Location Of Hemorrhage Research Articles

The efficacy and safety of Retcam in detecting neonatal retinal hemorrhages

BackgroundTo investigate the ability of characterizing neonatal retinal hemorrhage (RH) using RetCam in healthy newborns and the systemic effects during the procedure.MethodsThis prospective study enrolled 68 healthy newborns aged 2 to 4 days old. The RH was imaged and classified according to the location and numbers of hemorrhages. The heart rate (HR), respiration rate (RR), and oxygen saturation (OS) were recorded at 4 time points before (Phase 1, P1), during (P2 and P3) and after the examination (P4).ResultsThe median exam time was 151 s. RH was present in 15 infants and 23 eyes. All 23 eyes had hemorrhage in Zone II. Grade II and III hemorrhages were present in 5 and 18 eyes, respectively. The HR increased to 168 beats per minute (bpm) in P3 and recovered to 122.5 bpm in P4. The RR increased to 38 bpm in P3 and recovered to 25 bpm in P4. The OS was reduced to 83% in P2 and recovered to 96% in P4.ConclusionsRH in healthy newborns, mostly present in Zone II with grade II and III, can be characterized in detail by RetCam. Systemic effects during the process are mild and can be revolved spontaneously.

Intracerebral hemorrhage: positive predictive value of diagnosis codes in two nationwide Danish registries.

PurposeThe purpose of this study is to establish the validity of intracerebral hemorrhage (ICH) diagnoses in the Danish Stroke Registry (DSR) and the Danish National Patient Registry (DNPR).Patients and methodsWe estimated the positive predictive value (PPV) of ICH diagnoses for a sample of 500 patients from the DSR (patients recorded under ICH diagnosis) and DNPR (International Classification of Diseases, version 10, code I61) during 2010–2015, using discharge summaries and brain imaging reports (minimal data). We estimated PPVs for any ICH (a-ICH) and spontaneous ICH (s-ICH) alone. Furthermore, we assessed PPVs according to whether patients were recorded in both or only one of the registries. Finally, in a subsample with ICH diagnoses with access to full medical records and original imaging studies (extensive data, n=100), we compared s-ICH diagnosis and hemorrhage location after use of extensive vs minimal data.ResultsIn the DSR, the PPVs were 94% (95% CI, 91%–96%) for a-ICH and 85% (95% CI, 81%–88%) for s-ICH. In the DNPR, the PPVs were 88% (95% CI, 84%–91%) for a-ICH and 75% (95% CI, 70%–79%) for s-ICH. PPVs for s-ICH for patients recorded in both registries, DSR only, and DNPR only were 86% (95% CI, 82–99), 80% (95%CI, 71–87), and 49% (95%CI, 39–59), respectively. Evaluation of extensive vs minimal data verified s-ICH diagnosis in 98% and hemorrhage location in 94%.ConclusionThe validity of a-ICH diagnoses in DSR and DNPR is sufficiently high to support their use in epidemiologic studies. For s-ICH, validity was high in DSR. In DNPR, s-ICH validity was lower, markedly so for the small subgroup of patients only recorded in this registry. Minimal data including discharge summaries and brain imaging reports were feasible and valid for identifying ICH location.

Fluctuant Mass on an Infant’s Scalp

A term infant has the following scalp examination [click on the video]. Of the options shown in Fig 1A (A, B, C, or D) of the top of an infant’s head, what is the most likely location of the involved area in this infant? Video. Click here to view the video. Figure 1A. Locations for potential collections that are exterior and interior to an infant’s skull. The video of this newborn shows a moderate-to-large fluctuant mass gathered in the dependent portion of the neonate’s scalp. Upon gentle tapping of the boggy collection, there is a clearly visible fluid wave. This finding is most consistent with a subgaleal hemorrhage. Subgaleal hemorrhage is a serious, potentially fatal event in a newborn. It is caused by the rupture of large, bridging, emissary veins that connect the scalp veins to the intracranial dural sinuses. When these veins rupture, blood accumulates between the periosteum and the galeal aponeurotica, a large potential space composed of loose connective tissue. This space extends without restriction across the cranium and can hold as much as 260 mL of blood. (1) (Note: The average total blood volume in a term infant is 80–90 mL/kg.) A hemorrhage of …

