Cases Of Intracranial Hemorrhage Research Articles

Apolipoprotein A1 rs5070 A/G polymorphism with stroke subtypes in Taiwan

BackgroundApolipoprotein A1 (ApoA1) is a structural protein of high-density lipoprotein cholesterol; ApoA1 is involved in lipid and cholesterol metabolism. This study evaluated the association of ApoA1 polymorphism (rs5070) with different stroke subtypes in Taiwanese individuals. MethodsA total of 2139 cases, including 614 controls and 708 large artery atherosclerosis (LAA), 377 small-vessel occlusion, and 440 hypertensive intracranial hemorrhage cases, were enrolled in this study. ApoA1 polymorphism was genotyped through polymerase chain reaction amplification and then subjected to mass-assisted laser desorption ionization time-of-flight mass spectrometry using a Bruker SNP genotyping system in the National Center for Genome Medicine (Academia Sinica, Taipei, Taiwan; http://ncgm.sinica.edu.tw/). ResultsThe frequency of ApoA1 rs5070 dominant genotype (AA vs. AG+GG) was not significantly different among LAA, small-vessel occlusion, and hypertensive intracranial hemorrhage groups compared with that of the control group. Compared with diabetic patients with the AA allele, those with the AG+GG allele of ApoA1 rs5070 polymorphism showed a 1.58-fold likelihood of developing LAA (odds ratio=1.58; 95% confidence interval=1.00–2.42; p=0.046), but not small-vessel occlusion or hypertensive intracranial hemorrhage. In male diabetic patients, the odds ratio increased to 1.90-fold. ConclusionOur findings suggested that genetic polymorphisms of ApoA1 rs5070 A/G may play a role in the susceptibility to LAA among male diabetic patients.

CT of the head for acute stroke: Diagnostic performance of a tablet computer prior to intravenous thrombolysis.

The authors propose that tablet computers could benefit patients with acute stroke in the remote care setting, where time to and accuracy of CT interpretation greatly influences patient outcome. One hundred and fifty consecutive patients who presented to the Emergency Department of a tertiary referral neurosciences centre within a time window suitable for intravenous thrombolytic therapy were included. Images were wirelessly transmitted to a tablet computer (iPad 3rd Generation, model=A1430, Apple, Cupertino, CA) and were reviewed by radiologists with three levels of experience for signs of intracranial haemorrhage, large vessel occlusion and parenchymal infarction. Reference standard interpretation was performed by two neuroradiologists using a diagnostic monochrome display. Consensus neuroradiologist review on the tablet display found and correctly classified all of the 23 cases of intracranial haemorrhage including 21 cases of parenchymal haematoma, two cases of petechial haemorrhage and one patient with an acute subdural haematoma. Less experienced readers missed cases of petechial and subdural haematomas. There was excellent agreement between the tablet and diagnostic monochrome display in cases with no infarct or extensive parenchymal infarction. Tablet computers can be used to facilitate rapid preliminary CT interpretation in patients with acute stroke in the remote setting.

Abstract WMP98: A Nationwide Study of Non-traumatic Intracranial Hemorrhage in Patients Receiving Direct Oral Anticoagulant Therapy: J-Aspect Study

Background and purpose: The incidence of non-traumatic intracranial hemorrhage (ICH) during treatment with direct oral anticoagulants (DOACs) is lower than that during warfarin treatment. The characteristics of intracranial hemorrhage during DOAC therapy, however, remain unclear. Therefore, we performed a nationwide survey in Japan to examine the clinical characteristics and outcomes of DOAC-associated ICH using data obtained from the Japanese Diagnosis Procedure Combination (DPC)-based Payment System. Methods: We analyzed the data of 1,567 patients with ICH (DOAC-associated ICH, 88; warfarin-associated ICH, 1,479) who were urgently hospitalized at 575 institutions across Japan from April 2010 to March 2013 for whom prescription data before admission were available. Results: The annual number of patients with all anticoagulant (DOAC or warfarin)- associated ICH in each year from 2010 to 2013 was 226, 252, 426, and 663, representing 15.7%, 15.4%, 16.1%, and 16.1% of all ICH cases in the same period, respectively. There was an increase in the proportion of patients who presented with DOAC-associated ICH in all anticoagulant-associated ICH in each year from 2010 to 2013 (0%→0.4%→3.8%→10.7%). The proportion of patients with impaired consciousness (three-digit score on Japan Coma Scale) at admission (DOAC, 19.3%; Warfarin, 25.4%; P=0.20), in-hospital mortality within 7 days (DOAC, 11.4%; Warfarin, 19.5%; P=0.06), and mRS score of 5-6 at discharge (DOAC, 27.3%; Warfarin, 37.4%; P=0.06) were lower in the patients with DOAC-associated ICH. The rates of surgery for hematoma removal were significantly lower in the patients with DOAC-associated ICH (NOAC, 2.3%; Warfarin, 9.7%; P=0.019). Conclusions: This is the largest nationwide study of DOAC-associated ICH in a real-world situation in Japan, revealing that the patients with DOAC-associated ICH had better clinical outcomes compared with warfarin-associated ICH, probably due to milder hemorrhage at admission.

