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Longhitano Y, Bottinelli M, Pappalardo F, Maj G, Audo A, Srejic U, Rasulo FA, Zanza C. Electrocardiogram alterations in non-traumatic brain injury: a systematic review. J Clin Monit Comput 2024; 38:407-414. [PMID: 37736801 DOI: 10.1007/s10877-023-01075-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/30/2023] [Indexed: 09/23/2023]
Abstract
The presence of abnormal electrocardiograms in individuals without known organic heart disease is one of the most common manifestations of cardiac dysfunction occurring during acute non traumatic brain injury. The primary goal of the present review is to provide an overview of the available data and literature regarding the presence of new-onset electrocardiographic (ECG) alterations in acute non traumatic brain injury. The secondary aim is to identify the incidence of ECG alterations and consider the prognostic significance of new-onset ECG changes in this setting. To do so, English language articles from January 2000 to January 2022 were included from PubMed using the following keywords: "electrocardiogram and subarachnoid hemorrhage", "electrocardiogram and intracranial hemorrhage", "Q-T interval and subarachnoid hemorrhage ", "Q-T interval and intracranial bleeding ", "Q-T interval and intracranial hemorrhage", and "brain and heart- interaction in stroke". Of 3162 papers, 27 original trials looking at electrocardiogram alterations in acute brain injury were included following the PRISMA guideline. ECG abnormalities associated with acute brain injury could potentially predict poor patient outcomes. They could even herald the future development of neurogenic pulmonary edema (NPE), delayed cerebral ischemia (DCI), and even in-hospital death. In particular, patients with SAH are at increased risk of having severe ventricular dysrhythmias. These may contribute to a high mortality rate and to poor functional outcome at 3 months. The current data on ECG QT dispersion and mortality appear less clearly associated. While some patients demonstrated poor outcomes, others showed no relationship with poor outcomes or increased in-hospital mortality. Observing ECG alterations carefully after cerebral damage is important in the critical care of these patients as it can expose preexisting myocardial disease and change prognosis.
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Affiliation(s)
- Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maria Bottinelli
- Department of Anesthesiology and Intensive Care, "Maggiore Della Carità" University Hospital, Corso Mazzini18, 28100, Novara, Italy
| | - Federico Pappalardo
- Department of Cardiac Anesthesiology, AON SS. Antonio E Biagio E Cesare Arrigo H, Alessandria, Italy
| | - Giulia Maj
- Department of Cardiac Anesthesiology, AON SS. Antonio E Biagio E Cesare Arrigo H, Alessandria, Italy
| | - Andrea Audo
- Department of Cardiac Surgery, AON SS. Antonio E Biagio E Cesare Arrigo H, Alessandria, Italy
| | - Una Srejic
- Department of Anesthesiology, Pain Medicine, and Critical Care, University of California, San Diego, USA
| | - Frank Anthony Rasulo
- Department of Anesthesiology, Pain Medicine, and Critical Care, Spedali Civili, University of Brescia, Brescia, Italy
| | - Christian Zanza
- Italian Society of Pre-Hospital Emergency Medicine (SIS-118), Consultant in Anesthesia and Critical Care and Consultant in Internal and Emergency Medicine, Taranto, EU, Italy.
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Khan MZ, Shatla I, Darden D, Neely J, Mir T, Abideen Asad ZU, Agarwal S, Raina S, Balla S, Singh GD, Srivatsa U, Munir MB. Intracranial bleeding and associated outcomes in atrial fibrillation patients undergoing percutaneous left atrial appendage occlusion: Insights from National Inpatient Sample 2016-2020. Heart Rhythm O2 2023; 4:433-439. [PMID: 37520018 PMCID: PMC10373143 DOI: 10.1016/j.hroo.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023] Open
Abstract
Background Percutaneous left atrial appendage occlusion (LAAO) has proved to be a safer alternative for long-term anticoagulation; however, patients with a history of intracranial bleeding were excluded from large randomized clinical trials. Objective The purpose of this study was to determine outcomes in atrial fibrillation (AF) patients with a history of intracranial bleeding undergoing percutaneous LAAO. Methods National Inpatient Sample and International Classification of Diseases, Tenth Revision, codes were used to identify patients with AF who underwent LAAO during the years 2016-2020. Patients were stratified based on a history of intracranial bleeding vs not. The outcomes assessed in our study included complications, in-hospital mortality, and resource utilization. Result A total of 89,300 LAAO device implantations were studied. Approximately 565 implantations (0.6%) occurred in patients with a history of intracranial bleed. History of intracranial bleeding was associated with a higher prevalence of overall complications and in-patient mortality in crude analysis. In the multivariate model adjusted for potential confounders, intracranial bleeding was found to be independently associated with in-patient mortality (adjusted odds ratio [aOR] 4.27; 95% confidence interval [CI] 1.68-10.82); overall complications (aOR 1.74; 95% CI 1.36-2.24); prolonged length of stay (aOR 2.38; 95% CI 1.95-2.92); and increased cost of hospitalization (aOR 1.28; 95% CI 1.08-1.52) after percutaneous LAAO device implantation. Conclusion A history of intracranial bleeding was associated with adverse outcomes after percutaneous LAAO. These data, if proven in a large randomized study, can have important clinical consequences in terms of patient selection for LAAO devices.
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Affiliation(s)
- Muhammad Zia Khan
- Division of Cardiology, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia
| | - Islam Shatla
- Department of Internal Medicine, Kansas University Medical Center, Kansas City, Kansas
| | - Douglas Darden
- Division of Cardiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | - Joseph Neely
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, California
| | - Tanveer Mir
- Department of Medicine, Wayne State University, Detroit, Michigan
| | - Zain Ul Abideen Asad
- Department of Internal Medicine, University of Oklahoma, Oklahoma City, Oklahoma
| | - Siddharth Agarwal
- Department of Internal Medicine, University of Oklahoma, Oklahoma City, Oklahoma
| | - Sameer Raina
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Sudarshan Balla
- Division of Cardiology, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia
| | - Gagan D. Singh
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, California
| | - Uma Srivatsa
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, California
| | - Muhammad Bilal Munir
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, California
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Masi P, Bagate F, Tuffet S, Piscitelli M, Folliguet T, Razazi K, De Prost N, Carteaux G, Mekontso Dessap A. Dual titration of minute ventilation and sweep gas flow to control carbon dioxide variations in patients on venovenous extracorporeal membrane oxygenation. Ann Intensive Care 2023; 13:45. [PMID: 37225933 DOI: 10.1186/s13613-023-01138-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND The implantation of venovenous extracorporeal membrane oxygenation (VV-ECMO) support to manage severe acute respiratory distress syndrome generates large variations in carbon dioxide partial pressure (PaCO2) that are associated with intracranial bleeding. We assessed the feasibility and efficacy of a pragmatic protocol for progressive dual titration of sweep gas flow and minute ventilation after VV-ECMO implantation in order to limit significant PaCO2 variations. PATIENTS AND METHODS A protocol for dual titration of sweep gas flow and minute ventilation following VV-ECMO implantation was implemented in our unit in September 2020. In this single-centre retrospective before-after study, we included patients who required VV-ECMO from March, 2020 to May, 2021, which corresponds to two time periods: from March to August, 2020 (control group) and from September, 2020 to May, 2021 (protocol group). The primary endpoint was the mean absolute change in PaCO2 in consecutive arterial blood gases samples drawn over the first 12 h following VV-ECMO implantation. Secondary endpoints included large (> 25 mmHg) initial variations in PaCO2, intracranial bleedings and mortality in both groups. RESULTS Fifty-one patients required VV-ECMO in our unit during the study period, including 24 in the control group and 27 in the protocol group. The protocol was proved feasible. The 12-h mean absolute change in PaCO2 was significantly lower in patients of the protocol group as compared with their counterparts (7 mmHg [6-12] vs. 12 mmHg [6-24], p = 0.007). Patients of the protocol group experienced less large initial variations in PaCO2 immediately after ECMO implantation (7% vs. 29%, p = 0.04) and less intracranial bleeding (4% vs. 25%, p = 0.04). Mortality was similar in both groups (35% vs. 46%, p = 0.42). CONCLUSION Implementation of our protocol for dual titration of minute ventilation and sweep gas flow was feasible and associated with less initial PaCO2 variation than usual care. It was also associated with less intracranial bleeding.