Impact of Supratentorial Cerebral Hemorrhage on the Complexity of Heart Rate Variability in Acute Stroke

Acute stroke commonly affects cardiac autonomic responses resulting in reduced heart rate variability (HRV). Multiscale entropy (MSE) is a novel non-linear method to quantify the complexity of HRV. This study investigated the influence of intracerebral hemorrhage (ICH) locations and intraventricular hemorrhage (IVH) on the complexity of HRV. We recruited 93 supratentorial ICH patients (male 59%, mean age 61 years), and the locations of ICH included basal ganglia (n = 40), thalamus (n = 35), and lobar (n = 18) group. Continuous one-hour electrocardiography signals were obtained from patients after admission, and the complexity index was defined as the area under the MSE curve. The complexity index was lower in lobar ICH (21.6 ± 7.9) than basal ganglia (27.9 ± 6.4) and thalamus (28.5 ± 7.2) groups. The complexity index was inversely correlated with initial stroke severity (r = −0.26), size of hematoma (r = −0.35) and ICH score (r = −0.26), especially among patients with intraventricular hemorrhage (r = −0.60, −0.60, and −0.41 respectively). A higher complexity can predict a good functional outcome (adjusted odds ratio 1.09, 95% confidence intervals 1.00–1.19) at post-stroke 3 months. In summary, more severe stroke and larger hematoma volume resulted in lower complexity of HRV. Lobar hemorrhage and IVH had great impacts on the cardiac autonomic function.

The intraventricular-spot sign: prevalence, significance, and relation to hematoma expansion and outcomes

The presence of the spot sign on computed tomography angiogram (CTA) is considered a sign of active bleeding, and studies have shown it can predict hematoma expansion in intraparenchymal hemorrhage (IPH). The spot sign in intraventricular hemorrhage (IVH) has not been explored yet. The purpose of this study is to estimate the prevalence of the intraventricular-spot sign, and its prediction of hematoma expansion and clinical outcomes. We retrieved data of hemorrhagic stroke patients seen at our medical center from January 2013 to January 2018. A total of 321 subjects were filtered for the prevalence analysis (PA). We further excluded 114 subjects without a follow-up CT-head for the hematoma expansion analysis (HEA). Patients were grouped based on the location of hemorrhage into three groups: isolated IPH with the spot sign always in IPH (i-IPH), isolated IVH with the spot sign always in IVH (i-IVH), and combined IPH and IVH which would be further sub-grouped according to the location of the spot sign: in IPH only (IPH+/IVH) and in IVH only (IPH/IVH+). The prevalence, demographics, and incidence of hematoma expansion were compared between the groups using Pearson's chi-square test and Student's t test. The prevalence of the spot sign was 8, 20, 17, 5% in (i-IPH), (i-IVH), (IPH+/IVH), and (IPH/IVH+) groups, respectively. The rate of hematoma expansion were (42 vs. 13%), (33 vs. 31%), (80 vs. 22%), and (25 vs. 22%) in spot sign positive vs. negative subjects in each group, respectively (p values = 0.023, = 1, <0.001, and = 1). We studied the prediction of spot sign on hematoma expansion and clinical outcomes in the different subtypes of ICH. Our study showed that spot sign is a good predictor in IPH but not IVH. Despite the rarity of IVH; the prevalence of spot sign was higher in IVH than IPH. This might be due to anatomical and physiological variations.

