Types Of Intracranial Hemorrhage Research Articles

Mechanical thrombectomy with Embolus Retriever with Interlinked Cages device for medium vessel occlusions: First pass results and safety profile.

Reperfusion of medium vessel occlusions is correlated with good outcomes. However, optimal techniques and medical devices are still unclear. In this study, we sought to evaluate the safety and efficacy of mechanical thrombectomy with Embolus Retriever with Interlinked Cages (ERIC™) retrieval device in patients with acute ischemic stroke due to distal medium vessel occlusions. A retrospective review of the prospectively collected mechanical thrombectomy database revealed 50 patients who had fulfilled the inclusion criteria. The data collected includes clinical patient characteristics, procedural measures, timestamps at each stage, and patient outcomes. Intravenous thrombolytics application, pre- and post-intervention imaging findings, device-related adverse events and any type of intracranial hemorrhage were recorded. There were 25 men (50%) and 25 women (50%) with a median of 67 years (interquartile range (IQR) 41-84). Median presenting NIHSS was 14 (IQR, 3-23). First pass rates were: eTICI3 in 16 cases (32%), eTICI-2c in eight cases (16%), eTICI-2B67 in nine cases (10%), eTICI2B50 in three cases (6%) and mTICI 0-2A in 18 cases (36%). Final recanalization rate of mTICI 2b-3 was 90% and 2c-3 was 70%. In conclusion, the ERIC thrombectomy device offers a high rate of first-pass success along with a favorable safety profile. Larger series and multi-center studies are needed for further investigation.

Cerebral Amyloid Angiopathy and Risk of Isolated Nontraumatic Subdural Hemorrhage

Cerebral amyloid angiopathy (CAA) is a common cause of spontaneous intracerebral hemorrhage in older patients. Although other types of intracranial hemorrhage can occur in conjunction with CAA-related intracerebral hemorrhage, the association between CAA and other subtypes of intracranial hemorrhage, particularly in the absence of intracerebral hemorrhage, remains poorly understood. To determine whether CAA is an independent risk factor for isolated nontraumatic subdural hemorrhage (SDH). A population-based cohort study was performed using a 2-stage analysis of prospectively collected data in the UK Biobank cohort (discovery phase, 2006-2022) and the All of Us Research Program cohort (replication phase, 2018-2022). Participants included those who contributed at least 1 year of data while they were older than 50 years, in accordance with the diagnostic criteria for CAA. Participants with prevalent intracranial hemorrhage were excluded. Data were analyzed from October 2022 to October 2023. A diagnosis of CAA, identified using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code. The outcome was an isolated nontraumatic SDH, identified using ICD-10-CM codes. Two identical analyses were performed separately in the 2 cohorts. First, the risk of SDH in patients with and without CAA was assessed using Cox proportional hazards models, adjusting for demographic characteristics, cardiovascular comorbidities, and antithrombotic medication use. Second, multivariable logistic regression was used to study the association between CAA and SDH. The final analytical sample comprised 487 223 of the total 502 480 individuals in the UK Biobank cohort and 158 008 of the total 372 082 individuals in the All of Us cohort. Among the 487 223 participants in the discovery phase of the UK Biobank, the mean (SD) age was 56.5 (8.1) years, and 264 195 (54.2%) were female. There were 649 cases of incident SDH. Of the 126 participants diagnosed with CAA, 3 (2.4%) developed SDH. In adjusted Cox regression analyses, participants with CAA had an increased risk of having an SDH compared with those without CAA (hazard ratio [HR], 8.0; 95% CI, 2.6-24.8). Multivariable logistic regression analysis yielded higher odds of SDH among participants with CAA (odds ratio [OR], 7.6; 95% CI, 1.8-20.4). Among the 158 008 participants in the All of Us cohort, the mean (SD) age was 63.0 (9.5) years, and 89 639 (56.7%) were female. The findings were replicated in All of Us, in which 52 participants had CAA and 320 had an SDH. All of Us participants with CAA had an increased risk of having an SDH compared with those without CAA (HR, 4.9; 95% CI, 1.2-19.8). In adjusted multivariable logistic regression analysis, CAA was associated with higher odds of SDH (OR, 5.2; 95% CI, 0.8-17.6). In 2 large, heterogeneous cohorts, CAA was associated with increased risk of SDH. These findings suggest that CAA may be a novel risk factor for isolated nontraumatic SDH.

