Ventricular Hemorrhage Research Articles

Dramatic Reanimation and Spontaneous Re-Canalization of a Fourth Ventricular Hemorrhage: “REVIVE” Phenomenon

Background Intraventricular hemorrhage is a calamitous type of stroke where bleeding into the ventricular system can be defined as: primary, if confined within the ventricles; or secondary, due to intracerebral hemorrhage extending from adjacent parenchyma. Intraventricular blood clot can lead to secondary insult and inflammatory responses that culminates in hydrocephalus as the most common cause of death. Purpose THerein, we report a patient with a high modified Graeb scale and low Glasgow coma scale. She spontaneously recanalized her fourth ventricle, decompressed her reticular activating system with remarkable spontaneous bilateral eye opening, and a consequently experienced a halfway drop in her mGS. Results This is the first reported case of a spontaneous recanalization of 4th ventricle obstruction secondary to IVH without intervention and subsequent dramatic neurological improvement. We believe that the apixaban primarily preserved the liquid state of hemorrhage and her presumed elevated ICP was sufficient to push out the liquified blood in the 4th ventricle into the upper spinal canal , recanalizing the 4th ventricle by continuously creating downward CSF pressure waves. Given the RAS location around the 4th ventricle, we hypothesize spontaneous decompression from the clot lysis triggered the RAS activation with sudden arousal manifested as spontaneous bilateral eyes opening. Hence, we refer to this as the reticular activating system reactivation after ventricular hemorrhage evacuation, or simply the “REVIVE” phenomenon. Conclusion This dramatic improvement from coma to awake state is worthy of recognition for future neurotherapeutic interventions.

Treatment of post-thalamic hemorrhage hydrocephalus: ventriculoperitoneal shunt or endoscopic third ventriculostomy? A retrospective observational study

BackgroundThe aim of this study was to compare the efficacy of ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus after thalamic hemorrhage (TH) where external ventricular drainage (EVD) could not be removed after hematoma absorption, and to provide a theoretical basis for the clinical treatment of hydrocephalus after TH.MethodsThe clinical data of patients with hydrocephalus after TH whose EVD could not be removed after hematoma absorption were retrospectively analyzed. According to the patients’ surgical methods, the patients were divided into the VPS group and ETV group. The operative time, length of hospital stay, complications, and reoperation rates of the two groups were compared.ResultsThere was no statistically significant difference in intraoperative bleeding, length of hospital stay between the two groups. The EVD tubes were successfully removed in all patients after surgery. There were 4 (9.5%) complications in the ETV group and 3 (6.7%) complications in the VPS group, with no statistically significant difference in postoperative complications between the two groups. During the 1-year follow-up, 7 patients (16.7%) in the ETV group and 3 patients (6.7%) in the VPS group required reoperation. In the subgroup analysis of TH combined with fourth ventricular hemorrhage, 6 patients (14.3%) in the ETV group and 1 patient (2.2%) in the VPS group required reoperation, and the difference between the two groups was statistically significant.ConclusionsETV had good efficacy in treating hydrocephalus caused by TH and TH that broke into the lateral ventricle and the third ventricle. However, if hydrocephalus was caused by TH with the fourth ventricular hematoma, VPS was a better surgical method because the recurrence rate of hydrocephalus in ETV was higher than that in VPS. Therefore, the choice of surgical method should be based on the patient’s clinical features and hematoma location.

Clinical Outcomes of Left Ventricular Assist Device Bleeding Complication.

Bleeding complications have emerged as major causes of morbidity and mortality in patients with implantable left ventricular assist devices (LVAD). We hypothesized that the hemodynamics after LVAD implantation may influence the occurrence of bleeding complications after LVAD implantation. We retrospectively evaluated 78 patients who underwent continuous-flow LVAD implantation and hemodynamic ramp test after LVAD implantation between July 2017 and July 2023 at Osaka University. The bleeding complication occurred in 13 patients. The rates of freedom from bleeding complications at 1, 3, and 5 years were 94%, 85%, and 74%. Gastrointestinal bleeding, nose bleeding, and intraperitoneal hemorrhage occurred in six, three, and two patients, respectively. Preoperative average brachial-ankle pulse wave velocity (baPWV) was positively associated with bleeding complication (1,276 ± 280 vs. 1,098 ± 190 cm/s p = 0.04). In the hemodynamic ramp test, systemic vascular resistance (SVR) in patients with bleeding complications was higher than that in patients without bleeding complications (SVR: 1,359 ± 341 vs. 1,150 ± 217 dyne sec/cm5, p = 0.01). High preoperative baPWV and high SVR in the hemodynamic ramp test were significantly associated with bleeding complications after LVAD implantation. Arteriosclerosis is a risk factor for bleeding complications after LVAD implantation.