The role of oral anticoagulants in epistaxis

PurposeThe purpose of this retrospective study was to identify the impact of oral anticoagulants on epistaxis with the focus on new oral anticoagulants.MethodsThe study was conducted at the Department for Ear- Nose- and Throat (ENT), Head and Neck Surgery, Technical University Munich, Germany. All patients presenting in 2014 with the diagnosis of epistaxis to a specialized ENT accident and emergency department were identified and analyzed in clinical data and medication.Results600 adult cases, with a median age of 66.6 years were identified with active bleeding. 66.8% of all cases were anticoagulated. Classic oral anticoagulants (COAC) were three times more common in patients than new-generation oral anticoagulants (NOAC). Recurrent bleeding was significantly associated with oral anticoagulants (OAC) (p = 0.014) and bleeding location was most often anterior (p = 0.006). In contrast, severe cases, which required surgery or embolization were significantly more likely in non-anticoagulated middle-aged patients with posterior bleedings (p < 0.05). In our epistaxis cohort, OAC were highly overrepresented (40%) when compared to the general German population (1%) but COAC as well as NOAC played only a minor role in severe courses of epistaxis.ConclusionOral anticoagulation, especially with new-generation drugs, is not associated with more complicated and severe courses of epistaxis, but rather with recurrent bleeding. One should keep this information in mind when triaging the patient in the emergency room and when planning further procedures.

Clinical analysis of the relationship between hemorrhage and position of stigmata in patients with esophageal varices

Objective To investigate the predisposing locations of active hemorrhage in patients with esophageal variceal bleeding. Methods Data of 823 patients with acute esophageal and gastric variceal hemorrhage receiving emergency gastroscopy diagnosed from January 2003 to December 2013 were retrospectively studied. The location and site of active hemorrhage or stigmata were analyzed and its relationship with active hemorrhage was discussed. Results A total of 372(45.2%, 372/823) patients with active bleeding and stigmata were found under emergency endoscopy. Among 372 patients, 190 got accurate hemorrhage and stigmata location and site description. Bleeding or stigmata in 58(30.5%) patients was 28-32 cm from incisor in group A, and that in 132 (69.5%) patients was more than 35 cm in group B (χ2=57.642, P<0.000 1). In 190 cases, the proportion of bleeding or stigmata at 3: 00 point was the highest(37%, 70/132), followed by those at 12: 00 point(30%, 58/132), 6: 00 point(24%, 45/132), and 9: 00 point (9%, 17/132). The change trend of the percentage of each point in group A and group B was the same as that in all cases. The percentage of almost all points in group B was significantly higher than that in group A except that at 9: 00 point (P<0.000 1). Conclusion Esophageal variceal bleeding in cirrhosis is more common at 3: 00 point, 6: 00 point and 12: 00 point of esophagus, and the high risk area is 35 cm below the incisors. Key words: Esophageal and gastric varices; Hemorrhage; Active bleeding; Stigmata

Timing of Gastrointestinal Bleeding After Implantation of Left Ventricular Assist Devices Associates With Anatomic Location, Presentation, and Management

Continuous-flow left ventricular assist devices (LVADs) for advanced heart failure have been associated with gastrointestinal bleeding (GIB). We examined the association between time of GIB after LVAD implantation and bleeding location (determined by endoscopy), etiology, and patient outcomes. We performed a retrospective study of consecutive patients who underwent implantation of continuous-flow LVADs from 2008 through 2015. We analyzed data on anatomic location of GIB, etiology, length of hospital stay, transfusion requirement, time to endoscopy, and readmission to the hospital within 30 days (30-day readmission). GIB developed in 59 of the 271 patients (22%). Higher proportions of patients with GIB during their index hospitalization for LVAD implantation had upper or lower GIB (86.7%) than patients with GIB during a subsequent hospitalization (50.0%; P = .013). Patients with GIB during their index hospitalization also had lower rates of middle GIB (0 vs 20.5%; P = .052), higher rates of overt GIB (100% vs 63.6%; P = .006), longer hospital stays (24 days vs 11 days; P<.001), and more transfusions before endoscopy (7 units vs 4 units; P = .021) than patients with GIB during a subsequent hospitalization. There were no significant differences between groups in time to endoscopy (2 days vs 2.5 days) or 30-day readmission (6.7% vs 9.3%). Angiodysplasias were identified in 100% of patients with middle GIB compared to 48.5% of patients with upper or lower GIB (P < .001) in whom a bleeding lesion was identified. In a retrospective study of patients who underwent implantation of continuous-flow LVADs, we found that timing of GIB associates with the location and severity of bleeding. Although patients with LVADs have an overall increase in risk of middle GIB, patients with GIB during their index LVAD hospitalization should undergo initial evaluation by upper endoscopy and colonoscopy, due to insufficient time for development of small bowel angiodysplasias. Patients who later develop GIB should be evaluated early for middle GI bleeding.