Examination of the Cerebellomedullary Cistern Using Postmortem Computed Tomography in Various Types of Intracranial Hemorrhage

Intracranial hemorrhage is a major cause of sudden unexpected death and its identification is important for death investigations. Cisternal puncture of the cerebellomedullary cistern (CMC) can be used to identify intracranial hemorrhage during postmortem examination. Intracranial hemorrhage comprises various types of hemorrhage, and the possibility of hemorrhage identification by cisternal puncture can differ according to the type of intracranial hemorrhage. Postmortem computed tomography (PMCT) is non-invasive and can be performed before autopsy. In this study, we aimed to identify the hemorrhage in the CMC using PMCT in cases of various intracranial hemorrhage. PMCT was performed before the autopsy. Autopsy reports and PMCT were retrospectively reviewed for 108 cases of intracranial hemorrhage confirmed by conventional autopsy. Hemorrhagic regions showed ≥60 Hounsfield units on PMCT. Hemorrhage in the CMC was identified in 42.6% (46/108) by PMCT and was frequently identified in the cases of basal subarachnoid hemorrhage (SAH) (19/21). Hemorrhage in the CMC was identified in approximately 50% of patients with non-basal SAH and intracerebral hemorrhage. Detection of hemorrhage in the CMC by PMCT is hindered by several factors, such as dental artifacts. This study does not guarantee the usefulness of postmortem cisternal puncture. However, this study verified hemorrhage in the CMC according to the various types of intracranial hemorrhages using PMCT and showed its possibilities and limitations.

Abnormal Cerebral FDG Accumulation in Acute Intracerebral and Subarachnoid Hemorrhages Due to Different Mechanisms.

Changes in cerebral glucose metabolism after acute intracranial hemorrhage have been rarely described. We present a patient with abnormal cerebral FDG accumulation in acute intracerebral and subarachnoid hemorrhages due to different mechanisms on FDG PET/CT. The patient received conservative management and died 2 months later. This case demonstrated the different mechanisms of cerebral FDG accumulation in different types of intracranial hemorrhage, which may be helpful for future research to optimize patient care.

Radiological features of brain hemorrhage through automated segmentation from computed tomography in stroke and traumatic brain injury.

Radiological assessment is necessary to diagnose spontaneous intracerebral hemorrhage (ICH) and traumatic brain injury intracranial hemorrhage (TBI-bleed). Artificial intelligence (AI) deep learning tools provide a means for decision support. This study evaluates the hemorrhage segmentations produced from three-dimensional deep learning AI model that was developed using non-contrast computed tomography (CT) imaging data external to the current study. Non-contrast CT imaging data from 1263 patients were accessed across seven data sources (referred to as sites) in Norway and Sweden. Patients were included based on ICH, TBI-bleed, or mild TBI diagnosis. Initial non-contrast CT images were available for all participants. Hemorrhage location frequency maps were generated. The number of estimated haematoma clusters was correlated with the total haematoma volume. Ground truth expert annotations were available for one ICH site; hence, a comparison was made with the estimated haematoma volumes. Segmentation volume estimates were used in a receiver operator characteristics (ROC) analysis for all samples (i.e., bleed detected) and then specifically for one site with few TBI-bleed cases. The hemorrhage frequency maps showed spatial patterns of estimated lesions consistent with ICH or TBI-bleed presentations. There was a positive correlation between the estimated number of clusters and total haematoma volume for each site (correlation range: 0.45-0.74; each p-value < 0.01) and evidence of ICH between-site differences. Relative to hand-drawn annotations for one ICH site, the VIOLA-AI segmentation mask achieved a median Dice Similarity Coefficient of 0.82 (interquartile range: 0.78 and 0.83), resulting in a small overestimate in the haematoma volume by a median of 0.47 mL (interquartile range: 0.04 and 1.75 mL). The bleed detection ROC analysis for the whole sample gave a high area-under-the-curve (AUC) of 0.92 (with sensitivity and specificity of 83.28% and 95.41%); however, when considering only the mild head injury site, the TBI-bleed detection gave an AUC of 0.70. An open-source segmentation tool was used to visualize hemorrhage locations across multiple data sources and revealed quantitative hemorrhage site differences. The automated total hemorrhage volume estimate correlated with a per-participant hemorrhage cluster count. ROC results were moderate-to-high. The VIOLA-AI tool had promising results and might be useful for various types of intracranial hemorrhage.