Evaluation of SBDP145, melatonin, sLOX-1, HMGB1 and HIF-1α in preterm infants with brain injury

BackgroundPrematurity-related brain injury is a common and serious complication that has long-term effects on the survival and development of affected infants. Currently, the roles of certain biomarkers such as the protein hydrolysis product SBDP145, melatonin, soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1), high mobility group box 1 protein (HMGB1), and hypoxia-inducible factor 1-alpha (HIF-1α) in prematurity-related brain injury remain not fully elucidated. Our study aims to assess the significance of SBDP145, melatonin, sLOX-1, HMGB1 and HIF-1α in preterm infants with brain injury.Methods135 preterm infants admitted to our hospital from January 2020 to February 2022 were selected and divided into 78 cases in a prematurity-associated brain injury group, and 57 cases in another group of preterm infants without brain injury or other diseases according to the magnetic resonance imaging results. The levels of SBDP145, melatonin, sLOX-1, HMGB1 and HIF-1α in the two groups were analyzed. The serum concentrations of SBDP145, melatonin, sLOX-1, HMGB1 and HIF-1α in newborns with different severity of ventricular hemorrhage were observed, and the levels of SBDP145, melatonin, sLOX-1, HMGB1 and HIF-1α in those with different severity of white matter brain injury were compared.ResultsThe levels of SBDP145, sLOX-1, HMGB1 and HIF-1α were significantly higher in the preterm combined brain injury group than in the preterm group, and melatonin levels were significantly lower than in the preterm group(P < 0.05). The levels of SBDP145, sLOX-1, HMGB1 and HIF-1α were higher in the moderate to severe group and melatonin levels were lower in the mild group of newborns with ventricular hemorrhage (P < 0.05). The levels of SBDP145, sLOX-1, HMGB1 and HIF-1α were higher in the moderate-severe group and melatonin levels were lower in the mild group in newborns with cerebral white matter injury (P < 0.05). The independent variables were SBDP145, melatonin, sLOX-1, HMGB1, HIF-1α, and the dependent variable was the prognosis of neonates with brain injury. Univariate logistic regression analysis and multivariate logistic regression analysis were performed. The results showed that the influencing factors of newborns with brain injury were SBDP145, melatonin, sLOX-1, HMGB1, HIF-1α.ConclusionThe levels of SBDP145, melatonin, sLOX-1, HMGB1 and HIF-1α were highly expressed in preterm newborns with brain injury, and the levels were higher when the condition of the newborns was more severe. These findings suggest the potential clinical utility of these biomarkers in predicting and monitoring brain injury in preterm infants, which could aid in early intervention and improve long-term outcomes.

Prompt closure versus gradual weaning of external ventricular drain for hydrocephalus following aneurysmal subarachnoid haemorrhage: a statistical analysis plan for the DRAIN randomised clinical trial

BackgroundInsertion of an external ventricular drain (EVD) is a first-line treatment of acute hydrocephalus caused by aneurysmal subarachnoid haemorrhage (aSAH). Once the patient is clinically stable, the EVD is either removed or replaced by a permanent internal shunt. The optimal strategy for cessation of the EVD is unknown. Prompt closure carries a risk of acute hydrocephalus or redundant shunt implantations, whereas gradual weaning may increase the risk of EVD-related infections.MethodsDRAIN (Danish RAndomised Trial of External Ventricular Drainage Cessation IN Aneurysmal Subarachnoid Haemorrhage) is an international multicentre randomised clinical trial comparing prompt closure versus gradual weaning of the EVD after aSAH. The primary outcome is a composite of VP-shunt implantation, all-cause mortality, or EVD-related infection. Secondary outcomes are serious adverse events excluding mortality and health-related quality of life (EQ-5D-5L). Exploratory outcomes are modified Rankin Scale, Fatigue Severity Scale, Glasgow Outcome Scale Extended, and length of stay in the neurointensive care unit and hospital. Outcome assessment will be performed 6 months after ictus. Based on the sample size calculation (event proportion 80% in the gradual weaning group, relative risk reduction 20%, alpha 5%, power 80%), 122 participants are required in each intervention group. Outcome assessment for the primary outcome, statistical analyses, and conclusion drawing will be blinded. Two independent statistical analyses and reports will be tracked using a version control system, and both will be published. Based on the final statistical report, the blinded steering group will formulate two abstracts.ConclusionWe present a pre-defined statistical analysis plan for the randomised DRAIN trial, which limits bias, p-hacking, and data-driven interpretations. This statistical analysis plan is accompanied by tables with simulated data, which increases transparency and reproducibility.Trial registrationClinicalTrials.gov identifier: NCT03948256. Registered on May 13, 2019.