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Affiliation(s)
- Paul Masi
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France.
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France.
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France.
| | - François Bagate
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Samuel Tuffet
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Mariantonietta Piscitelli
- Service de chirurgie cardiaque, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Faculté de Santé, F-94010, Créteil, France
| | - Thierry Folliguet
- Service de chirurgie cardiaque, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Faculté de Santé, F-94010, Créteil, France
| | - Keyvan Razazi
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Nicolas De Prost
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
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Tiefenbach J, Favi Bocca L, Hogue O, Nero N, Baker KB, Machado AG. Intracranial Bleeding in Deep Brain Stimulation Surgery: A Systematic Review and Meta-Analysis. Stereotact Funct Neurosurg 2023:1-10. [PMID: 37232022 DOI: 10.1159/000530398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/20/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) is a neurosurgical treatment used for the treatment of movement disorders. Surgical and perioperative complications, although infrequent, can result in clinically significant neurological impairment. OBJECTIVES In this study, we evaluated the incidence and risk factors of intracranial bleeding in DBS surgery. METHOD Medline, EMBASE, and Cochrane were screened in line with PRISMA 2020 guidelines to capture studies reporting on the incidence of hemorrhagic events in DBS. After removing duplicates, the search yielded 1,510 papers. Abstracts were evaluated by two independent reviewers for relevance. A total of 386 abstracts progressed to the full-text screen and were assessed against eligibility criteria. A total of 151 studies met the criteria and were included in the analysis. Any disagreement between the reviewers was resolved by consensus. Relevant data points were extracted and analyzed in OpenMeta [Analyst] software. RESULTS The incidence of intracranial bleeding was 2.5% (95% CI: 2.2-2.8%) per each patient and 1.4% (95% CI: 1.2-1.6%) per each implanted lead. There was no statistically significant difference across implantation targets and clinical indications. Patients who developed an intracranial bleed were on average 5 years older (95% CI: 1.26-13.19), but no difference was observed between the genders (p = 0.891). A nonsignificant trend was observed for a higher risk of bleeding in patients with hypertension (OR: 2.99, 95% CI: 0.97-9.19) (p = 0.056). The use of microelectrode recording did not affect the rate of bleeding (p = 0.79). CONCLUSIONS In this review, we find that the rate of bleeding per each implanted lead was 1.4% and that older patients had a higher risk of hemorrhage.
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Affiliation(s)
- Jakov Tiefenbach
- Department of Neurosciences, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA,
| | - Leonardo Favi Bocca
- Center for Neurological Restoration, Neurological Institute, Cleveland, Ohio, USA
| | - Olivia Hogue
- Department of Quantitative Health Sciences, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | - Neil Nero
- Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kenneth B Baker
- Department of Neurosciences, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland, Ohio, USA
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Suarez-Meade P, Marenco-Hillembrand L, Sherman WJ. Neuro-oncologic Emergencies. Curr Oncol Rep 2022; 24:975-984. [PMID: 35353348 DOI: 10.1007/s11912-022-01259-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Patients with brain and spine tumors are at high risk of presenting cancer-related complications at disease presentation or during active treatment and are usually related to the type and location of the lesion. Here, we discuss presentation and management of the most common emergencies affecting patients with central nervous system neoplastic lesions. RECENT FINDINGS Tumor-related emergencies encompass complications in patients with central nervous system neoplasms, as well as neurologic complications in patients with systemic malignancies. Brain tumor patients are at high risk of developing multiple complications such as intracranial hypertension, brain herniation, intracranial bleeding, spinal cord compression, and others. Neuro-oncologic emergencies require immediate attention and multi-disciplinary care. These emergent situations usually need rapid decision-making and management on an inpatient basis.
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Affiliation(s)
| | | | - Wendy J Sherman
- Department of Neurology and Neurosurgery, Mayo Clinic, Jacksonville, FL, USA.
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Abstract
Oxygen (O2) toxicity remains a concern, particularly to the lung. This is mainly related to excessive production of reactive oxygen species (ROS). Supplemental O2, i.e. inspiratory O2 concentrations (FIO2) > 0.21 may cause hyperoxaemia (i.e. arterial (a) PO2 > 100 mmHg) and, subsequently, hyperoxia (increased tissue O2 concentration), thereby enhancing ROS formation. Here, we review the pathophysiology of O2 toxicity and the potential harms of supplemental O2 in various ICU conditions. The current evidence base suggests that PaO2 > 300 mmHg (40 kPa) should be avoided, but it remains uncertain whether there is an "optimal level" which may vary for given clinical conditions. Since even moderately supra-physiological PaO2 may be associated with deleterious side effects, it seems advisable at present to titrate O2 to maintain PaO2 within the normal range, avoiding both hypoxaemia and excess hyperoxaemia.
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Affiliation(s)
- Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Paul J Young
- Medical Research Institute of New Zealand, and Intensive Care Unit, Wellington Hospital, Wellington, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Department of Critical Care Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, and School of Medicine, National University of Ireland, Galway, Ireland
| | - Pierre Asfar
- Département de Médecine Intensive - Réanimation Et Médecine Hyperbare, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081, Ulm, Germany.
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Xu S, Wu P, Zhang T, Ji Z, Wang C, Shi H. Prevalence and Clinical Predictors of Intracranial Hemorrhage Following Carotid Artery Stenting for Symptomatic Severe Carotid Stenosis. World Neurosurg 2021; 155:e353-61. [PMID: 34419661 DOI: 10.1016/j.wneu.2021.08.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/12/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Hyperperfusion-induced intracranial hemorrhage (HICH) is the most frequent cause of death following carotid artery stenting (CAS). This study aimed to identify the presence of HICH after CAS and evaluate demographic and clinical variables associated with HICH. METHODS We retrospectively reviewed clinical data of 446 consecutive patients with symptomatic severe carotid stenosis treated with CAS between November 2011 and August 2018. Good collateral compensation was defined as patency of the anterior communicating artery with well-developed bilateral A1 segments with or without posterior communicating arteries, according to the classification of Katano et al. Univariate and multivariate analyses were performed to determine whether there was a correlation between demographic and clinical variables and development of HICH. RESULTS Stent placement was successful in all patients. Of 446 patients, 14 had HICH (3.14%); 1 of 14 (7.14%) patients displayed 80%-90% stenosis, and 13 patients had stenosis ≥90%. Thirteen patients (92.86%) had poor collateral circulation compensation. Two patients (14.3%) died despite rescue efforts. Age (≥70 years), degree of carotid artery stenosis (≥90%), and poor compensation of collateral circulation were associated with a higher frequency of HICH after CAS. Severe carotid artery stenosis (≥90%) was independently associated with HICH after stenting (odds ratio 13.633, P = 0.014). CONCLUSIONS The incidence rate of HICH was 3.14%. Patients with severe carotid artery stenosis (≥90%) are at high risk for developing HICH after CAS. Further investigations are needed to better describe the contribution of other risk factors, including poor compensation of collateral circulation (especially anterior circulation).
