification system. All forms of post-IVT hemorrhagic transformation in acute ischemic stroke are associated with increased odds of poor clinical outcomes. Of note, aICH after IVT should not be considered clinically innocuous. ClinicalTrials.gov (NCT01422616).

Endovascular treatment for brain arteriovenous malformations via the anterior choroidal artery for casting Onyx-18.

Background: Few studies have investigated the safety of endovascular treatment (EVT) for brain arteriovenous malformations (BAVMs) via the anterior choroidal artery (AchA); therefore, this topic is worth studying further. Materials and methods: This was a retrospective study of 18 consecutive patients with BAVMs that were treated via the AchA with Onyx casting. Clinical and angiographic data were collected from the patients and analyzed. Results: The ages of the 18 patients ranged from 13 to 67years (mean 39.2 ± 14.7years), and eight patients were male (44.4%, 8/18). All patients had intracranial hemorrhages, including 2 with previous hemorrhages. All 18 BAVMs were mainly fed by the AchA and were treated via the AchA as the route for casting Onyx-18. Of the 13 single-trunk AchAs, after EVT, all proximal segments were preserved. For the 5 double-trunk AchAs, EVT was performed via the lower trunk; the proximal segments of the lower trunk were occluded for 2 of these AchAs. Among the 18 BAVMs, 16 niduses were embolized to different degrees, as were twelve associated aneurysms. Five (27.8%, 5/18) of the 18 patients experienced complications, and appropriate management was provided. During long-term follow-up, 14 (77.8%, 14/18) patients achieved good outcomes. Conclusion: EVT for BAVMs via the AchA has significant risks, but overall, good long-term outcomes were achieved in approximal 80% of the patients. This study highlights the potential of this technique for embolizing BAVMs via the AchA.

New strategy of early surgery for infective endocarditis complicated by intracranial hemorrhage.

Early surgery for infective endocarditis with intracranial hemorrhage can cause severe bleeding, which is correlated with an increased mortality. In 2005, we started using nafamostat mesilate and low-dose heparin as anticoagulants during cardiopulmonary bypass for early surgery. The outcomes of this strategy have been reviewed. All patients who underwent cardiac surgery for active infective endocarditis with intracranial hemorrhage between 2005 and 2023 were evaluated. There were 23 consecutive patients (median age 62 years old). Ten patients (43%) had neurologic deficits. The indication for early surgery in most patients was the presence of mobile vegetation or existing embolic events (18 of 23, 78%). No complications were associated with cardiopulmonary bypass. The median interval between the diagnosis and surgery was two days. There was 1 early death (4%) due to sepsis. There was no exacerbation of intracranial hemorrhage. One patient had new ectopic microbleeds without deterioration of neurologic findings. One patient had a new-onset cerebral infarction with neurologic deficits. None of the patients exhibited neurologic deterioration. The median follow-up duration was 26months. overall survival was 90.7% after 5years. Our strategy of using nafamostat mesilate enabled us to safely perform early surgery in patients with intracranial hemorrhage without hemorrhage exacerbation.

Applying Conformal Prediction to a Deep Learning Model for Intracranial Hemorrhage Detection to Improve Trustworthiness.

"Just Accepted" papers have undergone full peer review and have been accepted for publication in Radiology: Artificial Intelligence. This article will undergo copyediting, layout, and proof review before it is published in its final version. Please note that during production of the final copyedited article, errors may be discovered which could affect the content. Purpose To apply conformal prediction to a deep learning (DL) model for intracranial hemorrhage (ICH) detection and evaluate model performance in detection as well as model accuracy in identifying challenging cases. Materials and Methods This was a retrospective (November 2017 through December 2017) study of 491 noncontrast head CT volumes from the CQ500 dataset in which three senior radiologists annotated sections containing ICH. The dataset was split into definite and challenging (uncertain) subsets, where challenging images were defined as those in which there was disagreement among readers. A DL model was trained on 146 patients (mean age = 45.7, 70 females, 76 males) from the definite data (training dataset) to perform ICH localization and classification into five classes. To develop an uncertainty-aware DL model, 1,546 sections of the definite data (calibration dataset) was used for Mondrian conformal prediction (MCP). The uncertainty-aware DL model was tested on 8,401 definite and challenging sections to assess its ability to identify challenging sections. The difference in predictive performance (P value) and ability to identify challenging sections (accuracy) were reported. Results After the MCP procedure, the model achieved an F1 score of 0.920 for ICH classification on the test dataset. Additionally, it correctly identified 6,837 of the 6,856 total challenging sections as challenging (99.7% accuracy). It did not incorrectly label any definite sections as challenging. Conclusion The uncertainty-aware MCP-augmented DL model achieved high performance in ICH detection and high accuracy in identifying challenging sections, suggesting its usefulness in automated ICH detection and potential to increase trustworthiness of DL models in radiology. ©RSNA, 2024.

