Prior Intracranial Hemorrhage Research Articles

Stroke in Patients with Atrial Fibrillation: Epidemiology, Screening, and Prognosis.

Atrial fibrillation (AF) is the most common sustained arrythmia and one of the strongest risk factors and causal mechanisms of ischemic stroke (IS). Acute IS due to AF tends to be more severe than with other etiology of IS and patients with treated AF have reported to experience worse outcomes after endovascular treatment compared with patients without AF. As cardioembolism accounts for more than a fifth of ISs and the risk of future stroke can be mitigated with effective anticoagulation, which has been shown to be effective and safe in patients with paroxysmal or sustained AF, the screening of patients with cryptogenic IS (CIS) for AF is paramount. Embolic stroke of undetermined source (ESUS) is a subtype of CIS with a high likelihood of cardioembolism. The European Stroke Organization and European Society of Cardiology guidelines recommend at least 72 h of screening when AF is suspected. The longer the screening and the earlier the time point after acute IS, the more likely the AF paroxysm is found. Several methods are available for short-term screening of AF, including in-hospital monitoring and wearable electrocardiogram recorders for home monitoring. Implantable loop monitors provide an effective long-term method to screen patients with high risk of AF after IS and artificial intelligence and convolutional neural networks may enhance the efficacy of AF screening in the future. Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in both primary and secondary prevention of IS in AF patients. Recent data from the randomized controlled trials (RCT) also suggest that early initiation of DOAC treatment after acute IS is safe compared to later initiation. Anticoagulation treatment may still predispose for intracranial bleeding, particularly among patients with prior cerebrovascular events. Left atrial appendix closure offers an optional treatment choice for patients with prior intracranial hemorrhage and may offer an alternative to oral anticoagulation even for patients with IS, but these indications await validation in ongoing RCTs. There are still controversies related to the association of found AF paroxysms in CIS patients with prolonged screening, pertaining to the optimal duration of screening and screening strategies with prolonged monitoring techniques in patients with ESUS. In this review, we summarize the current knowledge of epidemiology, screening, and prognosis in AF patients with stroke.

Left appendage closure after intracranial hemorrhage: safety, efficacy and timing

Abstract Background Oral anticoagulation (OAC) use increases the risk of intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF). Left atrial appendage occlusion (LAAO) is an alternative to OAC, however data about its use in patients with prior ICH is scare and the timing of its performance is controversial. Furthermore, the long-term outcomes in this group of patients have not been described. Objective To evaluate the safety and efficacy of LAAO in patients with non-valvular AF and prior ICH (CHA2SVASc >2) and to determine adequate timing of its performance. Methods The sample was obtained from a cohort of 397 patients with AF in which LAAO was performed between 2009 and 2020. In 115 of these patients, the indication for this procedure was ICH (29.8 %). Patients were divided into two groups: early occlusion (n=68; 59%), in which the procedure was performed before 90 days had elapsed after the bleeding, and late occlusion (n=47; 41%), after 90 days. Results Procedure success was 97% globally. Annual incidence of ischemic events was of 0,6%, with an absolute risk reduction of 5,9% and relative risk reduction of 90,3% compared to the predicted risk by CHA2DS2-VASC score. Regarding major hemorrhagic events, annual incidence was of 4%, with an absolute risk reduction of 3,4% and relative risk reduction of 45% compared to the predicted risk by HASBLED score. There were no significant differences between the procedures performed in patients with history of intracranial bleeding and other indications for the procedure. Early closure (first 90 days after the intracranial hemorrhage) was as safe as late closure, without an increase in in-hospital bleedings or complications. Furthermore, long-term follow-up demonstrated a significant reduction in all-cause mortality (11.76% versus 46.8%; HR 0.2, IC95% 0.07-0.55; p<0.001). compared with late occlusion. Conclusions Left atrial appendage occlusion is an effective and safe treatment option to reduce the risk of ischemic stroke in selected patients with AF patients and history of ICH over mean follow-up of 3 years. Early occlusion seems to be at least as safe and effective as late occlusion and therefore could potentially reduce the rate of complications after ICH in selected patients.Survival and closure timingIschemic and bleeding risk reduction

Stroke Prevention With Left Atrial Appendage Closure in Patients With Atrial Fibrillation and Prior Intracranial Hemorrhage