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Allen J, Ravichandiran K, McLaughlin TL, MacDonald C, Howard J, Lanting B, Vasarhelyi E. The utility of head CT scans in geriatric patients with hip fractures following a low energy injury mechanism: A retrospective review. Injury 2021; 52:1462-1466. [PMID: 33536129 DOI: 10.1016/j.injury.2020.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/15/2020] [Accepted: 12/19/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Hip fractures are common low-energy orthopaedic injuries in the geriatric population. The purpose of this study is to determine the frequency of CT head exams and the incidence of clinically significant intracranial bleed in patients with low energy hip fractures. DESIGN A retrospective cross-sectional review was completed to identify hip fractures presenting to an academic health centre between 2006 and 2015. Our inclusion criteria were those patients with low energy hip fractures and medical records were reviewed to determine whether a CT head scan was utilized as part of their workup. RESULTS A total of 2114 patients were reviewed with an average age of 83.2 years. Hip fractures were treated with a hemiarthroplasty in 59.1% of the patients and with a dynamic hip screw in 40.9% of the patients. 26.9% (n = 502) of the patients received a CT head scan as part of their workup. Sixty-two patients (12.3% of patients who received a CT scan or 2.9% of the study population) were found to have had an acute intracranial bleed. None of these patients required neurosurgical intervention and only 9 (14.5% of patients with a positive CT head) had a modification to their thromboprophylaxis post-op. Of the 15 (26.4%) patient on home anticoagulation for a pre-existing medical condition, 10 (67%) had a delay in reinitiating their anticoagulation greater than 24 h post-operatively. CONCLUSION During the study period, 26.7% of patients received a CT scan, with only 2.9% of patients suffering from a concurrent intracranial bleed. None of the patients with a positive scan required neurosurgical intervention, and scan results did not routinely alter DVT prophylaxis. Resuming home anticoagulation was delayed greater than 24 h post-operatively in ten (67%) of cases. With the challenges of resource allocation, potential delays to surgery and costs associated with CT scans, these investigations should be reserved for patients who have a history or physical exam findings of head trauma or are on anticoagulation pre-injury in the low energy hip fracture population. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- James Allen
- Department of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, ON Canada N6A 5A5.
| | - Kajeandra Ravichandiran
- Department of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, ON Canada N6A 5A5.
| | - Terry-Lyne McLaughlin
- Department of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, ON Canada N6A 5A5.
| | - Christie MacDonald
- Division of Emergency Medicine, Department of Medicine, London Health Sciences Centre, Victoria Hospital, Rm E6-117. London, ON, Canada N6A 5A5.
| | - James Howard
- Department of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, Room C9-002, 339 Windermere Rd. London, ON Canada N6A 5A5.
| | - Brent Lanting
- Department of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, ON Canada N6A 5A5.
| | - Edward Vasarhelyi
- Department of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, ON Canada N6A 5A5.
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Leitner L, El-Shabrawi JH, Bratschitsch G, Eibinger N, Klim S, Leithner A, Puchwein P. Risk adapted diagnostics and hospitalization following mild traumatic brain injury. Arch Orthop Trauma Surg 2021; 141:619-627. [PMID: 32705384 PMCID: PMC7966191 DOI: 10.1007/s00402-020-03545-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 07/15/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) remains a leading cause of hospital admission and mortality, intracranial hemorrhage (ICH) presents a severe complication. Low complication tolerance in developed countries and risk uncertainty, often cause excessive observation, diagnostics and hospitalization, considered unnecessary and expensive. Risk factors predicting ICH, progression and death in patients hospitalized with mild TBI have not been identified yet. METHODS Mild TBI cases indicated for cranial computer tomography (CT) and hospitalization, according to international guidelines, at our Level I Trauma Center between 2008 and 2018 were retrospectively included. Multivariate logistic regression was performed for ICH, progression and mortality predictors. RESULTS 1788 mild TBI adults (female: 44.3%; age at trauma: 58.0 ± 22.7), were included. Skull fracture was diagnosed in 13.8%, ICH in 46.9%, ICH progression in 10.6%. In patients < 35 years with mild TBI, chronic alcohol consumption (p = 0.004) and skull fracture (p < 0.001) were significant ICH risk factors, whilst in patients between 35 and 65 years, chronic alcohol consumption (p < 0.001) and skull fracture (p < 0.001) revealed as significant ICH predictors. In patients with mild TBI > 65 years, age (p = 0.009), anticoagulation (p = 0.007) and neurocranial fracture (p < 0.001) were significant, independent risk factors for ICH, whilst increased age (p = 0.01) was a risk factor for mortality following ICH in mild TBI. Late-onset ICH only occurred in mild TBI cases with at least two of these risk factors: age > 65, anticoagulation, neurocranial fracture. Overall hospitalization could have been reduced by 15.8% via newly identified low-risk cases. CONCLUSIONS Age, skull fracture and chronic alcohol abuse require vigilant observation. Repeated CT in initially ICH negative cases should only be considered in newly identified high-risk patients. Non-ICH cases aged < 65 years do not gain safety from observation or hospitalization. Recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics.
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Affiliation(s)
- Lukas Leitner
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Jasmin Helena El-Shabrawi
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Gerhard Bratschitsch
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Nicolas Eibinger
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Sebastian Klim
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Andreas Leithner
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Paul Puchwein
- Department of Orthopedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
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Chang K, Huang CH, Chen TC, Lin CY, Lu PL, Chen YH. Clinical characteristics and risk factors for intracranial hemorrhage or infarction in patients with dengue. J Microbiol Immunol Infect 2021; 54:885-892. [PMID: 33840603 DOI: 10.1016/j.jmii.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 02/15/2021] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) or infarction in dengue cases is rare but very challenging for clinicians. We report these uncommon complications of dengue patients and focused on the significant factors associated with ICH or infarction in dengue patients. METHODS This investigation was a retrospective study of 182 adult dengue patients who received brain computed tomography at three Taiwan hospitals during the 2014 and 2015 dengue outbreaks. This included 13 hemorrhage cases, 26 infarction cases and 143 cases without brain infarction or hemorrhage. RESULTS Among them, 13 (7.14%) suffered from ICH (6 had subdural hemorrhage, 3 had subarachnoid hemorrhage, 1 had subdural and subarachnoid hemorrhage, and 3 had intracerebral hemorrhage) and 26 (14.3%) had brain infarction. The overall mortality rate was 4/13 (30.8%) in the ICH group and 3/26 (11.5%) in the infarction group. The significant variables from the univariate analysis, including difference between 2014 and 2015, age, history of cerebrovascular accident, bone pain, arthralgia, dizziness, altered consciousness, and a higher Charlson comorbidity score. Multivariate analysis revealed that significant risk factors for ICH/infarction in dengue cases were the year of occurrence, 2014 vs. 2015 (p < 0.0001, OR = 25.027, 95% CI = 8.205-76.336), Charlson score >4 (p = 0.01, OR = 3.764, 95% CI = 1.364-10.386) and altered consciousness (p < 0.0001, OR = 6.3, 95% CI = 2.242-17.7). The factors physicians should notice in dengue endemic regions for brain infarction or ICH include altered consciousness and a Charlson score >4, especially in the year that a higher frequency of infarction/ICH was observed.
