Prevalence Of Intracranial Hemorrhage Research Articles

Birth-related subdural hemorrhage in asymptomatic neonates: evolution over time and differentiation from traumatic subdural hemorrhage.

Intracranial birth-related subdural hemorrhage frequently occurs in asymptomatic newborns and has no adverse long-term sequelae. It is medically and medicolegally important to differentiate birth-related subdural hemorrhage from other pathological causes of intracranial hemorrhage. There is limited literature available on the incidence of birth-related subdural hemorrhage, its imaging features, and evolution over time, mainly because asymptomatic infants do not routinely undergo cranial MRI. To establish the incidence and distribution of birth-related subdural hemorrhage and evaluate their association with various modes of delivery, identify associated features, and evaluate the sequential evolution of signal changes of the birth-related hemorrhages on MRI. A total of 200 healthy term neonates and young infants were included in this retrospective review study. All infants underwent MRI of the brain and cervical spine at postnatal age of 0-2 months with acquisition of a 3D T1-weighted (T1W), 3D or 2D T2-weighted (T2W), and axial diffusion-weighted imaging (DWI) sequences. The scans were evaluated for the presence and distribution of subdural hemorrhages, other intracranial hemorrhages, and associated injuries. Prevalence of intracranial hemorrhage in various modes of delivery was analyzed. Relationship between the signal intensities of the bleeds on T1W, T2W, and DWI scans and the age of the infants was analyzed. Appropriate tests were applied to test for statistical significance of the data. Out of 200 neonates, 66 (33%) had detectable intracranial hemorrhage on MRI with an age range of 11-25 days, including 31 (47%) males and 35 (53%) females. All of them had subdural hemorrhages, 54 (81.8%) of which were in the posterior fossa. Additional parenchymal hemorrhages were present in a few, but no subarachnoid hemorrhages, cervical spinal canal hemorrhages, cortical bridging vein injury, or cervical spinal ligamentous injury were identified within the limitations of the study. No detectable intracranial hemorrhage was found in subjects above 25 days of age. Overall incidence of subdural hemorrhage by mode of delivery was 8/68 (11.8%) in babies born by cesarean section and 58/132 (43.9%) in babies born by vaginal delivery. Among the vaginal deliveries, the highest incidence was observed in assisted vaginal delivery (19/30, 63.3%). Subjects with birth-related subdural hemorrhage were categorized into three age groups: <13 days, 13-21 days, and >21 days. All detected hemorrhages were T1W hyperintense. In the <13 days group, all bleeds were T2W hypointense. In the 13-21 days group, 73.1% were T2W hypointense, while 26.9% were T2W mixed. All bleeds in the >21 days group were T2W hypointense. All DWI hyperintense bleeds were found in the 13-21 days group. Birth-related subdural hemorrhage occurs in over a third of normal deliveries and has a characteristic distribution, predominantly in the posterior fossa. Associated cervical spinal subdural hemorrhages, cervical spinal ligamentous injury, or cortical bridging vein injury, which are concerning for traumatic etiology, were not identified. Birth-related subdural hemorrhages follow a characteristic pattern of signal changes on MRI. Although not completely reliable, this can help in differentiating them from traumatic intracranial hemorrhages which usually occur postnatally. No birth-related subdural hemorrhages were seen after 25 days of age in our cohort.

P.048 Prevalence, type and risk factors of intracranial hemorrhage in term neonates: a systematic review and meta-analysis

Background: Intracranial hemorrhage (ICH) in newborns poses a significant challenge to wellbeing and development. In preterm neonates, germinal matrix hemorrhage is most common. In term neonates, prevalence and type of ICH has not been well elucidated. This systematic review aims to assess prevalence, type, and risk factors of ICH in term neonates. Methods: A systematic review was conducted. Inclusion criteria was ICH in neonates born at 37+ weeks gestation. Exclusion criteria was one type of ICH, one risk factor, sample size &lt;20, text not in English, full text not accessible. Eligible studies were evaluated by two authors, data was extracted and analyzed using a predesigned template and MetaXL. Results: A total of 1226 records were initially identified and 20 studies were included in the final analysis. The overall prevalence of ICH was 9.3%. This was subdivided into an asymptomatic subgroup (5.8%) and symptomatic subgroup (29.3%). Analysis showed CT detected ICH most commonly. Extra-axial hemorrhage was most commonly detected (~30%), with subdural more common than extradural hemorrhages. The odds of having an ICH was significantly higher with instrumental delivery (3.75%). Conclusions: This shows that prevalence of ICH is relatively high in symptomatic children. Measured prevalence varies according to the type of modality used for screening.

