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OBJECTIVES Compare color Doppler (Color) ultrasound-guided puncture to common type-B (Type-B) ultrasound-guided puncture in reducing the incidence of hemorrhagic complications of percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS A total of 348 patients who received PCNL from September 2017 to December 2018 were divided into Color (231 cases) and Type-B groups (117 cases). The avascular area of the target fornix was pinpointed in the Color group while the middle of the target fornix was the default puncture point in the Type-B group. Tract bleeding, nephrostomy tract creation time, operation time, postoperative hemoglobin (Hb) values and serum creatinine (Scr) concentrations, and stone-free rates were analyzed. RESULTS Color Doppler imaging revealed that 35.1% of the cases in the Color group (81/231) had variable artery positioning in the target fornix. Tract bleeding and postoperative Hb reduction in the Color group were significantly lower than the Type-B group (10.8% vs 24.8%, P=0.0007, and 4.87±8.58 vs 7.70±8.90 g/L, P=0.0044, respectively). The postoperative hospitalization of the Color group was also shortened (8.3±5.9 vs 9.7±3.0 d, P

Stent-assisted coiling (SAC) for ruptured intracranial aneurysms (RIAs) remains controversial due to an inherent risk of potential thromboembolic and hemorrhagic complications. We compared SAC and coiling alone for the management of RIAs using propensity score-adjustment. Sixty-four patients treated by SAC and 220 by stand-alone coiling were retrospectively reviewed and compared using inverse probability of treatment weighting (IPTW) with propensity scores. Functional outcome, procedure-related and overall complications and angiographic results were analyzed. Aneurysms treated by SAC had a larger diameter, a wider neck and were more frequently located at the posterior circulation. SAC had a higher risk for thromboembolic complications (17.2% vs. 7.7%, p = 0.025), however, this difference did not persist in the IPTW analysis (OR 1.2, 95% CI 0.7–2.3, adjusted p = 0.458). In the adjusted analysis, rates of procedural cerebral infarction (p = 0.188), ventriculostomy-related hemorrhage (p = 0.584), in-hospital mortality (p = 0.786) and 6-month favorable functional outcome (p = 0.471) were not significantly different between the two groups. SAC yielded a higher complete occlusion (80.0% vs. 67.2%, OR 3.2, 95% CI 1.9–5.4, p

To determine whether a single dose of preoperative enoxaparin for venous thromboembolism (VTE) prophylaxis impacts rates of thrombotic and bleeding events after robotic partial nephrectomy (RPNx).A retrospective cohort study of RPNx patients from 2009 to 2020 was performed. Clinical characteristics and perioperative outcomes were compared between patients receiving a single dose of preoperative enoxaparin and those who did not. The primary outcome was 30-day hemorrhagic complications (transfusion ≥2 units, embolization, or reoperation for bleeding). Secondary outcomes were 30-day VTE events. Multivariable logistic regression was performed to control for significant differences between groups and to identify predictors of hemorrhagic complications among patients.Among 945 RPNx procedures, 794 (84%) received preoperative enoxaparin (PPx) and 151 (16%) did not (NPPx). The PPx cohort was older (P = .004), had lower BMI (P = .03), lower ASA class (P = .049), and fewer smokers (P = .03). Warm ischemia time was longer for PPx patients (P.001). 4.9% and 2.6% of the PPx and NPPx cohorts, respectively, developed postoperative hemorrhagic complications (P = .29). After adjustment for potential covariates, pharmacologic prophylaxis was not associated with 30-day hemorrhagic complications (P = .39). On multivariable regression, longer warm ischemia time (OR 1.05, 95% CI 1.01-1.10, P = .02) and greater tumor size (OR 1.27, 95% CI 1.03-1.56, P = .02) were predictors of hemorrhagic complications. 30-day readmissions, VTE events, and mortality were similar between groups (all P0.05).Similar rates of thrombotic and bleeding events occurred between patients receiving pharmacologic prophylaxis and those who did not. Single dose of preoperative enoxaparin did not significantly alter perioperative outcomes after RPNx.

To evaluate whether extended catheter-directed thrombolysis (CDT) with repeat visits to the angiography suite provide added benefit in treatment of acute pulmonary embolism (PE).This was a retrospective review of CDT procedures performed for acute PE in 156 patients (age 56.1 y ± 15.3, 46.2% women) between 2009 and 2019. All patients underwent at least 1 follow-up visit to the angiography suite for evaluation of pulmonary artery pressure (PAP) and thrombus burden (Miller score) before termination (111/156, 71.2%) or continuation of CDT (45/156, 28.8%).Patients who had CDT extended beyond the first follow-up visit required a higher total dose of tissue plasminogen activator (40.7 mg ± 14.3 vs 22.6 mg ± 9.9, P.001) to achieve a similar final Miller score (6.4 ± 3.8 vs 7.6 ± 3.9, P = .1) and a similar reduction in systolic PAP (-14.4 mm Hg ± 10.2 vs -12.6 mm Hg ± 11.9, P = .6). The initial Miller scores were similar in both groups (19.7 ± 5.8 vs 19 ± 4, P = .4) but were significantly higher during the first follow-up visit (after 18 hours ± 5.5 vs 20 hours ± 4.8, P = .06) in patients requiring multiple follow-up visits (12.2 ± 5 vs 7.6 ± 3.9, P.001). Multiple regression analyses identified heart rate100 beats/min and systolic PAP55 mm Hg as associated with the need for extended CDT. Extended CDT did not result in a higher hemorrhagic complication rate (1/45 vs 6/111, P = .7).Patients presenting with higher heart rates and systolic PAP may benefit from extended CDT to achieve similar reductions in PAP and thrombus burden, without clear added risk of hemorrhage.

Hemorrhagic and thrombotic complications are a significant source of morbidity and mortality for pediatric patients on extracorporeal membrane oxygenation (ECMO). Optimal anticoagulation therapies and monitoring strategies remain unknown. In 2013, our institution changed the anticoagulation monitoring protocol from activated clotting time (ACT) to antifactor Xa (anti-Xa) levels. We conducted a retrospective review of patients who received anticoagulation management directed by ACT results (n = 96) or anti-Xa levels (n = 72) between January 2010 and March 2016. Hemorrhagic complications occurred in 25% of the ACT group and 39% of the anti-Xa group (p = 0.054). Thrombotic complications were observed in 12.5% of the ACT group and 14% of the anti-Xa group (p = 0.8). There was a greater incidence of extracorporeal cardiopulmonary resuscitations (E-CPR; 36% vs. 15%; p = 0.005) in the anti-Xa group as compared with the ACT group. Secondary analysis showed no difference in transfusion requirements for red blood cells (ml/kg; p = 0.32) or platelets (ml/kg; p = 0.32). There was no difference in average heparin infusion rates (unit/kg/hr) per cannulation (p = 0.17) between the groups. Management of anticoagulation based on anti-Xa levels appears to be as effective as management based on ACT results.

Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

Intracranial recordings are integral to evaluating patients with pharmacoresistant epilepsy whom noninvasive testing fails to localize seizure focus. Although stereo-electroencephalography is the preferred method of intracranial recordings in most centers, subdural electrode (SDE) implantation is necessary in selected cases.To identify imaging correlates that predict SDE complications (extra-axial fluid collections [EFCs]), and determine if modifications that diminish stiffness of electrode sheets reduce complications.A prospective epilepsy surgery database was used to identify adults undergoing craniotomy for SDE implantation over a 14-year period. EFCs and midline shift were measured via magnetic resonance imaging and computed tomography imaging. Correlation analyses and multivariable logistic regression explored associations between use of conformal arrays, serial order of patients, previous ipsilateral intracranial surgery, midline shift, number of SDEs, and neurologic complications.A total of 111 consecutive patients (59 female) underwent 117 craniotomies (mean, 115 electrode contacts) for SDE implantation. There were 8 surgical complications, 3 in the first 17 (17.7%). and 5 (after electrode modifications) in a subsequent 100 craniotomies (5.0%). We noted an increase in electrode numbers implanted over time (P0.001) and decreased midline shift with conformal grids (ρ = - 0.32; P0.001). A multivariable regression showed that midline shift correlated with complications (odds ratio, 2.32; 95% confidence interval, 1.12-4.78; P = 0.023).Hemorrhagic complications after SDE implantation are difficult to detect because of artifact from electrodes, but predictable by prominent midline shift (4 mm). Risks inherent to SDE implantation may be minimized using conformal grids. With symptomatic EFCs, a single electrode cable exit site allows hematoma evacuation without terminating intracranial recordings.