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Affiliation(s)
- Ko Chang
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Chung-Hao Huang
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Tun-Chieh Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Chun-Yu Lin
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Po-Liang Lu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Cohort Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Yen-Hsu Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine, Graduate Institute of Medicine, Sepsis Research Institute, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Science and Technology, College of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan.
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Johansson K, Johansson L, Nilsson TK, Lind MM. Factor XII Concentrations and Risk of Intracerebral Haemorrhage. A Prospective Case-Referent Study. J Stroke Cerebrovasc Dis 2021; 30:105565. [PMID: 33412399 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES In a previous pilot study, we found an association between high factor XII levels and risk of haemorrhagic stroke suggesting that factor XII is a risk marker for intracerebral haemorrhage (ICH). The aim of this study was to further investigate the association between factor XII and risk of ICH in a larger population. MATERIALS AND METHODS This study was conducted as a prospective nested case-referent study. All participants underwent a health examination and blood sampling for factor XII analysis at baseline. Cases were defined as participants who were diagnosed with a first-ever ICH between 1985 and 2000. Two referents were matched to each case. RESULTS We identified 70 individuals with first-ever ICH and 137 matched referents who had undergone a health examination and donated blood samples before the ICH event. The mean age was 54 years, and 33% were women. The median time-to-event was 3.5 years (range 0.04 to 10.2 years). Conditional logistic regression showed no association between factor XII and risk of ICH, (odds ratio 1.06 per SD; [95% confidence interval: 0.57-1.97] in a multivariable model). CONCLUSIONS A previous finding of an association between high concentration of factor XII and risk of ICH could not be replicated in this larger study.
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Affiliation(s)
- Kristina Johansson
- Department of Public Health and Clinical Medicine, Skellefteå Research Unit, Umeå University, SE-901 81 Umeå, Sweden.
| | - Lars Johansson
- Department of Public Health and Clinical Medicine, Skellefteå Research Unit, Umeå University, SE-901 81 Umeå, Sweden.
| | - Torbjörn K Nilsson
- Department of Medical Biosciences, Clinical Chemistry, Umeå University, SE-901 81 Umeå, Sweden.
| | - Marcus M Lind
- Department of Public Health and Clinical Medicine, Skellefteå Research Unit, Umeå University, SE-901 81 Umeå, Sweden.
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12
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Soleimani T, Mosher B, Ochoa-Frongia L, Stevens P, Kepros JP. Delayed Intracranial Hemorrhage After Blunt Head Injury With Direct Oral Anticoagulants. J Surg Res 2020; 257:394-398. [PMID: 32892136 DOI: 10.1016/j.jss.2020.08.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/23/2020] [Accepted: 08/02/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Patients presenting to the Emergency Department (ED) following head injury are frequently evaluated with an initial computed tomography scan (CT) of the brain. Imaging is particularly important in patients who are receiving medications that alter normal blood hemostasis. As an imaging modality, CT has a high negative predictive value when used to rule out clinically significant acute intracranial hemorrhage. Patients receiving anticoagulant or antiplatelet therapy have both an increased risk of initial hemorrhage, as well as an increased risk of mortality above nonanticoagulated patients, should they suffer hemorrhage. Multiple studies of delayed intracranial hemorrhage have placed the risk among the patients taking warfarin at the time of head injury in the range of 0.6-6.0%. However, data regarding the risk of delayed intracranial hemorrhage in patients taking the class of agents referred to as Direct-Acting Oral Anticoagulants (DOACs) remains limited. This study aims to estimate this risk. METHODS A retrospective chart review was performed to identify patients on DOACs who presented to our Level I trauma center following blunt head injury between January 2017 and August 2018. Patients with a negative initial head CT were selected. From this subset, data regarding demographics, injury characteristics, anticoagulant use, and antiplatelet use were collected. RESULTS Overall, 314 patients were included; 129 patients taking rivaroxaban, 182 patients taking apixaban, and four patients taking dabigatran. In approximately 29% of the patients, the sole indication for admission was close monitoring following head injury while taking an anticoagulant agent. The mechanism of injury for the majority of the patients was fall. Of the 314 patients, three were found to have delayed intracranial hemorrhage on the repeated head CT (0.95%). Two of these three patients were on concomitant antiplatelet medication. None of the three individuals required neurosurgical intervention. CONCLUSIONS at the time of submission, this is the largest study estimating the risk of delayed intracranial hemorrhage among patients on DOACs. Based on the results of this study, patients who sustain a blunt head injury while taking only DOACs; that is, without concurrent antiplatelet medication, admission, and repeat head CT may not be necessary after confirming a negative initial CT scan.
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Affiliation(s)
- Tahereh Soleimani
- Department of Surgery, Michigan State University, College of Human Medicine, Lansing, Michigan.
| | | | - Laura Ochoa-Frongia
- Department of Surgery, Michigan State University, College of Human Medicine, Lansing, Michigan
| | - Penny Stevens
- Trauma Department, Sparrow Health System, Lansing, Michigan
| | - John P Kepros
- Trauma Department, Honor Health System, Scottsdale, Arizona
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Lokhandwala AM, Asmar S, Khurrum M, Chehab M, Bible L, Castanon L, Ditillo M, Joseph B. Platelet Transfusion After Traumatic Intracranial Hemorrhage in Patients on Antiplatelet Agents. J Surg Res 2021; 257:239-45. [PMID: 32862051 DOI: 10.1016/j.jss.2020.07.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/05/2020] [Accepted: 07/03/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients. METHODS We analyzed our prospectively maintained TBI database from 2014 to 2016. We included all isolated TBI patients with an IB, who were on preinjury antiplatelet agents and excluded patients taking anticoagulants. Outcome measures included the progression of IB, neurosurgical intervention, and mortality. Regression analysis was performed. RESULTS A total of 343 patients met the inclusion criteria. Mean age was 58 ± 11 y, 58% were men, and median injury severity score was 15 (10-24). Distribution of antiplatelet agents was as follows: aspirin (60%) and clopidogrel (35%). Overall, 74% patients received platelet transfusion after admission with a median number of two platelet units. After controlling for confounders, patients who received one unit of pooled platelets had no difference in progression of IB (odds ratio [OR]: 0.98, [0.6-1.9], P = 0.41), need for neurosurgical intervention (OR: 1.09, [0.7-2.5], P = 0.53), and mortality (OR: 0.84, [0.6-1.8], P = 0.51). However, patients who received two units of pooled platelets had lower rate of progression of IB (OR: 0.69, [0.4-0.8], P = 0.02), the need for neurosurgical intervention (OR: 0.81, [0.3-0.9], P = 0.03), and mortality (OR: 0.84, [0.5-0.9], P = 0.04). Both groups were compared with those who did not receive platelet transfusion. CONCLUSIONS The use of two units of platelet may decrease the risk of IB progression, neurosurgical intervention, and mortality in patients on preinjury antiplatelet agents and TBI. Further studies should focus on developing protocols for platelet transfusion to improve outcomes in these patients. LEVEL OF EVIDENCE Level III prognostic.