Location of Disc Hemorrhage and Direction of Progression in Glaucomatous Retinal Nerve Fiber Layer Defects

To investigate the relationship between glaucomatous disc hemorrhage (DH) location with respect to the nasal or temporal margin of the retinal nerve fiber layer defect (RNFLD) and the direction of RNFLD widening. This is a retrospective, cross-sectional study. Patients with any documented episode of glaucomatous DH throughout the follow-up period, and definite RNFLD widening on retinal nerve fiber layer photographs were analyzed. The location of DH was recorded as either nasal or temporal, and the direction of RNFLD widening was investigated. The laterality of DH location on the RNFLD border and the direction of RNFLD widening were correlated with each other. We also compared clinical parameters between eyes with nasal versus temporal margin DHs. We analyzed 123 eyes from 116 patients with definite widening of the RNFLD and glaucomatous DH at the border between the healthy and damaged retinal nerve fiber layer. The most common diagnosis was normal-tension glaucoma (109, 87.9%). The most frequent location of DH was the temporal margin of an inferotemporal RNFLD (75, 61.0%), and the most frequent pattern of change in RNFLD was temporal widening (89, 72.4%). The absolute congruency was 82.9% and the total congruency was 99.2%. No significant differences were identified between eyes with nasal versus temporal margin DHs. The lateral location of DH on the RNFLD border was highly congruent with the direction of RNFLD widening. This correspondence of laterality between DH development and progression of RNFLD may suggest an intimate structural relationship during the pathogenesis of DH, at the enlarging RNFLD border.

Location of Thalamic Hemorrhage Impacts Prognosis

Approximately 12% of intracerebral hemorrhages (ICHs) occur in the thalamus. Understanding the anatomic regions involved with thalamic hemorrhages is potentially useful, offering the physician a more accurate prognosis for patient outcomes. This study was performed to determine if thalamic hemorrhage location observed on a computed tomography (CT) scan was predictive of neurologic outcomes. A sample of 168 thalamic hemorrhage patients admitted to a tertiary care center were analyzed. Axial CT scans of thalamic hemorrhages were classified into 1 of 6 possible categories based on thalamic nuclei anatomy: anterior, posterior, medial, lateral, central, or global. For each classification, patient clinical characteristics were collected to identify variables indicative of clinical outcome. Outcome measures used in this study included mortality, hospital length of stay, readmission within 30 days, ICH score, Glasgow Coma Scale score, neurologic deterioration (calculated as a change in modified Rankin scale score from admission to discharge), and discharge disposition. On multivariable analysis, patients with posterior and lateral thalamic hemorrhages demonstrated a decreased likelihood of mortality; patients with posterior hemorrhages were less likely to have neurologic deterioration relative to global thalamic hemorrhages when controlling for hemorrhage volume and ventriculomegaly. Ventriculomegaly and hemorrhage volume were also predictive of both mortality and neurologic deterioration. In thalamic hemorrhages, patient prognosis may be influenced by hemorrhage location, with posterior and lateral hemorrhages demonstrating better clinical outcome versus hemorrhages in other locations. This is potentially valuable because hemorrhage location affords the treating physician a readily available prognostic factor when assessing intracranial hemorrhages.