Risk factors and outcomes associated with external ventricular drain related hemorrhage

ObjectiveThe objective of this study was to determine risk factors predictive of external ventricular drain (EVD)-related hemorrhage and the association of such hemorrhages with mortality, discharge disposition, length of stay (LOS), and total cost. MethodsAfter Institutional Review Board approval, data was collected retrospectively for adult patients requiring EVD placement from 2015 to 2018 at the authors’ institution. Collected data included demographic patient information, peri-procedural factors, and relevant post-procedural measures. Computerized tomography (CT) images and associated radiologic reports were independently reviewed, identifying hemorrhages accompanying EVD placement. ResultsFrom this 487-patient sample, 85 (17.5 %) patients had hemorrhages, including asymptomatic hemorrhages identified on imaging alone. A univariable analysis of patient parameters in the overall cohort was performed to identify possible predictors of hemorrhage. Age (p = 0.002), Charlson Comorbidity Index (CCI) (p < 0.001), platelet count (p = 0.002), presence of uremia (p = 0.035), and the number of times the EVD was replaced (p < 0.001) were associated with hemorrhage in univariable models. The experience of the resident surgeon based on post-graduate year (PGY level) and the number of attempts/passes needed for EVD placement were not associated with hemorrhage risk. Significant predictor of hemorrhage confirmed in a multivariable analysis only included the number of times the EVD was replaced (OR = 2.78, adjusted p < 0.001). Outcomes between EVD-related hemorrhage versus no hemorrhage groups, including mortality, discharge disposition, LOS, and cost, were compared. EVD-related hemorrhage was found to be associated with increased mortality (OR = 3.58, adjusted p < 0.001) and decreased likelihood of discharge home (OR = 0.13, adjusted p = 0.030) in the associated multivariable regressions. ConclusionThe number of times an EVD was replaced was associated with EVD-related hemorrhage outcome. EVD-related hemorrhage is associated with increased mortality and a decreased likelihood of being discharged home.

Comparison of scales for the evaluation of aneurysmal subarachnoid haemorrhage: a retrospective cohort study

Background/ObjectivesAneurysmal subarachnoid haemorrhage (aSAH) is a life-threatening event with major complications. Delayed cerebral infarct (DCI) occurs most frequently 7 days after aSAH and can last for a prolonged period. To determine the most predictive radiological scales in grading subarachnoid or ventricular haemorrhage or both for functional outcome at 3 months in a large aSAH population, we conducted a single-centre retrospective study.MethodsA 3-year single-centre retrospective cohort study of 230 patients hospitalised for aSAH was analysed. Initial computed tomography (CT) scans in patients hospitalised for aSAH were blindly assessed using eight grading systems: the Fisher grade, modified Fisher grade, Barrow Neurological Institute scale, Hijdra scale, Intraventricular Haemorrhage (IVH) score, Graeb score and LeRoux score.ResultsOf 200 patients with aSAH who survived to day 7 and were included for DCI analysis, 39% of cases were complicated with DCI. The Hijdra scale was the best predictor for DCI, with a receiver operating characteristic area under the curve (ROCAUC) of 0.80 (95% confidence interval (CI), 0.74–0.85). The IVH score was the most effective grading system for predicting acute hydrocephalus, with a ROCAUC of 0.85 (95% CI, 0.79–0.89). In multivariate analysis, the Hijdra scale was the best predictor of the occurrence of DCI (hazard ratio, 1.18; 95% CI, 1.10–1.25).ConclusionsAlthough these results have yet to be prospectively confirmed, our findings suggest that the Hijdra scale may be a good predictor of DCI and could be useful in daily clinical practice.Clinical relevance statementBetter assessment of subarachnoid haemorrhage patients would allow for better prognostication and management of expectations, as well as referral for appropriate services and helping to appropriate use limited critical care resources.Key PointsAneurysmal subarachnoid haemorrhage is a life-threatening event that causes severe disability and leads to major complications such as delayed cerebral infarction.Accurate assessment of the amount of blood in the subarachnoid spaces on computed tomography with the Hijdra scale can better predict the risk of delayed cerebral infarct.The Hijdra scale could be a good triage tool for subarachnoid haemorrhage patients.

