Symptomatic Hemorrhage Research Articles

Efficacy of palliative hemostatic radiotherapy for tumor bleeding and pain relief in locally advanced pelvic gynecological malignancies.

The appearance of symptomatic tumor-related vaginal bleeding and pain in advanced incurable cancer patients with pelvic gynecological malignancies remains atherapeutic challenge in oncological treatment. The aim of our analysis was to evaluate the efficacy and safety of palliative hemostatic radiotherapy. We retrospectively identified patients who had received palliative hemostatic radiotherapy (RT) at our institution between 2011 and 2023 and evaluated acute toxicity, local control, cessation of bleeding, and pain relief. In total, 40patients with amedian planning target volume of 804 cm3 were treated with amedian total dose of 39 Gy in 13fractions, resulting in 6‑month and 1‑year local control rates of 66.9 and 60.8%, respectively. No higher-grade (>gradeIII) acute RT-induced toxicity appeared. Complete cessation of bleeding was achieved in 80.0% of all patients after amedian of 16days and pain relief was documented in 60.9% at first follow-up. 37.5% of the women required ablood transfusion and 25% an additional tamponade with local hemostatic agents. Successful stopping of bleeding was significantly less frequent in patients receiving anticoagulation concurrently with radiation and in the case of infield re-irradiation. Patients with ahigher total RT dose had cessation of bleeding significantly more often, with acut-off value of at least EQD2 (α/β = 10) = 36 Gy. The applied RT technique and planning target volume had no significant influence on the occurrence of bleeding cessation. Palliative hemostatic radiotherapy for locally advanced pelvic gynecological malignancies is safe and effective in achieving high control rates of hemostasis in tumor bleeding and pain relief.

NCOG-47. DEFINING PERIOPERATIVE RISK FACTORS IN STEREOTACTIC BRAIN BIOPSIES AMONG DIFFERENT HISTOLOGIC DIAGNOSES

Abstract INTRODUCTION Stereotactic brain biopsies (SBB) are critical for diagnosing neoplastic central nervous system pathologies including gliomas, metastatic carcinomas (cA), and lymphomas. While SBB-related complications have been cited in the literature, we sought to characterize the perioperative risk factors/outcomes. METHODS We conducted a retrospective review of 615 patients who underwent a SBB at the same tertiary academic hospital between 2000-2020. Logistic regression was conducted across all recorded variables to assess the relative impact on intra/postoperative complications, and Kaplan-Meier curves were calculated to assess probability of 1-year hospice enrollment. RESULTS Of the 615 patients, the average (+/- SD) age was 56+/- 19 years with 286 (46.5%) female patients and the following histological groups: glioma (n=422), lymphoma (n=74), and metastatic cA (n=22). Complications included intraoperative bleeding (7.1%), general postoperative hemorrhage (34%), symptomatic postoperative hemorrhage (3.3%), and discharge-to-hospice (6.8%). General hemorrhage and discharge-to-hospice were most common in glioma (p < 0.001) and lymphoma patients (p=0.003), respectively. Independent risk factors for general hemorrhage included medical history (mental status deficits, glioma, GBM; p= 0-0.02) and biopsy characteristics (parietal lobe, subcortical, eloquent, M8 hole, multiple depths; p= 0-0.05). Preoperative systematic workups and history of lymphoma were independently associated with lower hemorrhage risk (p= <0.001). Risk factors for hospice discharge included preoperative deficits (gait, speech, and mental status; p=0.001-0.05) and postoperative complications (prolonged ICU, UTI, pneumonia; p<0.001). Of the 15 cases of symptomatic hemorrhage, there was a significantly greater representation of glioma patients (p<0.001) with 67% GBM patients and 50% with multiple-depth biopsies. These patients had similar probability of 1-year hospice enrollment compared to non-hemorrhagic patients (p= 0.92). DISCUSSION While complication rates were relatively similar among different histological categories, perioperative risk factors broadly differed based on the type of complication. Understanding perioperative risk factors in SBB may help inform surgical decision making and prognostication.

An Algorithm for the Microsurgical Resection of Cerebellar Cavernomas.