Optimal timing of oral anticoagulation initiation in patients with acute ischaemic stroke and atrial fibrillation: a comprehensive meta-analysis and systematic review

The optimal timing for initiating direct oral anticoagulants (DOACs) for secondary stroke prevention in patients with atrial fibrillation and acute ischaemic stroke remains controversial due to concerns about haemorrhagic transformation....

External validation and performance analysis of a deep learning-based model for the detection of intracranial hemorrhage.

We aimed to investigate the external validation and performance of an FDA-approved deep learning model in labeling intracranial hemorrhage (ICH) cases on a real-world heterogeneous clinical dataset. Furthermore, we delved deeper into evaluating how patients' risk factors influenced the model's performance and gathered feedback on satisfaction from radiologists of varying ranks. This prospective IRB approved study included 5600 non-contrast CT scans of the head in various clinical settings, that is, emergency, inpatient, and outpatient units. The patients' risk factors were collected and tested for impacting the performance of DL model utilizing univariate and multivariate regression analyses. The performance of DL model was contrasted to the radiologists' interpretation to determine the presence or absence of ICH with subsequent classification into subcategories of ICH. Key metrics, including accuracy, sensitivity, specificity, positive predictive value, and negative predictive value, were calculated. Receiver operating characteristics curve, along with the area under the curve, were determined. Additionally, a questionnaire was conducted with radiologists of varying ranks to assess their experience with the model. The model exhibited outstanding performance, achieving a high sensitivity of 89% and specificity of 96%. Additional performance metrics, including positive predictive value (82%), negative predictive value (97%), and overall accuracy (94%), underscore its robust capabilities. The area under the ROC curve further demonstrated the model's efficacy, reaching 0.954. Multivariate logistic regression revealed statistical significance for age, sex, history of trauma, operative intervention, HTN, and smoking. Our study highlights the satisfactory performance of the DL model on a diverse real-world dataset, garnering positive feedback from radiology trainees.

Efficacy and Safety of a Dedicated Device for Cerebral Venous Thrombectomy: A Pilot Randomized Clinical Trial.

Lack of a dedicated thrombectomy device for cerebral venous thrombosis hinders the recanalization ability of endovascular treatment (EVT). Novel NiTi-braided stent retriever (Venous-TD) is a dedicated venous sinus thrombectomy device. This study aims to demonstrate the safety and efficacy of Venous-TD. In this pilot, prospective, randomized, single-blind, parallel-group control, single-center clinical study, patients with cerebral venous thrombosis from Beijing Xuanwu Hospital were included. Randomization was performed to EVT with either the Venous-TD or Angioguard with Sterling balloon (control group). The primary efficacy outcome was the proportion of immediate complete recanalization during EVT. Secondary outcomes included the proportion of functional independence and moderate to severe residential headache at 180 days after EVT. Safety outcomes included peri-procedural complications, all-cause mortality, and symptomatic intracranial hemorrhage after EVT. A total of 61 patients were enrolled and randomized. Thirty-one patients were randomized to the Venous-TD group, and 30 were randomized to the control group. The median (interquartile range) age was 28 (21-45) in the Venous-TD group and 34 (24-43) in the control group. The proportion of patients with a National Institutes of Health Stroke Scale score >8 on admission was 8 (25.8%) in the Venous-TD group and 11 (36.7%) in the control group. During EVT, Venous-TD significantly improved the proportion of complete recanalization compared with Angioguard (23 [76.7%] versus 6 [20.0%]; relative risk, 3.833 [95% CI, 1.825-8.054]). The proportions of long-term functional independence at 180 days in the Venous-TD group and the control group were not significantly different. The proportion of patients with severe residual headache at 180 days in the Venous-TD group was significantly lower than that in the control group (3 [9.7%] versus 10 [35.7%]; relative risk, 0.271 [95% CI, 0.083-0.886]). Safety outcomes showed no statistically significant difference between the 2 groups. This trial indicated that Venous-TD did not increase complications in EVT of cerebral venous thrombosis and can significantly increase the proportion of complete recanalization. A multicenter phase III randomized control trial assessing efficacy and safety of Venous-TD is warranted. URL: https://www.clinicaltrials.gov; Unique identifier: NCT05291585.