Tranexamic Acid, Mortality, and Intracranial Hemorrhage Type in Moderate or Severe Traumatic Brain Injury

This cohort study examines the association of tranexamic acid administration with intracranial hemorrhage type, neurologic outcomes, and mortality in patients with traumatic brain injury.

Correlation between the degree of severity and type of intracranial hemorrhage with the incidence of coagulopathy in head injuries at the Ulin Regional General Hospital, Banjarmasin, Indonesia

Link of Video Abstract: https://youtu.be/iUu03npEjEo Background: Trauma cases, especially head injuries, are cases that are often found in hospital emergency departments. Coagulopathy can occur in head injuries and intracranial bleeding, where a low Glasgow Coma Scale (GCS) is associated with coagulopathy. This study aims to evaluate the correlation between the degree of severity and type of intracranial hemorrhage and the incidence of coagulopathy in head injuries at the Ulin Regional General Hospital, Banjarmasin, Indonesia. Methods: An observational analytic study with 74 sample populations was conducted among patients with a head injury treated at Ulin Regional General Hospital, Banjarmasin, in the 2019-2022 period taken by total sampling, which met the inclusion and exclusion criteria. The data of each variable was analyzed with the Kruskal-Wallis test. Data were analyzed using SPSS version 25.0 for Windows. Results: There was a significant relationship between the two variables towards the occurrence of coagulopathy; namely, the degree of severity was 0.000 (p &lt;0.05), and the type of bleeding was 0.003 (p&lt;0.05). Conclusion: There is a significant relationship between the degree of severity of the incidence of coagulopathy and the bleeding with the incidence of coagulopathy, so knowing the degree of severity by clinical examination of GCS and the type of intracranial bleeding by CT scan of the head, as well as blood tests to determine the incidence of coagulopathy are important so that management can be carried out and assessing outcomes.

External Validation of a Tool to Identify Low-Risk Patients With Isolated Subdural Hematoma and Preserved Consciousness

The SafeSDH Tool was derived to identify patients with isolated (no other type of intracranial hemorrhage) subdural hematoma who are at very low risk of neurologic deterioration, neurosurgical intervention, or death. Patients are low risk by the tool if they have none of the following: use of anticoagulant or nonaspirin antiplatelet agent, Glasgow Coma Score (GCS) <14, more than 1 discrete hematoma, hematoma thickness >5 mm, or midline shift. We attempted to externally validate the SafeSDH Tool. We performed a retrospective chart review of patients aged ≥16 with a GCS ≥13 and isolated subdural hematoma who presented to 1 of 6 academic and community hospitals from 2005 to 2018. The primary outcome, a composite of neurologic deterioration (seizure, altered mental status, or symptoms requiring repeat imaging), neurosurgical intervention, discharge on hospice, and death, was abstracted from discharge summaries. Hematoma thickness, number of hematomas, and midline shift were abstracted from head imaging reports. Anticoagulant use, antiplatelet use, and GCS were gathered from the admission record. The validation data set included 753 patients with isolated subdural hematoma. Mortality during the index admission was 2.1%; 26% of patients underwent neurosurgical intervention. For the composite outcome, sensitivity was 99% (95% confidence interval [CI] 97 to 100), and specificity was 31% (95% CI 27 to 35). The tool identified 162 (21.5%) patients as low risk. Negative likelihood ratio was 0.03 (95% CI 0.01 to 0.11). The SafeSDH Tool identified patients with isolated subdural hematoma who are at low risk for poor outcomes with high sensitivity. With prospective validation, these low-risk patients could be safe for management in less intensive settings.