Cavernous malformations (CMs) account for 8% to 15% of all cerebrovascular anomalies and pose clinical significance due to their potential to cause symptomatic hemorrhage, seizures, and focal neurological deficits. While the majority of CMs are located supratentorial, the less common posterior fossa, particularly cerebellar CMs (cCMs), pose a unique treatment challenge. This study aims to contribute to the understanding and management of cerebellar CMs, thereby assisting in the decision-making process for clinical interventions in this patient population. We conducted a retrospective analysis of all patients who were treated for CMs from 2010 to 2023 at our tertiary healthcare facility. Patients with cCMs were further analyzed concerning their treatment strategy and functional outcome based on the modified Rankin Scale. Nine hundred fourteen patients with CMs were treated between 2013 and 2023 at our center. Among these subjects, 6.5% (n = 59) presented with cerebellar lesions. The median age was 54 [37-64] years, and 15 (25.4%) patients showed associated developmental venous anomalies. Nearly half of these patients (49.0%) were surgically treated. Surgical approaches were tailored and individualized to the specific CM location based on a treatment algorithm and encompassed supracerebellar-infratentorial, telovelar, suboccipital transcortical, retrosigmoid transcortical, and retrosigmoidal transhorizontal fissure approaches. Univariate analysis revealed no risk factors concerning postoperative morbidity. The surgically treated patients showed a significant improvement between preoperative and follow-up functional outcomes. cCMs are rare but frequently necessitate surgical intervention. This study enhances the current understanding of cCMs, underscoring the intricate challenges associated with their management. Differentiated algorithms with tailored approaches ensure the optimization of outcomes in the treatment of these challenging lesions.

Safety and efficacy of cangrelor in endovascular thrombectomy compared with glycoprotein IIb/IIIa Inhibitors.

Cangrelor, an intravenous P2Y12-receptor inhibitor, is a reversible and short-acting antithrombotic medication non-inferior to irreversible glycoprotein IIb/IIIa inhibitors (GPIs) like eptifibatide. There are insufficient data to compare the medications in endovascular thrombectomies (EVTs) requiring emergent platelet inhibition. To review our institution's experience with cangrelor in EVT and compares its safety and efficacy against GPIs. A large healthcare system retrospective review identified all patients who had received cangrelor or eptifibatide intraoperatively during EVT between December 2018 and March 2023 for this cohort study. Clinical data were reviewed. Functional status was defined by the modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) at multiple time points. Multivariate regression was performed. Of 1010 EVT patients, 36 cangrelor and 104 eptifibatide patients were selected. There were no differences in baseline function or presentations. Cangrelor was frequently administered for stenting tandem occlusions (n=16, 44.4%), and successful reperfusion occurred in 30 (83.3%) patients. On multivariate analysis, cangrelor was associated with decreased odds of hemorrhagic conversion (adjusted OR (aOR)=0.76, P=0.004) and symptomatic hemorrhage (aOR=0.86, P=0.021). There were no differences in thrombotic re-occlusion. Cangrelor was associated with a lower 24-hour NIHSS score (7.0 vs 12.0, P=0.013) and discharge NIHSS score (3.0 vs 9.0, P=0.004). There were no differences in in-hospital mortality or length of stay. Cangrelor was associated with improved odds of favorable outcome, defined as mRS score 0-2, at discharge (aOR=2.69, P=0.001) and on 90-day follow-up (aOR=2.23, P=0.031). Cangrelor was associated with a decreased risk of hemorrhagic conversion and might lead to favorable functional outcomes for patients during hospitalization in comparison with GPIs. Prospective studies are warranted to investigate its use in EVT.

Alteplase vs. Tenecteplase: An In-depth Analysis of Their Relative Effectiveness in Treating Acute Ischaemic Stroke.

Dear Editor, Stroke stands as the second-leading cause of death worldwide [1, 2]. Each year, over 12 million individuals are impacted by stroke, resulting in approximately 6.5 million fatalities [1]. Stroke globally ranks as the third-leading factor causing a combination of death and disability [2]. Every year, around seven hundred thousand individuals in the United States undergo an Acute Ischemic Stroke (AIS), making up 85% of all stroke cases [2]. New treatments like intravenous thrombolysis and mechanical thrombectomy have cut mortality by 10% compared to older methods, enhancing long-term disability prevention rates following Acute Ischemic Stroke [2]. Alteplase is the sole FDA-approved thrombolytic drug in AIS within the first 4.5 hours. Despite its potential for disability-free recovery, its usage is constrained by a brief time window and adverse effects, notably a 6% risk of symptomatic bleeding. In addition, its fibrinolytic efficacy is limited, achieving vascular reopening in less than half of the patients, and can cause cytotoxicity to the already hypoxic brain with resultant cerebral edema [2]. Tenecteplase (TNK), a modified variant of alteplase, has improved features including greater fibrin selectivity and longer half-life and is given as a single bolus instead of an infusion, thanks to genetic recombinant technology [3]. Numerous studies have supported TNK's efficacy over alteplase in treating AIS. In 2016, Bruce C.V. Campbell and colleagues demonstrated that, according to the analysis of modified Rankin scale scores, tenecteplase exhibited a more favorable overall functional outcome compared to alteplase [4]. A dosage of 0.25 mg/kg of tenecteplase emerges as a promising alternative to replace alteplase as the preferred treatment for patients with AIS occurring within 4.5 hours due to TNK's superior early neurological recovery rates and comparable safety outcomes [3]. Despite gathering evidence from experimental trials indicating TNK's advantages over alteplase for AIS, the use of TNK at a dosage of 0.4 mg/kg appears to pose safety concerns when compared to alteplase [3]. Bruce C.V. Campbell and his fellow researchers revealed in their study that in spite of the beneficial effects of TNK relative to alteplase, there was no significant variation in the speed of recovery to independent function. Notably, they found no discernible distinction in the occurrence of intracranial hemorrhage [4]. ---Continue

