Intracranial Hemorrhage In Patients Research Articles

Optimal Timing for Resumption of Anticoagulation After Intracranial Hemorrhage in Patients With Mechanical Heart Valves.

Anticoagulation in patients with intracranial hemorrhage (ICH) and mechanical heart valves is often held for risk of ICH expansion; however, there exists a competing risk of acute ischemic stroke (AIS). Optimal timing to resume anticoagulation remains uncertain. We retrospectively studied patients with ICH and mechanical heart valves from 2000 to 2018. The primary outcome was a composite end point of symptomatic hematoma expansion or new ICH, AIS, and intracardiac thrombus up to 30 days post-ICH. The exposure was timing of reinitiation of anticoagulation classified as early (resumed up to 7 days after ICH), late (≥7 and up to 30 days after ICH), and never if not resumed or resumed after 30 days post-ICH. We included 184 patients with ICH and mechanical heart valves (65 anticoagulated early, 100 late, 19 not resumed by day 30 post-ICH). Twelve patients had AIS, 16 new ICH, and 6 intracardiac thromboses. The mean time from ICH to anticoagulation was 12.7 days. Composite outcomes occurred in 12 patients resumed early (18.5%), 14 resumed late (14.0%), and 4 never resumed (21.1%). There was no increased hazard of the composite outcome (hazard ratio [HR], 1.1 [95% CI, 0.2-6.0]), AIS, or worsening or new ICH among patients resumed early versus late. There was no difference in the composite among patients never resumed versus resumed. Patients who never resumed anticoagulation had significantly more severe ICH (median Glasgow Coma Scale: 10.6, 13.9, and 13.9 among those who resumed never, early, and late, respectively; P=0.0001), higher in-hospital mortality (56.5%, 0%, and 0%, respectively; P<0.0001), and an elevated 30-day AIS risk (HR, 15.9 [95% CI, 1.9-129.7], P=0.0098). In this study of patients with ICH and mechanical heart valves, there was no difference in 30-day thrombotic and hemorrhagic brain-related outcomes when anticoagulation was resumed within 7 versus 7 to 30 days after ICH. Withholding anticoagulation >30 days was associated with severe baseline ICH, higher in-hospital case fatality, and elevated AIS risk.

Incidence of intracranial bleeding in mild traumatic brain injury patients taking oral anticoagulants: a systematic review and meta-analysis.

Traumatic brain injury (TBI) is one of the leading causes of disability and death worldwide. Most TBI cases occur in older people, because they are at a higher risk of accidental falling. As the population ages, the use of anticoagulants is increasing. Some serious complications of TBI, such as intracranial hemorrhage (ICH), may occur even in mild cases. According to the current guidelines regarding managing mild TBI patients, a CT head scan is recommended for all patients receiving anticoagulation. We aim to assess the incidence of ICH in patients with mild TBI taking oral anticoagulants. Our systematic review and meta-analysis were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The protocol was registered in PROSPERO (CRD42024503086). Twenty-eight studies evaluating patients with a mild TBI from ten countries with a total sample size of 11,172, 5671 on DOACs, and 5501 on VKAs were included in our meta-analysis. The random-effects overall incidence of ICH among oral anticoagulated patients with mild TBI was calculated to be 9.4% [95% CI 7.2-12.1%, I2 = 89%]. The rates of immediate ICH for patients taking DOACs and VKAs were 6.4% and 10.5%, respectively. The overall rate of immediate ICH in anticoagulated mild TBI patients was 8.5% [95% CI 6.6-10.9%], with a high heterogeneity between studies (I2 = 88%). Furthermore, the rates of delayed ICH in patients with mild TBI taking DOACs and VKAs were 1.6% and 1.9%, respectively. The overall incidence of delayed ICH among oral anticoagulated mild TBI patients was 1.7% [95% CI 1-2.8%, I2 = 79%]. The overall rate of ICH among mild TBI patients taking DOAC was calculated to be 7.3% [95% CI 5.2-10.3%], with significant heterogeneity between studies (I2 = 79%). However, the overall ICH rate is higher in patients who take only VKAs 11.3% [95% CI 8.6-14.7%, I2 = 83%]. Patients on DOACs were at lower risk of ICH after mild TBI compared to patients on VKAs (OR = 0.64, 95% CI 0.48-0.86, p < 0.01, I2 = 28%). Our meta-analysis confirms the need for performing brain CT scan in patients with mild TBI patients who receive oral anticoagulants before injury. Due to limited data, further multi-center, prospective studies are warranted to confirm the true incidence of traumatic ICH in patients on anticoagulants.