BACKGROUND AND PURPOSE: Intracranial hemorrhage represents a severe complication of brain arteriovenous malformation treatment. The aim of this cohort was to report the rate of hemorrhagic complications after transvenous endovascular embolization and analyze the potential angioarchitectural risk factors as well as clinical outcomes. MATERIALS AND METHODS: During an 11-year period, 57 patients underwent transvenous endovascular embolization. All cases of hemorrhagic complications were identified. We analyzed the following variables: sex, age, hemorrhagic presentation, Spetzler-Martin grade, size of the AVM before the transvenous treatment, number of venous collectors, pattern of drainage, presence of dilated veins, and technical aspects. Univariate and multivariate multiple regression analyses were performed to evaluate the potential risk factors for procedure-related hemorrhagic complications. RESULTS: Hemorrhagic complications (either intraprocedural or periprocedural) unrelated to a perforation due to micronavigation occurred in 8 (14.0%) procedures. Significant (mRS > 2) and persistent neurologic deficits were present in 2 (3.5%) patients at 6-month control. Larger nidi, especially >3 cm (P = .03), and a larger number of venous collectors have shown a statistically significant correlation with hemorrhagic complications. Only the number of venous collectors was identified as an independent predictor of hemorrhagic complications in the multivariate analysis (OR, 8.7; 95% confidence interval, 2.2–58.2) (P = .006). CONCLUSIONS: Larger nidus sizes and an increased number of venous collectors may increase the risk of hemorrhagic complications when implementing transvenous endovascular treatment of AVMs. The technique is effective and promising, especially with small nidi and single venous collectors.

To analyze the frequency of resumption of anticoagulant therapy (ACT) after major and clinically significant bleeding among AF patients who received oral anticoagulants and were observed in the Department of clinical problems of atherothrombosis from 1999 to 2019 within the retro-prospective register Regata-2, and to search for clinical factors associated with recurrence of hemorrhagic complications among patients who resumed anticoagulant therapy after a bleeding episode.In cohort study of patients with high-risk AF with absolute indications for ACT we enrolled 290 AF patients (130 women and 160 men) aged 32 to 85 years (the average age was 65.188.89 years). During the follow-up period, 92 patients developed hemorrhagic complications, and 73 of them resumed ACT. 35 of the 73 patients who resumed ACT developed a relapse of major/clinically significant bleeding.The frequency of resuming ACT after the first hemorrhagic complication increased over time from 75% in the period from 19992003 to 90% in the period 20152019. We were not able to establish an exact relationship between the presence of concomitant pathology and the decision to resume the ACT after bleeding. The only reliable reason for refusing to resume the ACT was the patients categorical reluctance. Among patients who had recurrent hemorrhagic complications, the total score on the Charleson comorbidity scale was significantly higher (4.232.01vs3.521.43;p=0.0425). Patients with recurrent bleeding were significantly more likely to suffer from CKD with a decrease in GFR less than 60 ml/min/1.73 sq. m, and also had a history of erosive and ulcerative lesions of the gastrointestinal tract. There was also a significant Association of recurrent bleeding with the use of proton pump inhibitors. Subgroups of patients who switched from warfarin to taking direct oral anticoagulants after the first bleeding and subsequent recurrent bleeding did not differ in basic clinical characteristics from patients without bleeding after changing the anticoagulant. According to multiple regression analysis, NSAIDs showed a tendency to develop a relapse of B/C bleeding on the background of direct oral anticoagulants in patients who underwent GO on the background of warfarin therapy (b=0.4524,p=0.0530).During the 20-year follow-up, the frequency of all major and clinically significant bleeding was 2.6/100 patients-years, the frequency of first bleeding was 5.86/100 patients-years, while the frequency of repeated hemorrhagic complications was 7.06/100 patients-years. Patients with a high thromboembolic risk should receive anticoagulants, provided that the modifiable risk factors for bleeding are carefully corrected.Цель.Анализ частоты возобновления терапии антикоагулянтами после случившихся больших и клинически значимых кровотечений среди пациентов с фибрилляцией предсердий (ФП), получавших пероральные антикоагулянты и наблюдавшихся в отделе клинических проблем атеротромбоза с 1999 по 2019 г. в рамках ретропроспективного регистра Регата-2, а также поиск клинических факторов, ассоциированных с рецидивом геморрагических осложнений (ГО) среди пациентов, возобновивших терапию антикоагулянтами после эпизода кровотечения. Материалы и методы.Исследование представляет собой анализ когорты больных ФП высокого тромботического риска с абсолютными показаниями к назначению антикоагулянтрой терапии (АКТ). В исследование включены 290 пациентов с ФП (130 женщин и 160 мужчин) в возрасте от 32 до 85 лет (средний возраст составил 65,188,89 года). За время наблюдения у 92 пациентов развились ГО, у 73 из них возобновлена АКТ. У 35 из 73 больных, возобновивших АКТ, развился рецидив большого/клинически значимого кровотечения. Результаты.Частота возобновления АКТ после развития первого ГО увеличивалась с течением времени с 75% в период с 1999 по 2003 г. до 90% в период 20152019 гг. Нам не удалось установить точной связи между наличием сопутствующей патологии и принятием решения о возобновления АКТ после случившегося кровотечения. Единственной достоверной причиной отказа от возобновления АКТ стало категорическое нежелание больного. Среди пациентов, у которых рецидивировали ГО, сумма баллов по шкале коморбидности Чарльсона больше (4,232,01vs3,521,43;p=0,0425). Больные с рецидивирующими кровотечениями достоверно чаще страдали хронической болезнью почек со снижением скорости клубочковой фильтрации менее 60 мл/мин/1,73 м2, а также имели эрозивно-язвенное поражение желудочно-кишечного тракта в анамнезе. Также выявлена достоверная связь рецидива кровотечений с приемом ингибиторов протонной помпы. Подгруппы пациентов, перешедших с варфарина на прием прямых оральных антикоагулянтов после первого кровотечения и с последующими рецидивирующими кровотечениями по основным клиническим характеристикам не отличались от больных без кровотечений после смены антикоагулянта. По данным множественного регрессионного анализа прием нестероидных противовоспалительных препаратов показал тенденцию к развитию рецидива больших или клинически значимых кровотечений на фоне прямых оральных антикоагулянтов у больных, перенесших ГО на фоне терапии варфарином (b=0,4524;р=0,0530). Заключение.За время 20-летнего наблюдения частота развития всех больших и клинически значимых кровотечений составила 2,6/100 пациенто-лет, частота развития первого кровотечения 5,86/100 пациенто-лет, тогда как частота повторных ГО 7,06/100 пациенто-лет. Больные с высоким тромбоэмболическим риском должны получать антикоагулянты при условии тщательной коррекции модифицируемых факторов риска кровотечений.

BackgroundThe coronavirus disease 2019 is associated with neurological manifestations including stroke.ObjectivesWe present a case series of coronavirus disease 2019 patients from two institutions with acute cerebrovascular pathologies. In addition, we present a pooled analysis of published data on large vessel occlusion in the setting of coronavirus disease 2019 and a concise summary of the pathophysiology of acute cerebrovascular disease in the setting of coronavirus disease 2019.MethodsA retrospective study across two institutions was conducted between 20 March 2020 and 20 May 2020, for patients developing acute cerebrovascular disease and diagnosed with coronavirus disease 2019. We performed a literature review using the PubMed search engine.ResultsThe total sample size was 22 patients. The mean age was 59.5 years, and 12 patients were female. The cerebrovascular pathologies were 17 cases of acute ischemic stroke, 3 cases of aneurysm rupture, and 2 cases of sinus thrombosis. Of the stroke and sinus thrombosis patients, the mean National Institute of Health Stroke Scale was 13.8 ± 8.0, and 16 (84.2%) patients underwent a mechanical thrombectomy procedure. A favorable thrombolysis in cerebral infarction score was achieved in all patients. Of the 16 patients that underwent a mechanical thrombectomy, the mortality incidence was five (31.3%). Of all patients (22), three (13.6%) patients developed hemorrhagic conversion requiring decompressive surgery. Eleven (50%) patients had a poor functional status (modified Rankin Score 3–6) at discharge, and the total mortality incidence was eight (36.4%).ConclusionsDespite timely intervention and favorable reperfusion, the mortality rate in coronavirus disease 2019 patients with large vessel occlusion was high in our series and in the pooled analysis. Notable features were younger age group, involvement of both the arterial and venous vasculature, multivessel involvement, and complicated procedures due to the clot consistency and burden.