Bleeding Complications between Bivalirudin and Heparin for ECMO in Neonates with CDH.

Infants with congenital diaphragmatic hernia (CDH) who undergo repair while on extracorporeal membrane oxygenation (ECMO) are at risk for developing post-operative bleeding complications. Balanced anticoagulation is critical to maintain ECMO flow and avoid bleeding. Heparin has historically been our first-line anticoagulant; however, recently, we transitioned to bivalirudin, a direct thrombin inhibitor. The objective of this pilot study was to compare post-operative surgical bleeding complications between the two groups. A single center retrospective cohort study of patients who underwent CDH repair while on ECMO between 2008-2023 was performed. Neonates were stratified based on type of anticoagulant initiated after CDH repair. Outcomes included bleeding requiring surgical re-operation, intracranial hemorrhage, volume of blood products transfused, number of circuit changes, days on ECMO, and overall survival. Among 62 infants with CDH who underwent repair on ECMO, 44 (71%) were managed post-CDH repair with heparin and 18 (29%) with bivalirudin. Demographics and prenatal predictors of CDH severity were not significantly different between the two cohorts. One (5.6%) neonate managed with bivalirudin required re-operation following CDH repair for a bleeding complication compared to 17 (38.6%) managed with heparin (p=0.022). In addition, the bivalirudin cohort required half of the total blood product volume compared to the heparin cohort (p=0.020). Despite these benefits, there were no significant differences between groups for incidence of intracranial hemorrhage, number of circuit changes, days on ECMO, and overall survival. Anticoagulation with bivalirudin in neonates who underwent CDH repair while on ECMO was associated with decreased surgical bleeding complications and less total blood product transfused. This pilot analysis is the first to directly compare heparin to bivalirudin and stresses the importance of a randomized trial.

Postoperative Blood Pressure Goals After Craniotomy for Tumor Resection: A National Survey.

Acute hypertension can occur in 90% of postcraniotomy patients for tumor resection, and 60% to 90% of patients require treatment with antihypertensive agents. Postoperative intracranial hemorrhage is a major driver of morbidity and mortality after craniotomy for tumor resection, and perioperative hypertension is believed to be a risk factor. Many neurosurgeons impose postoperative blood pressure (BP) goals to mitigate this risk, but there is little evidence to guide the selection of a specific target BP, leading to a wide variation in patient care. In this article, we have conducted a national survey to report the current practices regarding postoperative BP management. We conducted a cross-sectional survey of academic neurosurgical programs by distributing a 10-item questionnaire to neurosurgical residents of each accredited national neurosurgical residency training program (n = 117). Responses were collected over 3 months, from July 2023 to September 2023. Analysis was performed at the program level; for programs with multiple responding residents, the responses of the senior residents were retained. Responses were received from 66 residents at 45 institutions. Forty-two programs set postoperative BP goals using systolic blood pressure (SBP) as a parameter, and 2 used mean arterial pressure. Among programs using an SBP goal, most programs kept a goal SBP of <140 mm Hg (41%-43% depending on the tumor type), followed by SBP <160 mm Hg (36%-39%). Most programs maintained this goal until the morning of the first postoperative day. Intravenous nicardipine (n = 12, 27%) and labetalol (n = 12, 27%) were the most frequently administered medications to maintain BP goals. Most of the academic neurosurgical programs use a postoperative SBP goal after craniotomy for tumor resection. Programs are evenly divided between goals of SBP <140 mm Hg and SBP <160 mm Hg. The variability among programs indicates clinical equipoise between these 2 approaches in the context of a future clinical trial.

Evaluation of Door-to-Needle Times Between Alteplase and Tenecteplase for Acute Ischemic Stroke at Two Academic Medical Centers.