The relationship between antiplatelet therapies and the outcome of endovascular treatment for acute ischemic stroke

PurposeWe conducted this study to investigate the safety and efficacy of antiplatelet therapies (APT) for acute ischemic patients received endovascular treatment (EVT). MethodsThe population of our study was derived from a nationwide multicentered registry conducted by 111 centers in China. Patients were divided to groups of no APT, single APT (SAPT) or dual APT (DAPT) according to the APT received at 24 h after EVT. The primary outcome was 90-day functional independence, and the safety outcomes included the symptomatic intracranial hemorrhage (sICH), any type of intracranial hemorrhage, and all-caused death within 90 days. Patient characteristics, procedural data, and outcomes were analyzed. ResultsA total of 1679 patients were included in this study, 71.42% of whom received oral APT at 24 h after EVT, and the initial time was 20.53(13.94–27.17) hours after recanalization or the end of procedure. 90-day functional independence was significantly more observed in patients with DAPT (54.02% vs. 33.64%; adjusted odds ratio [OR] 1.940, 95% CI 1.444–2.606), but not in SAPT (40.75% vs. 33.64%; adjusted OR 1.280, 95% CI 0.907–1.804) compared with patients without APT. APT increased the risk of sICH (1.14% vs. 0, p = 0.036). Both the application of DAPT (adjusted OR 0.264, 95% CI 0.178–0.392, p < 0.001) and SAPT (adjusted OR 0.341, 95% CI 0.213–0.545, p < 0.001) could reduce the 90-day mortality. ConclusionsIn this uncontrolled series of patients APT at 24 h after EVT showed improvement of the patients' functional independence and reduction of mortality, even though the rate of sICH was increased, especially in the DAPT-group.

Abstract Number ‐ 175: First Pass Results of Mechanical Thrombectomy with two‐drop zone NeVaTM Device

Introduction Occlusive thrombi in acute ischemic stroke can be in various types which limits the success of the thrombectomy.The NeVaTM(Vesalio, Nashville, Tennessee) thrombectomy device was originally designed for all types of clot. Our aim was to evaluate the efficacy and safety of the NeVaTMdevice for mechanical thrombectomy. Methods Retrospective review of prospectively collected mechanical thrombectomy database revealed 145 patients who had fullfilled the inclusion criteria.The data collected includes clinical patient characteristics, procedural measures, timestamp at each stage, and patient outcome. IV thrombolytics application, pre and post‐intervention imaging findings, device related adverse event and any type of intracranial hemorrhage were recorded. Results There was female pre‐dominance (54.5%). Median presenting NIHSS was 16 (IQR, 3–32). 88 MCA‐m1 (60,6%), 43 ICA‐tip (29,6%), 11 MCA‐m2 (7,5%), 2 ACA (1,4%) and 1 basilar (0,7%) occlusions were underwent for mechanical thrombectomy. Median procedure time was 25 min (IQR, 7–136). First‐pass reperfusion scores were mTICI 0–2a 22.7%, mTICI 2b 23.4%, mTICI 2c 17.9% andmTICI 3 35.9%.Mean number of pass was1,84±1,14.Final mTICI 2b‐3 score was 97.9% and TICI2c‐3 score was 87.6%. No device related adverse event occurred. The mean 24‐hour NIHS score was 6 (IQR 0–33). Conclusions In conclusion, the NeVa thrombectomy device offers a high rate of first‐pass success along with favorable safety profile. Larger series and multi‐center studies are needed for further investigation

Abstract 164: Cerebral Amyloid Angiopathy Is Associated With A Higher Risk Of Subdural Hemorrhage: Combined Analysis Of The Uk Biobank And All Of Us