BackgroundOral anticoagulation (OAC) is deemed a relative contraindication after intracranial hemorrhage (ICH) if the cause cannot be eliminated and the risk of recurrence is high. That leaves atrial fibrillation (AF) patients at high risk of thromboembolic events. Endovascular left atrial appendage closure (LAAC) can be an alternative to OAC for patients requiring stroke prevention. MethodsWe performed a retrospective single-centre analysis of 138 consecutive ICH patients with nonvalvular AF and high stroke risk who underwent LAAC between 2010 and 2022 at Vancouver General Hospital. We report the baseline characteristics, procedural results, and follow-up data, comparing the observed stroke/transient ischemic attack (TIA) rate with the predicted event rate based on their CHA2DS2-VASc scores. ResultsThe average age was 76.1 ± 8.5 years; the mean CHA2DS2-VASc score was 4.4 ± 1.5; and the mean HAS-BLED score was 3.7 ± 0.9. The procedural success rate was 98.6%, and the complication rate was 3.6% with no periprocedural death, stroke, or TIA. The antithrombotic regimen post-LAAC consisted of short-term dual antiplatelet therapy (1-6 months) followed by aspirin alone for a minimum of 6 months in 86.2%. At mean follow-up of 14.7 ± 13.7 months, 9 deaths (6.5%, 7 cardiovascular, 2 noncardiovascular), 2 strokes (1.4%), and 1 TIA (0.7%) had occurred. The annualized observed stroke/TIA rate was 1.8%, which was lower than the adjusted predicted stroke rate of 7.0% (95% confidence interval: 4.8%-9.2%). Two patients (1.5%) suffered another ICH (both on aspirin monotherapy). One device-related thrombus (0.7%) was confirmed and treated with OAC without sequelae. ConclusionEndovascular LAAC is a feasible alternative to OAC for stroke prevention in patients with nonvalvular AF and prior ICH.

Factors Associated With Short-Term Outcomes of Burr-Hole Craniostomy Associated With Brain Re-Expansion and Subdural Hematoma Shrinkage for Chronic Subdural Hematoma.

Chronic subdural hematoma (CSDH) is a commonly encountered neurosurgical pathology that frequently requires surgical intervention. With an increasingly aging demographic, more older people and patients with comorbidities will present with symptomatic CSDH. This study evaluated clinical and laboratory factors affecting the short-term outcomes of CSDH after surgical intervention. We retrospectively analyzed 170 patients who underwent burr-hole trephination for CSDH in a single institution from January 2019 to December 2021. All patients were examined for risk factors and evaluated for hematoma thickness change and midline shifting on brain computed tomography (CT) scans at 3 days after burr-hole trephination. This consecutive series of patients included 114 males (67.1%) and 56 females (32.9%); mean age 72.4±12.5 years. Renal disease (p=0.044) and prior intracranial hemorrhage (p=0.004) were clinical factors associated with poorer prognosis. A statistically significant association was found between initial laboratory findings, including high creatine kinase (p=0.025) and low platelet (p=0.036) levels, and CT findings 3 days postoperatively. The 3-day mean arterial pressure and postoperative ambulation were not significantly associated with outcomes. Burr-hole craniostomy is an effective surgical procedure for initial CSDH. However, patients with a history intracranial hemorrhage and abnormal laboratory findings, such as low platelet levels, who underwent burr-hole trephination had poor short-term outcomes. Therefore, these patients should be carefully monitored.

Risk of Intracranial Hemorrhage in US Patients with Hemophilia a: Real-World Retrospective Cohort Study Using the Athndataset