Not only the Sugar, Early infarct sign, hyperDense middle cerebral artery, Age, Neurologic deficit score but also atrial fibrillation is predictive for symptomatic intracranial hemorrhage after intravenous recombinant tissue plasminogen activator.

Background:Symptomatic intracranial hemorrhage (sICH) is the most unwanted adverse event in patients with acute ischemic stroke who received intravenous recombinant tissue plasminogen activator (i.v. rt-PA). Many tool scores are available to predict the probability of sICH. Among those scores, the Sugar, Early infarct sign, hyperDense middle cerebral artery, Age, Neurologic deficit (SEDAN) gives the highest area under the curve-receiver operating characteristic value.Objective:We aimed to examine any factors other than the SEDAN score to predict the probability of sICH.Methods:Patients with acute ischemic stroke treated with i.v. rt-PA within 4.5 h time window from January 2010 to July 2012 were evaluated. Compiling demographic data, risk factors, and comorbidity (hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation (AF), ischemic heart disease, valvular heart disease, previous stroke, gout, smoking cigarette, drinking alcoholic beverage, family history of stroke, and family history of ischemic heart disease), computed tomography scan of patients prior to treatment with rt-PA, and assessing the National Institutes of Health Stroke Scale (NIHSS) score for the purpose of calculating SEDAN score were analyzed.Results:Of 314 patients treated with i.v. rt-PA, there were 46 ICH cases (14.6%) with 14 sICH (4.4%) and 32 asymptomatic intracranial hemorrhage cases (10.2%). The rate of sICH occurrence was increased in accordance with the increase in the SEDAN score and AF. Age over 75 years, early infarction, hyperdense cerebral artery, baseline blood sugar more than 12 mmol/l, NIHSS as 10 or more, and AF were the risk factors to develop sICH after treated with rt-PA at 1.535, 2.501, 1.093, 1.276, 1.253, and 2.492 times, respectively.Conclusions:Rather than the SEDAN score, AF should be a predictor of sICH in patients with acute ischemic stroke after i.v. rt-PA treatment in Thai population.

Association of Selective Serotonin Reuptake Inhibitors With the Risk for Spontaneous Intracranial Hemorrhage

Selective serotonin reuptake inhibitors (SSRIs) may increase the risk for spontaneous intracranial hemorrhage (ICH), an effect that is in theory linked to the strength of inhibition of serotonin reuptake of an antidepressant. However, whether antidepressants that are strong inhibitors of serotonin reuptake actually increase the risk for ICH and the effect of concomitant use of antithrombotics are unknown. To assess the risk for ICH associated with the use of SSRIs compared with tricyclic antidepressants (TCAs) among new users of antidepressants and according to the relative affinity of the antidepressant for the serotonin transporter and to assess whether concomitant use of antithrombotics modifies this risk. This population-based cohort study included new users of antidepressants 18 years or older from January 1, 1995, to June 30, 2014. More than 650 general practices in the United Kingdom contributing to the Clinical Practice Research Datalink enrolled patients. with use of a nested case-control approach, each case of a first ICH identified during follow-up was matched with as many as 30 control individuals by age, sex, calendar time, and duration of follow-up. Follow-up was completed on October 31, 2014. Current use of SSRIs compared with TCAs and strong compared with weak serotonin reuptake inhibitors. Incidence rate ratios (RRs) of ICH. Among a cohort of 1 363 990 incident users of antidepressants (36.8% male; 63.2% female; mean [SD] age, 47.9 [18.5] years), 3036 cases of ICH were identified during follow-up and matched to 89 702 controls. Current SSRI use was associated with an increased risk for ICH (RR, 1.17; 95% CI, 1.02-1.35) relative to TCAs, highest during the first 30 days of use (RR, 1.44; 95% CI, 1.04-1.99), and translating in very few additional events. Similarly, the risk was increased by 25% with strong inhibitors (RR, 1.25; 95% CI, 1.01-1.54) and highest during the first 30 days of use (RR, 1.68; 95% CI, 0.90-3.12). Concomitant use of anticoagulants may increase the risk substantially (RR, 1.73; 95% CI, 0.89-3.39). The use of SSRIs and more generally of antidepressants with strong inhibition of serotonin reuptake are associated with an increased risk for ICH, particularly in the first 30 days of use and when used concomitantly with oral anticoagulants.