Hemorragia intracerebral espontânea

Introdução: A hemorragia intracraniana espontânea (HICE) pode ser a primeira manifestação clínica de um tumor cerebral, cujas características sintomatológicas e tomográficas se assemelham a uma hemorragia típica por hipertensão arterial sistêmica, dificultando e retardando um possível diagnóstico precoce para os casos, sendo a definição dessa dúvida de fundamental importância para uma evolução favorável. Objetivo: Analisar as dificuldades diagnósticas entre hemorragias intracerebrais espontâneas e aquelas decorrentes de lesões secundárias a processos expansivos cerebrais.Métodos: Analisamos uma série de 3694 casos de hemorragia cerebral, entre 1979 e 2011, obtendo 101 casos decorrentes de hemorragia secundária a tumores cerebrais, dos quais em 26 houve dúvidas diagnósticas entre a hemorragia hipertensiva e a transformação hemorrágica neoplásica. Estes casos foram analisados, observando-se suas manifestações clínicas, localização mais frequente do hematoma intracerebral, o estudo anatomopatológico das lesões que sangraram, e a resolução dos casos de acordo com a evolução versus tempo. Resultados: As metástases foram os tumores que mais frequentemente apresentaram sangramento. Os glioblastomas multiformes foram os tumores encefálicos primários mais comumente relacionados a transformação hemorrágica. Conclusão: As hemorragias intratumorais podem ser a manifestação inicial de tumores encefálicos, sendo ela algumas vezes indistinguíveis de AVCh típico (hipertensivo), tanto nas características clínicas quanto na imagem tomográfica, dificultando o diagnóstico. A hemorragia intratumoral ocorre com mais freqüência nas metástases cerebrais do quenos gliomas, Dos tumores cerebrais primários, o glioblastoma multiforme foi a causa mais comum de sangramento.

Natural history of brain arteriovenous malformations: systematic review.

The appropriate interpretation of natural history of brain arteriovenous malformations (bAVMs) and of factors that negatively affect the risk of future hemorrhage are important when recommending management pathways. With the present systematic review, we aim to provide an overview of the available evidence on natural history of brain arteriovenous malformations (bAVMs), focusing on hemorrhage rates and risk factors for future hemorrhage. We performed a systematic literature analysis using the Ovid Medline database, encompassing English language studies (published between 1980 and 2018) reporting the natural history of untreated bAVMs. Annual hemorrhage rates in both unruptured and previously ruptured bAVMs, as well as risk factors for future hemorrhage were extracted for analysis. Eighteen studies with a total of 8418 bAVM-cases could be extracted from the literature. Seventeen studies reported annual hemorrhage rates and ten studies reported risk factors for future hemorrhage. The average annualized hemorrhage rate was 2.2% for unruptured bAVMs and 4.3%, for bAVMs that presented with hemorrhage. Prior hemorrhage and deep AVM location could be identified as most consistently reported risk factors for future hemorrhage. Previously ruptured bAVMs have a higher annual hemorrhage rate than unruptured bAVMs. Deep bAVM location and prior hemorrhage may increase the risk for subsequent hemorrhage.

Cranial Cavernous Malformations: Natural History and Treatment.

Cavernous malformations (CMs), also known as cavernous angiomas or cavernomas, are low-flow vascular malformations of the brain and spinal cord that consist of clusters of dilated sinusoidal channels lined with endothelial cells that do not exhibit intervening tight junctions. The involved blood vessels lack muscular and elastic layers, and blood at various stages of thrombosis and organization often fills the thin-walled vascular caverns. CMs are grossly distinct from adjacent brain and have a lobulated appearance sometimes likened to a mulberry, with a characteristic dark red or purple color. Hemosiderin and gliosis often surround CMs of the brain and spinal cord; no neural tissue is present inside the lesion. Except for developmental venous anomalies (DVAs) present in ≈33% of CMs,1 no abnormal vascularity is typically seen on digital subtraction angiography, leading CMs to be termed cryptic or occult vascular malformations (Figure 1). Multiple small hemorrhage events lead to a pathognomonic popcorn appearance on magnetic resonance (MR) imaging because of hemosiderin staining from blood products of various ages. Calcifications may be present on computed tomographic imaging (Figure 2). Figure 1. A 48-year-old woman presented with headaches. A , Magnetic resonance imaging of the brain with T2-weighted imaging demonstrated a 1.1-cm lesion in the cerebellar vermis with mixed signal intensity. B – D , Susceptibility-weighted imaging demonstrated hemosiderin within the lesion’s core and a developmental venous anomaly associated with the cavernous malformation (arrowheads). Figure 2. A 28-year-old woman presented with partial seizures without secondary generalization. A , Noncontrast computed tomography of the head demonstrated a 1.4-cm right posterior cingulate hyperdensity, with evidence of mild hemorrhage and calcification. Magnetic resonance imaging of the brain demonstrated the cavernous malformation to have a core of mixed signal intensity, heterogeneous enhancement, and a rim of hemosiderin consistent with a cavernous malformation, as evidenced on ( B ) susceptibility-weighted imaging, ( C ) T2-weighted …