Abstract 2023: Plasminogen Activator Inhibitor-1 Deficiency Augments Angiotensin II-induced Cardiac Fibrosis, But Not Aortic Aneurysm Formation In Mice

Background: Plasminogen activator inhibitor-1 (PAI-1) is highly abundant in human thoracic aortic aneurysms (TAA). This high abundance is mimicked in TAAs created by chronic infusion of angiotensin II (AngII) into mice. The purpose of this study was to determine whether deletion of PAI-1 influenced the development of thoracic aortic aneurysms during AngII infusion. Methods and Results: To determine the role of PAI-1 in acute and chronic phases of AngII-induced pathology, whole-body PAI-1 deficient mice (PAI-1 -/-) and wild type littermates (PAI-1 +/+) were infused with AngII (1,000 ng/kg/min) for 7 or 28 days, respectively. Aortic diameters were measured by ultrasonography and in situ measurement. PAI-1 deficiency did not alter maximal luminal or external aortic diameters at 7 or 28 days of AngII. At 7 days of AngII, ventricular hemorrhage was visibly evident in PAI-1 -/- mice. Mid-ventricular heart sections were next examined by hematoxylin and eosin staining, and red blood cell accumulation was found primarily within the epicardium. Masson’s trichrome staining revealed interstitial fibrosis in the epicardium, myocardium, and posterior septum of PAI-1 -/- mice. At 28 days of AngII, PAI-1 -/- mice displayed primarily epicardial fibrosis evident by trichrome staining and gross appearance. The posterior septum presented less fibrosis after 28 days of AngII relative to 7 days of AngII. Conclusions: PAI-1 deficiency did not alter aortic dilatation, indicating that PAI-1 is not a key contributor to AngII-induced TAAs. Paradoxically, PAI-1 deficiency augmented AngII-induced cardiac fibrosis with distinct distributions between acute and chronic phases.

Case report: Rare case Pandoraea ssp causing bacteremia associated with CRBSI in patients with hydrocephalus post intraventricular hemorrhage drain revision at Prof. Ngoerah Hospital, Denpasar, Bali

Introduction: Pandoraea species is a multidrug-resistant, gram-negative bacillus usually isolated from patients with cystic fibrosis (CF) and also commonly found in water and soil. Bloodstream infection with Pandoraea ssp in non-CF patients is uncommon. We report the first case of post-revision VP shunt hydrocephalus with bacteremia and associated CRBSI caused by Pandoraea ssp. Case description: A 50-year-old Balinese man with underlying disease of sepsis by Pandoraea ssp. after several histories of surgery, a patient with non-communicating hydrocephalus and intraventricular hemorrhage after endoscopic Intra Ventricular Hemorrhage evacuation and revision of the proximal shunt. The patient complained of being unconscious for 2 days, slurred speech, weakness in half of the body, vomiting once, seizures, and a fever. The CVC device was installed for 20 days, and he had a fluctuating fever during the hospitalization. Ceftriaxone and levofloxacin were given intravenously for empiric treatment. Pandoraea ssp. were isolated from both his blood samples and exit site; once the pathogen and drug sensitivity were confirmed, levofloxacin was planned for definitive treatment. One month after the patient was admitted, his condition worsened and he was pronounced dead. Discussion: Pandoraea ssp. had been reported in this patient with multiple organ dysfunction as a complicating factor. In our case, the potential source of this bacteria was considered to be contamination from the environment. This infection is considered CRBSI during hospitalization. This bacteria is multi-drug-resistant, which makes treatment of Pandoraea infections complicated. Conclusion: The finding case will be beneficial to clinicians because it provides additional information about the lesser-known Pandoraea species.