Prevalence of Subarachnoid Hemorrhage in Traumatic Brain Injury Patients: A Cross-Sectional Study

Background: One of the clinical manifestations and complications of traumatic brain injury patients is traumatic intracranial hemorrhages, divided into primary and secondary hemorrhages. Objectives: The present study was conducted to determine the prevalence of subarachnoid hemorrhage (SAH) in traumatic brain injury (TBI) patients. Methods: The present cross-sectional study was conducted on all TBI patients with SAH for one year. Data collection tools include a demographic profile form and a researcher-made checklist. The severity of TBI is divided according to the Glasgow Coma Scale (GCS) score. The patient’s history and clinical examinations were considered when admitting to the hospital. The consciousness level was measured at 6-to-24-hour intervals, a computed tomography (CT) scan was performed, and any abnormal SAH-related clinical findings and symptoms were recorded. If the patient had other hemorrhages besides SAH, the hematoma volume was recorded. The collected data were entered into and analyzed by SPSS version 16 software. Results: A total of 534 patients were investigated, of whom 84 (15.3%) had intracranial hemorrhage. Out of 84 patients with intracranial hemorrhage, 12 (2.2%) had SAH, of whom ten were male and 2 were female. Also, SAH occurred to traffic accidents, falls, and other related reasons in 7 (58.3%), 4 (33.3%), and 1 (8.3%) patients, respectively. It was also shown that 1 (8.3%), 2 (16.6%), and 9 (75%) patients with SAH had mild, moderate, and severe consciousness, respectively. Regarding the frequency of SAH-related diseases, it was shown that 2 (16.6%) and 10 (82.3%) patients were diabetic and non-diabetic, 4 (33.3%) and 8(66.6%) patients were hypertensive and non-hypertensive, and 7 (58.3%) and 5 (41.6%) patients were with and without a history of skull fractures, respectively, 12 (100%) of them had a history of coagulation disorders. Conclusions: The prevalence of intracranial hemorrhage and SAH in TBI patients is significantly high, which should be taken into consideration when performing diagnostic and therapeutic procedures for these patients.

Construction of zebrafish models for screening intracranial hemorrhage associated genes

Objective: To construct zebrafish models for the screening of intracranial hemorrhage (ICH) associated genes. Methods: ICH zebrafish models were constructed through morpholino oligonucleotides (MOs) technique and microinjection technique, and multiple verification was performed from macro and micro perspectives. First, the normal wild-type AB strain zebrafish injected with control MO was used as the control group, and AB zebrafish embryos microinjected with MOs of genes related to development of neural crest-derived cells (NCDCs) were used as the study group, such as col8a1 MO, tfap2α MO, msx1a MO, msx2 MO, and dkk1a MO. Preliminary verification of the model was conducted under a white-light optical microscope. Then, the model was verified by Tg (flk1: gfp; gata1: dsRed) double transgenic zebrafish, with vascular endothelial cells labeled by green fluorescent protein (GFP) and red blood cell labeled by fluorescent protein (dsRed), and thus the location of cerebral hemorrhage can be observed more clearly. Specifically, zebrafish embryos were microinjected with Control MO as the control group and those microinjected with col8a1 MO as the study group. Then the embryos were cultured until 48 hours post-fertilization to observe the leakage of red blood cells under the confocal laser scanning microscope. Finally, Tg (flk1: gfp) transgenic zebrafish was used to verify the model based on the blood-brain barrier (BBB). Through the leakage of dextran-rhodamine and DAPI dyes, the destruction of BBB and the occurrence of cerebral hemorrhage in zebrafish were further clarified, and quantitative statistics were carried out to verify the relationship between NCDCs development related genes and cerebral hemorrhage phenotype, which proved that the modeling was effective. Results: The zebrafish with col8a1, tfap2α, and msx1 mutations in the study group had apparent ICH compared with wildtype zebrafish, and the prevalence of ICH was 18.18% (52/286), 23.04% (62/251), and 35.94% (23/64), respectively. While, the zebrafish with msx2 and dkk1a mutations rarely had ICH, with the ICH prevalence of 1.03% (1/97) and 1.15% (1/87), respectively. The prevalence of red blood cells leakage in Tg (flk1:gfp; gata1:dsred) double transgenic zebrafish injected with Control Mo and col8a1 Mo was 0.37% (1/273) and 18.18% (52/286) (P<0.001). The number of DAPI positive nuclei of Tg (flk1: gfp) transgenic zebrafish injected with Control Mo and col8a1 Mo was 10.05±5.27 and 60.35±3.96 (P<0.001), and the fluorescent intensity of midbrain parenchymal induced by dextran-rhodamin leakage was 2.54±4.70 and 5.13±3.52 (P<0.001). Conclusion: This study successfully constructs the ICH zebrafish models, and ICH-related genes are screened out, such as col8a1, tfap2α, msx1, and so on.

