Severe Intracranial Hemorrhage Research Articles

Neonatal Presentation of Severe Hemophilia A: An Original Case Report and a Literature Review

Introduction: We report the case of a neonate diagnosed with severe hemophilia A (HA) and conduct a literature review of cases of severe HA presenting at the neonatal age to help define the clinical diagnostic findings and existing differences between the sporadic and familial onset of this condition. Report of a Case: A 6-day-old newborn presented with worsening pallor, inappetence, and hyporeactivity for 48 h. The diagnosis was severe hemophilia A (HA), leading to an unfavorable outcome. A literature review focusing on case reports and series focusing on the clinical expression of HA in neonates was conducted, documenting clinical presentation, family history, and outcomes. Literature review: Forty patients were included. HA was observed in five cases (12.5%) of very preterm births (≤32 weeks) and in four cases (10%) of moderately or late preterm births. Seventeen patients (43%) had a family history, with inheritance being sporadic (21 newborns, 53%) or acquired (2 cases, 4%). Clinical onset typically occurred within the first week of life (approximately 8 out of 10 cases), while only three cases (7.5%) had onset after the first month. Inherited cases presented with hemorrhagic states (nine cases), hypovolemic shock (five cases), or intracranial hypertension (two cases). Sporadic cases showed localized bleeding (11 cases), hypovolemic shock (5 cases), or neurological symptoms like seizures and anisocoria (5 cases). Acquired cases included severe intracranial hemorrhage in one case. Conclusions: Neonatal HA can manifest with severe symptoms and rapid progression, making early diagnosis crucial. Non-specific signs and the absence of coagulophaty disorders in family history can delay diagnosis. Symptoms like prolonged bleeding, cutaneous hematomas, or intracranial bleeding necessitate ruling out major coagulopathy, and neurological signs require immediate imaging to exclude intracranial bleeding.

Intraventricular baclofen for intractable spasticity and secondary dystonia: a frame-based stereotactic approach and case series

ObjectiveIntraventricular baclofen has been reported as an alternative to intrathecal baclofen for managing refractory spasticity and dystonia in some circumstances. In this report, we described a frame-based stereotactic approach for precisely positioning of the infusion catheter into the third ventricle.Material and methodsHigh resolution contrast-enhanced anatomical MR sequences was acquired prior to surgery for pre-planning. Catheter trajectory was planned to pass from the lateral ventricle to the third ventricle through the Foramen of Monro. The surgical procedure was adapted from the frame-based deep brain stimulation surgery. The Touch-Loc kit (SceneRay, China) was used to temporarily secure the catheter in place during the surgery. From July 2022 to December 2022, three patients suffering from intractable spasticity and/or secondary dystonia received IVB successfully using the described technique.ResultsNo severe adverse events, including death, intracranial hemorrhage, infection, catheter migration or fracture, were documented at the last follow-up (range: 12‒24 months). Transient side effects included mild nausea following the initiation of infusion or the increase in infusion rate. All three patients responded to the IVB.ConclusionsThe described frame-based stereotactic technique for IVB catheter implant is feasible and could be quickly mastered by neurosurgeons in related fields. Larger prospective cohorts with longer follow-up periods are necessary to further evaluate the long-term safety and efficacy of this procedure.

The benefit of favorable venous outflow profiles is mediated through the reduced risk of intracranial hemorrhage in acute ischemic stroke patients undergoing endovascular treatment

BackgroundFavorable venous outflow (VO) has been recognized as an independent predictor of excellent clinical outcomes in acute ischemic stroke caused by anterior circulation large vessel occlusion (AIS-LVO) patients who received...

OTHR-01. ALK-DRIVEN INFANT-TYPE HEMISPHERIC HIGH-GRADE GLIOMA AND CNS HISTIOCYTOSIS SUCCESSFULLY TREATED WITH A SECOND GENERATION ALK-INHIBITOR: MOLECULAR CHARACTERIZATION SAVES THE DAY