Effects of reperfusion grade and reperfusion strategy on the clinical outcome: Insights from ESCAPE-NA1 trial.

We evaluated the association of reperfusion quality and different patterns of achieved reperfusion with clinical and radiological outcomes in the ESCAPE NA1 trial. Data are from the ESCAPE-NA1 trial. Good clinical outcome [90-day modified Rankin Scale (mRS) 0-2], excellent outcome (90-day mRS0-1), isolated subarachnoid hemorrhage, symptomatic hemorrhage (sICH) on follow-up imaging, and death were compared across different levels of reperfusion defined by expanded Treatment in Cerebral Infarction (eTICI) Scale. Comparisons were also made between patients with (a) first-pass eTICI 2c3 reperfusion vs multiple-pass eTICI 2c3; (b) final eTICI 2b reperfusion vs eTICI 2b converted-to-eTICI 2c3; (c) sudden reperfusion vs gradual reperfusion if >1 pass was required. Multivariable logistic regression was used to test associations of reperfusion grade and clinical outcomes. Of 1037 included patients, final eTICI 0-1 was achieved in 46 (4.4%), eTICI 2a in 76 (7.3%), eTICI 2b in 424 (40.9%), eTICI 2c in 284 (27.4%), and eTICI 3 in 207 (20%) patients. The odds for good and excellent clinical outcome gradually increased with improved reperfusion grades (adjOR ranging from 5.7-29.3 and 4.3-17.6) and decreased for sICH and death. No differences in outcomes between first-pass versus multiple-pass eTICI 2c3, eTICI 2b converted-to-eTICI 2c3 versus unchanged eTICI 2b and between sudden versus gradual eTICI 2c3 reperfusion were observed. Better reperfusion degrees significantly improved clinical outcomes and reduced mortality, independent of the number of passes and whether eTICI 2c3 was achieved suddenly or gradually.

Dual Antiplatelet Versus Alteplase for Early Neurologic Deterioration in Minor Stroke With Versus Without Large Vessel Occlusion: Prespecified Post Hoc Analysis of the ARAMIS Trial.

Dual antiplatelet therapy (DAPT) was noninferior to alteplase in minor nondisabling strokes in the ARAMIS trial (Antiplatelet Versus R-tPA for Acute Mild Ischemic Stroke); however, early neurological deterioration (END) associated with vessel stenosis may benefit from DAPT. We investigated whether the efficacy of DAPT was greater than alteplase in minor strokes with no large vessel occlusion (LVO). This study was a prespecified post hoc analysis of the ARAMIS trial and included patients with responsible vessel examination in the as-treated analysis set of the ARAMIS trial who were divided into LVO group and non-LVO group. In each group, patients were further classified into DAPT and intravenous alteplase treatments. Primary outcome was END at 24 hours defined as more than or equal to 4-point National Institutes of Health Stroke Scale score increase compared with baseline, and safety outcomes were symptomatic intracerebral hemorrhage and bleeding events during study. The primary analysis was estimated with a risk difference calculated by a generalized linear model including adjusted different baseline characteristics between treatments. Of 723 patients from the ARAMIS trial, 480 patients were included: 36 were categorized into LVO group and 444 into non-LVO group, of whom 20 patients had END. Compared with intravenous alteplase, a lower proportion of END was found after DAPT treatment in the non-LVO group (adjusted risk difference, -4.8% [95% CI, -6.9% to -2.6%]; P<0.001), but not in the LVO group (adjusted risk difference, 2.3% [95% CI, -17.6% to 22.3%]; P=0.82). The interaction was marginally significant between groups (P=0.06). In the non-LVO group, a lower proportion of bleeding events was found after DAPT treatment than intravenous alteplase (adjusted risk difference, -6.4% [95% CI, -8.9% to -3.9%]; P<0.001). Other safety outcomes were similar between the 2 treatments. Among minor nondisabling acute ischemic stroke without LVO, DAPT may be superior to intravenous alteplase regarding preventing END with a better safety profile. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03661411.

Recurrent symptomatic intracranial hemorrhage in high-grade astrocytoma with piloid features: illustrative case.