Background Intracranial hemorrhage (ICH), a serious complication of hemophilia A (HA), causes high rates of mortality and morbidity (Zanon. Blood Transfus. 2019). The risk of developing ICH is 10 to 20 times higher in patients with HA (PWHA) than in individuals without (Zanon. 2019). Patient data from 1998 through 2008 identified several risk factors for ICH, including presence of an inhibitor and prior ICH (Witmer. Br J Haematol. 2010). However, standard of care and the treatment landscape have evolved (Srivastava. Haemophilia. 2020). This study leverages clinical information from the ATHNdataset to assess the incidence of ICH in non-neonate (≥2 years of age) PWHA and determine the association between ICH risk and key characteristics. Methods This retrospective cohort study used data from PWHA (male, aged >2 and <75 years) who had visit information from January 1, 2010, through September 30, 2020, as identified in the ATHNdataset. The American Thrombosis & Hemostasis Network (ATHN) is the steward of the ATHNdataset, a Health Insurance Portability and Accountability Act-compliant, de-identified patient health dataset containing data from individuals with bleeding disorders receiving care through ATHN affiliates who opt in to contribute. The unadjusted incidence rate (IR) and incidence rate ratio (IRR) were evaluated by inhibitor and prophylaxis status. Association between patient characteristics and risk of ICH (HR) was evaluated by time-to-event analysis using univariate and multivariate Cox proportional-hazards (CoxPH) models. Stratified bootstrap analysis and penalty-based ridge regression sensitivity analyses were done to account for the rarity of ICH and small sample bias. Results In over 10 years and 9 months of collected data, 135 of 7837 PWHA (1.7%) had an ICH, with a median follow-up time of 10.7 patient-years. The incidence of ICH by demographic, clinical, and treatment characteristics is described in Table 1. In the unadjusted analysis, stratification by inhibitor status had an IRR (IR+/IR-) of 1.76 (95% CI: 0.97-3.20; P=0.059). IRR (IR+/IR-) by prophylaxis status in the unadjusted analysis was 0.63 (95% CI: 0.43-0.94; P=0.02). Univariate CoxPH modeling and multivariate CoxPH modeling with interaction, with associated bootstrap and ridge regression analyses, identified factors associated with differential risk of developing ICH (Table 2). Characteristics associated with a greater risk of developing ICH include being between the ages of 2 and 12 years, having ever been on Medicaid, having had HIV, hepatitis C (HCV), or hypertension (HTN) comorbidities, and never having received factor VIII (FVIII) or prophylactic treatment. In the multivariate population analysis, the estimated HR for patients never receiving prophylaxis was 7.67 (95% CI: 0.81-3.27). This HR estimate shrunk to 2.03 (95% CI: 0.26-2.21) in the associated bootstrapping analysis and 3.09 in the associated highest penalty ridge regression analysis but was still found to be statistically significant. Inhibitor status was not found to be statistically associated with ICH. Results related to an interaction between prophylaxis and inhibitor status (Table 2) could not be interpreted because of the small sample size. Discussion ICH is a serious, life-threatening complication for PWHA, hence the need to identify factors associated with increased risk of ICH. This is the first study in a decade evaluating key demographic, clinical, and HA treatment characteristics for associated risk of PWHA developing ICH. These results demonstrate that risk factors for ICH include age (greatest risk in children between the ages of 2 and 12 years), having ever been on Medicaid, having had HIV, HCV, or HTN comorbidities, and never having received FVIII or prophylactic treatment. It was previously shown that prophylaxis confers a protective effect against ICH in instances of severe disease (Witmer 2010) and in children and adolescents (Andersson. Br J Haematol. 2017). Inhibitor positivity has been shown to increase risk for ICH (Witmer 2010; Zanon. Haemophilia. 2012); however, this study was unable to corroborate those findings. A larger sample size is required to draw substantive conclusions regarding the joint impact of prophylaxis and inhibitor status on risk of ICH. As the treatment landscape for HA evolves with the increased use of non-factor products and gene therapy, continued evaluation of risk factors for ICH will be needed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Treatment patterns and outcomes of second-line rituximab and thrombopoietin receptor agonists in adult immune thrombocytopenia: A Canadian retrospective cohort study

BackgroundThe optimal choice of second-line treatment for immune thrombocytopenia (ITP) is unclear. Guidelines recommend either rituximab, splenectomy, or thrombopoietin receptor agonists (TPO-RA). There is, however, scarce data comparing treatment patterns, outcomes and resource utilization across second-line treatments. Despite Canada's universal healthcare system, publicly funded access to second-line ITP therapies is highly variable across provinces/territories. ObjectivesTo describe treatment patterns and compare health service utilization and outcomes among recipients of second-line rituximab and TPO-RA for ITP. MethodsIn this multicentre retrospective cohort study, we included adults who received second-line ITP therapies rituximab, eltrombopag and romiplostim (2012-2020) in Alberta, Canada. Patients were identified through a provincially-funded special drug access (STEDT) program. We examined treatment patterns, predictors of second-line treatment, hospitalizations, blood product utilization, and outcomes. Kaplan-Meier survival curves were used to estimate the cumulative incidence of ITP-related hospitalizations (bleeding or infections), overall survival (OS) and relapse-free survival (RFS). Cox proportional hazards regression was used to examine the impact of second-line therapy on OS. Results223 patients received rituximab (67 %), eltrombopag (29 %), and romiplostim (4 %). TPO-RA recipients experienced significantly longer time from ITP diagnosis to second-line therapy compared with rituximab recipients (15.9 vs 6.7 months, P < 0.0001), accompanied by significantly higher platelet and IVIG utilization prior to second-line therapy. Age (adjusted odds ratio [aOR] 1.04, 95 % CI 1.02–1.07, P < 0.0001) and prior intracranial hemorrhage (aOR 12.7, 95 % CI 1.6–272.8, P = 0.03) were significant predictors of second-line TPO-RA. TPO-RA is associated with a trend towards longer median RFS (6.3 vs 3.8 years, P = 0.06) compared with rituximab, and similar rates of ITP-related hospitalizations, major bleeding, and thromboembolism. Age, time period, and Charlson comorbidity index, but not second-line ITP therapy, were significant predictors of OS. ConclusionsOur study identified older age and intracranial hemorrhage as predictors of second-line TPO-RA prescription in a real-world practice. There were no significant differences in hospitalizations and outcomes between second-line rituximab and TPO-RA, although delayed initiation of TPO-RA was associated with higher blood product utilization.