Abstract BACKGROUND Molecular characterization of brain tumors (BT) is increasingly becoming essential for diagnosing and managing central nervous system (CNS) tumors. Infant BT is a particular category of pediatric CNS tumors that poses a challenge to the neuro-oncologist. METHODS Here, we present two distinctive cases where molecular characterization significantly influenced diagnosis, management, and outcome. RESULTS The first case is a 2-year-old boy presented with generalized seizures. MRI of the brain showed multiple dural-based tumors. Biopsy was consistent with ALK-positive histiocytosis (KIF5B-ALK fusion). Additional lesions were detected in the right kidney and left femoral head. Despite three months of LCH-based therapy, the tumor progressed. Chemotherapy was halted, and treatment with alectinib was initiated. Follow-up MRIs after 3 and 6 months showed marked regression and a complete resolution of the lesions, respectively. The second case is a 12-month-old boy who exhibited developmental regression and increased head circumference over the past three months. MRI revealed a large complex right ventricle mass measuring 8.6x7.2x8 cm. Subtotal resection was complicated by severe intracranial bleeding, requiring prolonged intensive care stay. The initial pathological diagnosis was anaplastic ependymoma. He received two cycles of neoadjuvant chemotherapy followed by a second look surgery, which failed to achieve a gross total resection. Molecular testing by this time identified an ALK-CCDC85A fusion, altering the diagnosis to infant-type hemispheric glioma. He was started on alectinib. MRI after 3 and 6 months showed a favorable response with an overall improvement in his cognitive function. Both patients tolerated alectinib well, remaining on therapy for 6 and 12 months, respectively. No toxicities were reported. CONCLUSION These cases illustrate the transformative role of molecular characterization in managing infants with CNS tumors, highlighting its potential as a game-changer in pediatric neuro-oncology.

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

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

Hemorrhagic transformation of cerebral infarction: risk factors, diagnosis, and new approaches to treatment

Background. Hemorrhagic transformation (HT) is a frequent complication of acute cerebral infarction, which is unfavo­rable for the treatment and prognosis of patients. It can be divided into two main subtypes, hemorrhagic infarction, and parenchymal hematoma, depending on the type of hemorrhage. Although the pathophysiological mechanism of HT is still unclear, hypotheses have been proposed about the loss of microvascular integrity and impaired neurovascular homeostasis. The purpose of the study was to analyze the current scientific literature on risk factors, diagnosis, and new approaches to the treatment of hemorrhagic transformation of cerebral infarction. Materials and methods. A literature search using keywords was conducted in Web of Science, Scopus, PubMed, and Elsevier databases. Results. Ischemic tissues have a natural tendency to bleed. In addition, the first trials of recanalization using intravenous thrombolysis showed an increase in the incidence of mild to severe intracranial hemorrhages. Symptomatic intracerebral hemorrhage is closely associated with poor outcomes and is an important factor in recanalization decisions. The development of HT after stroke involves numerous interrelated pathological processes from peripheral blood cells to neurovascular units such as hyperactive ischemic cascades with increased levels of matrix metalloproteinases, excessive reactive oxygen species, coagulopathy, blood-brain barrier breakdown, and reperfusion injury. A number of risk factors or prognostic factors for HT after cerebral infarction have been identified, namely the use of antiplatelet agents or anticoagulants, infarct size, atrial fibrillation, hypertension, age, gender, heart failure, coronary artery disease, diabetes mellitus, lipid profile, reperfusion therapy, and white matter hyperintensity load. The incidence of HT is reported mainly in clinical studies using brain imaging techniques such as computed tomography or magnetic resonance imaging, diffusion weighted imaging, and perfusion weighted imaging. Recombinant tissue plasminogen activator therapy and mechanical thrombectomy are currently the main treatments for ischemic stroke, but reperfusion injury due to revascula­rization increases the risk of cerebral hemorrhage. Understanding the risk factors and in-depth evaluation of predictors can significantly help physicians develop strategies to reduce the occurrence of HT, as well as provide insight into the pathophysiological mechanism of the disease. Conclusions. Patients at risk of hemorrhagic transformation require invasive and non-invasive neuromonitoring to help make decisions in decompressive neurosurgery for large cerebellar infarction, specific cardiorespiratory treatment, nutrition, blood pressure control, biochemical parameters, and the choice of an individual management strategy.