Off-label tenecteplase use for acute ischemic stroke (AIS) has increased due to ease of administration and comparable efficacy and safety to alteplase. This study aimed to evaluate time to thrombolysis before and after transition from alteplase to tenecteplase for treatment of AIS at 2 institutions. This retrospective cohort study included adult patients receiving thrombolysis for AIS before and after transition from alteplase to tenecteplase at 2 academic medical centers from January 1, 2020 to January 31, 2024. The primary endpoint was door-to-needle (DTN) time, defined as minutes from hospital arrival to thrombolysis administration. Notable secondary endpoints included time from last known well (LKW) to thrombolysis, time from brain imaging to thrombolysis, hospital length of stay (LOS), and incidence of symptomatic intracranial hemorrhage (sICH). A total of 328 patients (168 tenecteplase and 160 alteplase) were included. Patients were 51.5% female with a median (interquartile range [IQR]) age of 70 [58-80] years and initial National Institutes of Health Stroke Scale (NIHSS) score of 8 [5-14]. There was no statistically significant difference in DTN time (60 vs 56 minutes), time from LKW to thrombolysis (134 vs 147.5 minutes), or time from brain imaging to thrombolysis (32 vs 31 minutes) between tenecteplase and alteplase. Hospital LOS (5.7 vs 4.9 days) and the rates of sICH (3% vs 3.8%) were similar between groups. Tenecteplase and alteplase had comparable DTN times for treatment of AIS and similar safety endpoints. Further studies are warranted to identify opportunities to streamline DTN times with tenecteplase.

The clinical value of fibrosis indices for predicting the hemorrhagic transformation in patients with acute ischemic stroke after intravenous thrombolysis

BackgroundThe incidence of stroke in China is approximately 343 per 100,000 people each year, the highest rate worldwide. Hemorrhagic transformation (HT), particularly symptomatic intracerebral hemorrhage (sICH) following acute ischemic stroke (AIS) with or without intravenous thrombolysis (IVT), can lead to rapid neurological deterioration, poor prognosis, and even death. Non-alcoholic fatty liver disease (NAFLD) has been identified as a risk factor for stroke occurrence and associated with poor long-term functional outcomes. Nonetheless, no studies have examined the association between liver fibrosis and HT in AIS patients who underwent IVT.MethodA total of 826 patients with AIS who underwent IVT were included in this study. We calculated nine validated liver fibrosis indices to assess the extent of liver fibrosis. HT was detected by follow-up cranial CT/MRI within 24 h post-IVT and was classified as either hemorrhagic infarction (HI) or parenchymal hematoma (PH). Symptomatic intracranial hemorrhage was defined as a sudden symptomatic neurological deterioration, indicated by an increase in (National Institutes of Health Stroke Scale) NIHSS score of 4 points or more.ResultThe median values of fibrosis-4 (FIB-4), modified FIB-4 (mFIB-4), aspartate aminotransferase (AST)-platelet ratio index (APRI), Forns index, alanine aminotransferase (ALT)/AST (ARR), AST/ALT ratio-platelet ratio index (AARPRI), fibrosis quotient (FibroQ), and Fibrosis Index were significantly higher, while the fibrosis-5 (FIB-5) was significantly lower in the HT and sICH groups (all P &amp;lt; 0.001). After adjusting for potential confounders, all nine liver fibrosis indices remained associated with HT and sICH. Receiver operating characteristic (ROC) curve analysis revealed that the FibroQ score had the best predictive ability for HT (AUC = 0.707, CI = 0.652–0.762, P &amp;lt; 0.001), while FIB-4 had the best predictive ability for sICH (AUC = 0.802, CI = 0.711–0.892, P &amp;lt; 0.001).ConclusionLiver fibrosis, as validated by FIB-4, mFIB-4, FIB-5, APRI, Forns index, ARR, AARPRI, FibroQ, and Fibrosis Index, was associated with HT and sICH in AIS patients after IVT.