BackgroundWhile dual antiplatelet therapy (dAPT) is standard of care following carotid artery stenting (CAS), the optimal dAPT regimen and duration has not been established.MethodsWe canvassed a large national database (IBM MarketScan) to identify patients receiving carotid endarterectomy (CEA) or CAS for treatment of ischemic stroke or carotid artery stenosis from 2007 to 2016. We performed univariable and multivariable regression methods to evaluate the impact of covariates on post-CAS stroke-free survival, including post-discharge antiplatelet therapy.ResultsA total of 79 084 patients diagnosed with ischemic stroke or carotid stenosis received CEA (71 178; 90.0%) or CAS (7906; 10.0%). After adjusting for covariates, ConclusionsIncreased duration of post-CAS dAPT is associated with lower rates of readmissions for stroke, and with increased risk of hemorrhagic complications, particularly extracranial hemorrhage. The potential benefit of prolonging dAPT with regard to ischemic complications must be balanced with the corresponding increased risk of predominantly extracranial hemorrhagic complications.

BACKGROUND AND PURPOSE: Embolization is widely performed to treat brain arteriovenous malformations, but little has been reported on factors contributing to complications. We retrospectively reviewed a nationwide surveillance to identify risk factors contributing to complications and short-term clinical outcomes in the endovascular treatment of brain arteriovenous malformations. MATERIALS AND METHODS: Data for endovascular treatment of brain arteriovenous malformations were extracted from the Japanese nationwide surveillance. Patient characteristics, brain arteriovenous malformation features, procedures, angiographic results, complications, and clinical outcomes at 30 days postprocedure were analyzed. RESULTS: A total of 1042 endovascular procedures (788 patients; mean, 1.43 ± 0.85 procedures per patient) performed in 111 institutions from 2010 to 2014 were reviewed. Liquid materials were used in 976 procedures (93.7%): to perform presurgical embolization in 638 procedures (61.2%), preradiosurgical embolization in 160 (15.4%), and as sole endovascular treatment in 231 (22.2%). Complete or near-complete obliteration of brain arteriovenous malformations was obtained in 386 procedures (37.0%). Procedure-related complications occurred in 136 procedures (13.1%), including hemorrhagic complications in 59 (5.7%) and ischemic complications in 57 (5.5%). Univariate analysis identified deep venous drainage, associated aneurysms, infratentorial location, and preradiosurgical embolization as statistically significant risk factors for complications. Multivariate analysis showed that embolization of brain arteriovenous malformations in the infratentorial location was significantly associated with complications. Patients with complications due to endovascular procedures had worse clinical outcomes 30 days after the procedures than those without complications. CONCLUSIONS: Complications arising after endovascular treatment of brain arteriovenous malformations are not negligible even though they may play a role in adjunctive therapy, especially in the management of infratentorial brain arteriovenous malformations.

Background Cone beam computed tomography (CBCT) imaging is used commonly in neurointerventional surgery for rapid intraprocedural assessment and planning of intracranial interventions. Our goal was to evaluate the ability of immediate postprocedural CBCT scan in assessing potential complications in pediatric patients. Methods A retrospective review was completed to include all pediatric patients at our hospital with an immediate postprocedural CBCT scan with the Artis Q system. Demographic, clinical, and imaging data were examined. CBCT images were reviewed by 3 independent neurointerventionalists to assess ventricular system/subarachnoid spaces, gray-white differentiation, and ischemia or hemorrhage if present. Each assessment was rated qualitatively on a 4-point scale and was compared with conventional computed tomography (cCT) scan when available. Interrater reliability was assessed and radiation dose data were reviewed. Results Thirty-five patients were included with an average age of 11.0 ± 5.1 years (median, 10.9; range, 1.1–18 years). Of the patients, 54.3% were boys; 34.3% were Hispanic and 34.3% were non-Hispanic white. Diagnoses included a variety of vascular pathologies. CBCT scan had a mean score of 2.69 ± 0.54 out of 3 for ventricular and subarachnoid space assessment with a combined interrater reliability of 0.82, 1.71 ± 1.38 for hemorrhage with a combined interrater reliability of 1.00, and 0.52 ± 0.60 for gray-white differentiation with a combined interrater reliability of 0.79. Conclusions Immediate postprocedural CBCT images were adequate to detect ventricular size/subarachnoid spaces changes and large volume hemorrhage compared with cCT scan in pediatric patients. However, there are limitations using immediate CBCT images to detect small volume hemorrhage and ischemic changes.

Background Patients who present emergently with focal neurological deficits concerning for acute ischemic stroke can be extremely challenging to diagnose and treat. Unnecessary administration of thrombolytics to potential stroke patients whose symptoms are not caused by an acute ischemic stroke—stroke mimics—may result in patient harm, although the overall risk of hemorrhagic complications among stroke mimics is low. Case Report We present a case of a stroke mimic patient with underlying psychiatric disease who was treated with intravenous alteplase on four separate occasions in four different emergency departments in the same city. Although he did not suffer hemorrhagic complications, this case highlights the importance of rapid exchange of health information across institutions to improve diagnostic quality and safety. Why Should an Emergency Physician Be Aware of This? Increased awareness of stroke mimics by emergency physicians may improve diagnostic safety for a subset of high-risk patients. Establishing rapid cross-institutional communication pathways that are integrated into provider's workflows to convey essential patient health information has potential to improve stroke diagnostic decision-making and thus represents an important topic for health systems research in emergency medicine.

PURPOSE: Hemorrhagic complications during extracorporeal membrane oxygenation are frequent and have a negative impact on outcome. We studied the association between activated partial thromboplastin time or platelet count and the occurrence of hemorrhagic complications. The secondary objective was to determine risk factors for hemorrhagic complications.METHODS: Retrospective cohort study in a single-center Dutch university hospital. We included all adult patients on extracorporeal membrane oxygenation admitted to the intensive care unit between 2010 and 2017.RESULTS: We included 164 consecutive patients of which 73 (45%) had a hemorrhagic complication. The most prevalent hemorrhagic complications were surgical site (62%) and cannula site bleeding (18%). Survival to discharge was 67% in the patients without a hemorrhagic complication and 33% in the patients with hemorrhagic complications (p CONCLUSIONS: Higher activated partial thromboplastin time is associated with the occurrence of hemorrhagic complications.

Hospitalized cancer patients are at increased risk for Thromboembolic Events (TEs). As untailored thromboprophylaxis is associated with hemorrhagic complications, the definition of a risk-assessment model (RAM) in this population is needed. INDICATE was a prospective observational study enrolling hospitalized cancer patients, with the primary objective of assessing the Negative Predictive Value (NPV) for TEs during hospitalization and within 45 days from discharge of low-grade Khorana Score (KS = 0). Secondary objectives were to assess KS Positive Predictive Value (PPV), the impact of TEs on survival and the development of a new RAM. Assuming 7% of TEs in KS = 0 patients as unsatisfactory percentage and 3% of as satisfactory, 149 patients were needed to detect the favorable NPV with one-sided α = 0.10 and power = 0.80. Stepwise logistic regression was adopted to identify variables included in a new RAM. Among 535 enrolled patients, 153 (28.6%) had a KS = 0. The primary study objective was met: 29 (5.4%) TEs were diagnosed, with 7 (4.6%) cases in the KS = 0 group (NPV = 95.4%, 95% CI 90.8–98.1%; one-sided p = 0.084). However, the PPV was low (5.7%, 95% CI 1.9–12.8%); a new RAM based on albumin (OR 0.34, p = 0.003), log(LDH) (OR 1.89, p = 0.023) and presence of vascular compression (OR 5.32, p

Background: Transvenous lead extraction (TLE) is a relatively safe procedure, but it may cause severe complications such as cardiac/vascular wall tear (CVWT) and tricuspid valve damage (TVD). Methods: The risk factors for CVWT and TVD were examined based on an analysis of data of 1500 extraction procedures performed in two high-volume centers. Results: The total number of major complications was 33 (2.2%) and included 22 (1.5%) CVWT and 12 (0.8%) TVD (with one case of combined complication). Patients with hemorrhagic complications were younger, more often women, less often presenting low left ventricular ejection fraction (LVEF) and those who received their first cardiac implantable electronic device (CIED) earlier than the control group. A typical patient with CVWT was a pacemaker carrier, having more leads (including abandoned leads and excessive loops) with long implant duration and a history of multiple CIED-related procedures. The risk factors for TVD were similar to those for CVWT, but the patients were older and received their CIED about nine years earlier. Any form of tissue scar and technical problems were much more common in the two groups of patients with major complications. Conclusions: The risk factors for CVWT and TVD are similar, and the most important ones are related to long lead dwell time and its consequences for the heart (various forms of fibrotic scarring). The occurrence of procedural complications does not affect long-term survival in patients undergoing lead extraction.