Exacerbation of thromboinflammation by JAK2V617F mutation worsens the prognosis of cerebral venous sinus thrombosis

AbstractCerebral venous sinus thrombosis (CVST) is an uncommon venous thromboembolic event accounting for <1% of strokes resulting in brain parenchymal injuries. JAK2V617F mutation, the most frequent driving mutation of myeloproliferative neoplasms, has been reported to be associated with worse clinical outcomes in patients with CVST. We investigated whether hematopoietic JAK2V617F expression predisposes to specific pathophysiological processes and/or worse prognosis after CVST. Using an in vivo mouse model of CVST, we analyzed clinical, biological, and imaging outcomes in mice with hematopoietic-restricted Jak2V617F expression, compared with wild-type Jak2 mice. In parallel, we studied a human cohort of JAK2V617F-positive or -negative CVST. Early after CVST, mice with hematopoietic Jak2V617F expression had increased adhesion of platelets and neutrophils in cerebral veins located in the vicinity of CVST. On day 1, Jak2V617F mice had a worse outcome characterized by significantly more frequent and severe intracranial hemorrhages (ICHs) and higher mortality rates. Peripheral neutrophil activation was enhanced, as indicated by higher circulating platelet–neutrophil aggregates, upregulated CD11b expression, and higher myeloperoxydase plasma level. Concurrently, immunohistological and brain homogenate analysis showed higher neutrophil infiltration and increased blood-brain barrier disruption. Similarly, patients with JAK2V617F-positive CVST tended to present higher thrombotic burden and had significantly higher systemic immune-inflammation index, a systemic thromboinflammatory marker, than patients who were JAK2V617F-negative. In mice with CVST, our study corroborates that Jak2V617F mutation leads to a specific pattern including increased thrombotic burden, ICH, and mortality. The exacerbated thromboinflammatory response, observed both in mice and patients positive for JAK2V617F, could contribute to hemorrhagic complications.

Air pollution and serious bleeding events in high-risk older adults

ImportanceDespite biological plausibility, very few epidemiologic studies have investigated the risks of clinically significant bleeding events due to particulate air pollution. ObjectiveTo measure the independent and synergistic effects of PM2.5 exposure and anticoagulant use on serious bleeding events. DesignRetrospective cohort study (2008–2016). SettingNationwide Medicare population. ParticipantsA 50% random sample of Medicare Part D-eligible Fee-for-Service beneficiaries at high risk for cardiovascular and thromboembolic events. ExposuresFine particulate matter (PM2.5) and anticoagulant drugs (apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin). Main outcomes and measuresThe outcomes were acute hospitalizations for gastrointestinal bleeding, intracranial bleeding, or epistaxis. Hazard ratios and 95% CIs for PM2.5 exposure were estimated by fitting inverse probability weighted marginal structural Cox proportional hazards models. The relative excess risk due to interaction was used to assess additive-scale interaction between PM2.5 exposure and anticoagulant use. ResultsThe study cohort included 1.86 million high-risk older adults (mean age 77, 60% male, 87% White, 8% Black, 30% anticoagulant users, mean PM2.5 exposure 8.81 μg/m3). A 10 μg/m3 increase in PM2.5 was associated with a 48% (95% CI: 45%–52%), 58% (95% CI: 49%–68%) and 55% (95% CI: 37%–76%) increased risk of gastrointestinal bleeding, intracranial bleeding, and epistaxis, respectively. Significant additive interaction between PM2.5 exposure and anticoagulant use was observed for gastrointestinal and intracranial bleeding. ConclusionsAmong older adults at high risk for cardiovascular and thromboembolic events, increasing PM2.5 exposure was significantly associated with increased risk of gastrointestinal bleeding, intracranial bleeding, and epistaxis. In addition, PM2.5 exposure and anticoagulant use may act together to increase risks of severe gastrointestinal and intracranial bleeding. Thus, clinicians may recommend that high-risk individuals limit their outdoor air pollution exposure during periods of increased PM2.5 concentrations. Our findings may inform environmental policies to protect the health of vulnerable populations.

Optimizing shunt integrity during acute subdural hematoma evacuation.