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14
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Korobey MJ, Sadaka F, Javed M, Moynihan M, Alsaei A. Efficacy of 4-Factor Prothrombin Complex Concentrates in Factor Xa Inhibitor-Associated Intracranial Bleeding. Neurocrit Care 2020; 34:112-120. [PMID: 32430804 DOI: 10.1007/s12028-020-00968-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVE Intracranial bleeding (ICB) is a feared complication of systemic anticoagulation. Factor Xa inhibitors (FXaI) are used frequently due to their improved safety profile and predictable kinetics. Andexanet alfa was recently approved for emergent reversal of FXaI agents but was not compared formally to 4-Factor Prothrombin Complex Concentrates (4FPCC) which are the current standard of care in many centers. The objective of this study is to formally evaluate the hemostatic efficacy of 4FPCC in patients with FXaI-associated ICB. METHODS We performed a retrospective cohort study of patients receiving 4FPCC for the reversal of a FXaI in the setting of acute ICB. Hemostatic efficacy was adjudicated via evaluation of post-4FPCC CT scan using the criteria closely mirroring those outlined in Annexa-4 (excellent < 20% expansion, good > 20% but ≤ 35% expansion, poor > 35% expansion). Each image was reviewed by two neurointensivist attendings for grading. Mortality was assessed until date of discharge. Charts were screened for thrombotic events out to 30 days post-4FPCC administration. RESULTS A total of 59 patients were included in the final analysis. The mean age in years was 78.5 ± 10.9 and 56% were male. Apixaban was the most common FXaI prescribed at the time of presentation (67.8%). Most patients were on FXaI therapy for stroke prevention in the setting of atrial fibrillation (81.3%). Median Glasgow Coma Scale at presentation was 15(IQR 12-15), with the most frequently presenting ICB type being intracerebral hemorrhage (52.5%). The mean dose of 4FPCC prescribed was 46.6 (± 8.2) units/kg. Of those receiving 4FPCC for FXaI ICB, 88% were graded as having an excellent or good hemostatic outcome with excellent interrater reliability. Survival was high at 89.8%, and thrombotic events were seen in seven patients (11.9%). CONCLUSION 4FPCC appears to be an effective and safe option for FXaI-associated ICB with outcomes comparable to andexanet alfa. A formal prospective evaluation of this strategy versus andexanet alpha including cost analysis is warranted.
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Affiliation(s)
- Matthew J Korobey
- Department of Critical Care Medicine, Mercy Hospital St. Louis, 615 S. New Ballas Road, St. Louis, MO, 63303, USA.
| | - Farid Sadaka
- Department of Critical Care Medicine, Mercy Hospital St. Louis, 615 S. New Ballas Road, St. Louis, MO, 63303, USA
| | - Muhammad Javed
- Department of Critical Care Medicine, Mercy Hospital St. Louis, 615 S. New Ballas Road, St. Louis, MO, 63303, USA
| | | | - Ahmed Alsaei
- Department of Critical Care Medicine, Mercy Hospital St. Louis, 615 S. New Ballas Road, St. Louis, MO, 63303, USA
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15
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Esmaeilzadeh M, Uksul N, Hong B, von Kaisenberg C, Scheinichen D, Lang JM, Hermann EJ, Hillemanns P, Krauss JK. Intracranial emergencies during pregnancy requiring urgent neurosurgical treatment. Clin Neurol Neurosurg 2020; 195:105905. [PMID: 32428795 DOI: 10.1016/j.clineuro.2020.105905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/19/2020] [Accepted: 05/07/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Despite contemporary diagnostic and therapeutic techniques intracranial emergencies in the obstetric setting pose still a major challenge for the clinicians. There are limited guidelines and differing ethical views. Multidisciplinary teams are needed to support the pregnant woman in a way that she can deliver a viable and healthy child. The aim of the present study was to scrutinize the management of intracranial emergencies during pregnancy which needed urgent neurosurgical treatment. PATIENTS AND METHODS Data of all pregnant women who presented with newly diagnosed intracranial pathologies and neurological symptoms caused by these pathologies in an emergency setting were collected over a 10-year period (2008-2018). Patient characteristics including maternal age, gestational age, and preoperative work-up of both mother and fetus were recorded. Furthermore, the surgical treatment, mode of delivery, and neonatal and maternal outcomes were analysed. RESULTS The mean maternal age was 32.7 years and most patients were in their third trimester. There was one twin pregnancy (total of 12 fetuses). Five out of eleven pregnant women suffered from intracerebral haemorrhage (epidural haematoma (1), arteriovenous malformation (1), subarachnoid haemorrhage (2) and intracerebral haemorrhage (1)) and the other six patients had intracranial neoplasms (primary meningeal sarcoma (1), trigeminal schwannoma (1), anaplastic astrocytoma (2), glioblastoma (1) and sphenoid wing meningioma (1)).Neurosurgical procedures were performed via craniotomies in eight patients. A stereotactic biopsy via a frontal burr hole was achieved one patient. The two other patients with subarachnoid haemorrhage due to rupture of PICA aneurysms were treated with coil embolization. Depending on the gestational age and the clinical condition of the pregnant women it was decided to perform an emergency Caesarean section prior to further therapeutic measures in seven patients. Two out of 12 fetuses were unviable. Six women survived, while five women succumbed to the intracranial pathology. CONCLUSION The individualized treatment approach in this peculiar obstetric scenario needs to consider various issues such as the clinical condition of the pregnant woman, prognosis of the disease, gestational age and the status of the pregnancy. The primary concern in this context must be the mother`s health and safety. Caesarean section is the primary mode of delivery in most cases. While contemporary care can insure survival for the majority of infants, maternal mortality still poses an extraordinary challenge. Interdisciplinary consulting of the patient and/or her family is necessary to develop a treatment strategy for both the expectant woman and her offspring.
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Affiliation(s)
| | - Nesrin Uksul
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Bujung Hong
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Dirk Scheinichen
- Department of Anaesthesiology, Hannover Medical School, Hannover, Germany
| | - Josef M Lang
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Elvis J Hermann
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Peter Hillemanns
- Department of Gynaecology & Obstetrics, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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Olszewska A, Farke D, Schmidt MJ. Spontaneous hemispheric ventricular collapse and subarachnoid haemorrhages in a dog with congenital hydrocephalus internus. Ir Vet J 2020; 73:5. [PMID: 32226604 PMCID: PMC7098093 DOI: 10.1186/s13620-020-00159-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 03/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background Overdrainage and collapse of the hemispheres is a potential severe complication after surgical treatment of internal hydrocephalus using ventriculoperitoneal shunts. Here we describe a case of a spontaneous hemispheric ventricular collapse in an untreated dog with congenital hydrocephalus internus. Case presentation A twelve-week-old, male, intact Golden Retriever was presented with a history of peracute obtundation, impaired vision, and progressive gait abnormalities of all limbs for three days. Neurological examination revealed a dome shaped skull, a broad-based stance and a moderate cerebellar ataxia. The postural responses were markedly delayed in all limbs. Moderate ventro-lateral strabismus, vertical nystagmus and absent menace response were observed bilaterally. Clinical signs indicated multifocal localisation (forebrain, cerebellum). Magnetic resonance imaging (MRI) showed dilation of all cerebral ventricles, irregular thinning of the periventricular white and grey matter, consistent with internal hydrocephalus. In addition, the hemispheres were collapsed at the right temporal and left frontal lobe with haemorrhage filling the adjacent subarachnoid space. The dog underwent left frontal and right temporal craniotomy for removal of the haemorrhage. The dog improved on all neurological signs and was discharged after seven days. A repeat MRI three months postsurgical intervention showed reexpansion of the cerebral hemispheres. Subarachnoid haemorrhages were markedly reduced. Conclusions Collapse of the hemispheres can occur spontaneously in dogs with hydrocephalus internus. Removal of the haemorrhage can improve clinical signs.