Objectives To evaluate whether continuing the antiplatelet drug acetylsalicylic acid≤100mg (ASA) during Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) increases the risk of peri-and postoperative hemorrhagic complications and overall morbidity. Indeed, guidelines recommend interrupting antiplatelet therapy before radical cystectomy; however, RARC with ICUD is associated to reduced estimated blood loss and blood transfusions compared to its open counterpart. Methods Data from a multicentric European database were analyzed. All participating centers maintained a prospective database of patients undergoing RARC with ICUD. We identified patients receiving antiplatelet therapy by acetylsalicylic acid ≤100mg. Patients were divided into three groups: those not taking acetylsalicylic acid (no-ASA), those where ASA was continued perioperatively (c-ASA) and those where ASA was interrupted perioperatively (i-ASA). Estimated blood loss and peri-and post-operative transfusions were recorded. Hemorrhagic complications, ischemic, thrombotic and cardiac morbidity was recorded and classified using the Clavien-Dindo score by a senior urologist. Results 640 patients were analyzed. Patients on acetylsalicylic acid were significantly older and had more comorbidities. No significant difference was found for estimated blood loss between no-ASA, c-ASA and i-ASA (280 vs. 300 vs. 200ml respectively; P = 0.09). Similarly, no significant difference was found for intraoperative (5% vs. 9% vs. 11%; P = 0.07) and postoperative transfusion rate (11% vs. 13% vs. 18%; P = 0.17). Higher ischemic complications were noted in the i-ASA group compared to no-ASA and c-ASA (4% vs. 0.6% vs. 1.4%; P = 0.03). On uni and multivariate logistic regression, continuing acetylsalicylic acid was not significantly associated to either major complications or post-operative transfusions. Conclusions Peri-operative acetylsalicylic acid continuation in RARC with ICUD does not increase hemorrhagic complications. Interrupting acetylsalicylic acid peri-operatively may expose patients to a higher risk of ischemic events.

Pituitary gland adenoma bleeding is an uncommon complication after coronary artery surgery. Clinical presentation may be variable. We report a case of hemorrhagic complication of a pituitary gland adenoma requiring urgent surgery in a 60-year-old male patient who underwent coronary artery bypass grafting operation.

Purpose Intravenous ketorolac (IVK) is an effective agent to reduce postoperative pain without the risks inherent to opioid analgesics. However, many clinicians avoid using this agent due to concerns regarding hemorrhagic complications. This study was performed to assess the efficacy and safety of IVK in the setting of orbital surgery. Methods In a single dose prospective study, patients either received IVK immediately before orbital surgery (n = 50) or acted as controls (n = 50). Postoperative pain was evaluated via a numerical scale (range = 0-10) immediately after surgery, before discharge to home, and on the first postoperative day (POD1). The requirements for opioid analgesic and anti-emetic medications were determined by the nursing staff and recorded. Statistical analyses were performed via a dedicated software package. Results Fifty patients received IVK (24 males, 26 females, mean age = 54 years, SD = 18 years) and 50 patients acted as controls (26 males, 24 females, mean age = 50 years, SD = 19 years) immediately before orbital surgery. Mean pain scores were lower in patients who received IVK than in controls immediately after surgery (3.08 vs. 5.44, p = 0.0001) and on POD1 (1.04 vs. 2.66, respectively, p = 0.0001). Four patients (8%) who received IVK and 12 patients who did not (24%) required opioid analgesics to control pain (p = 0.03). No patient experienced a hemorrhagic complication or required an emergent return to the operating room. Conclusions In the setting of orbital surgery, IVK safely and effectively reduces pain and the requirement for opioid analgesics. Within the limits of the study size, increased risks of bleeding-related complications were not identified.

Purpose Venous thromboembolisms (VTE) are a major concern after acute survival from trauma. Variations in treatment protocols for trauma patients exist worldwide. This study analyzes the differences in the number of VTE events and the associated complications of thromboprophylaxis between two level I trauma populations utilizing varying treatment protocols. Methods International multicenter trauma registry-based study was performed at the University Medical Center Utrecht (UMCU) in The Netherlands (early commencement chemical prophylaxis), and Harborview Medical Center (HMC) in the United States (restrictive early chemical prophylaxis). All severely injured patients (ISS ≥ 16), aged ≥ 18 years, and admitted in 2013 were included. Primary outcomes were VTE [deep venous thrombosis (DVT) (no screening), pulmonary embolism (PE)], and hemorrhagic complications. Results In UMCU, 279 patients were included and in HMC, 974 patients. Overall, 75% of the admitted trauma patients in UMCU and 81% in HMC (p p p = 0.06) developed a VTE. At UMCU, a greater percent of patients with VTE had traumatic brain injuries (TBI). Most VTE occurred despite adequate prophylaxis being given (75% UMCU and 81% HMC). Hemorrhagic complications occurred in, respectively, 4 (1.4%) and 10 (1%) patients in UMCU and HMC (p = 0.570). After adjustment for age, ISS, HLOS, and injury type, no significant difference was demonstrated in UMCU compared to HMC for the development of VTE, OR 2.397, p = 0.102 and hemorrhagic complications, OR 0. 586, p = 0.383. Conclusions A more early commencement protocol resulted in almost twice as much chemical prophylaxis being started within the first 48 h in comparison with a more delayed initiation of treatment. Interestingly, most episodes of VTE developed while receiving recommended prophylaxis. Early chemical thromboprophylaxis did not significantly increase the bleeding complications and it appears to be safe to start early.

A prospective trial was conducted to investigate the platelet function and association between thrombelastographic (TEG) parameters and embolic or hemorrhagic complications in patients with intracranial aneurysm undergoing stent treatment.Between September 2013 and June 2016, we prospectively recruited patients with intracranial aneurysm who were treated with stent-assisted coiling. TEG parameters were used to assess the platelet function before stenting procedures. The primary study end point was the onset of ischemic stroke, transient ischemic attack, or silent ischemic events in the territory of the stented artery within 6 months after the procedure. The secondary end point was assessed by bleeding events.Four hundred and thirty-one patients with 453 intracranial aneurysms were enrolled. A total of 519 neurovascular stents were implanted. During the follow-up, a total of 70 primary end points (16.2%) and 59 secondary end points (13.7%) were detected. Thromboembolic complications such as symptomatic and slient ischemic complications were more frequently observed in patients with large aneurysms (10 mm, P = 0.01), lower adenosine diphosphate (ADP) inhibition rate (P0.0001), and higher ADP-induced platelet-fibrin clot strength (maximum amplitude of adenosine diphosphate [MA-ADP]) (P0.0001). Besides, based on multivariate analysis, a higher ADP inhibition ratio was identified as a significant independent predictor of subsequent bleeding events (P0.0001). According to the receiver operating characteristic curve analysis, the safe range of the ADP inhibition ratio and MA-ADP of the TEG analysis were identified as 29.45%-55.4% and46.15, respectively.The ADP inhibition ratio and MA-ADP of TEG analysis were associated with subsequent cerebral ischemic events and intracranial or extracranial bleeding events in patients with intracranial aneurysm after stent treatment.

Cerebral artery fenestrations are rare anatomical variants usually detected incidentally on cross-sectional imaging or cerebral angiography. Although considered benign findings, many reports have described their association with vascular abnormalities such as aneurysms or arteriovenous malformations, and to a lesser extent with ischemic or hemorrhagic complications. We report a case of middle cerebral artery fenestration associated with subarachnoid hemorrhage and middle cerebral artery thrombosis. To our knowledge, there has been no prior report of middle cerebral artery fenestration with a similar presentation.

Background We present our operative experience of patients with movement disorders who developed intracerebral hemorrhage (ICH), which was identified on intraprocedural stereotactic computed tomography (CT) imaging performed immediately after deep brain stimulation (DBS) lead placement and prior to the implantation of further components of the DBS hardware. Methods Patients who underwent DBS lead implantation from January 2009 through December 2017 were included in the present study. Most of the surgeries were performed in a staged fashion. All patients were operated using identical surgical and intraprocedural imaging techniques, and no microelectrode recordings were done. Leksell Stereotactic G frame and neuronavigation software was utilized for all surgeries. Intraprocedural stereotactic CT was performed to confirm the precise position of the implanted DBS lead and to rule out any hemorrhagic complications. Results Overall, 222 patients underwent 322 DBS lead implantations during 316 stereotactic procedures. Six patients exhibited early ICH recognized on intraprocedural stereotactic CT performed immediately after DBS lead placement; in addition, two patients developed delayed ICH due to large venous infarction. Four patients with ICH were asymptomatic. The ICH rate was 2.5% per electrode and 3.6% per patient; the permanent deficit rate was 1.2% per electrode and 1.8% per patient. The death rate due to ICH in our cohort was 0.6% per electrode and 0.9% per patient. Conclusions Intraprocedural stereotactic CT can not only visualize the implanted DBS lead in the stereotactic space but also rule out early ICH. Identified predisposing factors for development of ICH include patient's age, hypertension, and previous antiplatelet therapy. Careful planning of stereotactic trajectories plays a paramount role in reducing the rate of ICH in DBS surgery.