Assessment of Intracranial Hemorrhage Demographics in Children with Hemophilia: A Multicentre Study in China

Objective: Intracranial hemorrhage (ICH) is a severe complication in hemophilia patients with high mortality and disabling sequelae. This study is to provide key insights on the demographics of hemophilic patients with ICH in China.Method: The database and medical notes ofHemophilia patients who were diagnosed between 1995 and 2014 are reviewed with a goal to find the effective factors which relate to ICH such as age of onset, type, severity, cause, and ICH position, presence of inhibitor and neurological sequelae. A total of 145 hemophilic boys who are diagnosed with ICH and come from multiple hemophilia centers in China, are included.Result: The median age of ICH is 18 months. 123/145 (85%) are Hemophilia A and 22/145 (15%) are Hemophilia B. Intracranial hemorrhages most commonly occur in patients with severe disease 79/145 (54%), while 58/145 (40%) and 8/145 (5%) in moderate and mild disease respectively. There is obvious trauma history in 53/145 (37%) children. Neurological disabilities are seen only in 34/145 (23%). No deaths from ICH have been reported in our study. Data about the position of ICH is available only in 30% of patients; including involvement of multiple areas is seen in 50%. ICH in epidural space is 14%, brain parenchyma is 14%, subdural is 11% and subarachnoid is 5%.Out of 30 patients inhibitor is found only in 9 cases while in other 115 patients inhibitor data is unavailable. After the onset of ICH only 53/145 (37%) children are put on regular prophylaxis to prevent further episode of ICH.Conclusion: Risk of ICH is high in patients with severe hemophilia. In most cases of ICH, there is no trauma history and relatively less neurological consequences. About half of children with ICH multiple areas of brain are involved. We need more data to conclude the other risk factors in the incidence of ICH. DisclosuresNo relevant conflicts of interest to declare.

United Kingdom Experience of Intracranial Bleeds in Childhood Immune Thrombocytopenia

Childhood immune thrombocytopenia (ITP) is an uncommon disease that is usually self-limiting and resolves spontaneously without treatment. Less than 1% of children with ITP will develop an intracranial haemorrhage (ICH). The aim of this project was to review data from all available cases of ICH and identify features associated with an increased risk of intracranial bleeding. The data were obtained from three main resources: patient notes, the UK ITP Registry and surveys sent out to centres across the UK. 19 cases were reviewed, occurring over a period of 12 years from 2004 to 2016.Platelet counts below 20x109/L were associated with severe bleeding, as were moderate or severe bleeding manifestations beyond cutaneous bleeding in the 28 days leading up to an ICH. Patient comorbidity was also reviewed and a significant number of patients had co-existing issues, including positive autoantibody tests. Presentations of ICH varied. In 10 patients, headache was a presenting feature. 3 patients presented with seizures, and 5 with vomiting. The majority of patients also had at least one active bleeding site in the 28 days before the episode of ICH. The mouth and nose were the most common bleeding sites. The mortality rate was 4/19, 21%. Neurological disability on discharge was present in 4/15, 27% of the patients who survived. Most identified risk factors for ICH were consistent with previous research, however none had an arteriovenous malformation and only three of 19 cases were documented to have experienced head trauma prior to ICH. Based on UK ITP registry data the incidence of ICH is estimated to bet 0.14-0.57% of paediatric ITP patients. DisclosuresGrainger:Amgen: Consultancy, Honoraria, Speakers Bureau; GSK: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Bolton-Maggs:Novartis: Honoraria; Grifols: Honoraria.