871 Bedside Neuronavigation for External Ventriculostomy as a Training Tool for Success: A Single-institution Experience and Meta-Analysis of Patients Outcomes and Procedural Accuracy

INTRODUCTION: External ventricular drain (EVD) placement is the most universally performed neurosurgical procedure, frequently by trainees. Freehand insertion, which approximates anatomical landmarks to achieve percutaneous ventricular access, bodes a complication risk as high as 40%. Neuronavigation is widely used for neurosurgical procedures; however, its use case for EVD has been inadequately explored. METHODS: A single-institution retrospective cohort study was performed, including all EVDs inserted in 2022. A PRISMA-guided systematic review was then conducted, querying databases for relevant articles. Primary outcomes of interest were optimal positioning (using Kakarla grading) and number of passes for ventricular access. Secondary outcomes included postoperative ventricular enlargement, hemorrhage, edema, and drain malfunction. Clinical data was pooled between single-institution and systematic review for meta-analyses. Outcomes were compared using risk ratios (RR [95% CI]) and standardized mean differences (SMD). RESULTS: Forty-seven patients (49 EVDs) were included from a single institution (17 neuronavigation; 32 freehand). Through systematic review, 1,289 patients (255 neuronavigation; 1,034 freehand) were identified from 10 eligible studies. Pooled together, patients were predominantly male (52%) and adult-aged (90%). EVD indications most commonly included hemorrhage (61%), obstructive pathology (15%), trauma (10%), and infection (7%). 85% of EVDs were placed by neurosurgical trainees. Frequency of catheter malposition was significantly lower in the neuronavigation cohort compared to the freehand cohort (10% vs. 36%; RR, 0.41 [0.24-0.69]). However, number of catheter passes remained the same between cohorts (mean [SD]; 1.11 [0.42] vs. 1.16 [0.51]; SMD; 0.04 [0.48]). Moreover, frequencies of postoperative ventricular enlargement, hemorrhage, edema, and drain malfunction, although were higher in the freehand cohort, did not differ significantly. CONCLUSIONS: These findings suggest neuronavigation helps trainees achieve safe and accurate ventricular access. Neuronavigation-guided external ventriculostomy may offer a promising, accessible, and bedside-ready approach to minimize morbidity, while mastering the procedural technique.

Effect of breast milk intake volume on early behavioral neurodevelopment of extremely preterm infants

BackgroundThis study aimed to explore the effects of breast milk feeding volume on the early behavioral neurodevelopment of extremely preterm infants (gestational age < 28 weeks).MethodsThe study was conducted from 1 January 2021 to 31 March 2023. A total of 187 preterm infants from a neonatal intensive care unit (NICU) in a Grade III Class A hospital in Zhejiang, China, were divided based on the proportion of breast milk in their total enteral nutrition: high proportion (≥ 80%, including exclusive breast milk feeding), medium proportion (20% ~ < 80%), and low proportion (< 20%). The study investigated motor performance and behavioral neurodevelopment at 37 weeks of corrected gestational age, as well as the total incidence of intracranial hemorrhage within the first four weeks postpartum.ResultsThe low breast milk feeding group had significantly lower scores in infant motor performance (31.34 ± 5.85) and elicited item scores (19.89 ± 5.55) compared to the medium and high groups (33.52 ± 4.33, 22.13 ± 4.22; and 35.86 ± 5.27, 23.91 ± 4.98), p < 0.05, respectively. Despite no significant difference in behavioral ability, the low proportion group exhibited lower passive muscle tension and primitive reflex scores than the medium and high proportion groups. The high proportion group showed higher active muscle tension scores. Ultrasound results revealed varying incidences of intracranial hemorrhage: 72.9% in low, 52.5% in medium, and 19.6% in the high proportion groups.ConclusionsMedium to high levels of breast milk feeding contribute positively to motor and behavioral neurological development in extremely preterm infants and decrease the likelihood of ventricular hemorrhage. However, it does not have a significant effect on the development of behavioral abilities. Due to the limited sample size, the next step will be to expand the sample size and further investigate the extent of the impact on various aspects of the nervous system.

The relationship between mean platelet volume (MPV) and intraventricular hemorrhage in very low birth weight infants.