High-grade astrocytoma with piloid features (HGAP) is a novel condition introduced in the 2021 World Health Organization classification. Given that it has been recently classified, reports clarifying its clinical features or diagnostic criteria are lacking, especially in cases of atypical presentation. Herein, the authors present a rare case of HGAP with repeated symptomatic hemorrhages. A woman in her 20s presented with an acute headache and vertigo. Computed tomography and magnetic resonance imaging revealed a 2.5 × 2.8 × 2.3-cm hemorrhagic cerebellar mass with calcifications. After moderate improvement of her symptoms, she developed recurrent hemorrhage, and the tumor size increased (3.0 × 3.6 × 4.0 cm) 18 days later, necessitating resection. Pathological and molecular analyses confirmed the diagnosis of HGAP with an FGFR1-TACC1 fusion, MTAP/CDKN2A/B deletion, and SETD2 rearrangement. Radiologically, the presence of calcification and cystic components and the absence of perilesional edema were atypical features of previously reported HGAP. Although recurrent symptomatic intracranial hemorrhages are rare in HGAP, enhancing lesions on magnetic resonance imaging suggest the need for resection to obtain tissue for molecular diagnosis and guide adjuvant treatment strategies. https://thejns.org/doi/10.3171/CASE24395.

Clinical features, hemorrhage risk and epilepsy outcomes of familial cerebral cavernous malformation: A 20-year observational pragmatic single-center study

IntroductionFamilial Cerebral Cavernous Malformations (fCCMs) are rare, hereditary conditions characterized by multiple central nervous system lesions. Despite their rarity, CCMs can cause significant clinical challenges when symptomatic, manifesting as seizure and symptomatic hemorrhage (CASH). Guidelines suggest neurosurgical intervention for symptomatic or previously symptomatic lesions, while conservative management is recommended for new-onset epilepsy. However, the natural history and optimal management remain unclear, necessitating further research. ObjectiveThis study aims to provide a comprehensive analysis of the clinical features, hemorrhage risk, and epilepsy outcomes in fCCM patients over an extended follow-up period, offering a more precise estimate of CASH and epilepsy rates in this population. MethodsThis retrospective longitudinal cohort study included fCCM patients enrolled from 2001 to May 2024. Data collected included demographic information, new neurological symptoms, symptomatic hemorrhages, seizures, and modified Rankin Scale (mRS) scores. Incidence rates of first symptomatic events and Kaplan-Meier survival curves were calculated, with logistic and Cox-proportional hazard regression models used to evaluate outcomes. ResultsA total of 47 patients were included in this study, with a mean age at diagnosis of 37.51 years. At diagnosis, 68 % were symptomatic, with 30 % having CASH and 36 % experiencing seizures without CASH. During a median follow-up of 126.0 months (interquartile range, 110.5 months), 17 % had a new CASH event, 20 % had seizures without CASH, and 60 % remained asymptomatic. The bleeding rate was 1.02 % per patient-year, with new focal neurological symptoms at 2.045 per 1000 patient-years and new CASH at 10.225 per 1000 patient-years. Most patients maintained minimal or no disability (mRS 0 or 1). Presenting with epilepsy at baseline significantly increased the odds of future seizures (OR 18.13, p = 0.001). ConclusionThis study highlights the complex presentation and progression of fCCMs, emphasizing the necessity for long-term monitoring. Baseline epilepsy is a significant predictor of future seizures, underscoring the need for individualized management strategies. Future research with larger cohorts and standardized criteria is essential to refine the understanding and management of fCCMs.

FreeClimb 88 catheter with Tenzing 8 delivery for contact aspiration mechanical thrombectomy of anterior circulation large vessel occlusions.

Contact aspiration mechanical thrombectomy (CAMT) with 0.088-inch catheters may improve first-pass success rates, but delivery of such catheters can be challenging and limit effectiveness. This study examines the initial multicenter experience using the FreeClimb 88 catheter paired with the Tenzing 8 delivery catheter. Retrospective analysis was performed of consecutive patients with large vessel occlusion (LVO) of the internal carotid artery (ICA) or M1 segment of the middle cerebral artery treated with off-label CAMT using the FreeClimb 88 and Tenzing 8 at eight sites participating in the early limited release for these devices. Demographic and procedural variables were collected and analyzed with descriptive statistics and multivariable analysis. Fifty-three consecutive patients were treated. Large vessel occlusion was located in the ICA in 19/53 (35.8%) patients; 34/53 (64.2%) were in the M1 segment. FreeClimb 88 was successfully delivered to the site of occlusion in 50/53 (94.3%) of patients. First-pass TICI 2c or 3 was achieved with FreeClimb 88 delivered by Tenzing 8 in 36 (67.9%) cases. Among cases with successful FreeClimb 88 delivery 9/50 (18.0%) required additional smaller devices to perform thrombectomy of distal occlusions after recanalization of the initial LVO. No complications or symptomatic hemorrhages occurred following thrombectomy. Contact aspiration mechanical thrombectomy performed for ICA or M1 LVOs using FreeClimb 88 delivered with Tenzing 8 was safe, effective, and efficient in this early experience, with first-pass TICI 2c or 3 was achieved in 68% of patients without procedural complications occurring in any cases.