Association of IVCF use with mortality and intracranial hemorrhage in patients with selected cancers and brain metastasis

AbstractWe investigated the association of inferior vena cava filter (IVCF) usage with early mortality and intracranial hemorrhage (ICH) in patients with cancer and venous thromboembolism (VTE) with and without brain metastasis. We used the California Cancer Registry data linked to hospitalization and emergency department databases to identify patients (all ages) with melanoma, kidney, breast, or lung cancers who had acute VTE between 2005 and 2017 at hospital admission. The primary outcomes were 30-day mortality and 180-day ICH post-index VTE hospitalization. Of the 16 847 patients with cancer and VTE, 19.1% had brain metastasis. Patients with brain metastasis were more likely to receive an IVCF (odds ratio, 2.24; 95% confidence interval [CI], 2.01-2.50). Among patients with active bleeding, IVCF placement was associated with ∼50% reduction in 30-day mortality (hazard ratio [HR], 0.53; 95% CI, 0.42-0.68), regardless of the presence or absence of brain metastasis. In patients without active bleeding, 30-day mortality decreased by nearly 30% among those with brain metastasis who received IVCF (HR, 0.72; 95% CI, 0.60-0.85), with no difference among those without brain metastasis who had an IVCF inserted. Patients with brain metastasis had an elevated hazard of 180-day mortality (HR, 5.14; 95% CI, 2.99-8.83), but no association was found between IVCF insertion and 180-day ICH. Our study suggests a potential mortality benefit of IVCF use among patients with selected cancers and VTE, particularly among patients with active bleeding and those with brain metastasis with no bleeding. IVFC use was not associated with 180-day ICH. Randomized clinical trials are warranted to confirm our results.

Use of the Canadian CT head rule for patients on anticoagulant/anti-platelet therapy presenting with mild traumatic brain injury: prospective observational study.

Background and importanceMild traumatic brain injury (mTBI) is a frequent presentation in Emergency Department (ED). There are standardised guidelines, the Canadian CT Head Rule (CCHR), for CT scan in mTBI that rule out patients on either anticoagulant or anti-platelet therapy. All patients with these therapies undergo a CT scan irrespectively of other consideration.ObjectiveTo determine whether standard guidelines could be applied to patients on anticoagulants or anti-platelet drugs.Design, settings, and participants1,015 patients with mTBI and Glasgow Coma Score (GCS) of 15 were prospectively recruited, 509 either on anticoagulant or anti-platelet therapy and 506 on neither. All patients on neither therapy underwent CT scan following guidelines. All patients with mTBI on either therapy underwent CT scan irrespective of the guidelines.Outcome measure and analysisPrimary endpoint was the incidence of post-traumatic intracranial bleeding in patients either on anticoagulants or anti-platelet drugs and in patients who were not on these therapies. Bayesian statistical analysis with calculation of Confidence Intervals (CI) was then performed.Main resultsSixty scans were positive for bleeding: 59 patients fulfilled the criteria and 1 did not. Amongst patients with haemorrhage, 24 were on either therapy and only one did not meet the guidelines but in this patient the CT scan was performed before 2 h from the mTBI. Patients on either therapy did not have higher bleeding rates than patients on neither. There were higher bleeding rates in patients on anti-platelet therapy who met the guidelines vs. patients who did not. These rates overlapped with patients on neither therapy, meeting CCHR.ConclusionThe CCHR might be used for mTBI patients on either therapy. Anticoagulants and anti-platelet drugs should not be considered a risk factor for patients with mTBI and a GCS of 15. Multicentric studies are needed to confirm this result.

A new score for predicting intracranial hemorrhage in patients using antiplatelet drugs

A new score for predicting intracranial hemorrhage in patients using antiplatelet drugs

Statin Therapy for Secondary Prevention in Ischemic Stroke Patients With Cerebral Microbleeds.