Intra ventricular hemorrhage (IVH) is a major cause of mortality among very low birth weight infants. This study aimed to investigate the relationship between mean platelet volume (MPV) and IVH in very low birth weight infants. In this cohort study, all premature infants weighing less than 1500 grams who were admitted to the NICU were enrolled from August 2018 to July 2019. Brain ultrasonography was performed on the first and seventh days and one month of age and were compared with Platelet count and MPV. From 183 neonates, 23 cases (12.6%) had IVH. The mean MPV on the first day in the group with IVH was 10.48±0.85 and in the non-IVH group was 9.9±0.74 (P = 0.005). The mean MPV on the seventh day in the IVH and non-IVH group were 10.4±0.92 and 10.03±0.74 (P = 0.04) respectively. On the first and seventh day, for one unit of MPV increase, the chance of IVH increased by 2.68 and 2.1 respectively. (p = 0.001; OR3.643; 95% CI [1.703-7.753]). The mean MPV index is significantly higher in the infants with IVH and therefore it can be used in early detection of IVH in neonates weighing less than 1500 grams.

Dual path sub-type diagnostic model based on the anatomic morphological feature

Intracranial hematoma can compress the brain tissue, resulting in increased cranial pressure and a high fatality rate. Therefore, providing a rapid and accurate clinical diagnosis and treatment plan is a crucial step. Intracranial hematoma can be classified into clinical sub-types such as cerebral lobes, ventricular, basal ganglia, pons, and cerebellum hemorrhage based on the location of the hemorrhage. To accurately identify different sub-types and provide targeted treatment, this paper proposes a dual path sub-type diagnosis model based on the anatomic morphological feature. It extracts anatomic morphological features of hematoma based on clinical prior knowledge to achieve prior feature enhancement. Then, a dual-path input model is constructed, and the dual-path module is used to analyze and integrate various features of different sub-types of intracranial hematoma. The model is validated on the clinical data set of the Second Affiliated Hospital of Dalian Medical University, and the corresponding accuracy can reach 0.993. This model can automatically recognize the sub-type of the clinical intracranial hematoma cases and improve diagnostic efficiency. Besides, it further aid in image analysis and enable specific treatment planning.

Ultraearly Intraventricular Hemorrhage Growth Predicts Early Neurologic Deterioration and Poor Functional Outcome After Acute Intracerebral Hemorrhage.

Background The presence of intraventricular hemorrhage (IVH) was extensively investigated and was associated with poor outcome in patients with intracerebral hemorrhage (ICH). However, the effect of the speed of ventricular bleeding on outcomes is unknown. Methods and Results We prospectively included patients with ICH who had baseline computed tomography scans within 6 hours after ictus between January 2016 and October 2021. The clinical characteristics were compared between patients with and without early neurologic deterioration (END). Ultraearly IVH growth (uIVHG) was defined as baseline IVH volume by onset-to-imaging time. The association between uIVHG and outcomes was assessed by using multivariable logistic regression analysis. We established the ultraearly IVH growth (uIVH) score and compared the areas under the receiver operating characteristic curves of the existing scores for predicting END. A total of 299 patients were finally enrolled. Of those, 38 patients (12.7%) experienced END at 24 hours and 89 patients (29.8%) had poor outcomes at 90 days. After adjustment for confounding factors, uIVHG (odds ratio, 1.061 [95% CI, 1.011-1.113]; P=0.016) was independently associated with END in multivariable analysis. A prediction score was developed on the basis of the logistic model. The uIVH score was developed as a sum of individual points (0-6) based on age, hematoma volume, National Institutes of Health Stroke Scale, hematoma expansion, and uIVHG ≥2.5 mL/h. In comparison with the ICH score and modified Emergency Department ICH Scale, the uIVH score exhibited best performance in the prediction of END. Conclusions uIVHG is associated with early neurologic deterioration and poor functional outcome in patients with ICH.

Хирургическое лечение синдрома Терсона на фоне субарахноидального кровоизлияния в левой гемисфере головного мозга (клинический случай)

Purpose. To describe a clinical case and treatment performed in a patient with Terson's syndrome at the background of subarachnoid hemorrhage. Clinical case. Patient O., born in 1981, came to our center with complaints of decreased vision, especially of the left eye. It is known from the anamnesis that a month ago a diagnosis of non-traumatic subarachnoid, ventricular hemorrhage in the left the of the brain was made. After examination, microinvasive vitrectomy, for total the of the left eye, partial hemophthalmos of the right eye was recommended. As the result of surgical intervention, it was possible to significantly improve the visual functions of both eyes. Conclusion. Currently, there are no uniform recommendations that would say at what point vitrectomy is necessary. In case of wait-and-see tactics and conservative therapy, complications such as vitreous fibrosis, development of traction syndrome, retinal detachment, or development of epiretinal fibrosis are possible. With timely surgical treatment within 1–1.5 months, it is possible to restore the initial visual functions of the patient. However, it is necessary to conduct large-scale research in this area in order to reach a consensus. Key words: Terson`s syndrome; hemophthalmos; microinvasive vitrectomy; subarachnoid hemorrhage.