Safety and efficacy of intravenous thrombolysis in acute ischemic stroke patients with a history of intracranial hemorrhage: A systematic review and meta-analysis

Acute ischemic stroke (AIS) is a fatal and debilitating condition killing 2.7 million people each year worldwide. The most commonly used treatment modality for AIS is intravenous thrombolysis (IVT) with alteplase which is indicated for those presenting within 4.5 h of onset. Due to a lack of reliable evidence on harm or benefit, the 2019 American Heart Association/American Stroke Association (AHA/ASA) guidelines consider a history of previous intracranial hemorrhage (ICH) as potentially harmful and no longer an absolute contraindication for IVT in patients with AIS, and the U.S. Food and Drug Administration (FDA) removed chronic ICH as a specific contraindication for IVT from the label in 2015. Despite a shift in guidelines, physicians frequently face the dilemmatic choice whether to administer IVT in this subset of patients due to the risk of symptomatic intracranial hemorrhage (SICH). The benefit of IVT in such patients has not been thoroughly investigated, and there are only a few studies on the subject in the literature to date. We conducted the present meta-analysis in an aim to provide solid evidence on the efficacy and safety of IVT for treating AIS in patients with a history of remote ICH. Our meta-analysis found that IVT improves functional outcomes in AIS patients with prior remote ICH without increasing SICH or all-cause mortality. These findings may contribute to the decision-making process for IVT administration in AIS patients.

Intravenous thrombolysis in ischemic stroke patients with a prior intracranial hemorrhage: a meta-analysis

Background:The history of intracranial hemorrhage (ICrH) is considered a contraindication for intravenous thrombolysis (IVT) among patients with acute ischemic stroke (AIS). Objective: This study aimed at comparing the safety of IVT among patients with and without a history of ICrH.Methods:We performed a systematic review of the literature. Data regarding all AIS patients with prior ICrH who received IVT were retrieved. Meta-analysis was performed to compare the rate of symptomatic hemorrhagic transformation (sHT), death within 90 days, and favorable and unfavorable 90-day functional outcomes based on modified Rankin Scale (mRS) among stroke patients with and without prior ICrH.Results:Out of 13,032 reviewed records, 7 studies were included in the systematic review and meta-analysis. Quantitative synthesis of data regarding the rate of sHT (5068 patients) revealed no significant difference between the two groups [odds ratio, OR: 1.55 (0.77, 3.12); p = 0.22]. However, a significantly higher risk of death within 90 days [OR: 3.91 (2.16, 7.08); p < 0.00001] and a significantly higher 90-day poor functional outcomes (mRS, 4–6) [OR: 1.57 (1.07, 2.30); p = 0.02] were observed among patients with prior ICrH. Likewise, the percentage of 90-day good functional outcomes (mRS, 0–1) was lower in the prior ICrH group [OR: 0.54 (0.35, 0.84); p = 0.06]. Subgroup analyses in patients with a history of ICrH (based on both patients’ medical history and imaging confirmation) revealed no significant between-group differences in rates of sHT. Also, sensitivity analysis consisting of only studies using standard-dose IVT showed no difference in sHT rates and 90-day outcomes between the two groups. There was no evidence of heterogeneity (I2 >50%) among included studies.Conclusion:The results of this study indicated that prior history of ICrH does not increase the risk of sHT post-IVT, but it is associated with a higher risk of death and poor functional outcomes in 90 days.

Intracranial Bleeding After Percutaneous Coronary Intervention: Time-Dependent Incidence, Predictors, and Impact on Mortality.

BackgroundLimited data are available on intracranial hemorrhage (ICH) in patients undergoing antithrombotic therapy after percutaneous coronary intervention (PCI).Methods and ResultsUsing the Korean National Health Insurance Service database, we identified 219 274 patients without prior ICH and who underwent a first PCI procedure between 2007 and 2016 and analyzed nontraumatic ICH and all‐cause mortality. ICH after PCI occurred in 4171 patients during a median follow‐up of 5.6 years (overall incidence rate: 3.32 cases per 1000 person‐years). The incidence rate of ICH showed an early peak of 21.66 cases per 1000 person‐years within the first 30 days, followed by a sharp decrease to 3.68 cases per 1000 person‐years between 30 days and 1 year, and to <1 case per 1000 patient‐years from the second year until 10 years after PCI. The 1‐year mortality rate was 38.2% after ICH, with most deaths occurring within 30 days (n=999, mortality rate: 24.2%). No significant difference in mortality risk was observed between patients who had ICH within and after 1 year following PCI (adjusted hazard ratio, 1.04; 95% CI, 0.95–1.14; P=0.43). The predictors of post‐PCI ICH were age ≥75 years, hypertension, atrial fibrillation, end‐stage renal disease, history of stroke or transient ischemic attack, dementia, and use of vitamin K antagonists.ConclusionsNew ICH most frequently occurs in the early period after PCI and is associated with a high risk of early death, regardless of the occurrence time of ICH. Careful implementation of antithrombotic strategies is needed in patients at an increased risk for ICH, particularly in the peri‐PCI period.

Impact of Non-Vitamin K Antagonist Oral Anticoagulants on the Change of Antithrombotic Regimens in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention.