The association between statin use and the risk of intracranial hemorrhage (ICrH) following ischemic stroke (IS) or transient ischemic attack (TIA) in patients with cerebral microbleeds (CMBs) remains uncertain. This study investigated the risk of recurrent IS and ICrH in patients receiving statins based on the presence of CMBs. We conducted a pooled analysis of individual patient data from the Microbleeds International Collaborative Network, comprising 32 hospital-based prospective studies fulfilling the following criteria: adult patients with IS or TIA, availability of appropriate baseline MRI for CMB quantification and distribution, registration of statin use after the index stroke, and collection of stroke event data during a follow-up period of ≥3 months. The primary endpoint was the occurrence of recurrent symptomatic stroke (IS or ICrH), while secondary endpoints included IS alone or ICrH alone. We calculated incidence rates and performed Cox regression analyses adjusting for age, sex, hypertension, atrial fibrillation, previous stroke, and use of antiplatelet or anticoagulant drugs to explore the association between statin use and stroke events during follow-up in patients with CMBs. In total, 16,373 patients were included (mean age 70.5 ± 12.8 years; 42.5% female). Among them, 10,812 received statins at discharge, and 4,668 had 1 or more CMBs. The median follow-up duration was 1.34 years (interquartile range: 0.32-2.44). In patients with CMBs, statin users were compared with nonusers. Compared with nonusers, statin therapy was associated with a reduced risk of any stroke (incidence rate [IR] 53 vs 79 per 1,000 patient-years, adjusted hazard ratio [aHR] 0.68 [95% CI 0.56-0.84]), a reduced risk of IS (IR 39 vs 65 per 1,000 patient-years, aHR 0.65 [95% CI 0.51-0.82]), and no association with the risk of ICrH (IR 11 vs 16 per 1,000 patient-years, aHR 0.73 [95% CI 0.46-1.15]). The results in aHR remained consistent when considering anatomical distribution and high burden (≥5) of CMBs. These observational data suggest that secondary stroke prevention with statins in patients with IS or TIA and CMBs is associated with a lower risk of any stroke or IS without an increased risk of ICrH. This study provides Class III evidence that for patients with IS or TIA and CMBs, statins lower the risk of any stroke or IS without increasing the risk of ICrH.

The value of SINO robot combined with Angio Render technology-assisted stereo-electroencephalography electrode implantation for the treatment of drug-resistant epilepsy.

Stereo-electroencephalography (SEEG) electrodes are implanted using a variety of stereotactic technologies to treat refractory epilepsy. The value of SINO-robot for SEEG electrode implantation is rarely reported. The aim of the current study was to assess the value of SINO-robot in conjunction with Angio Render technology, in SEEG electrode implantation. We also assess its efficacy by examining factors such as localization error, operation time, and complications. Between June 2018 and October 2020, we retrospectively reviewed 58 patients who underwent SEEG implantation to resect or ablate their epileptogenic zone (EZ) while minimizing the risk of hemorrhage. SINO-robot combined with Angio Render technology-assisted SEEG electrode implantation was used to visualize each patient' blood vessel in a 3D plane. The 3D view functionality was used to increase the safety and accuracy of the implantation, and reducing the risk of hemorrhage by avoiding said blood vessel. In this study, 634 SEEG electrodes were implanted in 58 patients. The mean 10.92(range 5- 18) leads per patient. The mean entry point localization error (EPLE) was 0.94 ± 0.23 mm (range: 0.39- 1.63 mm), and the mean target point localization error (TPLE) was 1.49 ± 0.37 mm (range: 0.80-2.78 mm). The mean operating time per lead (MOTPL) was 6. 18 ± 1.80 min (range: 3.02- 14.61 min). And the mean depth of electrodes was 56.96± 3.62 mm (range:27.23-124.85 mm). At a follow-up of at least one year, totally 81.57% (47/58) of patients achieved an Engel class I of seizure freedom. There were 2 patients with asymptomatic brain hematomas following SEEG placement, and no late complications or mortality in this cohort. SINO-robot in conjunction with Angio Render technology assist, in SEEG electrode implantation is safe and accurate in mitigating the risk of intracranial hemorrhage in patients suffering from drug-resistant epilepsy.

Andexanet alfa therapy showed No increased rate of thromboembolic events in spontaneous intracranial hemorrhage patients: A multicenter electronic health record study

•Intracranial hemorrhage accounts for two out of every three major intracranial hemorrhages.•Systemic anticoagulation is routinely prescribed for prevention of cerebrovascular accidents.•The FDA approved Andexanet alfa to treat life-threatening bleeding.•Andexanet alfa relationship to outcomes requires further investigation.