Endovascular Approach to Concurrent Anterior Cranial Fossa Dural AVF and Concurrent Flow-Related Ophthalmic Artery Aneurysm: A Case Study

AbstractDural arteriovenous fistulas (DAVFs) with concurrent flow-related ophthalmic artery aneurysms, particularly intraorbital aneurysms, are rare. Retrograde cortical blood flow and sinus thrombosis heighten the risk of rupture and optic nerve compression, yet treatment strategies remain poorly defined. This study aims to explore effective management for these complex cases. A 66-year-old hypertensive man presented with an acute severe headache, loss of consciousness, and decreased vision in the left eye. Imaging revealed a left frontal intracranial hemorrhage and an anterior cranial fossa DAVF with a left ophthalmic artery aneurysm. Endovascular embolization via the left ophthalmic artery, using a microcatheter distal to the aneurysm and controlled reflux of glue injection (N-butyl cyanoacrylate and lipiodol), successfully treated the DAVF and ophthalmic artery aneurysm. Visual acuity improved to finger counting at 1 foot, with no residual DAVF at 6 months. This case demonstrates that controlled glue embolization is a viable alternative when microsurgery is not feasible due to complex anatomy.

Veno-arterial extracorporeal membrane oxygenation under dual antiplatelet therapy, immediately after craniotomy

Introduction: Extracorporeal membrane oxygenation (ECMO) is often considered a relative contraindication for traumatic brain injury and cerebral hemorrhage because fatal intracranial hemorrhage can occur. Moreover, dual antiplatelet therapy (DAPT)-related cerebral hemorrhage is associated with a high mortality rate. Herein, we report a case in which the patient was placed on ECMO under DAPT and managed without anticoagulation immediately after craniotomy. Case Report: A 51-year-old man was hospitalized for surgery for Moyamoya disease. The surgery was performed as scheduled; however, the patient experienced cardiac arrest while awakening from anesthesia. After return of spontaneous circulation, during the emergency percutaneous coronary intervention (PCI), he was placed on ECMO for cardiac arrest which caused an electrical storm. Because computed tomography (CT) after PCI revealed a new cerebral hemorrhage, ECMO was managed with DAPT without anticoagulation. Subsequently, the CT showed no increase in hematoma; however, a thrombus was observed in the membrane of the ECMO, and ECMO was withdrawn on the 4th intensive care unit day. Conclusion: Anticoagulation therapy with or without DAPT should not be used because of the risk of bleeding associated with veno-arterial ECMO immediately after craniotomy. Additionally, the risk of thrombosis may be high; therefore, additional care must be taken, and it is necessary to manage the ECMO circuit to consider the possibility of early replacement it too.

DDANet: A deep dilated attention network for intracerebral haemorrhage segmentation.

Intracranial haemorrhage (ICH) is an urgent and potentially fatal medical condition caused by brain blood vessel rupture, leading to blood accumulation in the brain tissue. Due to the pressure and damage it causes to brain tissue, ICH results in severe neurological impairment or even death. Recently, deep neural networks have been widely applied to enhance the speed and precision of ICH detection yet they are still challenged by small or subtle hemorrhages. The authors introduce DDANet, a novel haematoma segmentation model for brain CT images. Specifically, a dilated convolution pooling block is introduced in the intermediate layers of the encoder to enhance feature extraction capabilities of middle layers. Additionally, the authors incorporate a self-attention mechanism to capture global semantic information of high-level features to guide the extraction and processing of low-level features, thereby enhancing the model's understanding of the overall structure while maintaining details. DDANetalso integrates residual networks, channel attention, and spatial attention mechanisms for joint optimisation, effectively mitigating the severe class imbalance problem and aiding the training process. Experiments show that DDANet outperforms current methods, achieving the Dice coefficient, Jaccard index, sensitivity, accuracy, and a specificity of 0.712, 0.601, 0.73, 0.997, and 0.998, respectively. The code is available at https://github.com/hpguo1982/DDANet.

Predicting Epidural Hematoma Expansion in Traumatic Brain Injury: A Machine Learning Approach.