Safety and effectiveness of high-dose, weight-based factor VIII inhibitor bypassing activity for warfarin-induced life-threatening bleeding.

: Previous studies suggest low, fixed-dose regimens of activated prothrombin complex concentrate [factor VIII inhibitor bypassing activity (FEIBA); 500 U for international normalized ratio (INR) < 5; 1000 U for INR > 5] is effective for reversal of warfarin-induced life-threatening bleeds. Little data are available on the use of high-dose, weight-based FEIBA for this indication. The objective of this study was to evaluate effectiveness and safety of high-dose, weight-based FEIBA (50 U/kg) vs. frozen plasma alone in this population. This was a matched case-control, multicenter retrospective study including patients who received high-dose, weight-based FEIBA or frozen plasma alone for warfarin-induced life-threatening bleeds matched (1 : 1) based on age and bleed location. Forty-eight patients were included in the analysis (24 FEIBA, 24 frozen plasma). The primary endpoint was time to INR less than 1.5 after administration of FEIBA or frozen plasma. Secondary endpoints include rates of thromboembolic events and mortality. Median baseline INR was 3.7 (interquartile range 2.7, 7.30) and 2.9 (2.3, 6.61) in the FEIBA and frozen plasma groups, respectively (P = 0.13). Median FEIBA dose was 4530 (3672, 5028) U. Use of FEIBA resulted in faster time to INR less than 1.5 with a median of 2.5 (1.25, 4.15) vs. 12 (5.6, 28.35) h; (P < 0.0001). Thromboembolic events occurred in nine (16.7%) patients (FEIBA n = 5; plasma n = 4); (P = 1.0). Mortality was similar in both groups (FEIBA 33% vs. frozen plasma 15%; P = 0.2). The use of high-dose, weight-based FEIBA resulted in faster time to reversal of warfarin-induced coagulopathy compared with frozen plasma alone and showed a similar safety profile.

Correction: Role of computed tomography angiography on the management of overt obscure gastrointestinal bleeding.

[This corrects the article DOI: 10.1371/journal.pone.0172754.].

Application of the FOUR Score in Intracerebral Hemorrhage Risk Analysis

The Full Outline of Unresponsiveness (FOUR) Score is a validated scale describing the essentials of a coma examination, including motor response, eye opening and eye movements, brainstem reflexes, and respiratory pattern. We incorporated the FOUR Score into the existing ICH Score and evaluated its accuracy of risk assessment in spontaneous intracerebral hemorrhage (ICH). Consecutive patients admitted to our institution from 2009 to 2012 with spontaneous ICH were reviewed. The ICH Score was calculated using patient age, hemorrhage location, hemorrhage volume, evidence of intraventricular extension, and Glasgow Coma Scale (GCS). The FOUR Score was then incorporated into the ICH Score as a substitute for the GCS (ICH ScoreFS). The ability of the 2 scores to predict mortality at 1 month was then compared. In total, 274 patients met the inclusion criteria. The median age was 73 years (interquartile range 60-82) and 138 (50.4%) were male. Overall mortality at 1 month was 28.8% (n = 79). The area under the receiver operating characteristic curve was .91 for the ICH Score and .89 for the ICH ScoreFS. For ICH Scores of 1, 2, 3, 4, and 5, 1-month mortality was 4.2%, 29.9%, 62.5%, 95.0%, and 100%. In the ICH ScoreFS model, mortality was 10.7%, 26.5%, 64.5%, 88.9%, and 100% for scores of 1, 2, 3, 4, and 5, respectively. The ICH Score and the ICH ScoreFS predict 1-month mortality with comparable accuracy. As the FOUR Score provides additional clinical information regarding patient status, it may be a reasonable substitute for the GCS into the ICH Score.