Background Anticoagulation therapy, particularly subcutaneous heparin therapy, is recommended for cancer-associated thrombosis. However, not starting or discontinuing anticoagulation was not rare. The aim of the present study was to examine the practical issues related to anticoagulation therapy and effects of subcutaneous heparin therapy for cancer-associated stroke. Methods Patients with cancer-associated stroke in our stroke center between October 2014 and August 2017 who were diagnosed as having acute ischemic stroke based on diffusion-weighted imaging were retrospectively enrolled. Baseline clinical characteristics, heparin injection, reasons for no subcutaneous heparin therapy, and clinical outcomes were collected. Results A total of 59 patients with cancer-associated stroke (75 ± 10 years old, male 42%) were enrolled. Lung cancer was the most frequently observed cancer (n = 17, 29%), followed by gastric cancer (n = 8, 14%) and pancreatic cancer (n = 8, 14%). Of the 19 patients (32%) who underwent subcutaneous heparin therapy, it was discontinued in 9 (47%), mainly because of patients’ medical conditions (deterioration of cancer or hemorrhagic complication). Ten patients with long-term subcutaneous heparin therapy did not have stroke recurrence. In contrast, among nine patients who discontinued subcutaneous heparin therapy, three (33%) had recurrence of ischemic stroke. Of the 40 patients without subcutaneous heparin therapy, the main reasons for no subcutaneous heparin therapy were the patients’ medical conditions (n = 22, 55%). Conclusions Although subcutaneous heparin therapy was given to only one third of cancer-associated stroke patients, long-term subcutaneous heparin therapy might prevent recurrence of cancer-associated stroke.

The Scepter XC balloon catheter can be used for balloon-assisted coiling (BAC) of cerebral aneurysms but also accommodates delivery of a low-profile visible intraluminal stent (LVIS Jr.). We assessed the safety and effectiveness of BAC using the Scepter XC, with LVIS Jr. stent-assisted coiling (SAC) as a bailout option.A single-institution prospectively maintained neurointerventional database was reviewed for wide-necked (neck width ≥4 mm or dome/neck ratio2) saccular aneurysms treated using the Scepter XC. Complication and angiographic occlusion rates of BAC and SAC procedures were compared. Multivariate logistic regression was used to identify variables predictive of complete aneurysm occlusion.The cohort included 141 wide-necked saccular intracranial aneurysms treated in 135 procedures. SAC was used to treat 30% of aneurysms by deploying the LVIS Jr. through the Scepter XC. The overall procedural complication rate was 8.9%, including a 1.5% rate of symptomatic thromboembolic events and 3.0% rate of hemorrhagic complications, with no significant differences in complications between BAC and SAC procedures (P = 0.27). The overall complete or near-complete aneurysm occlusion rate was 96%, with trends toward higher complete aneurysm occlusion and lower retreatment rates with SAC (78 vs. 57%; P = 0.13; 0 vs. 8.4%, P = 0.13). Multivariate logistic regression identified aneurysm size, procedure technique (BAC or SAC), and duration of follow-up as independent predictors of complete aneurysm occlusion.Use of the Scepter XC for BAC, with LVIS Jr. SAC as a bailout option, shows acceptable angiographic and clinical results.

Recently, trans-radial intervention has gained popularity as a common procedure to reduce hemorrhagic complications. However, the cuff-type hemostatic device (TR Band) previously used at our institution required 6 h to achieve hemostasis. Since July 2016, we have been using the VasoSTAT, a new hemostatic device that could achieve hemostasis in 4 h. In a verification study, we found that prolonged activated clotting time (ACT) was related to transient hemorrhage occurrence after the hemostatic procedure. Therefore, we designed a hemostatic protocol based on ACT and evaluated its efficacy. In this retrospective and observational study, 78 and 111 patients used the VasoSTAT and TR Band, respectively, from July 2015 to May 2017. In the VasoSTAT group, the ACTs were significantly lower in the hemostasis success (246 ± 46 s) than in the failure group patients (327 ± 59 s) (P P

Background Hybrid endovascular repair for thoracoabdominal aortic aneurysm (TAAA) is a less invasive alternative treatment than conventional open repair. However, disseminated intravascular coagulation (DIC) and hemorrhagic complications can occur postoperatively. We investigated risk factors for hemorrhagic complications after hybrid endovascular TAAA repair. Methods Sixty-one patients who underwent elective hybrid endovascular TAAA repair between 2007 and 2020 were included. Laboratory data before and after placing stent graft were collected, and DIC was diagnosed using a scoring system established by the Japanese Association for Acute Medicine. The length of the stent graft used to cover the aorta was defined as the aortic coverage length, which was measured using the first postoperative computed tomography image. Predictors of unexpected hemorrhagic complications were evaluated. Results Postoperative thrombocytopenia was observed in 57 (93%) patients, and their platelet count decreased significantly after stent graft placement (14.3 [9.5–18.0] vs. 8.2 [5.4–10.9] × 104/µL, P Conclusion Aortic coverage length is a risk factor for hemorrhagic complications. Patients undergoing extensive aortic coverage greater than 304 mm should be closely monitored.

Background Ticagrelor is a novel antiplatelet agent that is frequently used for secondary prevention in coronary artery disease and has emerging evidence in stroke after the recent results of SOCRATES and THALES trials. The use of intravenous thrombolysis with alteplase in acute ischemic stroke (AIS) patients on ticagrelor is a topic of debate as the safety profile of ticagrelor in this setting is not well established. Methods We identified consecutive AIS patients taking ticagrelor who received intravenous alteplase at a comprehensive stroke center from January 2016 to December 2019. We then performed a literature search to capture all known published cases of intravenous thrombolysis in stroke patients on ticagrelor. Results Of the 3896 patients who were treated for AIS at our local comprehensive stroke center during this time period, two patients received intravenous alteplase while on ticagrelor. Both patients had posterior circulation acute strokes and were successfully treated with intravenous alteplase without a systemic or intracranial bleeding event. Only five other cases of intravenous thrombolysis in AIS patients on ticagrelor have been reported in the literature. Among these cases, four of the five cases had a hemorrhagic complication. Conclusion Despite prior reports of hemorrhagic complications with use of IV alteplase in setting of pre-treatment with ticagrelor, we report the safe use of intravenous thrombolysis in two cases presenting with acute ischemic stroke. Until safety is established in large studies, decision for thrombolysis should be made on case-by-case basis.

Rationale: Hemorrhagic complications represent a major limitation of intravenous thrombolysis using tPA (tissue-type plasminogen activator) in patients with ischemic stroke. The expression of tPA receptors on immune cells raises the question of what effects tPA exerts on these cells and whether these effects contribute to thrombolysis-related hemorrhagic transformation. Objective: We aim to determine the impact of tPA on immune cells and investigate the association between observed immune alteration with hemorrhagic transformation in ischemic stroke patients and in a rat model of embolic stroke. Methods and Results: Paired blood samples were collected before and 1 hour after tPA infusion from 71 patients with ischemic stroke. Control blood samples were collected from 27 ischemic stroke patients without tPA treatment. A rat embolic middle cerebral artery occlusion model was adopted to investigate the underlying mechanisms of hemorrhagic transformation. We report that tPA induces a swift surge of circulating neutrophils and T cells with profoundly altered molecular features in ischemic stroke patients and a rat model of focal embolic stroke. tPA exacerbates endothelial injury, increases adhesion and migration of neutrophils and T cells, which are associated with brain hemorrhage in rats subjected to embolic stroke. Genetic ablation of annexin A2 in neutrophils and T cells diminishes the effect of tPA on these cells. Decoupling the interaction between mobilized neutrophils/T cells and the neurovascular unit, achieved via a S1PR (sphingosine-1-phosphate receptor) 1 modulator RP101075 and a CCL2 (C-C motif chemokine ligand 2) synthesis inhibitor bindarit, which block lymphocyte egress and myeloid cell recruitment, respectively, attenuates hemorrhagic transformation and improves neurological function after tPA thrombolysis. Conclusions: Our findings suggest that immune invasion of the neurovascular unit represents a previously unrecognized mechanism underlying tPA-mediated brain hemorrhage, which can be overcome by precise immune modulation during thrombolytic therapy.