Background: Cerebral amyloid angiopathy (CAA) is a condition characterized by amyloid deposition in the brain’s blood vessels. CAA is a common cause of spontaneous intracerebral hemorrhage (ICH) in older patients. Although other types of intracranial hemorrhages can occur in conjunction with CAA-related ICH, it is unknown whether CAA is a risk factor for other types of intracranial hemorrhage in the absence of ICH. Hypothesis: CAA is an independent risk factor for isolated non-traumatic subdural hemorrhage (SDH). Methods: We conducted a 2-stage (discovery and replication) observational study that retrospectively analyzed data from the UK Biobank (discovery phase) and the All of Us (replication phase) study. We included participants over 55 years of age to meet the age threshold for the modified Boston Criteria. The exposure was a diagnosis of CAA and the outcome was non-traumatic SDH, both identified using ICD-9 and ICD-10 codes. We used survival analyses with log-rank tests and multivariable Cox proportional hazards models adjusted for demographic characteristics and vascular risk factors. Results: The discovery phase included 283,452 UK Biobank participants comprising 123 CAA cases and 504 SDH cases. SDH subsequently occurred in 2.4% of participants with CAA versus 0.2% of those without CAA. In a multivariable Cox model, CAA was associated with a significantly increased risk of SDH (hazard ratio [HR], 7.3; 95% CI, 2.3-22.7). This finding was replicated among 168,370 study participants in All of US, where 66 had CAA and 443 had a SDH (HR, 11.66; 95% CI, 5.2-26.2). Conclusion: In two large heterogeneous cohorts conducted in different countries, CAA was independently associated with a higher risk of isolated non-traumatic SDH. Further research is needed to further determine causality and identify biological pathways that may mediate this association.

Blood creatinine and urea nitrogen at ICU admission and the risk of in-hospital death and 1-year mortality in patients with intracranial hemorrhage.

The relationship between renal function and clinical outcomes in patients with intracranial hemorrhage is controversial. We investigated the associations of blood creatinine and urea nitrogen levels with hospital death and 1-year mortality in patients with intracranial hemorrhage treated in the intensive care unit (ICU). A total of 2,682 patients with intracranial hemorrhage were included from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Clinical variables, including admission creatinine, urea nitrogen, type of intracranial hemorrhage, underlying diseases and other blood biochemistry parameters, were collected. Multivariable correction analysis was conducted of the relationships between blood creatinine and urea nitrogen levels on admission with hospital death and 1-year mortality in the included patients with intracranial hemorrhage. Smooth curve and subgroup analyses were also performed for these associations. A total of 2,682 patients had their blood creatinine and urea nitrogen levels measured within the first 24 h after ICU admission, with median values of 0.80 and 15.00 mg/dL, respectively. We observed steeply linear relationships between creatinine and urea nitrogen levels and the risk of in-hospital death and 1-year mortality, but the risk of in-hospital mortality and 1-year mortality increased little or only slowly above creatinine levels > 1.9 mg/dL or urea nitrogen > 29 mg/d (the inflection points). Consistently, conditional logistic regression analysis suggested that these inflection points had significant modification effects on the associations between blood creatinine levels, as well as blood urea nitrogen, and the risk of in-hospital death (interaction value < 0.001) and 1-year mortality (interaction value < 0.001). Our results supported the hypothesis that elevated blood creatinine and urea nitrogen levels on admission are associated with an increased risk of in-hospital death and 1-year mortality in patients with intracranial hemorrhage. Interestingly, these independent relationships existed only for lower levels of serum creatinine (<1.9 mg/dL) and uric acid (<29 mg/dL).

First pass results of mechanical thrombectomy with two-drop zone NeVaTM device.