Catheter Tract Hemorrhages and Intracerebral Hemorrhage Outcomes in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Trial.

Factors associated with external ventricular catheter tract hemorrhage (CTH) are well studied; whether CTH adversely influence outcomes after intracerebral hemorrhage (sICH), however, is poorly understood. We therefore sought to evaluate the association between CTH and sICH outcomes. We performed a post hoc analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial. The exposure was CTH and evaluated on serial computed tomography scans between admission and randomization (approximately 72 hours). The primary outcomes were a composite of death or major disability (modified Rankin Score >3) and mortality alone, both assessed at 6 months. Secondary outcomes were functional outcomes at 30 days, permanent cerebrospinal fluid (CSF) shunt placement, any infection, and ventriculitis. We performed logistic regression adjusted for demographics, comorbidities, sICH characteristics, and treatment assignment, for all analyses. Of the 500 patients included, the mean age was 59 (SD, ±11) years and 222 (44%) were female. CTH occurred in 112 (22.4%) patients and was more common in minority patients, those on prior antiplatelet therapy, and patients who had more than 1 external ventricular drain placed. The end of treatment intraventricular hemorrhage volume was higher among patients with CTH (11.7 vs 7.9 mL, P = .01), but there were no differences in other sICH characteristics or the total duration of external ventricular drain. In multivariable regression models, CTH was not associated with death or major disability (odds ratio, 0.7; 95% CI: 0.4-1.2) or death alone (odds ratio, 0.8; 95% CI, 0.5-1.4). There were no relationships between CTH and secondary outcomes including 30-day functional outcomes, permanent CSF shunt placement, any infection, or ventriculitis. Among patients with sICH and large intraventricular hemorrhage, CTH was not associated with poor sICH outcomes, permanent CSF shunt placement, or infections. A more detailed cognitive evaluation is needed to inform about the role of CTH in sICH prognosis.

Urokinase administration for intraventricular hemorrhage in adults: A retrospective analysis of hemorrhage volume reduction and clinical outcomes.

Intraventricular hemorrhage (IVH) is a type of ventricular bleeding that results in significant morbidity and mortality. Multiple studies have investigated the use of urokinase in IVH treatment. The use of urokinase may lead to higher rates of hematoma resolution and lower mortality rates. However, further studies are required to determine efficacy of urokinase administration. This study examined the association between urokinase use, IVH volume reduction, and clinical outcomes. In total, 94 adult patients with hypertensive intracerebral hemorrhage with ventricular extension or primary IVH were enrolled between 2015 and 2021. Participants were categorized into two groups: "EVD combined with fibrinolysis" and "EVD only." The primary objective was to assess the reduction of IVH severity. Additionally, the study evaluated the functional outcomes and shunt dependency rate as secondary outcomes. Non-contrast computed tomography scans were obtained to measure the severity of IVH using the mGRAEB score. The main outcomes were the association among urokinase administration, reduced IVH severity, and functional outcomes. There were no significant differences in the reduction rate of mGRAEB scores within a 7-day period (-50.0 [-64.4 to -32.5] % vs -44.2 [-59.3 to -7.9] %; p = 0.489). In addition, investigation of the third and fourth ventricles showed similar findings between the two groups. Urokinase treatment was not associated with significant differences in the modified Rankin Scale (5.0 (4.0-5.0) vs. 4.5 (4.0-5.0), p = 0.674) or shunt dependency rate (33.3% vs 39.3%, p = 0.58). This study found that intraventricular urokinase use in patients with IVH was not associated with reduced IVH severity. In addition, urokinase use was not associated with better functional outcomes or minor shunt dependency rates.

Clinical outcomes of transcatheter mitral valve replacement: two-year results of the CHOICE-MI Registry.