Higher risk of traumatic intracranial hemorrhage with antiplatelet therapy compared to oral anticoagulation-a single-center experience.

Traumatic brain injury is the main reason for the emergency department visit of up to 3% of the patients and a major worldwide cause for morbidity and mortality. Current emergency management guidelines recommend close attention to patients taking oral anticoagulation but not patients on antiplatelet therapy. Recent studies have begun to challenge this. The aim of this study was to determine the impact of antiplatelet therapy and oral anticoagulation on traumatic intracranial hemorrhage. Medical records of adult patients triaged with "head injury" as the main reason for emergency care were retrospectively reviewed from January 1, 2017, to December 31, 2017, and January 1, 2020, to December 31, 2021. Patients ≥ 18years with head trauma were included. Odds ratio was calculated, and multiple logistic regression was performed. A total of 4850 patients with a median age of 70years were included. Traumatic intracranial hemorrhage was found in 6.2% of the patients. The risk ratio for traumatic intracranial hemorrhage in patients on antiplatelet therapy was 2.25 (p < 0.001, 95% confidence interval 1.73-2.94) and 1.38 (p = 0.002, 95% confidence interval 1.05-1.84) in patients on oral anticoagulation compared to patients without mediations that affect coagulation. In binary multiple regression, antiplatelet therapy was associated with intracranial hemorrhage, but oral anticoagulation was not. This study shows that antiplatelet therapy is associated with a higher risk of traumatic intracranial hemorrhage compared to oral anticoagulation. Antiplatelet therapy should be given equal or greater consideration in the guidelines compared to anticoagulation therapy. Further studies on antiplatelet subtypes within the context of head trauma are recommended to improve the guidelines' diagnostic accuracy.

Risk of intracranial hemorrhage in patients using anticoagulant therapy for atrial fibrillation after cerebral microbleeds combined with acute ischemic stroke: a meta-analysis.

To evaluate intracerebral hemorrhage (ICH) risk in patients with ischemic stroke (IS) and cerebral microbleeds (CMBs) undergoing anticoagulation therapy for non-valvular atrial fibrillation (AF). We conducted a comprehensive search across multiple databases, including Embase, PubMed, Cochrane, UpToDate, Scopus, WOS, and SinoMed. The search covered observational literature published from each database inception until February 1, 2023. We analyzed the prevalence of CMBs during the follow-up period, compared future ICH risk between patients with and without baseline CMBs (CMBs presence/absence, ≧5 CMBs), and examined factors influencing ICH occurrence in patients with CMBs. Also studied recurrent stroke during anticoagulation therapy, the risk of future ICH when white matter hyperintensity (WMH) and CMBs coexist, and the effects of anticoagulants vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) on future ICH. We included 7 articles involving 5,134 participants. The incidence of CMBs was 24%; baseline CMBs were associated with an increased ICH risk compared to patients without CMBs. ICH-risk was more significant in patients with baseline ≥5 CMBs. After anticoagulant therapy, ICH risk was higher than that of recurrent IS. The risk of future ICH was significantly increased with anticoagulant VKAs compared with NOAC. Anticoagulant therapy for ischemic stroke patients with non-valvular AF and CMBs increases future ICH risk. Discontinuing anticoagulation due to ICH risk should be avoided. NOACs are safe and effective for patients with CMBs and IS.

The Short- and Long-Term Risk of Mortality in Intracranial Hemorrhage Patients with Tranexamic Acid Treatment in a Population-Based Cohort Study.

Background: The mortality rate associated with nontraumatic intracranial hemorrhage (NTICrH) remains consistently high under the current care modality. The effectiveness of tranexamic acid (TXA) as a treatment option is still a subject of debate. This study aims to assess the association between TXA administration and both short-term and long-term mortality rates in patients with NTICrH. Methods: We conducted a retrospective cohort study using data from the Taiwan National Health Insurance Research Database (NHIRD) spanning from January 2000 to December 2017. The study population consists of NTICrH patients admitted to the ICU, divided into two groups: patients who were treated with TXA and those who were not. Propensity score matching (PSM) was conducted to balance the baseline characteristics of the two groups. Cox proportional hazard analysis was conducted to estimate the hazard ratio (HR) for the all-cause mortality. Sensitivity analyses were performed using the inverse probability of treatment-weighted hazard ratio (IPTW-HR). To assess the timing of TXA use, we compared the risk of all-cause mortality within 180 days between patients receiving early TXA treatment and those receiving late TXA treatment. Results: There was no significant difference in 180-day all-cause mortality between the groups; the hazard ratio was 1.07 (95% CI: 0.96-1.20) in patients treated with TXA compared to those without TXA treatment. Within 7 days of admission, patients treated with TXA had a lower hazard ratio of 0.81 (95% CI: 0.74-0.90) for all-cause mortality. Conclusions: Lower mortality within the first 7 days was observed in patients with NTICrH who received TXA.