Occlusive thrombi in acute ischemic stroke can be in various types which limits the success of the thrombectomy. The NeVaTM (Vesalio, Nashville, Tennessee) thrombectomy device was originally designed for all types of clot. Our aim was to evaluate the efficacy and safety of the NeVaTM device for mechanical thrombectomy. Retrospective review of prospectively collected mechanical thrombectomy database revealed 145 patients who had fullfilled the inclusion criteria. The data collected includes clinical patient characteristics, procedural measures, timestamp at each stage, and patient outcome. IV thrombolytics application, pre and post-intervention imaging findings, device related adverse event and any type of intracranial hemorrhage were recorded. There was female pre-dominance (54.5%). Median presenting national institutes of health stroke scale (NIHSS) was 16 (IQR, 3-32). 88 MCA-m1 (60,6%), 43 ICA-tip (29,6%), 11 MCA-m2 (7,5%), 2 ACA (1,4%) and 1 basilar (0,7%) occlusions were underwent for mechanical thrombectomy. Median procedure time was 25 min (IQR, 7-136). First-pass reperfusion scores were mTICI 0-2a 22.7%, mTICI 2b 23.4%, mTICI 2c 17.9% and mTICI 3 35.9%. Mean number of pass was 1,84 ± 1,14. Final mTICI 2b-3 score was 97.9% and TICI2c-3 score was 87.6%. No device related adverse event occurred. The mean 24-h NIHSS score was 6 (IQR 0-33). In conclusion, the NeVa thrombectomy device offers a high rate of first-pass success along with favorable safety profile. Larger series and multi-center studies are needed for further investigation.

Type of intracranial hemorrhage after endovascular stroke treatment: association with functional outcome

BackgroundIntracranial hemorrhage (ICH) is a frequent complication after endovascular stroke treatment.ObjectiveTo assess the association of the occurrence and type of ICH after endovascular treatment (EVT) with functional outcome.MethodsWe analyzed data...

Susceptibility-weighted imaging is helpful in diagnosis of cerebral gnathostomiasis.

To describe the role of SWI compared with other MR imaging sequences and CT in diagnosis of cerebral gnathostomiasis. CTs and MRIs of patients with cerebral gnathostomiasis were retrospectively reviewed. The types of intracranial hemorrhage, including intraparenchymal hemorrhage (IPH), subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), and their locations were recorded. Four patients proven as cerebral gnathostomiasis were included. Intracranial hemorrhage was detected in all patients. There was IPH in all patients, SAH in 2 patients, and SDH in 2 patients. All patients (4/4) revealed hemorrhagic tracts which were very conspicuously seen on SWI. Other imaging sequences could also reveal hemorrhagic tracts in 3 patients (3/4) but are less conspicuously seen than SWI. None of the CT brains could detect hemorrhagic tracts. Intracranial hemorrhage associated with hemorrhagic tract, best demonstrated by SWI, is the key imaging characteristic in diagnosis of cerebral gnathostomiasis.

Early tirofiban administration for patients with acute ischemic stroke treated with intravenous thrombolysis or bridging therapy: Systematic review and meta-analysis

ObjectiveIn the present systematic review and meta-analysis, we sought to compare the efficacy and safety of tirofiban administered in patients with acute ischemic stroke (AIS) after intravenous thrombolysis (IVT) with or without mechanical thrombectomy (MT). MethodsWe searched PubMed, Web of Science, Embase and the Cochrane Library for randomized clinical trials and observational studies published between 2001 and 2021 that provided outcomes of AIS patients who underwent IVT alone or IVT bridging with or without tirofiban. The primary outcome was the proportion of patients achieving a modified Rankin Scale (mRS) score of 0–2 at 90 days. The secondary outcomes included the rates of (1) an excellent outcome defined as a mRS score of 0 or 1 at 90 days, (2) any type of intracranial hemorrhage (ICH), (3) symptomatic intracranial hemorrhage (sICH), (4) mortality, and (5) successful recanalization. ResultsWe included 722 patients with IVT bridging therapy in 3 trials; there were 171 patients in the tirofiban group and 551 patients in the nontirofiban group. We included 846 patients with IVT alone in 7 studies; there were 471 patients in the tirofiban group and 375 patients in the nontirofiban group. The patients treated with tirofiban had a reduced risk of mortality compared to the patients treated without tirofiban during IVT bridging (OR, 0.46; 95 % CI, 0.24–0.89; p = 0.02), but no significant differences were found in safety outcomes on sICH, ICH, recanalization or efficacy outcomes on modified Rankin scale 0–2 (p > 0.05). Pooled results showed that tirofiban combined with IVT alone did not increase the risks of sICH, ICH or mortality but was significantly associated with excellent (OR, 2.68; 95 % CI, 1.58–4.55; P = 0.0003) and favorable (OR, 2.36; 95 % CI, 1.58–3.52; p < 0.0001) functional outcomes at 90 days. ConclusionIn AIS patients who underwent IVT or bridging therapy, early administration of tirofiban may be effective and safe, but further studies are needed to confirm the efficacy.