Traumatic brain injury (TBI) is a leading cause of disability and mortality worldwide, with epidural hematoma (EDH) being a severe consequence. This study focuses on identifying factors predicting EDH volume changes in TBI patients and developing a machine learning (ML) model to predict EDH expansion. The study includes patients with traumatic EDH between 2019 and 2021. Data were gathered from CT scans performed at the time of admission and 6hours later, and subsequently analyzed. The data was divided into three cohorts: all cases, adults, and pediatrics. To predict EDH volume changes, we used Logistic Regression (LR), Random Forest (RF), XGBoost, and K-Nearest Neighbors (KNN) models. Data was divided into an 80% training set and a 20% test set. Through a rigorous process of parameter optimization and K-fold cross-validation, focusing on the area under the receiving operating curve (AUROC), we identified the best models in all cohorts. The best models were evaluated on the test sets, reporting AUROC, recall, precision, and accuracy using the youden index threshold. Results show that age, initial EDH volume, swirl sign, intra-hematoma air bleb, contusion, otorrhagia, subarachnoid hemorrhage, location, and other side extra-axial hematoma have significant effects on changing EDH volume. Based on test AUROC, the best models were RF for adults (82.4%), KNN for pediatrics (90%), and LR for all cases (81.6%). In this study, we identified key features for predicting EDH expansion as well as developing ML models. Using high sensitive models, can assist clinicians in identifying high-risk patients early. This allows for enhanced monitoring and timely intervention, improving patient outcomes by facilitating quicker decisions for follow-up imaging or treatment.

Spotting the scurvy’s sight: Spontaneous intraorbital hematomas causing bilateral acute proptosis

Spontaneous intraorbital hematomas in a child with no history of malignancy, coagulopathy, or child abuse can have nutritional deficiency leading to increased risk of bleeding. Children with neurological impairment are more prone to develop scurvy. Scurvy in a child presents with both musculoskeletal findings and bleeding diathesis and, therefore, a radiologist should be well-versed with the classical osseous changes on radiographs and with unusual, yet important radiological clues of intraorbital and intracranial hematomas on computed tomography.

Safety of early chemoprophylaxis for venous thromboembolism after traumatic brain injury: a systematic review and meta-analysis. A military traumatic brain injury initiative study.

There is continuing uncertainty about the safety of early chemoprophylaxis for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI). The objective of this paper was to 1) calculate the risk of progression of posttraumatic intracranial hemorrhage (ICH) after VTE chemoprophylaxis, and 2) compare the probability of ICH progression in early versus late VTE prophylaxis. The authors searched for English-language literature from database inception to January 2023. Two independent reviewers selected studies on post-TBI VTE chemoprophylaxis in hospitalized patients. Study parameters included ICH progression (as determined by follow-up imaging after starting chemoprophylaxis) in relation to use versus nonuse, timing, and type of VTE chemoprophylaxis. Pertinent variables included author, year, study type, demographic variables, cranial and systemic Injury Severity Scores, and data documenting ICH progression or indirect evidence of TBI worsening after the initiation of VTE chemoprophylaxis. Thirty studies fulfilled the inclusion criteria. There was a 7.0% (95% CI 4.0%-10.0%) risk of CT-documented ICH progression following VTE chemoprophylaxis in the prophylactically treated group. There was no difference between the early versus late VTE prophylaxis groups for ICH progression (12 studies; OR 0.79 [95% CI 0.56-1.12]). There was also no significant difference in CT-documented ICH progression between the prophylactically treated and nontreated groups (5 studies; OR 0.57 [95% CI 0.28-1.18]). The review of the literature shows that VTE chemoprophylaxis 72 hours after TBI is considered safe by the majority of authors. This meta-analysis did not reveal any evidence of increased risk of ICH when starting VTE chemoprophylaxis earlier, i.e., within 72 hours of TBI; however, it is important to emphasize that only a small number of lower-quality studies addressed the 48-hour or 24-hour time point. A randomized noninferiority trial should be the next step in answering the question of early (within 72 hours) VTE chemoprophylaxis after TBI.

Diagnosis and treatment of transient neonatal thrombocytopenia (Draft clinical recommendations for discussion by specialists)