COVID-19 and Intracranial Hemorrhage: A Multicenter Case Series, Systematic Review and Pooled Analysis.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) profoundly impacts hemostasis and microvasculature. In the light of the dilemma between thromboembolic and hemorrhagic complications, in the present paper, we systematically investigate the prevalence, mortality, radiological subtypes, and clinical characteristics of intracranial hemorrhage (ICH) in coronavirus disease (COVID-19) patients. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review of the literature by screening the PubMed database and included patients diagnosed with COVID-19 and concomitant ICH. We performed a pooled analysis, including a prospectively collected cohort of critically ill COVID-19 patients with ICH, as part of the PANDEMIC registry (Pooled Analysis of Neurologic Disorders Manifesting in Intensive Care of COVID-19). Results: Our literature review revealed a total of 217 citations. After the selection process, 79 studies and a total of 477 patients were included. The median age was 58.8 years. A total of 23.3% of patients experienced the critical stage of COVID-19, 62.7% of patients were on anticoagulation and 27.5% of the patients received ECMO. The prevalence of ICH was at 0.85% and the mortality at 52.18%, respectively. Conclusion: ICH in COVID-19 patients is rare, but it has a very poor prognosis. Different subtypes of ICH seen in COVID-19, support the assumption of heterogeneous and multifaceted pathomechanisms contributing to ICH in COVID-19. Further clinical and pathophysiological investigations are warranted to resolve the conflict between thromboembolic and hemorrhagic complications in the future.

Neurovascular Manifestations in Pediatric Patients With Hereditary Haemorrhagic Telangiectasia

BackgroundHereditary hemorrhagic telangiectasia (HHT) is a multiorgan vascular dysplasia with limited data regarding its neurovascular manifestations and genotype-phenotype correlation in children. The objective of this study was to describe the neurovascular findings in a large cohort of children with HHT and correlate between phenotype and genotype. MethodsThis retrospective study was conducted on 221 children (<18 years) with a definite or possible diagnosis of HHT based on Curacao criteria, or with positive genetics for the mutated genes of ENG, ACVRL-1, and SMAD-4, who also underwent brain MRI and/or conventional angiography. Demographic and clinical information, imaging findings, and follow up information were gathered. ResultsTwo hundred twenty-one children with HHT (70.6% genetically confirmed, and 99.5% positive family history) were included, with a median age of 7 years (interquartile range: 3 to 11 years) and 58.8% male predominance. Neurovascular lesions were found in 64 of 221 (28.9%), with 3.1% prevalence of intracranial hemorrhage. The most commonly observed vascular malformations were developmental venous anomalies (48.5%) and brain arteriovenous malformations (AVMs) (31.2%), followed by capillary malformations (14.1%). Multiple AVMs were seen in 10.0% of the cohort. We found no instances of de novo AVM (1281.8 patient-years).A significantly higher proportion of patients with ENG mutations (19.7%) had brain AVM than those with ACVRL-1 (4.9%) and SMAD-4 (0%) mutations (P < 0.01). There was no significant difference in the hemorrhagic risk of shunting lesions associated with ENG (35.3%) or ACVRL-1 (33.3%) positivity (P = 0.9). ConclusionsWe describe the neurovascular imaging and genetic findings from a large pediatric cohort of HHT, to enhance clinical awareness and guide management of patients with HHT.

Neurological Complications in COVID-19 Patients With ECMO Support: A Systematic Review and Meta-Analysis

BackgroundPatients with Coronavirus disease 2019 (COVID-19)-related acute respiratory disease (ARDS) increasingly receive extracorporeal membrane oxygenation (ECMO) support. While ECMO has been shown to increase risk of stroke, few studies have examined this association in COVID-19 patients.ObjectiveWe conducted a systematic review to characterise neurological events during ECMO support in COVID-19 patients.DesignSystematic review of cohort and large case series of COVID-19 patients who received ECMO support.Data SourcesStudies retrieved from PubMed, EMBASE, Cochrane, Cochrane COVID-19 Study Register, Web of Science, Scopus, Clinicaltrials.gov, and medRχiv from inception to November 11, 2020.Eligibility CriteriaInclusion criteria were a) Adult population (>18 year old); b) Positive PCR test for SARS-CoV-2 with active COVID-19 disease; c) ECMO therapy due to COVID-19 ARDS; and d) Neurological events and outcome described while on ECMO support. We excluded articles when no details of neurologic events were available.Results1,322 patients from 12 case series and retrospective cohort studies were included in our study. The median age was 49.2, and 75% (n=985) of the patients were male. Diabetes mellitus and dyslipidaemia were the most common comorbidities (24% and 20%, respectively). Most (95%, n=1,241) patients were on venovenous ECMO with a median P:F ratio at the time of ECMO cannulation of 69.1. The prevalence of intracranial haemorrhage (ICH), ischaemic stroke, and hypoxic ischaemic brain injury (HIBI) was 5.9% (n=78), 1.1% (n=15), and 0.3% (n=4), respectively. The overall mortality of the 1,296 ECMO patients in the 10 studies that reported death was 36% (n=477), and the mortality of the subset of patients who had a neurological event was 92%.ConclusionsNeurological injury is a concern for COVID-19 patients who receive ECMO. Further research is required to explore how neuromonitoring protocols can inform tailored anticoagulation management and improve survival in COVID-19 patients with ECMO support.