Abstract 2: Intracranial Hemorrhage Managed By A Mobile Stroke Unit

Background: Mobile stroke units (MSUs) improve outcomes in thrombolytic-eligible ischemic stroke patients. Outcomes of MSU management in patients with intracranial hemorrhage (ICH) have not been reported. Methods: We conducted a retrospective review of ICH patients enrolled in the Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST-MSU), a prospective multicenter controlled trial comparing MSU with standard EMS management (SM). The primary outcome was utility weighted modified Rankin Scale (uw-mRS) at 90 days; secondary outcomes were hematoma expansion, length of inpatient stay, favorable discharge disposition or 90-day mRS, and mortality. Groups were compared using Chi-square or Fisher’s exact tests for categorical variables, and two sample t-test or Wilcoxon rank sum test for continuous variables. Adjusted analysis was performed to evaluate the relationship between the intervention group and uw-mRS at 90 days. Kaplan-Meier curves and log-rank test were used to compare the survival by 90 days between groups. Results: 201 ICH patients were identified; 102 in the MSU and 99 in the SM groups. MSU patients had more antiplatelet/antithrombotic (AP/AT) use (30.4% vs 15.2%, p=0.016); edema was more frequent in the SM group (72.7% vs 52.0%, p = 0.004). Initial ICH volume was similar between MSU and SM groups (11.50 mL [5.0, 22.0] vs. 9.0 mL [5.0, 20.0], p = 0.62). Anti-hypertensives were given earlier on the MSU (39.0 min [31.00, 45.00] vs 61.0 min [46.50, 75.25], p&lt;0.001), and resulted in shorter time to systolic blood pressure (SBP) &lt; 150mmHg (52 min vs. 121 min, p&lt;0.001). The mean uw-mRS at 90 days was 0.364 ± 0.361 in the MSU and 0.465 ± 0.360 in the SM group (p=0.50, adjusted for AP/AT and edema). There was no difference in hematoma expansion, length of stay, discharge disposition or 90-day mRS. Higher mortality was noted after 5 days post-ictus in the MSU group (26.5% vs. 14.1%, p = 0.04). Conclusion: In ICH patients, MSU management resulted in faster treatment and time to target SBP with similar clinical outcomes except higher late mortality. Further study of the impact of prehospital ICH management including BP reduction and AT/AP reversal are required.

Abstract WP231: The Incidence of Intracranial Hemorrhage in Patients Anticoagulated With Factor Xa Inhibitors (FXai): A Multi-Country Observational Study (AXIOM ICH)

Background: Intracranial haemorrhage (ICH) is associated with significant long-term morbidity, high healthcare costs and mortality. There is a paucity of accurate national incidence rate data on ICH, fatal ICH and ICH sub-types in patients on FXai anticoagulants (e.g. rivaroxaban and apixaban). Aim: To describe patient characteristics and incidence of ICH following the initial use of FXai in an ongoing multi-country study. Methods: A retrospective observational cohort analysis of electronic health records from new users of FXai in the UK and Canada. Individuals with FXai prescriptions for a therapeutic indication such as venous thromboembolism, atrial fibrillation (AF), and/or non-mechanical cardiac-valve replacement, were included. Demographic and clinical data were summarised using descriptive statistics, and incidence rates for ICH events were reported per 100 person-years with 95% confidence intervals. Subgroups have been analysed. Results: In the UK and Canada, there were a total of 383,433 new users of FXai; average age 69 years, 54% male, average BMI 29 kg/m 2 and 88% of patients used an oral FXai. The most common indication was AF (73%). 1650 and 438 ICH events were reported in the UK and Canada, with 1-year incidence rates of 0.56 and 0.72 per 100 person-years, 27% and 26% were fatal (Table), respectively. Event rates remain elevated in the years following FXai initiation. Conclusions: Findings indicate incidence rates of ICH in patients treated with FXai were consistent over time, approximately 0.64 per 100 person-years or 1:160 patients per year throughout the course of treatment. Case fatality rates are high, around 27%, remaining elevated in the years following FXai initiation.