Background and Purpose: Anticoagulation therapy not only reduces the risk of ischemic stroke in atrial fibrillation (AF) but also predisposes patients to hemorrhagic complications. There is limited knowledge on the risk of first-ever ischemic stroke in patients with AF after extracranial hemorrhage (ECH). Methods: We conducted a retrospective study using the California State Inpatient Database including all nonfederal hospital admissions in California from 2005 to 2011. The exposure variable was hospitalization with a diagnosis of ECH with a previous diagnosis of AF. The outcome variable was a subsequent hospitalization with acute ischemic stroke. We excluded patients with stroke before or at the time of ECH diagnosis. We calculated adjusted hazard ratios for ischemic stroke during follow-up and at 6-month intervals using Cox regression models adjusted for pertinent demographics and comorbidities. In subgroup analyses, subjects were stratified by primary ECH diagnosis, severity/type of ECH, age, CHA 2 DS 2 -VASc score, or the presence/absence of a gastrointestinal or genitourinary cancer. Results: We identified 764 257 patients with AF (mean age 75 years, 49% women) without a documented history of stroke. Of these, 98 647 (13%) had an ECH-associated hospitalization, and 22 748 patients (3%) developed an ischemic stroke during the study period. Compared to patients without ECH, subjects with ECH had ≈15% higher rate of ischemic stroke (overall adjusted hazard ratio, 1.15 [95% CI, 1.11–1.19]). The risk appeared to remain elevated for at least 18 months after the index ECH. In subgroup analyses, the risk was highest in subjects with a primary admission diagnosis of ECH, severe ECH, gastrointestinal-type ECH, with gastrointestinal or genitourinary cancer, and age ≥60 years. Conclusions: Patients with AF hospitalized with ECH may have a slightly elevated risk for future ischemic stroke. Particular consideration should be given to the optimal balance between the benefits and risks of anticoagulation therapy and the use of nonanticoagulant alternatives, such as left atrial appendage closure in this vulnerable population.

Summary Despite successful clot retrieval in large vessel occlusion stroke, ∼50% of patients have an unfavorable clinical outcome. The mechanisms underlying this functional reperfusion failure remain unknown, and therapeutic options are lacking. In the thrombin-model of middle cerebral artery (MCA) stroke in mice, we show that, despite successful thrombolytic recanalization of the proximal MCA, cortical blood flow does not fully recover. Using in vivo two-photon imaging, we demonstrate that this is due to microvascular obstruction of ∼20%–30% of capillaries in the infarct core and penumbra by neutrophils adhering to distal capillary segments. Depletion of circulating neutrophils using an anti-Ly6G antibody restores microvascular perfusion without increasing the rate of hemorrhagic complications. Strikingly, infarct size and functional deficits are smaller in mice treated with anti-Ly6G. Thus, we propose neutrophil stalling of brain capillaries to contribute to reperfusion failure, which offers promising therapeutic avenues for ischemic stroke.

Introduction The most appropriate treatment for stroke prevention in standalone atrial fibrillation patients with a high CHADS2VASC score contraindicated for oral anticoagulation (OAC) or novel OAC (NOAC) still needs to be defined. Percutaneous left atrial appendage (LAA) closure devices are available, but because of their endocardial positioning need a period of antiplatelet therapy (APT). This study aimed to evaluate the safety and efficacy of epicardial left atrial appendage clipping in patients contraindicated for (N)OAC and APT. Methods and results We describe a standalone totally thoracoscopic LAA clipping of forty-five consecutive patients with nonvalvular atrial fibrillation (NVAF; 32 males; age, 73.1 ± 7.4 years; CHADVASC, 6.5 ± 1.1; HAS-BLED 4.9 ± 0.9) with absolute contraindications to (N)OAC. The patients were selected by a multidisciplinary Heart Team. Sixty percent had a previous ischemic stroke and 51% a history of the hemorrhagic event and 22% both. All patients were implanted with an LAA epicardial clip, guided by preoperative computed tomography and intraoperative transesophageal echocardiography. The mean procedural duration was 52.3 ± 12.6 minutes with postprocedural extubation interval of 22.8 ± 14.6 minutes. No procedure-related complications occurred. Intraprocedural transesophageal echocardiography (TEE) showed complete LAA occlusion in all patients. At a mean follow-up of 16.4 ± 9.1 months (range, 2-34), with all patients off (N)OAC or APT, no ischemic stroke or hemorrhagic complications occurred. computed tomography or TEE at follow-up demonstrated a correct LAA occlusion in all with mean stumps of 3.3 ± 2.8 mm. Conclusion Thoracoscopic epicardial closure of the LAA with the AtriClip PRO2 device is a potentially safe and efficient treatment for stroke prevention in patients with NVAF contraindicated for anticoagulant therapy or APT.

BackgroundThe optimal first-line mechanical thrombectomy (MT) method in cancer-related stroke (CRS) patients with emergent large vessel occlusion (ELVO) remains largely unknown. The aim of this study is to evaluate the efficacy and safety between contact aspiration (CA) first-line thrombectomy and stent retriever (SR) first-line thrombectomy in CRS patients.MethodsSixty-two CRS patients with ELVO, who underwent MT between January 2013 and October 2019 at our institution, were retrospectively analyzed. Patients were divided into two groups based on the first-line MT method and compared: the CA group (n=28), which included those who received CA alone or combined CA with SR, and the SR group (n=34), which included those who received conventional SR alone.ResultsOverall, reperfusion was successful in 75.8% (47/62) of CRS patients, and a good clinical outcome at 90 days was observed in 17.7%. The CA group showed a higher rate of successful reperfusion (89.3% vs 64.7%, P=0.025) shorter procedure time (22 vs 42 min; P=0.029), higher rate of first pass effect (35.7% vs 11.8%, P=0.025), and lower number of passes (1 vs 3, P=0.023) when compared with the SR group. The procedural and hemorrhagic complication rates were similar between the CA and SR groups. The first-line contact aspiration (OR 11.624, 95% CI 1.041 to 129.752; P=0.046) was an independent predictor of successful reperfusion.ConclusionsAmong patients with CRS, CA – whether alone or in combination with SR – as first-line MT seems to provide more rapid and successful reperfusion when compared with SR.

Background Deep brain stimulation of the ventral intermediate nucleus (VIM) or caudal zona incerta (cZI) is effective for refractory essential tremor (ET). To refine stereotactic planning for lead placement, we developed a unique individualized anatomy-based planning protocol that targets both the VIM and the cZI in patients with ET. Methods 33 patients with ET underwent VIM-cZI lead implantation with targeting based on our protocol. Indirect targeting was adjusted based on anatomic landmarks as reference lines bisecting the red nuclei and ipsilateral subthalamus. Outcomes were evaluated through the follow-up of 31.1 ± 18.4 months. Active contact coordinates were obtained from reconstructed electrodes in the Montreal Neurological Institute space using the MATLAB Lead-DBS toolbox. Results Mean tremor improvement was 79.7% ± 22.4% and remained stable throughout the follow-up period. Active contacts at last postoperative visit had mean Montreal Neurological Institute coordinates of 15.5 ± 1.6 mm lateral to the intercommissural line, 15.3 ± 1.8 mm posterior to the anterior commissure, and 1.4 ± 2.9 mm below the intercommissural plane. No hemorrhagic complications were observed in the analyzed group. Conclusions Individualized anatomy-based VIM-cZI targeting is feasible and safe and is associated with favorable tremor outcomes.

Background Current guidelines limit thrombolytic treatment of stroke to those patients who present within 4.5 h to minimize the risk of hemorrhagic complications. Risk of hemorrhage increases with increasing blood-brain barrier (BBB) disruption. This study aimed to determine, in a cohort of patients presenting outside of an IV-tPA treatment window, whether disruption of the BBB is time dependent, and what proportion of patients could be safely treated. Methods We analyzed untreated stroke patients, seen between 2011 and 2015, who had MRI studies in the time window of 4 to 24 h from symptoms onset. Permeability of the BBB was measured within the ischemic tissue using an application of dynamic susceptibility contrast imaging. Patients were dichotomized into two groups based on a 20% threshold of BBB disruption and compared using logistic regression. Results Of the 222 patients included in the final analysis, over half, 129 (58%), had preserved BBB integrity below the 20% threshold. There was no relationship between time imaged after symptom onset and the amount of BBB disruption (p = 0.138) across the population; BBB disruption varied widely. Conclusions Estimating BBB integrity may help to expand the treatment window for stroke patients by identifying those individuals for whom thrombolytic therapy can be considered.