Background and ObjectivesAntithrombotic therapy after percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF) has changed in recent years with new data from large randomized trials and updates to clinical guidelines. This study aimed to investigate the trends in periprocedural antithrombotic regimens in Korean patients with AF undergoing PCI with non-vitamin K antagonist oral anticoagulants (NOACs).MethodsUsing the claims database of the Health Insurance Review and Assessment during 2013–2018, 27,594 patients with AF undergoing PCI were identified. The annual prevalence of PCI and prescriptions of each antithrombotic agent, including antiplatelet agents and oral anticoagulants, within 30 days after PCI were investigated.ResultsDuring 2013–2018, the number of patients with AF undergoing PCI increased up to 1.3-fold (from 3,913 to 5,075 patients per year). After the introduction of NOACs, the proportion of dual antiplatelet therapy (DAPT) decreased from 71.9% to 49.8% but still occupied the largest proportion among antithrombotic regimens. Triple antithrombotic therapy (TAT) use increased from 25.4% to 46.0%, and NOAC has rapidly replaced warfarin as the oral anticoagulant of choice. TAT was preferred to DAPT for patients with CHA2DS2-VASc score ≥2. Among various factors, prior intracranial hemorrhage was the most powerful predictor of favoring DAPT use over TAT.ConclusionSince the introduction of NOACs, the patterns of periprocedural antithrombotic regimens have changed rapidly toward more use of TAT, specifically with NOAC-based regimen. Appropriate stroke prevention with oral anticoagulants is still underutilized in patients with AF undergoing PCI in Korea.

Association of Ischemic Stroke, Major Bleeding, and Other Adverse Events With Warfarin Use vs Non–vitamin K Antagonist Oral Anticoagulant Use in Patients With Atrial Fibrillation With a History of Intracranial Hemorrhage

Current guidelines recommend the use of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (AF). Data regarding warfarin sodium use compared with NOAC use in patients with AF with a history of intracranial hemorrhage (ICH) are limited. To compare the clinical outcomes of warfarin use and NOAC use in patients with AF with a history of ICH using a nationwide cohort with AF. A nationwide cohort study from January 1, 2012, to December 31, 2016, was performed using data from the Taiwan National Health Insurance Research Database. The dates of analysis were July 1 to September 1, 2019. The study population comprised patients with AF with a history of ICH and a CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, prior stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease], age 65-74 years, sex category [female]) of at least 1 for men or at least 2 for women who had received warfarin or NOACs. The clinical outcomes were examined using Cox proportional hazards regression analyses among the study population before and after propensity score matching. Oral anticoagulation with warfarin or NOACs. The clinical outcomes measured were all-cause mortality, ischemic stroke, ICH, major bleeding, and adverse events. The study cohort included 4540 patients (mean [SD] age, 76.0 [10.5] years; 2653 men [58.4%]), with 1047 patients receiving warfarin (mean [SD] age, 75.1 [11.4] years; 571 men [54.5%]) and 3493 patients receiving NOACs (mean [SD] age, 76.3 [10.2] years; 2082 men [59.6%]). Compared with warfarin use, NOAC use was associated with statistically significantly lower risk of all-cause mortality (adjusted hazard ratio [aHR], 0.517; 95% CI, 0.457-0.585), ICH (aHR, 0.556; 95% CI, 0.389-0.796), and major bleeding (aHR, 0.645; 95% CI, 0.525-0.793), whereas the rate of ischemic stroke was similar in the 2 groups (aHR, 0.879; 95% CI, 0.678-1.141). These results were generally consistent after propensity score matching among 973 patients in each group. Among patients with AF with prior ICH, NOAC use was associated with lower rates of ICH and major bleeding compared with warfarin use, whereas the rate of ischemic stroke was similar in the 2 groups. Among patients with AF with prior ICH, NOACs could be the preferred choice for stroke prevention.

Predictors of localization, outcome, and etiology of spontaneous intracerebral hemorrhages: focus on cerebral amyloid angiopathy

Despite its clinical relevance, cerebral amyloid angiopathy (CAA) is underdiagnosed worldwide. This retrospective study aimed to assess the incidence, etiology, predictors, and outcome of intracerebral hemorrhages (ICHs) in this region, with special focus on possible underlying CAA. Database screening of acute cares with intracranial hemorrhage diagnosis within 01/07/2014–01/07/2018 were conducted analyzing medical records and imaging. Spontaneous ICHs were classified as deep (basal ganglionic/thalamic/brainstem) and lobar/cerebellar (i.e., CAA-compatible) ICHs. Probable/definite CAA was established using the modified Boston criteria in a subgroup with ‘complete’ radiological/neuropathological work-up. The ability of several factors to discriminate between deep and lobar/cerebellar ICHs, between probable/definite CAA and non-probable CAA cases, and to predict 1-month case fatality was assessed. Of the 213 ICHs identified, 121 were in deep and 92 in lobar/cerebellar localization. Sub-analysis of 47 lobar/cerebellar ICHs with ‘complete’ work-up identified 16 probable/definite CAA patients, yielding an estimated 14.7% prevalence of CAA-related ICHs. Chronic hypertension was the most prevalent risk factor for all types of ICHs (including CAA-related), with hypertensive excess and younger age being independent predictors of deep whereas antiplatelet use of lobar/cerebellar localization. The 1-month case fatality was 33.8%, driven predominantly by age and INR > 1.4. Probable/definite CAA diagnosis was independently predicted by age, prior intracranial hemorrhage, and antiplatelet use. First in this region and among the few in the literature, this study reports a remarkable prevalence of CAA-related ICHs, emphasizing the need for an increased awareness of CAA and its therapeutic implications, especially regarding antiplatelets among the elderly.