Abstract P538: A Detailed Analysis of Intracranial Hemorrhage After Endovascular Treatment in Acute Ischemic Stroke Due to Large Vessel Occlusion in the Escape-NA1 Trial

Purpose: We investigated the prevalence and prognostic impact on outcome of any intracranial hemorrhage, hemorrhage morphology, type and volume in acute ischemic stroke patients undergoing mechanical thrombectomy. Methods: Prevalence of intracranial hemorrhage, hemorrhage type, morphology and volume was determined on 24h follow-up imaging (non contrast head CT or gradient-echo/susceptibility-weighted MRI). Proportions of good outcome (mRS 0-2 at 90 days) were reported for patients with vs. without any intracranial hemorrhage. Multivariable logistic regression with adjustment for key minimization variables and total infarct volume was performed to obtain adjusted effect size estimates for hemorrhage type and volume on good outcome. Results: Hemorrhage on follow up-imaging was seen in 372/1097 (33.9%) patients, among them 126 (33.9%) with hemorrhagic infarction (HI) type 1, 108 (29.0%) with HI-2, 72 /19.4%) with parenchymal hematoma (PH) type 1, 37 (10.0) with PH2, 8 (2.2%) with remote PH and 21 (5.7%) with extra-parenchymal/intraventricular hemorrhage. Good outcomes were less often achieved by patients with hemorrhage on follow-up imaging (164/369 [44.4%] vs. 500/720 [69.4%]). Any type of intracranial hemorrhage was strongly associated with decreased chances of good outcome ( adj OR 0.62 [CI 95 0.44 - 0.87]). The effect of hemorrhage was driven by both PH hemorrhage sub-type [PH-1 ( adj OR 0.39 [CI 95 0.21 - 0.72]), PH-2 ( adj OR 0.15 [CI 95 0.05 - 0.50])] and extra-parenchymal/intraventricular hemorrhage ( adj OR 0.60 (0.20-1.78) Petechial hemorrhages (HI-1 and HI-2) were not associated with poorer outcomes. Hemorrhage volume ( adj OR 0.97 [CI 95 0.05 - 0.99] per ml increase) was significantly associated with decreased chances of good outcome. Conclusion: Presence of any hemorrhage on follow-up imaging was seen in one third of patients and strongly associated with decreased chances of good outcome.

The safety and efficacy of low-dosage tirofiban for stent-assisted coiling of ruptured intracranial aneurysms.

Stent-assisted coiling (SAC) of acutely ruptured aneurysms with antiplatelet therapy has been controversial. Tirofiban has been used for the treatment of thromboembolism of ruptured aneurysms with a stent. However, there are few comparative studies of a reasonable dosage for the prophylactic use of tirofiban. This study evaluated the safety and efficacy of reducing the dosage of tirofiban for the ruptured aneurysms with SAC. Patients with ruptured intracranial aneurysms in our institution from January 2014 to June 2018 were retrospectively reviewed. Three hundred and nine patients were treated using SAC within 72h of onset. Patients were divided into either a standard group (211 patients, 10μg/kg intravenous bolus within 3min, maintained with 0.15μg/kg/min) or a half-dose group (98 patients, 5μg/kg intravenous bolus within 3min, maintained with 0.075μg/kg/min) according to the dose of tirofiban received intraoperatively. Medical records including clinical and radiological details were reviewed. No significant differences in demographic information or aneurysm characteristics existed between the two groups. Thromboembolic complications were found in 15 patients (4.9%), including 11 patients (5.2%) in the standard group and four patients (4.1%) in the half-dose group, without significant difference (P = 0.782). Intracranial hemorrhage was found in 13 patients (4.2%), and all occurred in the standard group, which was significantly different (6.2% vs 0%, P = 0.011). Of these 13 patients, four were left disabled and five died. Except for three patients who had intraoperative aneurysm rupture, the incidence of postoperative early rebleeding (10 patients) was significantly different between the two groups (4.7% vs 0%, P = 0.034). The rate of initial complete occlusion in the half-dose group was significantly higher than that in the standard group (55.1% vs 39.8%). The rate of a good outcome (modified Rankin Scale 0-2) was not significantly different between the standard group and half-dose group (78.7% vs 87.8%, P > 0.05). Intravenous tirofiban for SAC of acutely ruptured intracranial aneurysms is feasible and safe. The half-dose tirofiban treatment was associated with a decrease in the prevalence of intracranial hemorrhage but no increase in thromboembolic events compared with those in standard-dose tirofiban treatment.