Background and aim In acute ischemic stroke, under- or overestimation of body weight can lead to dosing errors of recombinant tissue plasminogen activator with consequent reduced efficacy or increased risk of hemorrhagic complications. Measurement of body weight is more accurate than estimation of body weight but potentially leads to longer door-to-needle times. Our aim was to assess if weight modality (estimation of body weight versus measurement of body weight) is associated with (i) symptomatic intracranial hemorrhage rate, (ii) clinical outcome, and (iii) door-to-needle times. Methods Consecutive patients treated with intravenous thrombolysis between 2009 and 2016 from 14 hospitals were included. Baseline characteristics and outcome parameters were retrieved from medical records. We defined symptomatic intracranial hemorrhage according to the European Cooperative Acute Stroke Study (ECASS)-III definition and clinical outcome was assessed with the modified Rankin Scale. The association of weight modality and outcome parameters was estimated with regression analyses. Results A total of 4801 patients were included. Five hospitals used measurement of body weight (n = 1753), six hospitals used estimation of body weight (n = 2325), and three hospitals (n = 723) changed from estimation of body weight to measurement of body weight during the study period. In 2048 of the patients (43%), measurement of body weight was used and in 2753 (57%), estimation of body weight. In the measurement of body weight group, an inbuilt weighing bed was used in 1094 patients (53%) and a patient lift scale in 954 patients (47%). In the estimation of body weight group, policy regarding estimation was similar. Estimation of body weight was not associated with increased symptomatic intracranial hemorrhage risk (adjusted odds ratio = 1.16; 95% confidence interval 0.83–1.62) or favorable outcome (adjusted odds ratio = 0.99; 95% confidence interval 0.82–1.21), but it was significantly associated with longer door-to-needle times compared to measurement of body weight using an inbuilt weighing bed (adjusted B = 3.57; 95% confidence interval 1.33–5.80) and shorter door-to-needle times compared to measurement of body weight using a patient lift scale (−3.96; 95% confidence interval −6.38 to −1.53). Conclusion We did not find evidence that weight modality (estimation of body weight versus measurement of body weight) to determine recombinant tissue plasminogen activator dose in intravenous thrombolysis eligible patients is associated with symptomatic intracranial hemorrhage or clinical outcome. We did find that estimation of body weight leads to longer door-to-needle times compared to measurement of body weight using an inbuilt weighing bed and to shorter door-to-needle times compared to measurement of body weight using a patient lift scale.

Introduction Capsular warning syndrome (CWS) is characterized by recurrent conventional episodes of motor and/or sensory deficits without cortical symptoms. The purpose of this case series study was to evaluate the safety and appropriate treatment for CWS to prevent the development of complete stroke. Methods We reviewed our hospital records and previous reports to find patients with neurologically fluctuating profiles, and excluded those with unknown details of initial treatment/final treatment of antiplatelet therapy or radiological findings. Results We retrieved two cases of CWS from our hospital, which presented motor and/or sensory symptoms followed by complete resolution without complete ischemia. The recurring episodes in both were unable to be stabilized by single antiplatelet therapy but were successfully managed using two or more antiplatelet drugs. In 11 previously reported cases of CWS, the recurring episode was frequency stabilized with plural antiplatelet therapy. Conclusion Multiplicate antiplatelet therapy is important for treatment of CWS, and caution is needed regarding hemorrhagic complications.

Endovascular embolization is an essential therapeutic approach in the multidisciplinary management of cerebral arteriovenous malformations (AVM). However, it rarely occludes the AVM in its entirety. It is often combined with surgery or stereotactic radiosurgery. The aim of embolization is to reduce the size of the nidus and the intra-nidal flow in order to facilitate the microsurgical or the radiosurgical procedure. We report the case of a 61-year-old patient with a right frontal hemorrhagic AVM treated with complete embolization in a single session. Initially, a surgical procedure for excision of the AVM was scheduled 24hours post-embolization. This surgery was canceled due to a good angiographic result of the embolization. Eight days post-embolization, there was a massive re-bleed of the AVM which justified emergency surgical management. This case illustrates a delayed post-embolization hemorrhagic complication of an occluded AVM and prompts a review of the therapeutic strategy of the cerebral AVM to select the most effective and least morbid procedure or combination of procedures.

There is a growing body of evidence on the incidence and negative prognostic impact of postdischarge hemorrhagic complications after an acute coronary syndrome (ACS). However, the risk of subsequent cancer after postdischarge bleeding in these patients is currently poorly known. The aim of this study was to assess the association of postdischarge bleeding with newly diagnosed cancers after an ACS. Data from a single-center registry of 3,644 ACS patients, who were discharged with dual antiplatelet therapy and treated with percutaneous coronary intervention, were used to investigate the association between postdischarge bleeding and diagnosis of cancer. During a median follow-up of 56.2 months, bleeding events were documented in 1,216 patients and newly diagnosed cancers in 227 patients. Postdischarge bleeding was associated with cancer diagnosis (adjusted hazard ratio [HR] 3.43, 95% confidence interval [CI] 2.62 to 4.50), but only spontaneous bleeding (adjusted HR 4.38, 95% CI 3.31 to 5.79). This association was stronger as the severity of the bleeding increased (HR 1.52, 4.88, 7.30, and 12.29, for BARC type 1, 2, 3a, and 3b bleeding, respectively). Positive predictive values for cancer diagnosis of postdischarge bleeding was 7.7%. Median time from bleeding to cancer was 4.6 months. In conclusion, spontaneous postdischarge bleeding in ACS patients is strongly associated with subsequent cancer diagnosis within the first 6 months. A prompt evaluation of bleeding could be useful for enabling an early detection of cancer in these patients.

Item does not contain fulltext BACKGROUND: Stent-assisted coiling (SAC) is increasingly being performed as intervention for wide-neck intracranial aneurysms. The NeuroForm Atlas Stent (CE-marked; Stryker, Kalamazoo, Michigan) is relatively new. OBJECTIVE: To evaluate the effectiveness and safety of NeuroForm Atlas SAC for intracranial aneurysms in the first such study. METHODS: We retrospectively analyzed data from all patients treated with the NeuroForm Atlas SAC of an intracranial aneurysm, both ruptured and unruptured, between June 2015 and December 2016. Primary end-points were favorable clinical outcomes (modified Rankin scale score 0-2) and successful aneurysm occlusion (Raymond-Roy class I/II), both at 6-mo follow-up. Secondary end-points were the occurrence of intervention-related complications leading to permanent neurological deficit, the occurrence of intervention-related stroke and neurological death, immediate aneurysm occlusion, rupture (or rerupture) of the aneurysm, and recanalization. RESULTS: Twenty-seven consecutive patients, 10 with ruptured saccular wide-neck aneurysms, were treated with NeuroForm Atlas SAC. At 6-mo follow-up, 18/26 (69.2%) survivors had successful aneurysm occlusion and 22/26 (84.6%) had favorable clinical outcome. One patient had died of a cause unrelated to treatment. No intervention-related complications leading to permanent neurological deficit occurred. However, intraprocedural thromboembolic complications occurred in 4/27 patients (14.8%), and ischemic stroke related to treatment occurred in 4/26 (15.4%). No hemorrhagic complications were observed. CONCLUSION: NeuroForm Atlas SAC is a feasible way to treat ruptured and unruptured wide-neck aneurysms that are not amenable to conventional coiling or clipping. Aneurysm occlusion and favorable clinical outcome are consistent with previously reported rates for SAC of wide-neck aneurysms with other devices.

A retrospective review to investigate rate and outcomes of re-exploration following liver transplantation in the United States.The NIS database was used to examine outcomes of patients who underwent re-exploration following liver transplantation from 2002 to 2012. Multivariate regression analysis was performed to compare outcomes of patients with and without reoperation.We sampled a total of 12,075 patients who underwent liver transplantation. Of these, 1505 (12.5%) had re-exploration during the same hospitalization. Hemorrhagic (67.9%) and biliary tract anastomosis complication (14.8%) were the most common reasons for reoperation. Patients with reoperation had a significantly higher mortality than those who did not (11.6% vs. 3.8%, AOR: 3.01, P 0.01). Preoperative coagulopathy (AOR: 1.71, P 0.01) and renal failure (AOR: 1.57, P 0.01) were associated with hemorrhagic complications. Peripheral vascular disorders (AOR: 2.15, P 0.01) and coagulopathy (AOR: 1.32, P 0.01) were significantly associated with vascular complications. Risk of wound disruption was significantly higher in patients with chronic pulmonary disease (AOR: 1.50, P 0.01).Re-exploration after liver transplantation is relatively common (12.5%), with hemorrhagic complication as the most common reason for reoperation. Preoperative coagulation disorders significantly increase hemorrhagic and vascular complications. Further clinical trails should investigate prophylactic strategies in high risk patients to prevent unplanned reoperation.

Utilization of flow diverting devices is accompanied with dual antiplatelet therapy to reduce the risk of thromboembolic events, even though this increases the risk of hemorrhagic complications. The updated Pipeline Flex embolization device with Shield Technology has been created using a phosphorylcholine coating that reduces thrombogenicity and possibly reduces the need for dual antiplatelet therapy. However, because of the potential risk to patients of utilizing a pipeline embolization device without dual antiplatelet therapy, the pipeline embolization device with Shield Technology has not been tested in human subjects without dual antiplatelet therapy, and its contribution to preventing thromboembolic events is therefore unknown. We report a case in which a patient, following complications that limited his absorption of dual antiplatelet therapy, had low levels of dual antiplatelet therapy medications in his bloodstream following treatment for an intracranial aneurysm with a pipeline embolization device with Shield Technology. The patient recovered without signs of luminal stenosis or thromboembolic event.