Differences in Outcomes Associated With Individual Radiologists for Emergency Department Patients With Headache Imaged With CT: A Retrospective Cohort Study of 25,596 Patients.

OBJECTIVE. The purpose of this study was to determine whether diagnostic radiologists impart variation into resource use and patient outcomes in emergency department (ED) patients undergoing CT for headache. MATERIALS AND METHODS. This was a single-institution retrospective quality assurance cohort study of 25,596 unique adult ED patients undergoing head CT for headache from January 2012 to October 2017. CT examinations were interpreted by 55 attending radiologists (25 neuroradiologists, 30 radiologists of other specialties) who each interpreted a mean of 1469.8 ± 787.9 CT examinations. Risk adjustment for variables thought to influence outcome included baseline risk (demographics, Elixhauser comorbidity score), clinical factors (vital signs, ED triage and pain scores, laboratory data, hydrocephalus, prior intracranial hemorrhage, neurosurgical consultation within last 12 months), and system factors (time of CT, physician experience, neuroradiology training). Multivariable models were built to analyze the effect of individual radiologists on subsequent outcomes. Any p value less than 0.007 was considered significant after Bonferroni correction. RESULTS. The study found 57.5% (14,718/25,596) of CT interpretations were performed by neuroradiologists, and most patients (98.1% [25,119/25,596]) had no neurosurgical history. After risk adjustment, individual radiologists were not an independent predictor of hospital admission (p = 0.49), 30-day readmission (p = 0.30), 30-day mortality (p = 0.14), or neurosurgical intervention (p = 0.04) but did predict MRI use (p < 0.001; odds ratio [OR] range among radiologists, 0.009-38.2), neurology consultation (p < 0.001; OR range, 0.4-3.2), and neurosurgical consultation (p < 0.001; OR range, 0.1-9.9). CONCLUSION. Radiologists with different skills, experience, and practice patterns appear interchangeable for major clinical outcomes when interpreting CT for headache in the ED, but their differences predict differential use of downstream health care resources. Resource use measures are potential quality indicators in this cohort.

Abstract TMP116: Intracranial Hemorrhage Rate in Familial Cerebral Cavernous Malformation Patients

Background: Familial cerebral cavernous malformations (FCCM) is an autosomal dominant disease caused by mutations in three genes: CCM1 , CCM2 , or CCM3 . FCCM patients typically present with multiple brain CCMs that can increase in number and size over time, and can cause intracranial hemorrhage (ICH) and other disabling symptoms, e.g., seizures, headaches, and deficits. Rates and predictors of ICH events in FCCM are not well described. The purpose of this study was to estimate ICH event rates and predictors in a cohort of FCCM patients followed prospectively. Methods: We collected baseline and follow-up data in 316 FCCM patients enrolled from 4 sites in the Brain Vascular Malformation Consortium CCM Project, including age, sex, race, CCM gene, CCM symptoms, and CCM burden (total and large CCMs&gt;5mm) at baseline. We initially recruited CCM1 patients with the Common Hispanic Mutation (CHM), and later expanded to include other genetic types. We performed Kaplan-Meier survival analysis to estimate ICH event rates after enrollment, censoring at date of first treatment, death or last follow-up, out to 10 years. Cox regression analysis was performed to estimate hazard ratios (HR) of predictors, adjusting for age, sex, and family. Results: The majority of patients were female (63%) and of Hispanic ethnicity (83%). CCM gene mutation was known for 82%; 98% had CCM1 mutations (94% with CHM), 1% CCM2 , and 1% CCM3 . At enrollment, mean age was 39±20 years (range: 1-85), 32% had a history of ICH event, 38% had seizures, and 60% had headaches. Mean number of total and large CCMs was 55±103 and 4±7, respectively. Mean follow-up was 4.1±2.7 years. During 1285 person-years (PY) of follow-up, there were 31 ICH events for a rate of 2.4 per 100 PY (95% CI: 1.7-3.4) overall, 4.0 (2.5-6.6) in prior ICH patients, and 1.6 (1.0-2.8) in patients without prior ICH (HR=2.4, 95% CI: 1.2-4.9). ICH-free survival was not statistically significantly different by sex (HR=1.2, 95% CI: 0.6-2.8), age (HR=1.0 per decade, 0.8-1.2), total lesions (HR=1.2 per doubling, 0.9-1.5), or large lesions (HR=1.3 per doubling, 1.0-1.7). Conclusions: FCCM patients with prior history of ICH events are at higher risk for re-hemorrhage during follow-up. Additional studies are needed to identify predictors of ICH risk in FCCM.