Prescreening for Intracranial Hemorrhage on CT Head Scans with an AI-Based Radiology Workflow Triage Tool: An Accuracy Study

Purpose: To evaluate a recently FDA-approved AI-based radiology workflow triage device for accuracy in identification of intracranial hemorrhage (ICH) on prescreening of real-world CT brain scans. Method/Materials: An AI-based device ("the algorithm") for ICH detection on CT brain scans was studied at our institution; the algorithm was developed by outside company Aidoc (Tel Aviv, Israel). A retrospective dataset of 533 non-contrast head CT scans was collected from our large urban tertiary academic medical center. Following convention for studies evaluating sensitivities and specificities of imaging computer-aided detection and diagnosis devices, a prevalence-enriched dataset was utilized such that a 50% prevalence of intracranial hemorrhage was obtained. The algorithm was run on the dataset. Cases flagged by the algorithm as positive for ICH were defined as “positive”, and the rest as “negative”. The results were compared to the ground truth, determined by neuroradiologist review of the dataset. Sensitivity and specificity were calculated. Additionally, Negative-Predictive-Value (NPV) and Positive-Predictive-Value (PPV) calculations were made from the prevalence-enriched study data, which enable lower and upper threshold estimates for real-world NPV and PPV, respectively. Metrics were analyzed using a two-sided, exact binomial, 95% confidence-interval. Results: Algorithm sensitivity was 96.2% (CI: 93.2%-98.2%); specificity was 93.3% (CI: 89.6-96.0%). Estimated realworld NPV was determined as at least 96.2% (CI: 93.2%-97.9%), and an estimated upper threshold for PPV was estimated as 93.4% (CI: 90.1%-95.7%). Conclusion: The tested device detects intracranial hemorrhage with high sensitivity and specificity. These findings support the potential utility of using the device to autonomously surveil radiology worklists for studies containing critical findings, triage a busy workflow and ultimately improve patient care in clinically time-sensitive cases.

Severe Respiratory Failure, Extracorporeal Membrane Oxygenation, and Intracranial Hemorrhage.

For patients supported with veno-venous extracorporeal membrane oxygenation, the occurrence of intracranial hemorrhage is associated with a high mortality. It is unclear whether intracranial hemorrhage is a consequence of the extracorporeal intervention or of the underlying severe respiratory pathology. In a cohort of patients transferred to a regional severe respiratory failure center that routinely employs admission brain imaging, we sought 1) the prevalence of intracranial hemorrhage; 2) survival and neurologic outcomes; and 3) factors associated with intracranial hemorrhage. A single-center, retrospective, observational cohort study. Tertiary referral severe respiratory failure center, university teaching hospital. Patients admitted between December 2011 and February 2016. None. Three hundred forty-two patients were identified: 250 managed with extracorporeal support and 92 managed using conventional ventilation. The prevalence of intracranial hemorrhage was 16.4% in extracorporeal membrane oxygenation patients and 7.6% in conventionally managed patients (p = 0.04). Multivariate analysis revealed factors independently associated with intracranial hemorrhage to be duration of ventilation (d) (odds ratio, 1.13 [95% CI, 1.03-1.23]; p = 0.011) and admission fibrinogen (g/L) (odds ratio, 0.73 [0.57-0.91]; p = 0.009); extracorporeal membrane oxygenation was not an independent risk factor (odds ratio, 3.29 [0.96-15.99]; p = 0.088). In patients who received veno-venous extracorporeal membrane oxygenation, there was no significant difference in 6-month survival between patients with and without intracranial hemorrhage (68.3% vs 76.0%; p = 0.350). Good neurologic function was observed in 92%. We report a higher prevalence of intracranial hemorrhage than has previously been described with high level of neurologically intact survival. Duration of mechanical ventilation and admission fibrinogen, but not exposure to extracorporeal support, are independently associated with intracranial hemorrhage.