In developed countries, the incidence of cardiovascular disease is increasing, therefore, anticoagulant and antiplatelet drugs are a widespread treatment nowadays. Percutaneous nephrolithotomy (PNL) is the first-line treatment for large or complex stones (> 2 cm) and remains an alternative for the smaller ones. The objective of this study is to analyze whether PNL surgery is a safe procedure in patients under a treatment discontinuation protocol for anticoagulant or antiplatelet therapies. We retrospectively studied 301 patients who underwent PNL in our hospital between 2008 and 2016 and identified 46 patients on chronic antiplatelet or anticoagulation treatment. With respect to PNL outcomes, the stone-free rate was similar (78 vs 74%, p = 0.762) in both groups, without any significant differences in the overall postoperative complications (17 vs 26%, p = 0.203). The incidence of hemorrhagic complications was similar between groups (12 vs 9%, p = 0.492), as demonstrated by the mean drop in hemoglobin (Hb), which was comparable in both cohorts (2.2 ± 1.3 vs 2.0 ± 1.4 p = 0.270) and the blood transfusion rate (14% in group A and 8% in group B, p = 0.205). No thromboembolic events were found within the year after the PNL procedure. PNL is a safe and effective intervention in patients under a treatment discontinuation protocol for anticoagulant or antiplatelet therapies. Although our study demonstrates the feasibility of this protocol, new scientific evidence aims to stratify the thromboembolic and bleeding risk of each patient to individualize the perioperative management thereafter.

Background: Invasive electrode monitoring provides more precise localization of epileptogenic foci in patients with medically refractory epilepsy. The use of hybrid depth electrodes that include microwires for simultaneous single-neuron monitoring is becoming more widespread. Objective: To determine the safety and utility of hybrid depth electrodes for intracranial monitoring of medically refractory epilepsy. Methods: We reviewed the medical charts of 53 cases of medically refractory epilepsy operated on from 2006 to 2017, where both non-hybrid and hybrid microwire depth electrodes were used for intracranial monitoring. We assessed the localization accuracy and complications that arose to assess the relative safety and utility of hybrid depth electrodes compared with standard electrodes. Results: A total of 555 electrodes were implanted in 52 patients. The overall per-electrode complication rate was 2.3%, with a per-case complication rate of 20.8%. There were no infections or deaths. Serious or hemorrhagic complications occurred in 2 patients (0.4% per-electrode risk). Complications did not correlate with the use of any particular electrode type, and hybrids were equally as reliable as standard electrodes in localizing seizure onset zones. Conclusions: Hybrid depth electrodes appear to be as safe and effective as standard depth electrodes for intracranial monitoring and provide unique opportunities to study the human brain at single-neuron resolution.

Ischemic stroke is one of the most common complications of infective endocarditis (IE). IE must be considered as one of the causes of acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO), but early diagnosis of IE is difficult. AIS with ELVO must be treated using endovascular thrombectomy (EVT), with or without intravenous thrombolysis (IVT). IVT for AIS due to IE is not well established and remains controversial because of the risk of intracranial hemorrhage. A 42-year-old man suffered from right hemiparesis and disorientation, and AIS with ELVO was diagnosed. EVT with IVT was successfully performed and recanalization was achieved, but catastrophic multiple cerebral microbleeds appeared after treatment. EVT without IVT could be chosen for AIS caused by IE to avoid hemorrhagic complications. Hypointense signal spots on T2*-weighted magnetic resonance imaging (MRI) and susceptibility-weighted MRI could facilitate early diagnosis of IE.

Background Selective serotonin reuptake inhibitors (SSRI) may interfere with platelet function, and pre-stroke SSRI treatment has been associated with increased hematoma volumes and mortality in hemorrhagic stroke patients. The effects of SSRI on the risk of hemorrhagic complications after thrombolysis in ischemic stroke patients are unclear. Aims To examine the effects of pre-stroke SSRI exposure on bleeding complications, functional outcome, and mortality following thrombolysis in ischemic stroke. Methods Data including standard demographic and clinical variables as well as baseline and follow-up stroke severity (measured by National Institutes of Health Stroke Score), functional outcome (measured by modified Rankin Scale) at 3 months, and mortality at 7 and 90 days were extracted from the Virtual International Stroke Trials Archive. Multivariable binary logistic regression was used for statistical analyses. Results Out of 1114 ischemic stroke patients treated with recombinant tissue-type plasminogen activator, 135 (12.1%) had previous SSRI exposure. Symptomatic intracranial hemorrhage occurred in 30 (2.7%) patients. Of those, 2 (1.5%, n = 135) were in the SSRI pretreatment group and 28 (2.9%, n = 979) were SSRI naive patients. Pre-stroke SSRI exposure in thrombolysed patients showed association with neither bleeding complications ( P = .58) nor functional outcome ( P = .38) nor mortality ( P = .65). Conclusions Results from this large retrospective ad hoc database cohort study indicate that pre-stroke SSRI exposure in ischemic stroke patients who receive thrombolytic treatment is not associated with bleeding complications, functional outcome, or mortality.

Purpose Intracranial hemorrhage after thrombectomy using a catheter to treat acute major cerebral artery occlusion is known to exacerbate patient outcomes. This study was performed to determine the relationship between middle cerebral artery (MCA) tortuosity and postoperative hemorrhage. Methods We examined 111 consecutive patients who underwent acute thrombectomy for major intracranial artery occlusion in the anterior circulation at our hospital between September 2013 and June 2016. Patients in whom intracranial hemorrhage or subarachnoid hemorrhage was seen on head computed tomography 12-24 hours after surgery were assigned to the hemorrhagic group, whereas all the other patients were assigned to the nonhemorrhagic group. The groups were compared for tortuosity of the MCA, which was evaluated by finding the top-to-bottom (TB) distance of the M1 segment on anterior–posterior view angiograms. A modified Rankin scale score of 0-2 at 3 months after onset was considered a favorable prognosis. Results The hemorrhagic group comprised 28 patients (25.2%) and the nonhemorrhagic group comprised 83 patients (74.8%). No significant difference in patient characteristics was seen between the groups. The hemorrhagic group displayed significantly fewer patients with a favorable prognosis (17.9% versus 43.4%, P = .016). The TB distance was significantly greater in the hemorrhagic group (hemorrhagic group, 9.7 mm; nonhemorrhagic group, 7.6 mm; P = .002); multivariate analysis also identified a TB distance over 8.8 mm as a factor independently associated with postoperative intracranial hemorrhage (P = .001). Conclusions Post-thrombectomy hemorrhage was significantly correlated with TB distance. A solution is needed for selecting and combining devices used in patients with a TB distance over 8.8 mm.

Various adjunctive techniques for neurointerventional procedures require a large-bore sheath introducer, but there is concern that this could result in more puncture site hemorrhagic complications despite using a vascular closure device. The purpose of this study was to assess the relationship between use of large-bore sheath introducer and post-procedural complications. Between January 2016 and April 2018, 126 neurointerventional procedures were performed in our hospital using 8 or 9 Fr sheath introducer in size and the Angio-Seal STS PLUS (St. Jude Medical, Minnetonka, USA). Hemorrhagic complications were defined as obvious swelling or bleeding at the puncture site or as extravascular bleeding detected by ultrasonography or contrast-enhanced computed tomography. The procedures were divided into a group with post-puncture bleeding (group B, n = 21) and a group without bleeding (group N, n = 105). Risk factors were compared between the groups according to the incidence of post-puncture bleeding. In addition, we assessed the outcome and approach to hemostasis in the procedures with bleeding. In result, hemorrhagic complications occurred in 21 procedures (17%), and pseudoaneurysm was detected in 4 procedures (3.2%). In 20 of group B (16%), manual compression was performed for an average of 36.4 min. One patient (0.79%) required surgical angioplasty. Risk factors for bleeding were not significantly different between the two groups. None of the patients with bleeding showed a decrease on the modified Rankin Scale. In conclusion, use of a large-bore sheath introducer may increase the incidence of post-puncture bleeding, but the outcome of this complication is acceptable.

A 31-year-old man with mild hemophilia B developed a herniated disc treated with prednisolone for back pain. Surprisingly, hemostasis result tests performed before epidural infiltration were a normal activated partial thrombin time at 36.1 s. (normal range 27.9–37.7 s.) and factor IX (FIX) level 76% (normal range>70%), 13 days after prednisolone introduction. After a second control with a normal FIX level and a second genetic confirmation of hemophilia, no FIX concentrates was administered to perform the infiltration, which occurred without hemorrhagic complication. This new case of FIX normalization showed the necessity to have a perfect knowledge of patient’s treatment to avoid misdiagnosis and a temporary normal hemostasis permit to perform epidural infiltration without replacement therapy.