Treatment of Acute VTE with Rivaroxaban - Results of the Prospective Dresden Noac Registry (NCT01588119)

Background: The effectiveness and safety of acute venous thromboembolism (VTE) treatment with rivaroxaban, demonstrated in phase-III trials, needs to be evaluated in unselected patients treated under daily care conditions.Patients and methods: The Dresden NOAC registry is a prospective regional registry in which patients with oral anticoagulation undergo prospective follow- up (FU). So far, more than 3200 patients have been enrolled, including 772 VTE patients with rivaroxaban treatment. For this analysis, only patients with acute VTE who started rivaroxaban within 14 days after diagnosis of VTE and who were enrolled within these 14 days were evaluated with regard to patient characteristics, treatment persistence and clinical outcomes. All reported outcome events were centrally adjudicated based on source documentation and standard definitions.Results: Between December 1st 2011 and March 31st 2016, 407 patients received rivaroxaban for acute VTE treatment (51.6% female, 80.8% DVT; 19.2% PE±DVT, mean age 61.4 years). Mean time between VTE diagnosis and initiation of rivaroxaban was 1.7±3.3 days (median 0d; 25th/75th percentile 0; 1d). At baseline, rivaroxaban doses consisted of 15 mg BID in 93.1%, 20 mg OD in 3.4%, 15 mg OD in 3.2% and 10 mg OD in 0.2% of patients. Reasons for not using 2x15 mg rivaroxaban BID were pre-treatment with therapeutic parenteral anticoagulants for ≥7 d in 14 cases, comorbidities (e.g. bleeding history, renal impairment) in 4 cases and unknown in 10 cases.During FU (mean 762.4±462.7d), the mean rivaroxaban exposure was 357.7±385.9 days. During treatment with rivaroxaban, 4/407 patients (1.0%) experienced a recurrent VTE, which translated into a recurrence rate of 1.0/ 100 pt. years.During treatment, 172/407 (42.3%) patients reported bleeding complications, which in 13 cases (3.2%; 3.3/100 pt. years) were major bleeding according to ISTH definition, including one fatal intracranial bleeding.Patients with deep vein thrombosis (DVT) and pulmonary embolism (PE) had similar rates of recurrent VTE during rivaroxaban treatment (1.01 and 1.01/100 pt. years) but PE patients had numerically higher rates of major bleeding (3.99/100 pt. years compared to 3.09/100 pt.years in the DVT group).Effectiveness and safety profiles were consistent across relevant subgroups (table 1).18 patients died during FU (2.12/100 pt.years), of which 8 deaths occurred during or within 3 days after last intake of rivaroxaban. Most common causes of death were fatal cardiovascular event (n=7) and terminal malignant disease (n=4), followed by sepsis/infection (n=3), age related death (n=1), fatal bleeding (n=1) and other reasons (n=2).At 6 months (FU completed in 365 pts.), 61.4% of patients were still taking rivaroxaban. The remaining patients had a scheduled end of treatment (28.8%) or were switched to other anticoagulants (7.1%). Therefore, the rate of unplanned complete discontinuation at 6 months was 2.7%.At 12 months (FU completed in 289 pts.), 41.5% of patients were still taking rivaroxaban. The remaining patients had a scheduled end of treatment (45.0%) or were switched to other anticoagulants (8.3%). Therefore, the rate of unplanned complete discontinuation at 12 months was 5.2%.After rivaroxaban interruption for more than 3 days or permanent discontinuation, 21 patients experienced a recurrent VTE (9 PE±DVT, 12 DVT) with a mean time between last intake of rivaroxaban and VTE recurrence of 351.2±282.6 days (range 7-926d). PE was a common manifestation of VTE recurrence and, despite numerically lower bleeding rates after discontinuation, 2 cases of intracranial haemorrhage occurred (table 2).Conclusions: In unselected patients in daily care, rivaroxaban treatment for acute VTE has high effectiveness and acceptable rates major bleeding. Initial dosing was according to label in over 90% of patients and, at 6 and 12 months, persistence to rivaroxaban therapy was excellent with low rates of unplanned complete discontinuation. Fatal VTE and fatal bleeding are rare events during rivaroxaban therapy and all-cause mortality is mostly related to underlying diseases, age or acute co-morbidities. Treatment discontinuation resulted in a relevant increase in VTE recurrence, of which more than 40% manifested as PE. In contrast, major bleeding rates declined after discontinuation but with 1%/year remained at a clinically relevant level, probably due to co-morbidities. [Display omitted] [Display omitted] DisclosuresMarten:Bayer: Honoraria; Daichii Sankyo: Honoraria. Werth:Pfizer: Honoraria; Bayer: Honoraria; Boehringer Ingelheim: Honoraria; Daiichi Sankyo: Honoraria; OmniaMed: Honoraria; LEO-Pharma: Honoraria. Beyer-Westendorf:Pfizer: Consultancy, Honoraria, Research Funding; Boehringer Ingelheim: Consultancy, Honoraria, Research Funding; Daichii Sankyo: Consultancy, Honoraria, Research Funding; Bayer: Consultancy, Honoraria, Research Funding; LEO: Consultancy, Honoraria, Research Funding.