Improved technical outcomes with converting thrombectomy techniques after failed first pass recanalization

BackgroundA higher number of recanalization attempts reduces the efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke secondary to large vessel occlusion (LVO). We assessed the impact of switching EVT...

A comparison of subperiosteal vs subdural drainage in the treatment of chronic subdural haemorrhage

Introduction. Symptomatic chronic subdural haemorrhages (CSDH) continue to be one of the most common diagnoses in modern neurosurgery. The current standard procedure for symptomatic CSDH is a burr-hole craniostomy with irrigation and the installation of close-system drainage. The purpose of this study is to conduct a direct comparison of two surgical procedures for the treatment of symptomatic CSDH that are effective in prior studies. Our main goal was to compare the efficacy of placing a subperiosteal drain (SPD) and a subdural drain (SDD) after a single burr-hole craniostomy and irrigation and to show any significant differences in terms of overall surgical complications, functional outcome and mortality rate at three months, and complications at six months. Materials and methods. From August 2022 to December 2023, the study was conducted in the Department of Neurosurgery at a tertiary care centre, with a total of 25 patients in both treatment groups. Results. Overall, there was no statistically significant difference between the two groups in terms of patient general characteristics, pre-and post-operative symptoms, Markwalder grades, postoperative hematoma volume and recurrence, mortality, and functional outcome at discharge and at three months follow-up. Despite not reaching statistical significance, we found a decreased risk of surgical complications, particularly post-operative cerebral haemorrhage, with SPD system implementation. Conclusions. According to our findings, both therapy modalities are extremely successful in the treatment of CSDH. therapy with a single burr-hole craniostomy, irrigation, and implantation of the SPD system, on the other hand, has a reduced overall surgical complication rate and can be regarded as a therapy of choice for the management of symptomatic CSDH.

Safety and Effectiveness Outcomes between Apixaban Versus Vitamin K Antagonists in Atrial Fibrillation Patients on Dialysis.

Anticoagulant therapy for atrial fibrillation (AF) in patients with end-stage kidney disease (ESKD) undergoing dialysis poses significant challenges. This review aimed to furnish clinicians with the latest clinical outcomes associated with apixaban and vitamin K antagonists (VKAs) in managing AF patients on dialysis. Literature from the PubMed and Embase databases up to March 2024 underwent systematic scrutiny for inclusion. The results were narratively summarized. Six studies were included in this review, comprising the AXADIA-AFNET 8 study, the RENAL-AF trial, and four observational studies. In a French nationwide observational study, patients initiated on apixaban demonstrated a diminished risk of thromboembolic events (hazard ratios [HR]: 0.49; 95% confidence interval [CI]: 0.20-0.78) compared to those on VKAs. A retrospective review with a 2-year follow-up, encompassing patients with AF and ESKD on hemodialysis, evidenced no statistical difference in the risk of symptomatic bleeding and stroke between the apixaban and warfarin groups. Two retrospective studies based on the United States Renal Data System (USRDS) database both indicated no statistical difference between apixaban and VKAs in the risk of thromboembolic events. One study reported that apixaban correlated with a reduced risk of major bleeding relative to warfarin (HR: 0.72, 95% CI: 0.59-0.87), while the other study suggested that apixaban was associated with a decreased risk of mortality compared to warfarin (HR: 0.85, 95% CI: 0.78-0.92). The AXADIA-AFNET 8 study found no differences between apixaban and VKAs in safety or effectiveness outcomes for AF patients on dialysis. The RENAL-AF trial, however, was deemed inadequate for drawing conclusions due to its small sample size. Currently, the published studies generally support that apixaban exhibits non-inferior safety and effectiveness outcomes compared to VKAs for AF patients on dialysis.

RNF213 Mutation Associated with the Progression from Middle Cerebral Artery Steno-Occlusive Disease to Moyamoya Disease.