Even mild head trauma can cause severe intracranial hemorrhage in patients with cerebrospinal fluid (CSF) shunts for hydrocephalus. CSF shunts are considered a risk factor for subdural hematoma (SDH). The management of acute SDH (ASDH) in shunted patients with normal pressure hydrocephalus can be challenging. Addressing the hematoma and the draining function of the shunt is important. To preserve the shunt, we set the shunt valve pressure to the highest and perform hematoma evacuation for ASDH. In this study, we report the surgical cases of ASDH in patients with shunts. Between 2013 and 2019, five patients with ASDH and CSF shunts underwent hematoma evacuation at our hospital. We retrospectively analyzed data regarding their clinical and radiological presentation, hospitalization course, the use of antithrombotic medications, and response to different treatment regimens. The patients presented with scores of 5-14 in the Glasgow coma scale and severe neurological signs, consciousness disturbance, and hemiparesis. Most patients were elderly, taking antithrombotic medications (four of five cases), and had experienced falls (4 of 5 cases). All patients underwent hematoma evacuation following resetting their programmable shunt valves to their maximal pressure setting and shunt preservation. ASDH enlargement was observed in only one patient who underwent burr-hole drainage. Glasgow outcome scale scores at discharge were 1 and 3, respectively. In hematoma evacuation, increasing the valve pressure may reduce the bleeding recurrence. To preserve the shunt, setting the shunt valve pressure to the highest level and performing endoscopic hematoma evacuation with a small craniotomy could be useful.

Fatal Oedipism: A Case Report and Literature Review.

To describe a unique case of a fatal self-enucleation and review previously published cases. The authors describe a unique case of a complete unilateral self-enucleation while under the influence of drugs, which resulted in severe intracranial hemorrhages, right internal carotid artery opacification, and death. A literature review was performed by searching articles published before January 2023 in the Pubmed/MEDLINE database using the keywords "auto-enucleation or self-enucleation." Cases of self-inflicted damage to the globe without severing any connections were excluded. A literature review identified a total of 54 articles and 75 patients who had self-enucleated at least one globe completely (84.0%). Their average age was 37 years and 50.7% were male. At the time of auto-enucleation, 64.0% of these patients had known psychiatric disorders, and 28.0% were found to be under the influence of illicit drugs or alcohol. Auto-enucleation resulted in intracranial complications in 26.7% of cases. There has been 1 prior case, which, like the authors' case, resulted in death due to intracranial complications. However, this occurred in a patient who partially enucleated one eye after a self-inflicted injury to the fellow eye. The current case is unique as these complications resulted from a complete unilateral auto-enucleation. The severity of this case's presentation and outcome highlights the importance of prompt neuroimaging and a thorough assessment. Prompt psychiatric assessment and treatment are also required.

Identifying Pregnancies at Higher Risk for HPA-1a Alloimmunization and Fetal/Neonatal Alloimmune Thrombocytopenia (FNAIT): An International, Prospective, Natural History Study