Transcatheter mitral valve replacement (TMVR) using dedicated devices is an alternative therapy for high-risk patients with symptomatic mitral regurgitation (MR). This study aimed to assess the 2-year outcomes and predictors of mortality in patients undergoing TMVR from the multicentre CHOICE-MI Registry. The CHOICE-MI Registry included consecutive patients with symptomatic MR treated with 11different dedicated TMVR devices at 31 international centres. The investigated endpoints included mortality and heart failure hospitalisation rates, procedural complications, residual MR, and functional status. Multivariable Cox regression analysis was applied to identify independent predictors of 2-year mortality. Atotal of 400patients, median age 76 years (interquartile range [IQR] 71, 81), 59.5% male, EuroSCORE II 6.2% (IQR 3.8, 12.0), underwent TMVR. Technical success was achieved in 95.2% of patients. MR reduction to ≤1+ was observed in 95.2% at discharge with durable results at 1 and 2years. New York Heart Association Functional Class had improved significantly at 1 and 2years. All-cause mortality was 9.2% at 30days, 27.9% at 1year and 38.1% at 2years after TMVR. Chronic obstructive pulmonary disease, reduced glomerular filtration rate, and low serum albumin were independent predictors of 2-year mortality. Among the 30-day complications, left ventricular outflow tract obstruction, access site and bleeding complications showed the strongest impact on 2-year mortality. In this real-world registry of patients with symptomatic MR undergoing TMVR, treatment with TMVR was associated with adurable resolution of MR and significant functional improvement at 2years. Two-year mortality was 38.1%. Optimised patient selection and improved access site management are mandatory to improve outcomes.

HDAC3 inhibitor (BRD3308) modulates microglial pyroptosis and neuroinflammation through PPARγ/NLRP3/GSDMD to improve neurological function after intraventricular hemorrhage in mice

Neuroinflammation plays a vital role in intraventricular hemorrhage (IVH). Excessive neuroinflammation after IVH can activate the inflammasome in the cell and accelerate the occurrence of pyroptosis in cells, produce more inflammatory mediators, increase cell death, and lead to neurological deficits. Previous studies have reported that BRD3308 (BRD), an inhibitor of histone deacetylation by histone deacetylase 3 (HDAC3), suppresses inflammation-induced apoptosis and exhibits anti-inflammatory properties. However, it is unclear how BRD reduces the occurrence of the inflammatory cascade. In this study, we stereotactically punctured the ventricles of male C57BL/6J mice and injected autologous blood via the tail vein to simulate ventricular hemorrhage. Magnetic resonance imaging was used to detect ventricular hemorrhage and enlargement. Our findings demonstrated that BRD treatment significantly improved neurobehavioral performance and decreased neuronal loss, microglial activation, and pyroptosis in the hippocampus after IVH. At the molecular level, this treatment upregulated the expression of peroxisome proliferator-activated receptor γ (PPARγ) and inhibited NLRP3-mediated pyroptosis and inflammatory cytokines. Therefore, we concluded that BRD reduced pyroptosis and neuroinflammation and improve nerve function in part by activating the PPARγ/NLRP3/GSDMD signaling pathway. Our findings suggest a potential preventive role for BRD in IVH.

P.128 Recurrent subarachnoid hemorrhage secondary to Chiari 1 malformation

Background: We describe a patient with recurrent subarachnoid hemorrhage (SAH) secondary to Chiari 1 malformation. Methods: A retrospective review of the clinical chart was performed. Results: A previously healthy female in her 70’s presented with worst headache of life. CT demonstrated 4th ventricular hemorrhage with SAH extending into the bilateral cerebellomedullary fissures. CTA did not show a vascular etiology and patient was discharged home. Incidental note was made of a right persistent trigeminal artery. The patient then represented 2 weeks later with worst headache of life and decreased level of consciousness. CT demonstrated extensive SAH extending into the 3rd and 4th ventricles. CTA and diagnostic cerebral angiogram did not show a vascular etiology. MRI brain/C-spine revealed Chiari 1 malformation. An external ventricular drain was placed but could not be weaned. She underwent suboccipital craniectomy with C1 laminectomy. Intraoperatively, there was a prominent dorsal spinal vein that appeared under tension as it pierced the arachnoid membrane and subsequently entering the dura as a rudimentary occipital sinus. This vein was coagulated and divided. The patient recovered well and was at neurological baseline at 6 month follow-up. Conclusions: This is the first reported case of recurrent SAH secondary to Chiari 1 malformation.