Predictive Factors for Clinical Outcome After Direct Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion Within 4.5 h.

BackgroundRecent trials including DIRECT-MT, DEVT, and SKIP have found that direct mechanical thrombectomy (MT) is equally effective as the combination of MT and intravenous thrombolysis. However, the results of the other trials, namely MR-CLEAN NO-IV and the SWIFT-DIRECT trial have failed to confirm the non-inferiority of direct MT vs. the combination therapy.AimWe aimed to identify prognostic factors of direct MT for anterior circulation large vessel occlusion within 4.5 h.Materials and MethodsData from January 2018 to January 2022 were retrospectively collected and analyzed. Adult patients with confirmed anterior circulation large vessel occlusion within 4.5 h of onset with baseline NIHSS of ≥6 and baseline ASPECTS of ≥6 treated using direct MT within 6 h were recruited.ResultsA total of 140 patients were enrolled in the study with a median age of 65.5 years [interquartile range (IQR), 59–76.5], median baseline NIHSS of 13.5 (IQR, 11–16), and median baseline ASPECTS of 8 (IQR, 7–8). Direct MT was feasible in all patients (100%). Successful reperfusion (mTICI 2b-3) was achieved in 124/140 patients (88.6%) with a low rate of complications (8/140, 5.7%). Any type of intracranial hemorrhage (ICH) and symptomatic ICH occurred in 44/140 (31.4%) and 5/140 (3.6%), respectively. Overall, a good outcome (mRS 0–2) was achieved in 93/140 (66.4%), and the mortality rate was 9.3% (13/140 patients). Using multivariate analysis, lower age [odds ratio (OR), 0.96; 95% CI, 0.92–1.00; P = 0.05], low baseline NIHSS (OR, 0.82; 95% CI, 0.74–0.92; P = 0.00), and absence of ICH (OR, 0.29; 95% CI, 0.10–0.81; P = 0.02) were independently associated with favorable outcome. Independent predictors of mortality were baseline NIHSS (OR, 1.21; 95% CI, 1.01–1.46; P = 0.04), successful reperfusion (OR, 0.02; 95% CI, 0.00–0.58; P = 0.02), and ICH (OR, 0.12; 95% CI, 0.02–0.75; P = 0.02). Further analysis showed that the median mRS at 90 days was significantly better in the MCA occlusion group compared to the ICA plus M1 occlusion group [1 (IQR 0–3) vs. 2 (IQR 1–4); P = 0.05].ConclusionsOur findings suggest that direct thrombectomy may be an adequate clinical option for younger patients (≤70) experiencing proximal middle artery occlusion within 4.5 h and who have low baseline NIHSS (≤14).

Females Exhibit Better Cerebral Pressure Autoregulation, Less Mitochondrial Dysfunction, and Reduced Excitotoxicity after Severe Traumatic Brain Injury.