Clinical analysis and treatment of symptomatic intracranial hemorrhage after deep brain stimulation surgery

Background: Symptomatic intracranial hemorrhage (ICH) may lead to permanent neurological disability of patients and has impeded the extensive clinical application of deep brain stimulation (DBS). The present study was conducted to discuss the incidence, prevention, and treatment of symptomatic ICH after DBS surgery.Methods: From January 2009 to December 2014, 396 patients underwent DBS with a total of 691 implanted leads. In all, 10 patients had symptomatic ICH. We analyzed these cases’ clinical characteristics, including comorbid diagnoses and coagulation profile. We described the onset of ICH, imaging features, clinical manifestations, treatment, neurological impairment, and outcome of DBS.Results: Of the 10 patients with symptomatic ICH, 2 had hypertension. Three cases of ICH occurred within 12 h of the procedure; four cases within 24 h. Five experienced grand mal seizures concurrently with hemorrhage. Unilateral frontal lobe hemorrhage occurred in all cases. In seven cases, hematomas occurred around the electrodes. Some hematomas were not well-circumscribed and had perihematomal edema. Conservative therapy was administered to 8 patients, and 2 patients underwent craniotomy and hematoma evacuation. All electrodes were successfully preserved. Neurological dysfunction in all patients gradually improved. Nine patients ultimately experienced effective symptom relief of Parkinson’s disease with DBS.Conclusions: Symptomatic ICH should be identified as soon as possible after implantation surgery and treated effectively to limit neurological deficit and preserve DBS leads.

Peri-operative Considerations in Intracranial Hemorrhage in Dengue Virus Infected Patients: A Prospective Mini Case Series

Dengue is one of the most common mosquito-transmitted arboviral diseases of tropical and few subtropical areas of the world. It is estimated that 100 million cases occur every year and 2.5 billion people are at risk. Hemorrhagic complications causing encephalopathy is quite a rare presentation but usually fatal. We discuss the peri-operative management of 8 uncommon cases of intracranial hemorrhage (ICH) in dengue. High index of suspicion is required for prompt diagnosis and treatment.Eighteen dengue serology positive patients who presented with neurological manifestations were managed in neurosurgery unit of our tertiary health care center in six months duration. Most of the patients had deranged prothrombin time and thrombocytopenia. They were given platelet concentrates for correction of thrombocytopenia. All vital parameters and neurologic status were closely monitored in high dependency unit. Eight of these patients had deterioration in neurologic status; five of them underwent surgery.All patients who underwent surgery had excellent outcome. Rest of the patients including one patient of cervical extradural hemorrhage were managed conservatively with intravenous fluid and cerebral decongestants. Two patients with deep-seated bleed deteriorated very rapidly and died. Rest who were managed either surgically or conservatively including cervical EDH improved well without any residual deficit.High index of suspicion of ICH is required in dengue especially during convalescence. Special attention should be given to those patients who are disoriented and have altered sensorium and should not be misinterpreted as fever delirium or toxic encephalopathy. It needs immediate attention and investigation. Timely diagnosis and intervention can save lives.Nepal Journal of Neuroscience 13:43-46, 2016

Anticoagulation Reversal Strategies for Left Ventricular Assist Device Patients Presenting with Acute Intracranial Hemorrhage.