Oral Anticoagulation in Asian Patients With Atrial Fibrillation and a History of Intracranial Hemorrhage.

Background and Purpose- Warfarin is associated with a better net clinical benefit compared with no treatment in patients with nonvalvular atrial fibrillation (AF) and history of intracranial hemorrhage (ICH). There are limited data on nonvitamin K antagonist oral anticoagulants (NOACs) in these patients, especially in the Asian population. We aimed to compare the effectiveness and safety of NOACs to warfarin in a large-scale nationwide Asian population with AF and a history of ICH. Methods- Using the Korean Health Insurance Review and Assessment database from January 2010 to April 2018, we identified patients with oral anticoagulant naïve nonvalvular AF with a prior spontaneous ICH. For the comparisons, warfarin and NOAC groups were balanced using propensity score weighting. Ischemic stroke, ICH, composite outcome (ischemic stroke+ICH), fatal ischemic stroke, fatal ICH, death from composite outcome, and all-cause death were evaluated as clinical outcomes. Results- Among 5712 patients with AF with prior ICH, 2434 were treated with warfarin and 3278 were treated with NOAC. Baseline characteristics were well-balanced after propensity score weighting (mean age 72.5 years and CHA2DS2-VASc score 4.0). Compared with warfarin, NOAC was associated with lower risks of ischemic stroke (hazard ratio [HR], 0.77 [95% CI, 0.61-0.97]), ICH (HR, 0.66 [95% CI, 0.47-0.92]), and composite outcome (HR, 0.73 [95% CI, 0.60-0.88]). NOAC was associated with lower risks of fatal stroke (HR, 0.54 [95% CI, 0.32-0.89]), death from composite outcome (HR, 0.53 [95% CI, 0.34-0.81]), and all-cause death (HR, 0.83 [95% CI, 0.69-0.99]) than warfarin. NOAC showed nonsignificant trends toward to reduce fatal ICH compared with warfarin (HR, 0.47 [95% CI, 0.20-1.03]). Conclusions- NOAC was associated with a significant lower risk of ICH and ischemic stroke compared with warfarin. NOAC might be a more effective and safer treatment option for Asian patients with nonvalvular AF and a prior history of ICH.

Left atrial appendage closure: A therapy uniquely suited for specific populations of patients with atrial fibrillation.

Atrial fibrillation (AF) is the most common clinically relevant arrhythmia and confers a fivefold increased risk for stroke. Cardioembolic stroke secondary to AF is a devastating event, but is largely preventable with appropriate oral anticoagulation (OAC). The PROTECT and PREVAIL trials demonstrated that the WATCHMAN left atrial appendage closure (LAAC) device in combination with short-term warfarin therapy is noninferior to long-term warfarin with respect to a composite endpoint of stroke, cardiovascular death, and systemic embolism. Importantly, the WATCHMAN confers a significant reduction in life-threatening bleeding compared to OAC. Although direct-acting oral anticoagulant (DOAC) are superior to warfarin in eligible patients, several important AF populations exist in whom left atrial appendage (LAA) closure may be preferable to DOAC. Populations warranting strong consideration of LAAC include patients with contraindications to DOAC, end-stage renal disease, prior intracranial hemorrhage, recurrent gastrointestinal bleeding, and patients undergoing transcatheter aortic valve replacement or left atrial electrical isolation. Device-related thrombosis is an important complication of LAAC, and DOAC may be preferential to warfarin for prevention and treatment of this complication remains unexplored. Prospective clinical trials comparing DOAC to LAAC in these unique populations are either ongoing or needed.

Derivation of a clinical decision instrument to identify patients with status epilepticus who require emergent brain CT

BackgroundStudies have shown the value of CT brain imaging in adults with first-time seizures, but there are no recommendations regarding emergent brain CTs in persons with an established seizure disorders. Our study aimed to derive a clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) require emergent brain imaging. MethodsThis was a retrospective chart review of patients who presented to our emergency department with SE between 2010 and 2018. Patients with first-time seizures were excluded. A priori, we defined high risk criteria for emergent imaging as well as positive findings on brain CT. High risk criteria included known malignancy, trauma, and immunosuppression. Positive CT scans included findings such as intracranial hemorrhage (ICH) and mass. ResultsWe identified 214 patients who met inclusion criteria Of the 181 patients without high risk criteria, 3% had positive CT scans. Of the 33 patients with high risk criteria, 10% had positive CT scans. The sensitivity, specificity, PPV, and NPV for our initial CDI were 38%, 85%, 9%, and 97%. Adding the criterion of prior ICH would have lowered our miss rate to 0.6%. Modifying our CDI to 1) History of ICH, 2) Malignancy, 3) Immunosuppression, and 4) Trauma would result in a CDI with sensitivity, specificity, PPV, and NPV of 87.5%, 87.4%, 21.2%, and 99.5%. ConclusionsBy using four criteria to identify high risk patients, we can defer CT scanning in the vast majority of patients with SE and known seizure disorders. This CDI should be prospectively validated before adoption.