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Affiliation(s)
- Agnieszka Olszewska
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Neurosurgery, Neuroradiology and Clinical Neurology, Justus-Liebig-University, Frankfurter Strasse 108, 35392, Giessen, Germany
| | - Daniela Farke
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Neurosurgery, Neuroradiology and Clinical Neurology, Justus-Liebig-University, Frankfurter Strasse 108, 35392, Giessen, Germany
| | - Martin Jürgen Schmidt
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Neurosurgery, Neuroradiology and Clinical Neurology, Justus-Liebig-University, Frankfurter Strasse 108, 35392, Giessen, Germany
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Pouru JP, Lund J, Jaakkola S, Vasankari T, Biancari F, Saraste A, Airaksinen KEJ. Percutaneous left atrial appendage closure in patients with prior intracranial bleeding and thromboembolism. Heart Rhythm 2020; 17:915-21. [PMID: 32036026 DOI: 10.1016/j.hrthm.2020.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Percutaneous left atrial appendage closure (LAAC) is an alternative treatment in atrial fibrillation patients with contraindication to oral anticoagulation. However, patient selection criteria for LAAC are debated. OBJECTIVE The purpose of this study was to evaluate the outcome after LAAC in patients with prior intracranial bleeding and thromboembolism. METHODS Consecutive patients with atrial fibrillation and prior intracranial bleeding who underwent LAAC from February 2009 to August 2018 at the Turku University Hospital, Finland, were included in a prospective registry. Patients were followed through clinical visits and annual phone calls up to 5 years. RESULTS Overall 104 patients (mean age 73 ± 7 years; 30% women; CHA₂DS₂-VASc score 4.7 ± 1.4; HAS-BLED score 3.3 ± 0.9) with atrial fibrillation and prior intracranial bleeding underwent successful LAAC using mainly (n = 102) Amplatzer devices. Median time from intracranial bleeding to LAAC was 7 months, and median follow-up 3.6 years. Antithrombotic treatment was ≤6 months in 71 patients (68%), and 48 patients (46%) received aspirin or clopidogrel alone. The rates of thromboembolism and intracranial bleeding (per 100 patient-years) were 3.4 and 1.9, respectively. In 39 patients with previous thromboembolism, the rate of thromboembolism was 3.6 per 100 patient-years (95% confidence interval 1.5-7.0), yielding a 69% relative risk reduction with respect to predicted risk based on median CHA2DS2-VASc score. Overall, rates of thromboembolism and intracranial bleeding were broadly similar in patients with and those without prior thromboembolism. CONCLUSION Percutaneous LAAC with minimized antithrombotic treatment was demonstrated to be a valid treatment option in high-risk patients with prior intracranial bleeding and thromboembolism.
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Genebat González M, Dusseck Brutus R, García-Olloqui Á, García-Delgado Rosado H, Bellido Alba R, Pérez Torres I. Role of antiplatelet therapy in the development of intracranial bleeding after mild traumatic brain injury. Med Clin (Barc) 2020; 154:52-4. [PMID: 30857793 DOI: 10.1016/j.medcli.2019.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 11/20/2022]
Abstract
INTRODUCTION AND OBJECTIVE The use of antiplatelet agents is increasing, mainly in elderly patients in whom cranial trauma is a frequent reason for consultation to the emergency department. In this context, discordances have been described regarding the increased risk of post-traumatic injury that involves taking antiplatelet drugs. Therefore, the objective of this present study was to analyse factors associated with intracranial bleeding after mild brain trauma. PATIENTS AND METHODS A retrospective study was designed that included all patients who had consulted the emergency department during 2016 because of mild brain trauma (Glasgow coma scale 14-15) and excluded patients under anticoagulant therapy. A logistic regression analysis was performed to analyse the variables associated with intracranial bleeding. RESULTS 566 patients were included in the study. 18% of them were taking antiplatelet drugs. Tomography showed haemorrhagic intracranial damage in 16.1%. Factors associated with intracranial bleeding were: advanced age, Glasgow coma scale < 15, high-energy trauma and antiplatelet therapy. DISCUSSION Antiplatelet therapy emerges as a risk factor for intracranial bleeding after mild head trauma, in addition to other known factors.
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Sinurat R. The Glasgow Outcome Scale-Extended Pediatric Scores of Intracranial Bleeding Patients with Acquired Prothrombin Complex Deficiency Post Craniotomy and Duraplasty. Pediatr Neurosurg 2020; 55:254-258. [PMID: 33171478 DOI: 10.1159/000511020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 08/15/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Surgical evacuation of intracranial bleeding in pediatric patients due to acquired prothrombin complex deficiency (APCD) is a life-saving surgery when conservative treatment insufficient and impending brain herniation. This study aimed to evaluate the Glasgow outcome scale-extended pediatric (GOS-ePed) score of the pediatric intracranial bleeding patients with APCD after craniotomy and duraplasty. METHOD This was a retrospective study in the last 5 years of our experience. All of the pediatric patients with intracranial bleeding due to APCD who needed surgery were investigated. The data were collected from medical records after their parents have given their written informed concern and approved by the Ethics Review Committee, Faculty of Medicine, Universitas Kristen Indonesia. The inclusion criteria were patients who operated on by craniotomy and duraplasty. The patient with a second disease was excluded. Blood tests include hemoglobin, prothrombin time, activated prothrombin time, and platelets were investigated before and after intravenous vitamin K injection, transfusion packed red cells (PRCs), and fresh frozen plasma (FFP) administration. The Glasgow coma scale (GCS) pre- and postoperatively was evaluated using a modified GCS for infants and children. The outcome was evaluated by the GOS-ePed score. All data were analyzed with the normality test and paired t test. RESULTS There were 5 patients age between 37 and 60 days, and all patients did not get vitamin K prophylaxis after birth. The blood tests of all patients revealed anemia, prothrombin, and activated prothrombin time increased, but platelets were normal. All these values returned to normal after vitamin K injection, transfusion of PRCs, and FFP. The paired t tests were p < 0.05. The GCS of all patients before surgery was 8 or below. After surgery, the GCS of 4 patients was increased become 12 and 15. One patient did not change significantly. The GOS-ePed score showed 4 patients (80%) had upper or lower good recovery, and 1 patient (20%) was in a vegetative state. CONCLUSIONS The GOS-ePed score of the pediatric intracranial bleeding with APCD after craniotomy and duraplasty was mostly in upper or lower good recovery.
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Affiliation(s)
- Robert Sinurat
- Surgery Department, Medical Faculty of Universitas Kristen Indonesia, Jakarta, Indonesia,
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Gitto L, Richardson TE, Serinelli S, Diana F, Peschillo S, Domenicucci M. Massive intracranial bleeding due to the rupture of a rare spontaneous pseudoaneurysm of the middle cerebral artery in a pediatric patient: case report with clinical, radiological, and pathologic findings. Forensic Sci Med Pathol 2019; 15:474-80. [PMID: 31218656 DOI: 10.1007/s12024-019-00122-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
Abstract
Intracranial pseudoaneurysm (IPA) is a rare but likely underdiagnosed cause of intracranial hemorrhage, which accounts for just 1-6% of all intracranial aneurysms. Spontaneous IPAs are exceptionally rare, and their etiology and features are not well defined. Herein, we report a case of a pediatric patient who died from massive intracranial bleeding due to the rupture of a spontaneous IPA after undergoing multiple radiological studies and neurosurgical operations. At the postmortem examination of the brain, a giant size pseudoaneurysm of the right middle cerebral artery was observed. Microscopic examination demonstrated variable wall thickness and dense fibrosis focally in the vessel wall with disruption of the media structure together with a loss and fragmentation of the elastic laminae, loss of organization of smooth muscle cells in the media, and multifocal areas of hemorrhage throughout the vessel wall, as well as direct evidence of wall dissection. Since IPAs without any traumatic or infective history are extremely uncommon, further pathologic studies should be performed to clarify spontaneous pseudoaneurysm etiology.