The safety of alternative vitamin K antagonist (VKA) reversal strategies in patients with left ventricular assist devices (LVAD's) who present with intracranial hemorrhage (ICH) are not well known. A review of LVAD patients with ICH from May 2008 to 2015 was conducted, comparing the safety and efficacy of 4-factor prothrombin complex concentrate-assisted VKA reversal (4F-PCC group, n = 10) to reversal with traditional agents alone (no-PCC group, n = 10). An analysis of a no-reversal strategy in selected patients (n = 11) with ICH was additionally performed. Thirty-one cases of ICH on LVAD support were reviewed. The rate of post reversal thromboembolic events was not significantly different between 4F-PCC and no-PCC patients (0% vs. 10%, p = 1.0); however, the time to VKA reversal was shorter (474 vs. 945 minutes, p = 0.02) and fresh frozen plasma (FFP) requirements lower (1.9 vs. 3.6 units, p = 0.05) in 4F-PCC patients, with no difference in mortality between groups (p = 1.0). Eleven patients (mean ICH volume: 0.4 cm) were successfully managed without active VKA reversal, with no increased hemorrhage noted on neuroimaging. These results suggest that 4F-PCC-assisted reversal in LVAD patients is safe and may improve the efficacy of VKA reversal. Our findings also indicate that carefully selected patients with small ICH volumes may be safely managed by discontinuing anticoagulation and allowing the international normalized ratio (INR) to normalize physiologically.

Analysis of Associated Spinal Fractures in Cases of Traumatic Intracranial Hemorrhage or Skull Fracture.

Introduction: Patients with traumatic intracranial hemorrhage (ICH) or skull fracture are typically admitted to the Department of Neurosurgery for fear of delayed neurological deterioration. Neurosurgeons, therefore, must be careful not to overlook a spinal fracture in these patients. In this study, we investigated the occurrence and risk factor of spinal fracture in patients with traumatic ICH or skull fracture.Patients and methods: We retrospectively analyzed the hospital records of 134 patients admitted to the Department of Neurosurgery at Kagawa Rosai Hospital for traumatic ICH or skull fracture. The etiology of trauma, level of consciousness, presence or absence of ICH, skull fracture, craniotomy and spinal surgery were investigated. Furthermore, in cases of spinal fracture, its type, neurological symptoms, treatment were investigated.Results: In an analysis of 134 patients, Ground level fall and traffic accident were the most frequent etiologies of trauma (47.0% and 23.9% respectively). Glasgow coma scale on admission was 15-13 for 106 patients (79.1%). spinal fracture was identified in 10 of 134 patients (7.5%). Two patients had cervical, 8 had thoracolumbar fractures. In the analysis of risk factors, an accidental fall and skull fracture was observed significantly more in the spinal fracture cases.Conclusion: The majority of traumatic ICH or skull fracture cases treated in the Department of Neurosurgery were caused by minor head impacts. When treating these patients, it is necessary to investigate not only the cervical, but also the thoracolumbar spine, especially when the cause of injury is an accidental fall and a skull fracture is identified.

Abstract 50: Evaluation of Candidate Polymorphisms for Association With Brain Arteriovenous Malformations and Intracranial Hemorrhage in Hereditary Hemorrhagic Telangiectasia