Abstract TP395: Lateralized Periodic Discharges are Predictive of Seizures in Patients With Intracerebral Hemorrhage

Background: Patients with intracerebral hemorrhages (ICH) have a higher incidence of seizures. Previous studies have suggested that the location and size of hemorrhage may increase epileptogenicity. We aim to evaluate seizure development risk factors from clinical examination, imaging, and continuous electroencephalography (CEEG) in critically ill patients with ICH. Methods: We reviewed 57 consecutive patients with ICH admitted to a neurocritical intensive care unit over a 24-month period who were monitored on CEEG. Their demographic and examination data, ICH score, Glasgow coma scale (GCS), location of bleed, CEEG patterns, and discharge status were analyzed. Results: Sixteen (28%) patients from our study cohort had seizures at a mean duration of 7.46 hours from CEEG hookup. Fifteen (93%) of those patients had electrographic only seizures. The finding of lateralized periodic discharges (LPDs) was significantly (p=0.019) associated with seizures. Other variables, such as ICH score, size and location of hemorrhage, GCS, mental status, and other CEEG patterns, were not significantly associated with seizures. Conclusion: We found that LPDs were predictive of seizures in ICH patients. CEEG for longer than 24-hours is preferred for detection of seizures as they occurred at a mean later than seven hours and most were without clinical signs.

Abstract WP333: Intracerebral Hemorrhage Volume and Location in Two Population-Based Studies: 1988 and 2008-2012

Objective: To compare two population-based studies of intracerebral hemorrhage (ICH), collected 20 to 24 years apart, with regard to hemorrhage volumes, location, and stroke risk factors. Methods: All cases of spontaneous ICH among adult residents of the primarily biracial Greater Cincinnati/Northern Kentucky (GCNK) region were ascertained for 1988 and 7/2008-12/2012. Subject information including age, sex, race, Glasgow Coma Scale, and baseline blood pressure were recorded, along with medical history and prescription of anticoagulant and antiplatelet medications. ICH location was defined as deep, lobar, brainstem, or cerebellar. ICH volume was calculated by the ABC/2 method. Results: There were 170 cases of ICH in 1988 and 1101 cases in 2008-2012 fulfilling inclusion criteria. There were no significant differences in mean age (71.2 vs. 70.5 years) or sex (57.7% vs. 51.6% female), but there was a higher proportion of blacks in 2008-2012 compared with 1988 (23.5 vs. 13.5%, P=0.0045). Among the 2008-2012 cases there was significantly less history of ischemic stroke and non-ischemic stroke, and there were no significant differences in history of hypertension, diabetes mellitus, and current smoking. The 2008-2012 cases were prescribed more anticoagulants and antiplatelets. The distribution of ICH location was similar between the two groups. The ICH volumes appear to be lower in 2008-2012 than for 1988 for all hemorrhage locations except the brainstem; however, statistical significance was reached only for deep ICH (Table 1). Conclusions: Although the distribution of ICH location was unchanged between 1988 and 2008-2012, deep ICH volume was smaller in the more recent study. This reduction in hemorrhage size occurred despite significantly more anticoagulant and antiplatelet medications in 2008-2012. More research is needed to investigate factors related to ICH size and trends over time.