Middle cerebral artery steno-occlusive disease (MCAD) has been recognized as a different clinical entity from moyamoya disease (MMD). Although MCAD can progress to MMD, the extent to which patients actually progress and the risk factors for this progression have not been fully elucidated. We retrospectively reviewed patients with MCAD who underwent RNF213 genotyping. Demographic features, RNF213 p.R4810K mutation, medical history, and longitudinal changes in angiography were analyzed. Sixty patients with 81 affected hemispheres were enrolled. During the follow-up period, 17 patients developed MMD, and the RNF213 p.R4810K mutation was the only factor significantly associated with progression to MMD (odds ratio, 16.1; 95% CI, 2.13-731; P = 0.001). The log-rank test demonstrated that patients with the mutation had a higher risk of progression to MMD (P = 0.007), stenosis progression (P = 0.010), and symptomatic cerebral infarction or hemorrhage (P = 0.026). In Cox regression analysis the p.R4810K mutation remained a significant factor after adjusting for age group (childhood or adult onset) at diagnosis (hazard ratio, 8.42; 95% CI, 1.10-64.4). Hemisphere-based analysis also showed that the mutation was associated with a higher risk of progression to the MMD hemisphere (P = 0.002), stenosis progression (P = 0.005), and cerebral infarction or hemorrhage (P = 0.012). The RNF213 p.R4810K mutation was identified as a risk factor for progression from MCAD to MMD. Genotyping for this mutation may contribute to risk stratification in MCAD.

Methods of a cluster-randomized, type II hybrid implementation effectiveness trial to prospectively assess extended-duration thromboprophylaxis for at-risk medical patients being discharged to prevent hospital-associated venous thromboembolism

BackgroundVenous thromboembolism (VTE) is the third leading cause of preventable hospital-associated (HA) death. Most HA-VTE, including fatal pulmonary emboli, occur among medically ill patients. The rate of symptomatic VTE more than doubles over the first 21 days after hospital discharge. Trials have demonstrated that the burden of HA-VTE may be reduced with postdischarge thromboprophylaxis; however, few patients receive this therapy. We formerly validated the ability of eVTE (eVTE is the abbreviation for a risk assessment tool constituted by 2 calculations: one predicts 90-day VTE and the other predicts 30-day major bleeding derived from only elements of the complete blood count and basic metabolic panel and age) to identify medical patients being discharged with both an elevated risk of VTE and a low risk of bleeding. ObjectivesImplement a cluster-randomized, stepped wedge, type II hybrid implementation/effectiveness trial generating an alert among select at-risk patients upon discharge for implementation of thrombosis chemoprophylaxis in a 23-hospital not-for-profit healthcare system. MethodsWe use the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to guide implementation and outcomes reporting. ResultsThe primary outcome for aim 1 (implementation) is the prescription of rivaroxaban 10 mg daily for 30 days as postdischarge thromboprophylaxis among at-risk patients. The primary efficacy and safety outcomes (effectiveness) are the 90-day composite of symptomatic VTE, myocardial infartcion, nonhemorrhagic stroke, all-cause mortality, and 30-day major bleeding. ConclusionThe eVTE trial will provide high-quality, real-world evidence on the effectiveness and safety of a pragmatic intervention to implement targeted postdischarge thromboprophylaxis using decision support embedded in the electronic health record.

Shorter observation times and smaller gauge needles in outpatient kidney biopsies.

Controversy exists as to the optimal observational time (OT) after outpatient percutaneous kidney biopsy. Further, there is some uncertainty about the benefit of smaller (18-gauge) vs. larger (16-gauge) biopsy needles. At our institution, we have been lowering the OT after outpatient kidney biopsies. Initially in 2015, we were monitoring for 6 hours and gradually began to decrease the OT over time. From 2020, we have adopted an OT of less than 4 hours. During this time period (in 2018), we also began using a smaller gauge needle (18 gauge). We reviewed all outpatient kidney biopsies performed by the nephrology division at our institution since 2015. There were 137 biopsies reviewed. 63 had OT of 4-6 hours, and 74 had OT &lt;4 hours. There was a total of 4 significant complications (2.9%). Two complications, symptomatic retroperitoneal bleeds, were detected in less than 3 hours. The other 2 complications were seen at 9 hours (clot retention) and 72 hours (retroperitoneal bleed after anticoagulation restarted). 63% of the biopsies were done using 18-gauge needles with 1 complication in this group vs. 3 in the 16-gauge group. All cases had adequate tissue for interpretation based on the ability to make a kidney diagnosis. The number of glomeruli obtained in the 18-gauge group was 29 ± 13 glomeruli, and in the 16-gauge group was 25 ± 10, which did not differ between groups. In summary, in an outpatient population, all significant post-biopsy complications were evident either within the first 3 hours or after 9 hours, and this suggests the feasibility of using shorter than standard OT in outpatient kidney biopsies. Furthermore, an 18-gauge needle may lower the risk of complications and obtain adequate tissue.