Background and significance Fetal and neonatal alloimmune thrombocytopenia (FNAIT) results from parental incompatibility of human platelet antigen (HPA) and subsequent maternal sensitization. When this occurs, fetal platelet production is impaired and platelet destruction accelerated. FNAIT is the platelet counterpart of Rhesus disease (RhD); however, FNAIT is rarer, more often occurs in first pregnancies, and alloimmunization may be detected as early as the 2nd trimester. Clinical presentation of FNAIT ranges from no/mild symptoms to severe thrombocytopenia and intracranial hemorrhage, which can take place in the second trimester and cause death or lifelong neurological impairment. Severe FNAIT outcomes impose substantial emotional and financial burden on affected families and healthcare systems. Among pregnant HPA-1a-negative women bearing an HPA-1a-positive fetus at risk of alloimmunization, ~27% carry the HLA-DRB3*01:01 gene variant, increasing sensitization risk ~25 fold and thus leading to much higher FNAIT risk. Screening for FNAIT in pregnancy is not routinely performed, unlike in RhD, resulting in failure to identify at-risk pregnancies prior to birth. To prevent severe FNAIT outcomes, we believe at-risk pregnancies must be identified very early in the second trimester, and prophylactic interventions started immediately. Current management of women with existing alloimmunization due to a prior FNAIT-affected pregnancy involves months of weekly antenatal intravenous immunoglobulin with or without steroid administration. Although fetal platelet counts often improve, this therapy is very burdensome to patients. Most data on FNAIT prevalence and risk are from Caucasian populations; studies in non-Caucasian populations have been too small to be informative. This is the first epidemiological study that seeks to identify HPA-1a-based FNAIT in a racially and ethnically diverse international population of pregnant women. Data to be tracked are: frequency of DRB3*0101 in HPA-1bb women; anti-HPA-1a alloimmunization; pregnancy outcomes; and neonatal thrombocytopenia. These data will provide a contemporary control population preceding future single-arm studies of a novel human anti-HPA-1a monoclonal antibody, RLYB212, in prophylaxis of maternal HPA-1a alloimmunization and FNAIT. The virtual elimination of RhD by screening of all pregnancies and administration of prophylaxis in at-risk cases remains one of the most significant medical advances ever achieved and provides a roadmap for FNAIT. Study design and methods Prospective, non-interventional, natural-history study assessing HPA-1a alloimmunization in pregnant women, conducted across multiple European centers in Norway, Netherlands, UK, and Germany, and in the USA. It will provide insights into anti-HPA-1a-mediated FNAIT risk and frequency among Caucasian and non-Caucasian pregnant women. Up to 30,000 women will be screened at gestational weeks 10-14 to enable early identification and follow-up of those women at higher alloimmunization risk, so that in the future, prophylaxis of the higher-risk women could be initiated. Informed consent will be requested for blood-sample collection at the 10-14 week visit for evaluation of FNAIT risk. Inclusion criteria Pregnant women aged ≥18 years Exclusion criteria Prior history of FNAIT or known HPA-1a alloimmunization Statistical methods Demographic, baseline characteristics and discrete variables will be summarized Primary objective To inform frequency of higher FNAIT risk among pregnant women of diverse racial and ethnic characteristics (all comers). (Figure) Secondary objectives Frequency of HPA-1a maternal alloimmunization at Weeks 10-14 postpartum in pregnant women at higher FNAIT risk and outcomes such as: - Spontaneous abortion: non-deliberate fetal death prior to 19 weeks of gestation - Elective abortion: deliberate termination of pregnancy at any time in gestation - Stillbirth: non-deliberate fetal death after 19 weeks of gestation - Premature birth: live birth prior to 37 completed weeks of gestation - Live births: ≥37 completed weeks of gestation Neonatal and severe neonatal thrombocytopenia: platelet count &amp;lt;150 × 10 9/L and &amp;lt;50 × 10 9/L, respectively, within 72 hours of birth Current status Enrolment for clinical-trial NCT05345561 is ongoing and expected to continue for ~3 years.

Risks of cardiovascular events after acute ischemic stroke and intra-cranial hemorrhage

Abstract Background The occurrence of acute ischemic stroke and intra-cranial hemorrhage (ICH) would result in severe stress for patients which may trigger cardiovascular (CV) events. In the present study, we aimed to report and compare the risks of CV events of patients who experienced ischemic stroke and ICH. Also, we analyzed the associations between the severities of stroke/ICH and risks of CV events. Methods A total of 413,000 and 131,313 patients who experienced acute ischemic stroke and ICH and did not have past history of acute myocardial infarction (AMI), heart failure (HF), atrial fibrillation (AF) and ventricular arrhythmia (VA) were identified from the Taiwan National Health Insurance Research Database, respectively. Risks of CV events within 90 days after stroke and ICH were analyzed and compared. Results There were 2.77% and 1.75% of patients who suffered from CV events after ischemic stroke and ICH, respectively. The risks of AMI (odds ratio [OR] 0.702, 95%CI 0.618-0.798), HF (OR 0.708, 95%CI 0.661-0.759), AF (OR 0.534, 95%CI 0.502-0.569) and any events (OR 0.626, 95%CI 0.598-0.655) were lower for patients with ICH compared to those with ischemic stroke (Figure 1). For patients with acute ICH, the risks of CV events expect for AF significantly increased from mild to severe ICH (Figure 2). For patients with acute ischemic stroke, all the risks of CV events were higher among patients with severe stroke. Conclusions When managing patients with acute ischemic stroke and ICH, the risks of acute CV events should also be kept in mind. The impacts of acute CV events on the long-term prognosis of these patients deserve a further study.