Abstract TMP99: Assessment of Management and Outcomes of a First Hemorrhage in Patients With Untreated Arteriovenous Malformations

Introduction: Invasive interventions are commonly used to prevent re-rupture of ruptured arteriovenous malformations (AVMs), but are controversial for managing unruptured AVMs. This study uses a retrospective design to identify influential factors and outcomes in our multimodal treatment program for AVMs following a first rupture. Methods: We reviewed data from a single institution for 89 patients aged 18 years or older, with a first intracranial hemorrhage due to untreated AVMs between 2002 and 2015. We analyzed patient-specific variables and initial modified Rankin Scale (mRS) score groups (A, 0-2; B, 3-5) to compare group differences. Group outcomes were also assessed via multivariate regression. Results: Locations of Hemorrhage were as follows: 43 (48.3%) intraparenchymal, 16 (18.0%) intraventricular, 6 (6.7%) subarachnoid, and 24 (27.0%) combined. Spetzler-Martin grades included 50 grade I/II, 26 grade III, and 13 grade IV/V AVMs. Interventions were utilized in 79 patients (20 surgical resection, 28 Gamma Knife surgery [GKS], and 31 combined with embolization), and conservative management in 10. Mean follow-up was 77.2±45.4 months. Peri-interventional morbidity was 5.1% and the mortality rate was zero. Re-bleeding was observed in 2 patients before intervention and 3 patients after GKS. The group A (N=69) was significantly younger (44.1±16.7 vs. 53.3±13.1, P=0.02), more likely to have a nidus fed by a perforator (30.4% vs. 5.3%, P=0.02), and more likely to undergo GKS with or without embolization (56.5% vs. 25.5%, P=0.01) than the group B (N=19). Significantly more patients in the group A had final mRS scores ≤2 than the group B (95.5% vs. 36.8%, P&lt;0.0001). Multivariate analyses indicated that a nidus fed by a perforator was the only independent pre-hemorrhagic factor for an initial mRS 0-2, which was the only independent pre-treatment factor for a good outcome. Conclusion: Although our treatment results seemed favorable, initial severity influenced the outcome after an untreated AVM-related first intracranial hemorrhage. Further analyses of the factors associated with severe hemorrhage of AVMs may improve both the outcome of ruptured AVMs and the management of unruptured AVMs.

Abstract WP345: Pre-Intracerebral Hemorrhage Antiplatelet and Anticoagulant Use and Differences in Hospital Course; A Population-Based Study

Objective: Patients on antiplatelet (AP) or anticoagulant (AC) agents cause more alarm when they develop intracerebral hemorrhage (ICH) compared with non-users. This analysis aimed to quantitatively evaluate the differences in the hospital course of ICH patients based on underlying AP and/or AC use, using a population-based cohort. Methods: Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) was a population-based study of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky region between July 2008 and December 2012. Baseline demographics, medications, hospital course, and discharge disposition were collected. Initial and subsequent computed tomography (CT) images of the head were reviewed to assess ICH location, volume, and presence of intraventricular hemorrhage (IVH). Change in ICH volume was calculated when repeat CT image was available. Results: There were 1121 cases of ICH during the study period. A higher proportion of white patients were on AP or AC than other races (56.4% vs. 39.7%, p&lt;.0001). The majority of patients with subsequent imaging experienced an increase in ICH size. Patients taking AC pre-ICH had a larger increase in volume despite more frequent use of pro-thrombotic therapy. There was no difference in IVH incidence based on AP or AC use. Length of stay and surgical hematoma evacuation rates were similar among the groups. Inpatient mortality was higher in AC users (44.4% vs. 21.3%, p&lt;.0001), but was virtually the same for AP users as for non-users. Of 272 pre-ICH AP users, 86 (31.6%) were discharged on AP (8 on dual AP). Of 91 pre-ICH AC users, 11 (12%) were discharged on AC. Conclusion: Pre-ICH AC use was associated with greater ICH volume increase and inpatient death. There was no significant difference in number of IVH, rate of surgical treatment, or length of stay. Inpatient mortality did not differ between AP users and non-users.