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Ceratto S, Savino F. Vitamin K deficiency bleeding in an apparently healthy newborn infant: the compelling need for evidence-based recommendation. Ital J Pediatr 2019; 45:30. [PMID: 30832683 PMCID: PMC6399912 DOI: 10.1186/s13052-019-0625-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 02/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vitamin K is a key point for guarantee normal blood clotting and its level in newborns is commonly low, so a supplementation after delivery is mandatory. Vitamin K prophylaxis in newborns is still an open field of debate: many types of protocol have been proposed in different years and Countries, and sometimes with great variability inside the same Nation (for instance, in Italy a national consensus is not available, so different protocols are employed). Recommendations include different protocols for healthy newborns born at term, but the unpreventable presence of bleeding favouring factors (i.e. blood vessels malformations) or limiting intestinal absorption of liposoluble vitamins (i.e. cholestasis), which could be unrecognized or subclinical in the perinatal period, rises some concerning about the most precautionary route of administration and the timing of further doses after the first one given at birth. The purpose of this report is to underline the most recent evidences available in literature and to arise a debate about this topic, in order to stimulate the production of evidence-based guidelines concerning the prophylaxis with vitamin K1 in newborn infants, considering that many bleeding risk factors are not recognizable at birth. CASE PRESENTATION We are hereby presenting an emblematic case concerning the risk of intracranial bleeding in an apparently healthy newborn: the described infant did not show any pathological elements in pregnancy history or perinatal life which suggest a possible increased risk of bleeding and the needing of a particular approach in the administration of vitamin K1, but at the end of the first week of life presented an intracranial bleeding with neurological symptoms that required treatment for vitamin K deficiency. CONCLUSIONS Univocal recommendations about vitamin K prophylaxis are not available and the contrast between oral and intramuscular routes persists unsolved. The difficulty to certainly identify an infant eligible for oral administration of vitamin K1 at birth suggests that the intramuscular route should be preferred. How to prosecute the supplementation in the first months of life is still an open topic of debate.
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Affiliation(s)
- Simone Ceratto
- Department of Public Health and Pediatric Sciences, Postgraduate School of Pediatrics, University of Turin, Turin, Italy
| | - Francesco Savino
- Early infancy Sub-intensive Care Unit, Città della Salute e della Scienza di Torino, "Regina Margherita" Children's Hospital, Piazza Polonia, 94, 10126, Turin, Italy.
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Löwensteyn YN, Jansen NJG, van Heerde M, Klein RH, Kneyber MCJ, Kuiper JW, Riedijk MA, Verlaat CWM, Visser IHE, van Waardenburg DA, van Hasselt PM. Increasing the dose of oral vitamin K prophylaxis and its effect on bleeding risk. Eur J Pediatr 2019; 178:1033-42. [PMID: 31062090 DOI: 10.1007/s00431-019-03391-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 04/18/2019] [Accepted: 04/24/2019] [Indexed: 11/30/2022]
Abstract
Vitamin K prophylaxis in infancy aims to prevent life-threatening vitamin K deficiency bleeding (VKDB). The Dutch prophylactic oral daily regimen was increased sixfold from 25 to 150 μg because of a high failure rate. To evaluate the efficacy of this new regimen, incidences of intracranial VKDB under both regimens were compared using both general and targeted surveillance. Late VKDB in the general pediatric population was identified by the Netherlands Pediatric Surveillance Unit, between 1 October 2014 and 31 December 2016. Additionally, infants with intracranial vitamin K deficiency bleeding were identified using the Dutch Pediatric Intensive Care Evaluation registry. The incidence of intracranial VKDB as assessed by general and targeted surveillance decreased from 1.6 per 100,000 (95% CI, 0.4-5.1) to 1.3 per 100,000 (95% CI, 0.5-3.2) and from 3.1 per 100,000 live births (95% CI, 1.9-5.0) to 1.2 per 100,000 live births (95% CI, 0.6-2.3), respectively. Median time between consecutive cases in the latter increased from 24 to 154 days (p < 0.001).Conclusion: A sixfold increase in oral vitamin K prophylaxis was associated with a surprisingly modest reduction in the incidence of intracranial VKDB, indicating that factors other than the dose need addressing to improve efficacy. What is Known: • The efficacy of intramuscular vitamin K prophylaxis is threatened by an increasing number of parents opting out. • Oral prophylaxis represents an attractive and less invasive alternative but is inferior, especially in infants with malabsorption of vitamin K due to cholestasis. What is New: • Increasing the daily oral dose of vitamin K sixfold had a surprisingly modest effect on the incidence of late vitamin K deficiency bleeding. • This finding indicates that factors other than the dose must play an important role.
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Lupercio F, Romero J, Peltzer B, Maraboto C, Briceno D, Villablanca P, Ferrick K, Gross JN, Kim S, Fisher J, Di Biase L, Krumerman A. Efficacy and Safety Outcomes of Direct Oral Anticoagulants and Amiodarone in Patients with Atrial Fibrillation. Am J Med 2018; 131:573.e1-573.e8. [PMID: 29274758 DOI: 10.1016/j.amjmed.2017.11.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 11/22/2017] [Accepted: 11/28/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) and amiodarone are widely used in the treatment of nonvalvular atrial fibrillation. The DOACs are P-glycoprotein (P-gp) and cytochrome p-450 (CYP3A4) substrates. Direct oral anticoagulant levels may be increased by the concomitant use of potent dual P-gp/CYP3A4 inhibitors, such as amiodarone, which can potentially translate into adverse clinical outcomes. We aimed to assess the efficacy and safety of drug-drug interaction by the concomitant use of DOACs and amiodarone. METHODS We performed a systematic review of MEDLINE, the Cochrane Central Register of Clinical Trials, and Embase, limiting our search to randomized controlled trials of patients with atrial fibrillation that have compared DOACs versus warfarin for prophylaxis of stroke or systemic embolism, to analyze the impact on stroke or systemic embolism, major bleeding, and intracranial bleeding risk in patients with concomitant use of amiodarone. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method. The fixed effects model was used owing to heterogeneity (I2) < 25%. RESULTS Four trials with a total of 71,683 patients were analyzed, from which 5% of patients (n = 3212) were concomitantly taking DOAC and amiodarone. We found no statistically significant difference for any of the clinical outcomes (stroke or systemic embolism [RR 0.85; 95% CI, 0.67-1.06], major bleeding [RR 0.91; 95% CI, 0.77-1.07], or intracranial bleeding [RR 1.10; 95% CI, 0.68-1.78]) among patients taking DOAC and amiodarone versus DOAC without amiodarone. CONCLUSION On the basis of the results of this meta-analysis, co-administration of DOACs and amiodarone, a dual P-gp/CYP3A4 inhibitor, does not seem to affect efficacy or safety outcomes in patients with atrial fibrillation.