Endovascular Thrombectomy Versus Intravenous Alteplase For Distal Medium Vessel Occlusions: A Propensity Score‐Matched Analysis

Background The benefits of endovascular thrombectomy (EVT) for distal medium vessel occlusions (DMVOs) are not well established. This study aimed to determine the superiority of EVT over intravenous tissue‐type plasminogen activator (IV tPA) in the treatment of DMVOs. Methods This study analyzed data from the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke Registry, a prospective, multicenter, observational registry of acute ischemic stroke patients treated with EVT or IV tPA. The study evaluated patients with acute DMVOs who were treated with EVT and/or IV tPA. DMVOs was defined as occlusions in M2–M3 segment of the middle cerebral artery, anterior cerebral artery, or posterior cerebral artery. The analysis included primary DMVOs and excluded secondary DMVOs, such as distal embolism after recanalization of proximal vessel occlusion. Propensity score‐matched analysis was conducted to compare the outcomes between EVT and IV tPA alone. A good outcome was defined as a modified Rankin Scale score 0–2 or no worsening at 90 days. An excellent outcome was defined as an modified Rankin Scale score 0–1. Results The study included 1148 patients with DMVOs, of whom 816 were treated with EVT and 332 were IV tPA alone. Before propensity score matching, the incidence of good and excellent outcomes was significantly lower in EVT group (good outcomes: EVT 50.3% versus IV tPA 68.0%; P &lt; 0.01; excellent outcomes: 39.8% versus 59.8%; P &lt; 0.001). After propensity score matching, there were no significant differences between EVT and IV tPA groups in good outcomes (EVT 57.8% versus IV tPA 61.3%; P = 0.51), excellent outcomes (46.6% versus 55.0%; P = 0.17), all cerebral hemorrhage (11.6% versus 12.7%; P = 0.74), and symptomatic hemorrhage (2.9% versus 0.6%; P = 0.13). Subarachnoid hemorrhage was more frequent in EVT group (14.5% versus IV tPA 0%). Conclusion The benefits of EVT for acute DMVOs were similar to IV tPA alone. Randomized multicenter trials are warranted to establish the superiority of EVT over IV tPA alone for DMVOs.

Prevalence and Angiographic Outcomes of Rescue Intracranial Stenting in Large Vessel Occlusion Following Stroke Thrombectomy – STRATIS

BACKGROUND Large vessel occlusion secondary to underlying intracranial atherosclerotic disease (ICAD‐LVO) has an estimated prevalence of 7% to30%. There is a large variation in the use of intracranial rescue stenting in interventional practice. We aimed to characterize the frequency and characteristics of intracranial rescue stenting in a large cohort of endovascular therapy for stroke. METHODS The Systematic Evaluation of Patients Treated With Stroke Devices for Acute Ischemic Stroke (STRATIS) angiography core lab adjudicated the location of the occlusion, hyperdense vessel sign on initial imaging, the use of angioplasty and stenting, and imaging outcomes following endovascular therapy. Underlying cause of stroke was categorized into intracranial atherosclerosis, cardioembolic, and other subtypes. Statistical analyses examined the relationship between intracranial rescue stenting and imaging outcomes including intracranial hemorrhage, and arterial reperfusion using expanded Thrombolysis in Cerebral Infarction reperfusion score in patients with ICAD‐LVO. RESULTS Among 978 patients with LVO stroke undergoing endovascular therapy, 91 (9.3%) patients had ICAD‐LVO. Baseline hyperdense vessel sign was observed among 44 (62.7%) with ICAD versus 178 (68.2%) with cardioembolic LVO ( P = 0.4). Final successful reperfusion (expanded Thrombolysis in Cerebral Infarction 2b50 or more) was significantly lower among ICAD‐LVO as compared with cardioembolic‐LVO (74.2% versus 87.5%; P = 0.007). Intracranial rescue stenting was used among 14/665 (2.1%) of patients with LVO (5 ICA terminus, 7 M1 middle cerebral artery, 1 M2 middle cerebral artery, 1 proximal basilar artery). Among 14 intracranial rescue stenting cases, 5/70 (7.1%) belonged to the ICAD group, 3/261 (1.1%) cardioembolic group, and 6/334 (1.8%) in other or undetermined group. Successful reperfusion following rescue stenting was achieved in all cases with ICAD‐LVO. Among ICAD‐LVO, the rate of 24 hours symptomatic intracranial hemorrhage was 0% with acute intracranial stenting versus 7.7% in the nonstenting subgroup. CONCLUSION In STRATIS, nearly 1 of every 11 thrombectomies were performed in patients with underlying ICAD, among whom 7.1% underwent rescue intracranial stenting concomitant with thrombectomy. Acute intracranial stenting as rescue therapy in ICAD‐LVO was associated with favorable angiographic outcomes and low symptomatic hemorrhage rates.