Increased Incidence and Mortality of Civilian Penetrating Traumatic Brain Injury in Sweden: A Single-Center Registry-Based Study

Penetrating trauma to the head and neck has increased during the past decade in Sweden. The aim of this study was to characterize these injuries and evaluate the outcomes for patients treated at a tertiary trauma center. Swedish trauma registry data were extracted on patients with head and neck injuries admitted to Karolinska University Hospital (Stockholm, Sweden) between 2011 and 2019. Outcome information was extracted from hospital records, with the primary endpoints focusing on the physiological outcome measures and the secondary endpoints on the surgical and radiological outcomes. Of 1436 patients with penetrating trauma, 329 with penetrating head and neck injuries were identified. Of the 329 patients, 66 (20%) had suffered a gunshot wound (GSW), 240 (73%) a stab wound (SW), and 23 (7%) an injury from other trauma mechanisms (OTMs). The median age for the corresponding 3 groups of patients was 25, 33, and 21 years, respectively. Assault was the primary intent, with 54 patients experiencing GSWs (81.8%) and 158 SWs (65.8%). Patients with GSWs had more severe injuries, worse admission Glasgow coma scale, motor, scores, and a higher intubation rate at the injury site. Most GSW patients underwent major surgery (59.1%) as the initial procedure and were more likely to have intracranial hemorrhage (21.2%). The 30-day mortality was 45.5% (n= 30) for GSWs, 5.4% (n= 13) for SWs, and 0% (n= 0) for OTMs. There was an annual increase in the incidence and mortality for GSWs and SWs. Between 2011 and 2019, an increasing annual trend was found in the incidence and mortality from penetrating head and neck trauma in Stockholm, Sweden. GSW patients experienced more severe injuries and intracranial hemorrhage and underwent more surgical interventions compared with patients with SWs and OTMs.

Optic Nerve Sheath Diameter as a Predictor of Raised Intracranial Pressure Findings on Orbital Ultrasound

BACKGROUND&#x0D; Several studies have found an association between raised intracranial pressure (ICP) and optic nerve sheath diameter (ONSD) in conditions with severe head injury and intracranial bleeding. Idiopathic intracranial hypertension is also a cause of elevated ICP. Because the meninges and subarachnoid space around the optic nerve are continuous, a rise in ICP can be detected with an increase in ONSD. The objectives of this study were to correlate Optic Nerve Sheath Diameter (ONSD) with features suggestive of raised intracranial pressure on CT / MRI of the Brain and describe the features suggestive of raised intracranial pressure on CT/MRI Brain in clinically suspected patients.&#x0D; METHODS&#x0D; This was a case control study carried out in the Department of Radio-diagnosis at MGMCRI for suspected raised intracranial pressure evaluation. All these patients were subjected to ultrasound examination of the eye and the optic sheath diameter was measured while the patients were in supine posture. ONSD was measured on Mind ray DC8, and/or GE S7 Expert using High frequency linear probe on the closed upper eyelid with adequate aqueous gel as a coupling agent. ONSD was also measured in Philips 1.5T MRI and Ge optima 128 slice CT. Patients were followed up on whether they were treated surgically or medically and if they developed clinical signs of raised ICP such as headache, vomiting, raised blood pressure, double vision, confusion or loss of consciousness.&#x0D; RESULTS&#x0D; The raised ICP was observed in 30.67 % of study patients and the optic nerve sheath distension was observed in 37.33% of patients. The diagnostic accuracy of determining the optic nerve sheath diameter was equal such as area under curve, sensitivity and specificity as 0.833, 66.67% and 100 % respectively in both methods.&#x0D; CONCLUSIONS&#x0D; ONSD has emerged as an interesting option for measuring intracranial hypertension in brain-injured states, owing to its simplicity, non-invasive nature, and accessibility.

Comparative Effectiveness of Surgical Ligation and Catheter Closure of Patent Ductus Arteriosus in Preterm Infants.

To evaluate the association, if any, between closure modality (surgical ligation SL vs. catheter CC) of a hemodynamically significant patent ductus arteriosus (PDA), after failure of or contraindication to medical therapy, and immediate procedural complications, and post-procedure physiologic status in preterm (gestational age < 32weeks) infants. In this single-center retrospective cohort study, data were accessed on infants < 32weeks gestation, who underwent SL or CC of PDA, born from 2019-2021. The choice of modality was determined by parents, after they were provided information on both procedures. Our cohort (n = 112) included 36 (32.1%) infants who underwent SL while 76 (67.9%) underwent CC. The SL group of infants were significantly more immature at birth, younger on admission to the level IV NICU and received more mean (SD) surfactant doses than the CC group. Higher proportions of infants in the SL group had 5-min Apgar scores ≤ 5, seizures, severe intracranial hemorrhage and had received medical therapy for PDA. Both procedures were highly efficacious, with 1 unsuccessful device placement attempt and had low associated adverse events. Two (2.6%) infants had device migration 24h after CC. SL was associated with a higher rate of immediate postoperative hypothermia whereas, in the CC group, mean airway pressure was significantly lower 48h after, compared to before the procedure. SL and CC are comparable in short-term efficacy and safety for PDA closure. Long-term outcomes data are needed following both procedures.