Abstract 151: GFAP Measurements for Rapid Prehospital Identification of Intracranial Hemorrhage in Patients With Acute Coma

Background: Prehospital triage and treatment of patients with acute coma is challenging for rescue services, as the underlying pathogenetic conditions are highly heterogenous and difficult to assess. Glial fibrillary acidic protein (GFAP) has been recently identified as a biomarker of intracerebral hemorrhage. The aim of this study was to test the diagnostic value of a GFAP point-of-care(poc) device to rapidly differentiate intracranial hemorrhage from other causes of acute coma (including seizures, metabolic disorders, cardiovascular disorders, and intoxication) in the prehospital phase. Methods: Patients who were admitted to the emergency department due to acute coma (Glasgow Coma Scale scores between 3-8) were enrolled prospectively. Blood samples were collected already in the prehospital phase. Plasma GFAP measurements were performed on the i-STAT Alinity® (Abbott) device (duration of analysis 15 min). The primary endpoint was the final diagnosis at hospital discharge. Results: 95 patients were enrolled (mean age 64±20 years, 43% female). GFAP concentrations were strongly elevated in patients with a primary cerebral cause of coma compared to primary non-cerebral causes (p&lt;0.001). The GFAP concentrations (mean±SD in pg/mL) according to final diagnosis were as follows: intracerebral hemorrhage 4840±4500 (n=15), subarachnoid hemorrhage 4858±4662 (n=11), subdural or epidural hematoma 3462±4005 (n=4), ischemic stroke 992±2857 (n=12), seizure 45±21 (n=11), cardiovascular or metabolic disorder 258±888 (n=29), intoxication 30±2 (n=6), psychogenic stupor 29±0 (n=2); n=5 patients had missing diagnoses. GFAP values over 1000 pg/ml indicated a primary cerebral cause of coma with 100% certainty (hereof, 86% had intracranial hemorrhage). Conclusion: Increased GFAP plasma values in patients with acute coma identify a primary cerebral cause of coma (mostly intracranial hemorrhage) with very high diagnostic accuracy. Patients with primary non-cerebral causes of coma showed overall low GFAP concentrations. Prehospital GFAP measurements on a poc platform may allow rapid stratification according to the underlying cause of coma by rescue services. This could have major impact on triage and management of these critically ill patients.

Abstract WMP90: Outcomes of Endovascular Treatment versus Best Medical Treatment for Acute Basilar-Artery Occlusion: Impacts of Etiology in the ATTENTION Randomized Trial

Objective: This study aimed to evaluate the efficacy and safety of endovascular treatment versus best medical treatment strategies in acute basilar artery occlusion with different stroke etiologies. Methods: The study was a post-hoc analysis of the Trial of Endovascular Treatment of Acute Basilar-artery Occlusion (ATTENTION), which was a multicenter, randomized trial at 36 centers in China from February 2021 to September 2022. Patients with acute basilar artery occlusion were classified into three groups according to stroke etiology: large-artery atherosclerosis (LAA), cardioembolism (CE), and undetermined/other determined cause (UC/ODC). The primary outcome was favorable outcome (modified Rankin scale 0-3) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Results: A total of 340 patients were included. Compared with best medical treatment, endovascular treatment was associated with higher rates of favorable outcome at 90 days in the LAA group (49.1% vs 23.8%; adjusted odds ratio [aOR] 2.79; 95% confidence interval [CI] 1.16-6.71), CE group (52.2% vs 30.8%; aOR 3.68; 95%CI 1.04-12.97), and UC/ODC group (37.5% vs 17.4%; aOR 5.73, 95%CI 1.99-16.48). The rate of symptomatic intracranial hemorrhage in patients receiving endovascular treatment with LAA, CE and UC/ODC was 8.3%, 2.2%, and 3.2%, respectively, and none of the best medical treatment patients. Endovascular treatment led to lower 90-day mortality than best medical treatment in LAA patients (33.3% vs 57.1%; aOR 0.41; 95% CI 0.19-0.91). Among patients receiving endovascular treatment, a better functional outcomes of CE etiology was found than the UC/ODC etiology (52.2% vs 37.5%; aOR 2.68; 95% CI 1.07-6.70); there was no differences in symptomatic intracranial hemorrhage and 90-day mortality among the three etiology subtypes. Conclusion: Endovascular treatment was associated with better outcomes than the best medical treatment in acute basilar artery occlusion patients regardless of stroke etiologies, but the benefits-risk ratios were different among etiologies. The stroke etiology might be an important factor in predicting the prognosis of thrombectomy in acute basilar artery occlusion.