Endovascular thrombectomy for ischemic stroke with large infarct, short- and long-term outcomes: a meta-analysis of 6 randomised control trials.

Endovascular Thrombectomy (EVT) as first-line treatment of patients with large core ischemic infarct is a subject of debate. A systematic literature search was conducted in four electronic databases for randomized control trials (RCTs) comparing EVT to best medical treatment (BMT) for large core infarcts (ASPECTS ≤ 5). Relevant studies were added after screening for titles, abstracts, and complete text. Meta-analysis was performed. The continuous outcomes were analyzed using the standardized mean difference (SMD) and 95% CI, while the binary outcomes were analyzed using the risk ratio (RR) and 95% confidence interval (CI). A funnel plot was used to visually evaluate publication bias, and if feasible, Egger's test was used to validate. We included 1918 patients from six RCTs that compared EVT plus BMT and BMT alone in patients with large core infarct due to large vessel occlusion in the anterior circulation. There were 946 patients in the EVT group and 972 patients in the BMT group. The one-year outcomes are available for 314 patients in the EVT group and 292 patents in the BMT group from two RCTs. EVT group had statistically significant higher rate of 90-day mRS 0-1 (RR = 3.1, P-value < 0.0001), mRS 0-2 (RR = 2.64, P-value < 0.0001), mRS 0-3 (RR = 1.80, P-value < 0.0001), lower 90-day mean mRS score (SMD = -0.29, P-value < 0.0001), lower 90-day mortality rate (RR = 0.85, P-value = 0.015), and greater early neurological improvement (RR = 2.16, P-value < 0.00001) compared to the BMT group. However, the rates of symptomatic intracerebral hemorrhage (sICH) (RR = 1.76, P-value = 0.01) and any ICH (RR = 2.18, P-value < 0.00001) were higher in EVT group. Our finding showed that EVT plus BMT led to in an absolute improvement of 5%, 12%, and 16% in 90-day mRS 0-1, 0-2, and 0-3, respectively. In addition, patients in EVT plus BMT group had a 3% increased probability of experiencing sICH and were 32% more susceptible to any ICH. Moreover, the one-year mRS 0-2 (RR = 2.16, P-value < 0.00001) and mRS 0-3 (RR = 1.80, P-value < 0.0001) was significantly favor the EVT plus BMT over BMT alone. Although, the one-year mortality rate was not significantly differed between two groups (RR = 0.91, P-value = 0.31). There was no statistically significant difference observed between the EVT plus BMT group and the BMT group concerning new stroke, decompressive craniectomy, and serious adverse events. Combined data from six RCTs shows that EVT plus BMT provides significantly better short- and long-term functional outcomes with minimal increase in symptomatic hemorrhage over BMT in patient with large core infarcts.

Risk factors for MACE and bleeding in atrial fibrillation patients undergoing surgery: Insights from the bridge trial

IntroductionPatients with atrial fibrillation (AF) undergoing elective procedures are at risk for Major Adverse Cardiovascular Events (MACE) and symptomatic bleeding. We aimed to identify risk factors to guide perioperative risk stratification. MethodsWe conducted a post-hoc analysis of the “Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery” randomized trial. The primary outcomes were MACE and symptomatic bleeding. Our statistical approach encompassed standard univariate analysis, logistic stepwise regression, and Cox regression models. Additional interaction analyses evaluated the interplay between low-molecular-weight heparin bridge therapy and other identified risk factors. ResultsAmong a total of 1,813 participants (mean age 71.6 ± 8.8, 73.3 % male), MACE occurred in 25 (1.4 %) individuals, with pre-procedure clopidogrel use (adjusted hazard ratio [aHR] 7.73, 95 % CI 2.63-22.72, p < 0.001) and CHA2DS2-VASc score ≥ 5 (aHR 2.89, 95 % CI 1.26-6.63, p = 0.012) identified as risk factors. Symptomatic bleeding occurred in 57 (3.1 %) individuals, with bridge therapy (aHR 1.84, 95 % CI 1.07-3.19, p = 0.029), renal disease (aHR 2.50, 95 % CI 1.34-4.67, p = 0.004), post-procedure aspirin use (aHR 2.86, 95 % CI 1.66-4.91, p < 0.001), post-procedure nonsteroidal anti-inflammatory drug use excluding aspirin (aHR 3.40, 95 % CI 1.22-9.43, p = 0.019), and major surgery (aHR 3.94, 95 % CI 2.26-6.85, p < 0.001) identified as risk factors. The interactions between risk factors and bridging therapy on MACE and symptomatic bleeding outcomes were not significant (p > 0.05). ConclusionWe identified predictors for MACE and symptomatic bleeding in AF patients undergoing elective procedures. These insights may help guide perioperative decisions to reduce the risk of adverse outcomes.