Prevalence of Intracranial Hemorrhage in Outside Hospital Cardiac Arrest Patients

SESSION TITLE: ICU Management SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: The purpose of this study is to evaluate patients with out-of-hospital cardiac arrest (OHCA) who have intracranial hemorrhage (ICH), and to determine if a protocol could be established in the emergency department (ED) to have head computed tomography (CT) performed prior to cardiac catheterization in certain patient populations. This is a retrospective study with the following specific aims: Aim 1) Determine the proportion of patients suffering an OHCA with return of spontaneous circulation (ROSC) diagnosed as having ICH. Aim 2) Compare demographic characteristics and co-morbidities of patients with and without ICH to determine which patient population is prone to OHCA and ICH, excluding those related to trauma. METHODS: This is a retrospective, multi-center (three institutions: Level I and II) study where 1987 patients over the age of 18 who had an OHCA were screened for obtaining ROSC either in the field or in the ED between January 1, 2010 and December 31, 2015. Out of 1987, 293 patients obtained ROSC. Information regarding pre-existing co-morbities; history of cerebrovascular diease, hypertension, diabetes mellitus, chronic kidney disease, tobacco use, anticoagulation therapy was collected. Presenting cardiac rhythm and whether head CT was obtained and presence of ICH on head CT was recorded. RESULTS: Of the 293 patients who experienced OHCA with ROSC, 50 (17.1%) patients had a head CT, 237 (80.9%) did not have a head CT, and presence/absence of a head CT was not documented for 6 (2.0%) patients. Patients who had a head CT were younger (mean: 59.3 years; SD: 18.5) than patients who did not have a head CT (mean: 65.9; SD: 18.0) (t: 2.34; df: 285; p=0.020). A smaller proportion of patients with hypertension, CKD had a head CT (14.7%, 6.0%) than patients without hypertension, CKD (27.9%, 22.7%) (χ2(1): 5.52; p=0.019), (χ2(1): 7.02; p=0.008). There was no difference in obtaining or not obtaining a head CT based on sex (χ2(1): 0.60; p=0.455), smoking status (χ2(1): 1.40; p=0.238), diabetes (χ2(1): 3.40; p=0.065), cerebrovascular disease (p=0.199), or anticoagulation therapy (p=0.158). Comparing presenting rhythm who had a CT; ventricular fibrillation/tachycardia (29.5%) , pulseless electrical activity/asystole (13.4%) (χ2(1): 7.78; p=0.005). Among the 50 patients who experienced OHCA with ROSC and had a head CT, 12 (24.0%) were diagnosed with ICH. Among patients who had a head CT, a greater proportion of patients with pulseless electrical activity/asystole had a diagnosis of ICH (42.9%) than patients with ventricular fibrillation/tachycardia (5.6%) (p=0.018). CONCLUSIONS: One fourth of the population presenting with OHCA who obtained ROSC were diagnosed with intracranial hemorrhage and presenting rhythm was PEA/asystole about 43% of the time. CLINICAL IMPLICATIONS: A substantial number of patients presenting with PEA/asytole who obtained ROSC had a diagnosis of ICH.Prompt neurosurgical intervention and transfer to appropriate facility may improve survival rate and functional outcome. Further pilot protocol can be established which triggers clinicians to obtain a head CT in patients with PEA/asystole who obtain return of spontaneous circulation. DISCLOSURE: The following authors have nothing to disclose: Aileen Ruffino, Sarita Gautam, Kruti Patel, Christy Collins, Moumita Chatterjee, Matthew Majzun No Product/Research Disclosure Information

Intracranial Hemorrhage: A Devastating Outcome of Congenital Bleeding Disorders-Prevalence, Diagnosis, and Management, with a Special Focus on Congenital Factor XIII Deficiency.

Intracranial hemorrhage (ICH) is a medical emergency. In congenital bleeding disorders, ICH is a devastating presentation accompanied with a high rate of morbidity and mortality. The prevalence of ICH is highly variable among congenital bleeding disorders, with the highest incidence observed in factor (F) XIII deficiency (FXIIID) (∼30%). This life-threatening presentation is less common in afibrinogenemia, FVIII, FIX, FVII, and FX deficiencies, and is rare in severe FV and FII deficiencies, type 3 von Willebrand disease and inherited platelet function disorders (IPFDs). In FXIIID, this diathesis most often occurs after trauma in children, whereas spontaneous ICH is more frequent in adults. About 15% of patients with FXIIID and ICH die; the bleeding causes 80% of deaths in this coagulopathy. Although in FXIIID, the bleed most commonly is intraparenchymal (> 90%), epidural, subdural, and subarachnoid hemorrhages also have been reported, albeit rarely. As this life-threatening bleeding causes neurological complications, early diagnosis can prevent further expansion of the hematoma and secondary damage. Neuroimaging plays a crucial role in the diagnosis of ICH, but signs and symptoms in patients with severe FXIIID should trigger replacement therapy even before establishment of the diagnosis. Although a high dose of FXIII concentrate can reduce the rate of morbidity and mortality of ICH in FXIIID, it may occasionally trigger inhibitor development, thus complicating ICH management and future prophylaxis. Nevertheless, replacement therapy is the mainstay of treatment for ICH in FXIIID. Neurosurgery is performed in patients with FXIIID and epidural hematoma and a hemorrhage diameter exceeding 2 cm or a volume of ICH is more than 30 cm3. Contact sports are not recommended in people with FXIIID as they can elicit ICH. However, a considerable number of safe sports and activities have been suggested to have more benefits than dangers for patients with congenital bleeding disorders, and are hence suitable for these patients.