Introduction: Brain arteriovenous malformations (AVM) are an important cause of intracranial hemorrhage (ICH) in young adults. Most are sporadic, but also occur in inherited diseases such as hereditary hemorrhagic telangiectasia (HHT). ICH presentation of brain AVM in both sporadic and HHT cases is a marker of high ICH risk. In order to investigate whether the same genetic modifiers influence sporadic and HHT brain AVM, we evaluated candidate genetic polymorphisms reported as associated with sporadic brain AVM, with ICH presentation or ICH during clinical course, in HHT patients. Methods: We genotyped 8 polymorphisms ( APOE E2/3/4 [rs7412, rs429358], ANGPTL rs116724, EPHB4 rs314308, IL6 -174G>C [rs1800795], IL1B -31T>C [rs1143627], ITGB8 rs10486391, TNF -238G>A[rs361525]) in 753 Caucasian HHT patients enrolled by the Brian Vascular Malformation Consortium (BVMC). Genotypes were collapsed into risk allele carriers vs. other for analysis, as published for sporadic AVM. APOE E2/3/4 haplotypes were assigned based on genotypes of the 2 APOE polymorphisms. Association of genotype with phenotype was evaluated by multivariable logistic regression adjusted for age, gender and accounting for family clustering. We used a nominal significance threshold of p=0.05, requiring the same direction of effect as in sporadic brain AVM (odds ratio for risk genotype [OR]>1). Results: Among 753 HHT patients, 155 (21%) had brain AVM, of whom 26 (17%) presented with ICH. Two additional brain AVM patients had ICH during follow-up. None of the 7 variants (6 single nucleotide polymorphisms and APOE haplotype) were significantly associated with brain AVM (OR=0.6-1.3), with ICH presentation of brain AVM (OR=0.4-1.9), or with any brain AVM ICH in HHT patients (OR=0.5-2.1). Conclusions: Common genetic variants previously reported to be associated with sporadic brain AVM were not associated with brain AVM nor with ICH in the BVMC HHT cohort, suggesting different genetic modifiers may influence sporadic and HHT brain AVM. However, the number of ICH cases in the cohort is small, so the confidence intervals are wide and we cannot rule out clinically important associations. The BVMC is enrolling additional HHT patients to expand the cohort and increase power for association analyses.

Clinical Characteristics and Prognostic Factors in Hemophiliacs with Intracranial Hemorrhage: A Single-Center, Retrospective Experience.

Intracranial hemorrhage (ICH) is the most serious bleeding event that occurs in patients with hemophilia; its estimated mortality rate is approximately 20%, accounting for the largest number of deaths from bleeding. We conducted this single-center, retrospective study to examine the characteristics of and prognostic factors in patients with hemophilia. A comprehensive review of 12 cases of intracranial hemorrhage (ICH) among 10 patients. All 12 cases of ICH in the 10 patients were treated with clotting factor concentrates. Three patients had intracerebral hemorrhage that required neurosurgical intervention. After presenting with ICH, two pediatric patients developed antibodies to clotting factors. Two adult patients with intracerebral hemorrhage died, and the mortality rate was thus 20.0% (2/10) in our clinical series. Prompt and intensive treatment with clotting factor concentrates may significantly lower the mortality rate among patients with hemophilia presenting with ICH. Our results showed a better prognosis in pediatric patients with intracerebral hemorrhage. Clinicians should pay special attention to the possible development of inhibitors after intensive treatment in pediatric patients. Further studies are needed to examine methods for administering clotting factor concentrates and to determine whether neurosurgical intervention is essential in each case.

Multiplanar Intracranial Hemorrhage in Trivial Head Injury: Impact of Coagulation Disorders on Perioperative Outcome

Multiplanar intracranial hemorrhage with coagulopathy significantly increases perioperative morbidity and should always be considered while evaluating brain injury in setting of trivial trauma. Aneurysm and cerebral venous thrombosis (CVT) must always be ruled out before definite surgical intervention. Here, we report a case of intracranial hemorrhage in multiple planes occurring in the setting of coagulopathy, its early diagnosis and its treatment which resulted in a good outcome.

Safety and efficacy of a new prophylactic tirofiban protocol without oral intraoperative antiplatelet therapy for endovascular treatment of ruptured intracranial aneurysms

BackgroundCoil embolization of intracranial aneurysms is being increasingly used; however, thromboembolic events have become a major periprocedural complication.ObjectiveTo determine the safety and efficacy of prophylactic tirofiban in patients with ruptured...

Abstract 17236: Intracranial Hemorrhage in Patients With Atrial Fibrillation in the ARISTOTLE Trial: Clinical Characteristics and Associated Outcomes