Abstract TP279: Atrial Cardiopathy and Intracerebral Hemorrhage in Patients With Acute Ischemic Stroke

Background and Purpose: Atrial cardiopathy is recognized as a potential contributor to cardiovascular events. Whether atrial cardiopathy is associated with the risk of intracranial hemorrhage in acute ischemic stroke (AIS) remains uncertain. We aimed to investigate the relationship between atrial cardiopathy and intracerebral hemorrhage risk in patients with AIS. Methods: This single-center observational study included 631AIS patients (median age: 70 years [IQR] 61-78; 31.5% female). Atrial cardiopathy was defined as any presence of ≥1: left atrial diameter ≥ 52 mm (males) or ≥ 47 mm (females), elevated P-wave terminal force in V1 (PTFV1) &gt; 5000 μV·ms, or serum NT-proBNP &gt;250 pg/ml. Our primary outcomes included any intracranial hemorrhage (ICH) and symptomatic ICH (sICH) during follow-up. Our secondary outcome was ischemic stroke recurrence. The association between atrial cardiopathy and outcomes was analyzed using Cox hazards regression models. Results: During a median of 1.57 years follow-up, 67 (10.6%) AIS patients experienced any ICH, and 18 (2.9%) patients developed sICH. In Kaplan-Meier analysis, the rate of any ICH or sICH during follow-up was more frequent in patients with atrial cardiopathy compared to those without (log-rank test, p &lt; 0.001, respectively; Figure 1 ). After adjustment for CHA 2 DS 2 -VAS C , atrial cardiopathy was significantly associated with the risk of any ICH (HR 3.99, 95% CI 2.20-7.22, p &lt; 0.001) or sICH (HR 7.93, 95% CI 1.77-35.51, p = 0.007). There was no significant association of ischemic stroke recurrence with atrial cardiopathy. Conclusions: This investigation suggests a potential link between atrial cardiopathy and an increased risk of intracranial hemorrhage in patients with acute ischemic stroke.

Deep learning-based white matter lesion volume on CT is associated with outcome after acute ischemic stroke.

Intravenous thrombolysis (IVT) before endovascular treatment (EVT) for acute ischemic stroke might induce intracerebral hemorrhages which could negatively affect patient outcomes. Measuring white matter lesions size using deep learning (DL-WML) might help safely guide IVT administration. We aimed to develop, validate, and evaluate a DL-WML volume on CT compared to the Fazekas scale (WML-Faz) as a risk factor and IVT effect modifier in patients receiving EVT directly after IVT. We developed a deep-learning model for WML segmentation on CT and validated with internal and external test sets. In a post hoc analysis of the MR CLEAN No-IV trial, we associated DL-WML volume and WML-Faz with symptomatic-intracerebral hemorrhage (sICH) and 90-day functional outcome according to the modified Rankin Scale (mRS). We used multiplicative interaction terms between WML measures and IVT administration to evaluate IVT treatment effect modification. Regression models were used to report unadjusted and adjusted common odds ratios (cOR/acOR). In total, 516 patients from the MR CLEAN No-IV trial (male/female, 291/225; age median, 71 [IQR, 62-79]) were analyzed. Both DL-WML volume and WML-Faz are associated with sICH (DL-WML volume acOR, 1.78 [95%CI, 1.17; 2.70]; WML-Faz acOR, 1.53 95%CI [1.02; 2.31]) and mRS (DL-WML volume acOR, 0.70 [95%CI, 0.55; 0.87], WML-Faz acOR, 0.73 [95%CI 0.60; 0.88]). Only in the unadjusted IVT effect modification analysis WML-Faz was associated with more sICH if IVT was given (p= 0.046). Neither WML measure was associated with worse mRS if IVT was given. DL-WML volume and WML-Faz had a similar relationship with functional outcome and sICH. Although more sICH might occur in patients with more severe WML-Faz receiving IVT, no worse functional outcome was observed. White matter lesion severity on baseline CT in acute ischemic stroke patients has a similar predictive value if measured with deep learning or the Fazekas scale. Safe administration of intravenous thrombolysis using white matter lesion severity should be further studied. White matter damage is a predisposing risk factor for intracranial hemorrhage in patients with acute ischemic stroke but remains difficult to measure on CT. White matter lesion volume on CT measured with deep learning had a similar association with symptomatic intracerebral hemorrhages and worse functional outcome as the Fazekas scale. A patient-level meta-analysis is required to study the benefit of white matter lesion severity-based selection for intravenous thrombolysis before endovascular treatment.