Is intracranial hemorrhage increased in cirrhosis?: An autopsy-based case control study

AbstractBackground: Patients with cirrhosis are perceived to be at increased risk for bleeding given the presence of coagulopathy leading to unnecessary head imaging studies. Our aim is to determine the prevalence of intracranial hemorrhage (ICH) in patients with cirrhosis using gold standard autopsy data. Methods: An autopsy-based case control study was performed in a tertiary care hospital with a specialized Liver Unit. Autopsies without both head and abdominal examinations were excluded. Results: Between 1986 and 2003, a total of 679 autopsies were performed. 37 autopsies were excluded and 642 autopsies were available for final review. A total of 21 (4.3%) patients in the cirrhosis group had ICH compared to 12 (7.9%) patients in the control group (p = 0.115). Since Alzheimer’s patients may be at higher risk for ICH given the presence of cerebral amyloid angiopathy, a separate analysis was performed after excluding these patients. The results were similar (4.3% vs. 9.3%, p = 0.061). The prevalence of ol...

Neuroimaging Findings in Cardiac Myxoma Patients: A Single-Center Case Series of 47 Patients

Background and Purpose: Cardiac myxomas can present with a myriad of neurological complications including stroke, cerebral aneurysm formation and metastatic disease. Our study had two objectives: (1) to describe the neuroimaging findings of patients with cardiac myxomas and (2) to examine the relationship between a history of embolic complications secondary to myxoma and intracranial aneurysm formation, hemorrhage and metastatic disease. We hypothesized that patients who present with embolic complications related to myxoma would be more likely to have such complications. Materials and Methods: We searched our institutional database for all patients with pathologically proven cardiac myxomas from 1995 to 2014 who received neuroimaging. Neuroimaging findings were categorized as acute ischemic stroke, intracerebral hemorrhage, oncotic aneurysm, and cerebral metastasis. Cardiac myxoma patients were divided into those presenting with embolic complications (i.e. lower extremity emboli or cerebral emboli) and those presenting with non-embolic complications prior to surgical resection of the myxoma. The prevalence of intracranial hemorrhage, myxomatous aneurysm formation, and cerebral metastases was compared in myxoma patients presenting with and without embolic complications using a Chi-squared test. Results: Forty-seven consecutive patients were included in this study. Sixteen patients (34.0%) had imaging evidence of acute ischemic stroke. Of these, 13 had acute ischemic strokes directly attributed to the cardiac myxoma (27.7%) and 3 had acute ischemic strokes secondary to causes other than myxoma (6.4%). Seven patients (14.9%) had aneurysms. Two patients (4.3%) had parenchymal metastatic disease on long-term imaging. Fourteen patients (29.8%) presented with ischemic symptoms that were attributed to cardiac myxoma (1 with lower extremity ischemia, 1 with lower extremity ischemia and ischemic stroke, and 12 with ischemic stroke). Patients presenting with embolic complications related to the myxoma (ischemic stroke or lower extremity ischemia) were more likely to have imaging evidence of intracranial hemorrhage (21.4 vs. 3.0%, p = 0.09), oncotic aneurysm (35.7 vs. 6.1%, p = 0.03), and cerebral metastasis (14.3 vs. 0.0%, p = 0.07) on follow-up imaging. Conclusions: Ischemic stroke and intracranial oncotic aneurysm were found in a substantial proportion of cardiac myxoma patients undergoing neuroimaging. Patients presenting with embolic complications of cardiac myxoma are more likely to have intracranial hemorrhage, intracranial oncotic aneurysms, and cerebral metastatic disease.

Leptomeningeal collateral vessels are a major risk factor for intracranial hemorrhage after carotid stenting in patients with carotid atherosclerotic plaque

AimTo evaluate the relationship between leptomeningeal collaterals and intracranial hemorrhage (ICH) after carotid artery stenting (CAS).MethodsA retrospective study was undertaken of 228 patients (median age 75 years (range 44–90); 187...