Background: Intracranial hemorrhage (ICH) is associated with poor outcomes in patients with atrial fibrillation (AF) treated with oral anticoagulation. Little is known about clinical characteristics and factors associated with ICH and subsequent outcomes in patients receiving apixaban. Methods: The ARISTOTLE trial randomized 18,201 patients with AF and risk of stroke to warfarin or apixaban. All ICH events were identified and adjudicated by a central committee blinded to the study treatment assignment. ICH events were analyzed in patients receiving at least one dose of study drug (N=18,140). Multivariable cox regression models were developed to identify factors associated with ICH. Results: There were 174 (1.0%) ICH events. Of those, 111 (67.7%) were intracerebral hemorrhage, 50 (30.7%) subdural hematomas, and 25 (15.3%) subarachnoid hemorrhage. Patients with ICH were older and had higher CHADS 2 score than patients without ICH. Computed tomography was used in 95.2% of patients for the diagnosis of ICH. The majority of ICH cases were spontaneous (71.7%) and 91.4% of patients with ICH presented with some type of neurological deficit. Most (72%) of the patients received conservative treatment and 21% underwent surgical intervention; 71 (40.8%) patients died in hospital. The mean modified Rankin score at discharge of survivors was ≥4 in 23 (22%) patients. Apixaban was superior to warfarin in causing less ICH, including as categorized by each ICH location. Factors associated with ICH were older age, warfarin randomized treatment assignment, prior stroke, geographic region of the world, and use of aspirin at randomization (Table). Conclusion: ICH is uncommon in patients with AF who are treated with oral anticoagulant and is associated with very high mortality. Apixaban is superior to warfarin in causing less ICH, irrespective of the location and other risk factors for ICH.

Reversal Strategies for Intracranial Hemorrhages in Patients Taking Oral Factor Xa Inhibitors.

Factor Xa (fXa) inhibitors are becoming more common in clinical practice due to a variety of reasons. Unfortunately, limited data are currently available on the safe and efficacious reversal of these agents. This series presents 3 patient cases of intracranial hemorrhage and illustrates the observed effect of different methodologies undertaken in an attempt to reverse the fXa inhibitors implicated. Additionally, a brief review of the current available literature in reversal strategies is provided. The appropriate reversal for fXa inhibitors at this time is unknown. The cases described indicate that the administration of fresh frozen plasma and 4-factor prothrombin complex concentrate may provide minimal benefit in reversing the coagulation abnormalities caused by fXa inhibitors. However, in a life-threatening situation, the addition of these agents should be considered to prevent further progression of the bleed.

Operation of superficial temporal artery-middle cerebral artery(STA-MCA)bypass combined with temporal muscle sticking therapy adult moyamoya disease

Objective To investigate the clinical effect of operation of superficial temporal artery-middle cerebral artery(STA-MCA)bypass combined with temporal muscle sticking in the treatment of adult moyamoya disease. Methods A retrospective analysis was the data of operation, including preoperative evaluation, operation method,postoperative follow-up. Results Postoperative complications occurred in 5 cases, including 3 cases of intracranial hemorrhage,2 cases of cerebral infarction. During the follow-up of 6-35 months, no recurrent hemorrhage cases,1 cases of cerebral infarction, TIA remission rate was 93.5%. Postoperative cerebral blood flow of 38 cases significantly improved compared with preoperative by SPET, accounted for 86.3%. Cerebral blood flow of 41 cases was well compensated by vascular bridge, accounted for 91%. Conclusion Operation of STA-MCA bypass combined with temporal muscle sticking can significantly reduce the incidence of stroke, fewer complications, which is an ideal method in the treatment of adult moyamoya disease. Key words: Moyamoya Disease; Surgical Procedures, Operative; Treatment Outcome

Head trauma and intracranial hemorrhage in children with idiopathic thrombocytopenic purpura.

The current guidelines for management of idiopathic thrombocytopenic purpura (ITP) does not address head trauma and the current emergency pediatric head trauma management guidelines do not address children with ITP. The characteristics of patients who develop intracranial hemorrhage (ICH) as a result of head trauma or the management of head trauma in patients with ITP are not clear. Review the literature to identify and describe the characteristics and outcomes of intracranial haemorrhage as a result of head trauma in children with ITP. We reviewed literature using Medline, Embase, and PUBMED databases from inception until December 2013. Articles were included if they described patients with head trauma and intracranial bleeding in children with ITP. Nine relevant articles met inclusion criteria and were included. Three case reports, 3 institution survey studies, and 5 retrospective chart reviews. There were 114 cases of ICH reported in children with ITP, and 26% (n = 30) were identified to have ICH due to head trauma. Of the 30 children with ITP who had an ICH in the context of head injury, 23% (7 patients) died as a result of ICH and 13% (4 patients) suffered significant neurological sequelae. Twenty-seven percent were 3 years or younger when the age was reported Intracranial haemorrhage after head trauma in children with ITP leads to significant morbidity and mortality. As such, more thorough investigations, including radiological imaging and aggressive treatment, are recommended for children with ITP presenting with head injuries.