Anticoagulant prescribing patterns in patients with primary central nervous system malignancies and secondary metastases.

To evaluate the safety of direct oral anticoagulants (DOACs) versus low-molecular weight heparin (LMWH) in patients with central nervous system (CNS) malignancies and secondary metastases. All adult patients with CNS malignancies and secondary metastases who were treated with a DOAC or LMWH for any indication from 2018 to 2022 were included. The primary outcome was the incidence of any intracranial hemorrhage (ICH) after anticoagulation initiation. Secondary outcomes included non-ICH bleeding events and thromboembolic events. Tolerability was assessed by any changes in anticoagulant therapy during study period. 153 patients were included; 48 patients received enoxaparin and 105 received DOACs, of which apixaban was used most commonly. The population was predominantly White (74%) and male (59%) with a median age of 65. Data was censored for immortal time bias for outcomes evaluated beyond 3months. ICH occurred in 7.7% of the population, more frequently in the enoxaparin group (DOACs 4, 4% vs. enoxaparin 7, 16%, p = 0.037). Non-ICH bleeds were predominantly minor and more common in the DOAC group (DOACs 13, 13% vs. enoxaparin 1, 2%, p = 0.037). Thromboembolic events were not different between groups (DOACs 9. 9% vs, enoxaparin 2, 4%, p = 0.503). Anticoagulant switches occurred more in the enoxaparin group (DOACs 12, 12.4% vs. enoxaparin, 37.8%, p < 0.001), primarily due to patient or provider preference. Our data supports DOACs to be preferred over LMWH for the treatment of VTE or for stroke prevention with AF to prevent ICH in patients with brain tumors or metastases.

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.

Is reversal of anticoagulants necessary in neurologically intact traumatic intracranial hemorrhage?

Falls are the leading cause of injury in older individuals, with intracranial hemorrhage (ICH) being a common complication. Anticoagulants, such as vitamin K antagonist and direct oral anticoagulants, are increasingly utilized, and clinicians may question the necessity of reversal in patients with minor ICH, especially in the setting of increased risk of adverse events. This study aimed to identify a population of patients with minor traumatic ICH at low risk for poor-neurologic status where anticoagulant reversal may not improve outcomes. This retrospective cohort study utilized data accessed from 35 trauma centers from 2018 to 2021. Patients included had a preinjury anticoagulant regimen, ICH due to blunt trauma, Glasgow Coma Scale score of 15, an Abbreviated Injury Scale (AIS) head score from 2 to 4, and an AIS of ≤1 for non-head regions within 24 h of hospital arrival. Patients were excluded if they required an emergent neurosurgical procedure or were on a preinjury purinergic-P2 receptor-12 protein (P2Y12) inhibitor. The primary outcome was the rate of in-hospital mortality or hospice. There were 654 patients on preinjury anticoagulation who were included with a minor traumatic ICH without neurologic deficits. Overall, 263 patients were reversed and 391 were not reversed. Twelve (4.6%) patients with in-hospital mortality or hospice were reversed compared with 19 (4.91%) patients who were not reversed (p = 0.861). A composite of hospital complications occurred in 21 (8%) reversed patients and 34 (8.7%) not reversed patients (p = 0.748). The average intensive care unit length of stay was 1.4 ± 3.4 days in the reversed group and 1.1 ± 1.8 days in the not reversed group (p = 0.069). This study found no difference in hospital outcomes between patients with minor traumatic ICH on oral anticoagulants who were neurologically intact that were reversed versus those who were not reversed. Further studies should continue to define the subset of traumatic ICH patients who may not require reversal of anticoagulation.