Repeated linac-based radiosurgery in high-grade cerebral arteriovenous-malformations (AVM) Spetzler–Martin grade III to IV previously treated with radiosurgery

BackgroundAim was to access outcome and toxicity of repeated linac-based radiosurgery in incompletely obliterated cerebral AVM. Patients and methodsBetween 1998 and 2008, 11 patients were treated with repeated radiosurgery. The median dose to the 80%-isodose was 15Gy (range, 12–18Gy). During initial radiosurgery the median dose was 18Gy (range, 9–22Gy). ResultsThe median time interval between initial radiosurgery and re-treatment was 9years (range, 4–16years). The median follow-up was 26months (range, 2–115months). Treatment response was seen in 8 patients (89%). Complete (partial) obliteration was achieved in 5 (3) patients (56%, 33%, respectively).The median time to complete obliteration was 26months (range, 5–45months). Pre-existing neurological symptoms improved in 2 patients (18%), were stable in 7 patients (64%) and worsened in 2 patients (18%). Prevalence of intracranial hemorrhage was 9% (1/11). Post-re-treatment intracranial hemorrhage rate was 2.7% (1/38years at risk). During follow-up, no secondary malignancies or toxicity>grade III were observed. ConclusionRepeated linac-based radiosurgery in incompletely obliterated cerebral AVM is an effective treatment option with a high rate of treatment response and an acceptable risk for side effects. Marginal doses above 15Gy might further improve the rate of complete obliterations.

Imaging pattern of intracranial hemorrhage in the setting of posterior reversible encephalopathy syndrome

Intracranial hemorrhage (ICH) has been rarely described in the setting of posterior reversible encephalopathy syndrome (PRES). However, existing studies have even more rarely addressed the imaging pattern of PRES-related intracranial hemorrhage. The primary purpose of this study was to define the imaging characteristics of subarachnoid and intraparenchymal hemorrhage in the setting of PRES, including the location of hemorrhage with respect to the regions of parenchymal edema. We also reviewed PRES-related clinical features. We conducted a retrospective review of 263 patients with PRES seen at our institution between 2001 and 2008, and identified patients with PRES-related hemorrhage. We reviewed clinical charts and imaging studies of these patients in detail. The clinical data studied included factors predisposing to PRES (such as hypertension, eclampsia, immunosuppressant toxicity, etc.), mean arterial pressure, and coagulation parameters. Imaging characteristics we analyzed included the amount of hemorrhage, its location, multiplicity, and spatial relationship with parenchymal edema. We identified a total of 51 patients with PRES-related hemorrhage. The blood pressure was elevated in 80% of these patients, while 47% patients showed coagulopathy. Intraparenchymal hemorrhage (IPH) was present in 46 patients and subarachnoid hemorrhage (SAH) in 14. SAH spared basal cisterns in all patients, and was usually small in amount. IPH was often multifocal, and associated mass effect was rare. In most of the 51 patients, hemorrhage occurred near the parenchymal edema. The prevalence of ICH in PRES was 19.4% in our series. Both SAH and IPH can occur in association with PRES, typically in a location approximating that of parenchymal edema.

Intracranial haemorrhage in haemophilia A and B

In countries with a good standard of health care, intracranial haemorrhage (ICH) during the neonatal period affects 3.5-4.0% of all haemophilia boys, which is considerably (40-80 times) higher than expected in the normal population. ICHs are also frequent after the neonatal period, affecting 3-10% of the haemophilia population who are mainly treated on demand. The risk is higher in inhibitor patients. Spontaneous haemorrhage is reported more frequently than trauma-induced haemorrhage in most studies. The prevalence of ICH in patients treated with a prophylactic regimen is not known. Although more frequent in younger patients, a substantial proportion of ICH occur in adults, suggesting that general risk factors because of age, such as hypertension, are increasingly important as the haemophiliac gets older. Some studies have reported a substantial proportion of ICH affecting patients with milder forms of haemophilia. The risk of ICH has to be considered when discussing treatment strategies for haemophilia patients.

Mild Hypothermia and the Distribution of Cerebral Lesions in Neonates With Hypoxic-Ischemic Encephalopathy

Hypothermia induced by whole-body cooling (WBC) and selective head cooling (SHC) both reduce brain injury after hypoxia-ischemia in newborn animals, but it is not known how these treatments affect the incidence or pattern of brain injury in human newborns. To assess this, 14 term infants with hypoxic-ischemic encephalopathy (HIE) treated with SHC, 20 infants with HIE treated with WBC, and 52 noncooled infants with HIE of similar severity were studied with magnetic resonance imaging in the neonatal period. Infants fulfilling strict criteria for HIE were recruited into the study after assessment of an amplitude-integrated electroencephalography (aEEG). Cooling was commenced within 6 hours of birth and continued for 48 to 72 hours. Hypothermia was not associated with unexpected or unusual lesions, and the prevalence of intracranial hemorrhage was similar in all 3 groups. Both modes of hypothermia were associated with a decrease in basal ganglia and thalamic lesions, which are predictive of abnormal outcome. This decrease was significant in infants with a moderate aEEG finding but not in those with a severe aEEG finding. A decrease in the incidence of severe cortical lesions was seen in the infants treated with SHC.