The aim of the study was to investigate sex-related differences in intracranial pressure (ICP) dynamics, cerebral pressure autoregulation (PRx55-15), cerebral energy metabolism, and clinical outcome after severe traumatic brain injury (TBI). One-hundred sixty-nine adult patients with TBI, treated at the Neurointensive Care (NIC) Unit at Uppsala University Hospital between 2008 and 2020 with ICP and cerebral microdialysis (MD) monitoring were included. Of the 169 patients with TBI, 131 (78%) were male and 38 (22%) female. Male patients were more often injured by motor vehicle accidents and less often by bicycle accidents (p < 0.05). There were otherwise no differences in age, neurological status at admission, and types of intracranial hemorrhages between the sexes. The percent of monitoring time with ICP above 20 mm Hg and cerebral perfusion pressure (CPP) below 60 mm Hg were similar for both sexes. Males exhibited more disturbed cerebral pressure autoregulation (PRx55-15 [mean ± standard deviation (SD)]; 0.28 ± 0.18 vs. 0.17 ± 0.23, p < 0.05) on day 1, worse cerebral energy metabolism (MD-lactate-/pyruvate-ratio [median (interquartile range)]; 25 [19-31] vs. 20 [17-25], p < 0.01) and mitochondrial dysfunction (higher burden of MD-lactate-/pyruvate-ratio >25 and MD-pyruvate >120 μM [median (interquartile range)]; 13 [0-58] % vs. 3 [0-17] %, p < 0.05) on days 2 to 5, increased excitotoxicity (MD-glutamate median [interquartile range]; 9 [4-32] μM vs. 5 [3-10] μM, p < 0.05) on days 2 to 5, and higher biomarker levels of cellular injury (MD-glycerol median [interquartile range]; 103 [66-193] μM vs. 68 [49-106] μM, p < 0.01) most pronounced on days 6 to 10. There was no difference in mortality or the degree of favorable outcome between the sexes. Altogether, females exhibited more favorable cerebral physiology post-TBI, particularly better mitochondrial function and reduced excitotoxicity, but this did not translate into better clinical outcome compared with males. Future studies are needed to further explore potential sex differences in secondary injury mechanisms in TBI.

Frequency of Intracranial Hemorrhage among Patients with Skull Fractures in Blunt Head Trauma

Background: The global incidence of fatal head injuries is greater than the number of non-fatal cases. The presence or absence of a skull fracture, its type and site along with the type of intracranial hemorrhage has immense significance in the final outcome in cases of head injuries.&#x0D; Objective: To determine the frequency of intracranial hemorrhage and its different pattern in patients presented with skull fracture following blunt head injury in a tertiary care setting.&#x0D; Material and Methods: The study employed cross sectional study design and was conducted in Neurosurgery Unit of Lady Reading Hospital, Peshawar. The study duration was six months after approval of synopsis (29-06-2019 to 29-12-2019). A sample size of 196 patients was calculated using WHO calculator. Non probability consecutive sampling was used for patient’s selection. Ethical approval and consent forms were taken. Diagnosis of skull fracture and intracranial bleeding were made on the basis of CT brain and per op findings. Data was analyzed using SPSS version 17. Post stratification chi-square test was applied. P value ≤0.05 was considered significant.&#x0D; Results: Total 196 patients were included in study. There were 129(65.8%) male and 67(34.2%) female. Mean age of patients was 35.7 years±9.9SD. Intracranial hemorrhage was present in 32(16.3%). Type of intracranial hemorrhage was subdural in 10(5.1%), intrcerebral 3(1.5%), subarchnoid 3(1.5%), intraventricular 4(2%), contusion 2(1%), combination 2(1%), and extradural 8(4.1%). Intracranial hemorrhage is significantly associated with GCS, Occupation, cause of injury, location of injury and type of intracranial injury (p&lt;0.001).&#x0D; Recommendation: According to the findings, frequency of intracranial hemorrhage was relatively high. This study recommend all patients with skull fractures due blunt head trauma be subjected to thorough brain damage check-up. The type and location of skull fracture is an indirect indicator of the severity of force of impact which leads to damage to the underlying brain and results in fatality.&#x0D;

Recent Review of Germinal Matrix Hemorrhage-Intraventricular Hemorrhage in Preterm Infants.

Germinal matrix hemorrhage-intraventricular hemorrhage (GMH-IVH) is a particular type of intracranial hemorrhage that affects the preterm population. GMH-IVH originates from bleeding within the highly vascular area near the center of the brain known as the germinal matrix. The pathogenesis of GMH-IVH is unclear; it is likely related to hemodynamic changes and fluctuations in cerebral blood flow within a fragile developing brain. Cranial ultrasound is the primary diagnostic test and reveals the degree of GMH-IVH based on a grading system. Management includes prevention of preterm delivery with meticulous antenatal and postnatal preventative strategies. This article discusses current evidence specific to the pathogenesis, risk factors, diagnosis, grading scales, and management approaches with GMH-IVH in preterm infants.