THERAPEUTIC HYPOTHERMIA OF NEWBORNS: RECOMMENDATIONS OF UNIVERSITÄTSKLINIKUM CARL-GUSTAV-CARUS (DRESDEN, GERMANY)

Therapeutic hypothermia (TH) is a modern standard of care for newborns with gestational age ≥36 weeks who have moderate to severe hypoxic-ischemic encephalopathy. The introduction of TH is based on evidence-based medicine, and multiple randomized controlled trials confirm its efficiency in significantly reducing the risk of death or severe infant disability. Recent practice emphasizes the vital importance of clearly defined protocols for TH and its use in neonatal care settings with facilities for multidisciplinary care and adequate resources for comprehensive monitoring and treatment.The article reports on the local protocol of TH in the neonatal intensive care unit of the University Hospital at Carl-Gustav-Carus at the Technical University Dresden (Dresden, Germany). TH is administered to newborns with moderate or severe hypoxic-ischemic encephalopathy who were born at a gestational age of ≥ 36+0 weeks, are less than 6 hours old and have no signs of massive intracranial hemorrhage. Exclusion criteria are threat to life, congenital malformations, severe intracranial hemorrhage and poor prognosis. Whole-body cooling to an internal body temperature of 33.5°C is preferred. The cooling period is 72 hours, with warming at a rate of 0.2°C per hour, followed by normothermia over the next 48 hours.Comprehensive assessment of the infant's status includes the Thompson score, amplitude and standard electroencephalography, magnetic resonance imaging, control of blood coagulation, acid-base status and blood gases, etc. Follow-up therapy is aimed at providing adequate ventilatory support to prevent hypocapnia, sufficient fluid supply, effective analgesia and anticonvulsant therapy, etc. Emphasis is placed on the need for further cathemnestic monitoring of infants who underwent TH.

Cranial CT is a mandatory tool to exclude asymptomatic cerebral hemorrhage in elderly patients on anticoagulation.

Traumatic brain injury (TBI) after falls causes death and disability with immense socioeconomic impact through medical and rehabilitation costs in geriatric patients. Diagnosing TBI can be challenging due to the absence of initial clinical symptoms. Misdiagnosis is particularly dangerous in patients on permanent anticoagulation because minimal trauma might result in severe intracranial hemorrhage. The aim of this study is to evaluate the diagnostic necessity of cranial computed tomography (cCT) to rule out intracranial hemorrhage, particularly in the absence of neurologic symptoms in elderly patients on permanent anticoagulation in their premedication. Retrospective cohort analysis of elderly trauma patients (≥ 65 years) admitted to the emergency department (ED) of the level-1-trauma center of the University Hospital Frankfurt from 01/2017 to 12/2019. The study included patients who suffered a ground-level fall with suspected TBI and subsequently underwent CT because of preexisting anticoagulation. A total of 227 patients met the inclusion criteria. In 17 of these patients, cCT showed intracranial hemorrhage, of which 14 were subdural hematomas (SDH). In 8 of the patients with bleeding showed no clinical symptoms, representing 5% (n = 160) of all symptom-free patients. Men and women were equally to suffer a post-traumatic hemorrhage. Patients with intracranial bleeding were hospitalized for 14.5 (±10.4) days. Acetylsalicylic acid (ASA) was the most prescribed anticoagulant in both patient cohorts-with or without intracerebral bleeding (70.6 vs. 77.1%, p = 0.539). Similarly, patients taking new oral anticoagulant (NOAC) (p = 0.748), coumarins, or other platelet inhibitors (p > 0.1) did not show an increased bleeding incidence. Acetylsalicylic acid and NOAC use are not associated with increased bleeding risk in geriatric trauma patients (≥ 65 years) after fall-related TBI. Even in asymptomatic elderly patients on anticoagulation, intracranial hemorrhage occurs in a relevant proportion after minor trauma to the head. Therefore, cCT is an obligatory tool to rule out cerebral hemorrhage in elderly patients under anticoagulation.