Transient neonatal thrombocytopenia occurs with a frequency of 0.7–0.9% and is divided by etiological factor into primary (alloimmune and transimmune) and secondary (symptomatic) thrombocytopenia, according to the time of occurrence of thrombocytopenia is divided into early and late. The main clinical manifestation of thrombocytopenia is hemorrhagic syndrome of varying severity, which occurs in 20–30% of newborns with thrombocytopenia, in other newborns thrombocytopenia is asymptomatic. The most severe clinical symptom is intracranial hemorrhages, which occur in 10–30% of cases. The most common types of bleeding of the platelet-vascular type are petechiae, ecchymoses, nosebleeds, melena, hematuria, cephalohematoma and other types of bleeding. In dynamics, symptoms of posthemorrhagic anemia may appear with massive bleeding (pallor, tachycardia, tachypnea, decreased blood pressure). The main criterion for the diagnosis of transient neonatal thrombocytopenia is a decrease in the number of platelets below the reference values for a given gestational and chronological age of a newborn child. To diagnose the type of thrombocytopenia, a thorough collection of maternal anamnesis is necessary, examination of parents if they suspect the immune nature of the disease, diagnosis of the disease as a result of which thrombocytopenia has developed, if it is secondary. Correction of thrombocytopenia, if indicated, is carried out by intravenous administration of platelet concentrate. If the immune nature of thrombocytopenia with severe thrombocytopenia is suspected and/or the presence of moderate and higher hemorrhagic syndrome, the administration of normal human immunoglobulin is recommended. If immunoglobulin therapy for immune thrombocytopenia is ineffective, glucocorticoids are prescribed.

Awake versus asleep deep brain stimulation targeting the caudal zona incerta for essential tremor

To compare awake and asleep deep brain stimulation (DBS) surgery for Essential Tremor (ET), we conducted this retrospective cohort study of patients consecutively operated with DBS targeting the caudal Zona incerta (cZi). 37 underwent surgery awake and 55 asleep. Tremor before surgery and on/off stimulation one year after surgery were evaluated using the Essential Tremor Rating Scale (ETRS). Procedural time, electrode localization, stimulation parameters and adverse events were noted and compared. ETRS scores were similar at baseline between the groups except for contralateral arm tremor, which was slightly worse in the awake group. Total ETRS, contralateral arm tremor and activities of daily living scores showed no significant difference between the groups on-stimulation at one-year follow-up. Compared to the awake group, the asleep group had shorter procedural time and lower stimulation parameters. There were no intracranial haemorrhages nor surgery site-infections. Both groups showed a good improvement of tremor at one-year follow-up. Image-guided DBS surgery targeting the cZi enables safe and efficient asleep surgery for ET.

Long-Term Outcome of Rescue Stenting for Acute Intracranial Atherosclerotic Stenosis Related Large Vessel Occlusion in Anterior Circulation.

Rescue stent (RS) is an accepted rescue option after failed mechanical thrombectomy (MT) for acute ischemic stroke due to intracranial atherosclerotic stenosis (ICAS)-related large vessel occlusion (LVO). However, the long-term outcomes (≥ 12 months) of RS have not yet been elucidated. We retrospectively analyzed the data of 154 patients with RS for ICAS-related LVO, which were identified from prospectively maintained multicenter database of RS after MT failure, to assess good outcome (mRS 0-2), mortality, stroke recurrence, symptomatic intracranial hemorrhage (SICH) and stent patency. Among 154 patients, successful recanalization was achieved in 132 (85.7%) after RS. Clinical follow-up was available in 148 patients at 3 months, of whom 126 were followed longer than 12 months. Good outcome was observed in 53.4% (79/148) at 3 months and 53.2% (67/126) at the final assessment among survivors (median [interquartile range (IQR)] months, 33 [13-91]). The overall incidence of mortality was 16.2% (24/148) Mortality occurred in 8.8% (13/148) of patients at 3 months and 8.7% (11/126) thereafter, respectively. Stroke recurrence was 0.7% (1/148) within 3 months and 3.2% (4/126) thereafter. The overall incidence of SICH was 9.5% (14/148). SICH occurred in 8.8% (13/148) within the first 3 months, and in 0.8% (1/126) thereafter. The stented vessel was patent in 81.1% (99/122) at the first follow-up (median [IQR] days, 3 [1-125]) and 96.7% (89/92) at the final follow-up (median [IQR] months, 18 [13-68]). Patients with RS for ICAS-LVO showed a low stroke recurrence rate in the long term. The long-term patency of rescue stent appears to remain durable, particularly when it remains patent during the initial follow-upABBREVIATIONS: ICAS = intracranial atherosclerotic stenosis; LVO = large vessel occlusion; AIS = acute ischemic stroke; MT = mechanical thrombectomy; RS = rescue stenting; CT = computed tomography; MR = magnetic resonance; MMD = moyamoya disease; Intra-arterial = IA; Intravenous = IV; DAPT = dual antiplatelet therapy.