Abstract WP32: Mechanical Thrombectomy for Mild Acute Ischemic Stroke with Large Vessel Occlusion: Results from the MISTWAVE Prospective Study

Introduction: Endovascular therapy (EVT) for emergent large vessel occlusion (ELVO) is standard of care for disabling strokes. There is no sufficient prospective data evaluating EVT for mild ischemic stroke with ELVO. Retrospective data suggests that many patients may not have favorable outcomes without intervention. We present our initial data investigating safety and outcomes of EVT in patients with ELVO and initial NIHSS of &lt; 6. Methods: Our single arm prospective study (Mild acute Ischemic Stroke With lArge Vessel occlusion - MISTWAVE) recruited patients in 2 large tertiary care centers. Inclusion criteria included anterior circulation or basilar artery ELVO within 24 hours of onset. We excluded patients with ASPECTS score ≤ 6 on pre-intervention imaging, prior intracranial hemorrhage, or current anticoagulant use. Our primary endpoints were symptomatic cerebral hemorrhage within 24 hours, and/or change in NIHSS by ≥ 4 points within 72 hours or during hospitalization. Secondary endpoints included angiographic recanalization grade, NIHSS and disability assessment at discharge, 30 days, or on last follow-up. Results: We screened over 50 patients, and enrolled 20 as of November 2018 (mean age 65.6 ± 12.3 years; 55% males; 12 M1 occlusions, 8 M2 occlusions). Main reasons for exclusion were: outside treatment window, worsening NIHSS to &gt;5, tandem or extracranial carotid occlusion, and inability to obtain consent. TICI 2B/3 thrombectomy was achieved in 95% of patients. The median NIHSS on presentation was 3 (range 0-5), and at last available follow-up it was 0 (0-10). The majority of patients (85%) were discharged home with minimal or no residual deficits. The average follow-up was 60.9 days (range 9-210 days), and mRS 0-2 was achieved in 90%. None of the patients suffered symptomatic cerebral hemorrhage. One patient (5%) had neurologic worsening within 24 hours despite TICI 3 recanalization. There were no other periprocedural complications. Conclusion: This is one of the first truly prospective studies designed to assess the safety and feasibility of EVT in patients with low NIHSS and ELVO. Our results are preliminary, but suggest excellent radiographic and clinical outcomes, and no significant procedural complications.

Left atrial appendage closure device implantation in patients with prior intracranial hemorrhage

The Watchman device (Boston Scientific), used for left atrial appendage closure (LAAC), was approved for stroke prevention in patients with atrial fibrillation (AF) and an appropriate rationale to avoid long-term oral anticoagulation. Patients with AF and prior intracranial hemorrhage (ICH) were excluded from clinical trials because of perceived risks of perioperative anticoagulation. The purpose of this study was to study the efficacy and safety of LAAC using Watchman in patients with AF and prior ICH. In a multidisciplinary AF/stroke prevention clinic, 38 consecutive patients with AF and prior ICH underwent Watchman implantation. Patients were enrolled in a prospectively maintained data registry. Patients' mean CHA2DS2-VASc score was 5.0 ± 1.3 and HAS-BLED score 4.2 ± 1.0. Prior ICH events were intraparenchymal (60%), subdural (24%), or subarachnoid bleeds (16%). The median event-to-implantation time was 637 days (minimum 60). Watchman was implanted in all patients with no procedural complications. All patients completed 45 days of anticoagulation with warfarin (55%), apixaban (37%), or dabigatran (8%). Transesophageal echocardiograms at 45 days showed no peridevice leak, and 1 patient had a small filamentous echodensity on device that resolved with anticoagulation. While undergoing anticoagulation, none of the patients developed recurrent ICH. Minor bleeding occurred in 1 patient (trauma-related lower extremity hematoma at 19 days postimplantation). At 13.4 months (quartiles 8-19) of follow-up, there were no strokes, ICH, or deaths. AF patients with prior ICH tolerated short-term anticoagulation for the purpose of Watchman implantation. LAAC with attendant short-term anticoagulation seems to be both safe and effective in this patient population.

P4798Safety of short-term anticoagulation for watchman implantation in patients with prior intracranial hemorrhage

P4798Safety of short-term anticoagulation for watchman implantation in patients with prior intracranial hemorrhage