675 - Congenital factor VII deficiency presenting with severe intracranial hemorrhage

675 - Congenital factor VII deficiency presenting with severe intracranial hemorrhage

Microsurgical and endovascular treatment of residual and recurrent cerebral aneurysms

Cerebral aneurysms are characterized by high risk of adverse outcome due to severe intracranial hemorrhages and their consequences. Aneurysm remnants after incomplete exclusion can cause hemorrhage. Filling of these fragments immediately after surgery is usually defined as residual aneurysms. Recurrent aneurysms develop in the area of excluded aneurysm in long-term period after surgery. The authors analyze foreign and national literature data on the diagnosis and management of residual and recurrent aneurysms. Risk factors, the most common classifications, diagnostic methods and surgical treatment are presented.

Postnatal treatment for children with fetal and neonatal alloimmune thrombocytopenia: a multicentre, retrospective, cohort study

Children affected by fetal and neonatal alloimmune thrombocytopenia (FNAIT) are at risk of severe intracranial haemorrhage. Management in the postnatal period is based on sparse evidence. We aimed to describe the contemporary management and outcomes of patients with FNAIT in high-income countries. In this multicentre, retrospective, cohort study, we set up a web-based registry for the collection of deidentified data on the management and course of neonates with FNAIT. Eight centres from seven countries (Australia, Norway, Slovenia, Spain, Sweden, the Netherlands, and the USA) participated. Eligibility criteria comprised neonates with FNAIT being liveborn between Jan 1, 2010, and Jan 1, 2020; anti-human platelet antigen (HPA) alloantibodies in maternal serum; confirmed maternal and fetal HPA incompatibility; and bleeding detected at antenatal ultrasound, neonatal thrombocytopenia (<150 × 109 platelets per L), or both in the current or previous pregnancy. Clinical data were retrieved from local medical records of the first neonatal admission and entered in the registry. The key outcome was the type of postnatal treatment given to neonates with FNAIT. Other outcomes were daily median platelet counts in the first week of life, median platelet count increment after first unmatched versus first matched transfusions, and the proportion of neonates with mild or severe bleeding. 408 liveborn neonates with FNAIT were entered into the FNAIT registry, of whom 389 from Australia (n=74), Norway (n=56), Slovenia (n=19), Spain (n=55), Sweden (n=31), the Netherlands (n=138), and the USA (n=16) were included in our analyses. The median follow-up was 5 days (IQR 2-9). More neonates were male (241 [64%] of 379) than female (138 [36%]). Severe thrombocytopenia (platelet count <50 × 109 platelets per L) was reported in 283 (74%) of 380 neonates, and extreme thrombocytopenia (<10 × 109 platelets per L) was reported in 92 (24%) neonates. Postnatal platelet count nadir was higher in the no-treatment group than in all other groups. 163 (42%) of 389 neonates with FNAIT received no postnatal treatment. 207 (53%) neonates received platelet transfusions, which were either HPA-unmatched (88 [43%] of 207), HPA-matched (84 [41%]), or a combination of both (35 [17%]). The proportion of neonates who received HPA-matched platelet transfusions varied between countries, ranging from 0% (Slovenia) to 63% (35 of 56 neonates; Norway). Postnatal intravenous immunoglobulin treatment was given to 110 (28%) of 389 neonates (alone [n=19] or in combination with platelet transfusions [n=91]), with the proportion receiving it ranging from 12% (17 of 138 neonates; the Netherlands) to 63% (ten of 16 neonates; the USA) across countries. The median platelet increment was 59 × 109 platelets per L (IQR 35-94) after HPA-unmatched platelet transfusions and 98 × 109 platelets per L (67-134) after HPA-matched platelet transfusions (p<0·0001). Severe bleeding was diagnosed in 23 (6%) of 389 liveborn neonates, with one having a severe pulmonary haemorrhage and 22 having severe intracranial haemorrhages. Mild bleeding was diagnosed in 186 (48%) neonates. Postnatal management of FNAIT varies greatly between international centres, highlighting the absence of consensus on optimal treatments. Our data suggest that HPA-matched transfusions lead to a larger median platelet count increment than HPA-unmatched transfusions, but whether HPA matching is also associated with a reduced risk of bleeding remains unknown. Sanquin.