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Affiliation(s)
| | - Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Bradley Peltzer
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Carola Maraboto
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - David Briceno
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Pedro Villablanca
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Kevin Ferrick
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Jay N Gross
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Soo Kim
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - John Fisher
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin; Department of Biomedical Engineering, University of Texas, Austin; Department of Cardiology, University of Foggia, Italy
| | - Andrew Krumerman
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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Zoppellaro G, Zanella L, Denas G, Gennaro N, Ferroni E, Fedeli U, Padayattil Jose S, Costa G, Corti MC, Andretta M, Pengo V. Different safety profiles of oral anticoagulants in very elderly non-valvular atrial fibrillation patients. A retrospective propensity score matched cohort study. Int J Cardiol 2018; 265:103-107. [PMID: 29728333 DOI: 10.1016/j.ijcard.2018.04.117] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Giacomo Zoppellaro
- Cardiology Clinic, Department of Cardiac, Thoracic and Vascular Sciences, Padua University Hospital, Padua, Italy
| | - Luca Zanella
- Cardiology Clinic, Department of Cardiac, Thoracic and Vascular Sciences, Padua University Hospital, Padua, Italy
| | - Gentian Denas
- Cardiology Clinic, Department of Cardiac, Thoracic and Vascular Sciences, Padua University Hospital, Padua, Italy
| | - Nicola Gennaro
- Epidemiological Department (SER), Veneto Region, Padua, Italy
| | - Eliana Ferroni
- Epidemiological Department (SER), Veneto Region, Padua, Italy
| | - Ugo Fedeli
- Epidemiological Department (SER), Veneto Region, Padua, Italy
| | - Seena Padayattil Jose
- Cardiology Clinic, Department of Cardiac, Thoracic and Vascular Sciences, Padua University Hospital, Padua, Italy
| | - Giorgio Costa
- Unified Pharmaceutical Coordination Centre (CRUF), Veneto Region, Venice, Italy
| | | | - Margherita Andretta
- Unified Pharmaceutical Coordination Centre (CRUF), Veneto Region, Venice, Italy
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiac, Thoracic and Vascular Sciences, Padua University Hospital, Padua, Italy.
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Afaneh A, Ford J, Gharzeddine J, Mazar A, Hayward RD, Buck J. Head injury on Warfarin: likelihood of delayed intracranial bleeding in patients with negative initial head CT. BMC Res Notes 2018; 11:183. [PMID: 29544531 PMCID: PMC5856205 DOI: 10.1186/s13104-018-3291-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/09/2018] [Indexed: 11/20/2022] Open
Abstract
Objective To determine the likelihood that head injured patients on Warfarin with a negative initial head CT will have a positive repeat head CT. A retrospective chart review of our institution’s trauma registry was performed for all patients admitted for blunt head trauma and on Warfarin anti-coagulation from January 2009 to April 2014. Inclusion criteria included patients over 18 years of age with initial GCS ≥ 13, INR greater than 1.5 and negative initial head CT. Initial CT findings, repeat CT findings and INR were recorded. Interventions performed on patients with a delayed bleed were also investigated. Results 394 patients met the study inclusion criteria. 121 (31%) of these patients did not receive a second CT while 273 patients (69%) underwent a second CT. The mean INR was 2.74. Six patients developed a delayed bleed, of which two were clinically significant. No patients had any neurosurgical intervention. Our results demonstrate a low rate of delayed bleeding. The utility of repeat head CT in the neurologically stable patient is thus questioned. Patients who have an abnormal baseline neurological status and those with INR >3 may represent a subgroup of patients in whom repeat head CT should be performed.
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Affiliation(s)
- Amer Afaneh
- Department of Surgery, Division of Trauma, St. John Hospital & Medical Center, 22151 Moross Rd., PB I, Suite 212, Detroit, MI, 48236, USA
| | - Jennifer Ford
- Department of Surgery, Division of Trauma, St. John Hospital & Medical Center, 22151 Moross Rd., PB I, Suite 212, Detroit, MI, 48236, USA
| | - Jenna Gharzeddine
- Department of Surgery, Division of Trauma, St. John Hospital & Medical Center, 22151 Moross Rd., PB I, Suite 212, Detroit, MI, 48236, USA
| | - Alexandre Mazar
- Department of Surgery, Division of Trauma, St. John Hospital & Medical Center, 22151 Moross Rd., PB I, Suite 212, Detroit, MI, 48236, USA
| | - R David Hayward
- Department of Surgery, Division of Trauma, St. John Hospital & Medical Center, 22151 Moross Rd., PB I, Suite 212, Detroit, MI, 48236, USA.
| | - Joseph Buck
- Department of Surgery, Division of Trauma, St. John Hospital & Medical Center, 22151 Moross Rd., PB I, Suite 212, Detroit, MI, 48236, USA
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Tatlı Güneş B, Önder Siviş Z, Ataseven E, Malbora B, Türker M, Belen FB, Atabay B, Atik T, Işık E, Özkınay F. Intracranial Bleeding in a Female Hemophilia Patient: Molecular Analysis of the Factor 8 Gene and Determination of a Novel Mutation. Turk J Haematol 2018; 35:202-203. [PMID: 29391337 PMCID: PMC6110442 DOI: 10.4274/tjh.2017.0385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Burçak Tatlı Güneş
- İzmir Tepecik Training and Research Hospital, Clinic of Pediatric Hematology, İzmir, Turkey
| | - Zühal Önder Siviş
- İzmir Tepecik Training and Research Hospital, Clinic of Pediatric Hematology, İzmir, Turkey
| | - Eda Ataseven
- İzmir Tepecik Training and Research Hospital, Clinic of Pediatric Hematology, İzmir, Turkey
| | - Barış Malbora
- İzmir Tepecik Training and Research Hospital, Clinic of Pediatric Hematology, İzmir, Turkey
| | - Meral Türker
- İzmir Tepecik Training and Research Hospital, Clinic of Pediatric Hematology, İzmir, Turkey
| | - Fatma Burcu Belen
- Başkent University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Berna Atabay
- İzmir Tepecik Training and Research Hospital, Clinic of Pediatric Hematology, İzmir, Turkey
| | - Tahir Atik
- Ege University Faculty of Medicine, Department of Pediatric Genetics, İzmir, Turkey
| | - Esra Işık
- Ege University Faculty of Medicine, Department of Pediatric Genetics, İzmir, Turkey
| | - Ferda Özkınay
- Ege University Faculty of Medicine, Department of Pediatric Genetics, İzmir, Turkey
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Schuhmann MK, Kraft P, Bieber M, Haarmann A, Homola GA, Pham M, Nieswandt B, Stoll G. Influence of Thrombolysis on the Safety and Efficacy of Blocking Platelet Adhesion or Secretory Activity in Acute Ischemic Stroke in Mice. Transl Stroke Res 2018; 9:493-8. [PMID: 29322481 DOI: 10.1007/s12975-017-0606-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/27/2017] [Accepted: 12/28/2017] [Indexed: 01/05/2023]
Abstract
In acute ischemic stroke (AIS), there is an alarming discrepancy between recanalization rates of up to 70% by combined recombinant tissue-type plasminogen activator (rt-PA) therapy and mechanical thrombectomy, and no clinical benefit in at least every second stroke patient. This is partly due to ischemia/reperfusion (I/R) injury. In a translational approach, we used mice lacking dense- (Unc13d-/-) or α-granules (Nbeal2-/-) and mice after blocking of platelet glycoprotein receptor (GP) Ib conferring protection from I/R injury. These mice underwent transient middle cerebral artery occlusion (tMCAO) and, as in the clinic, were treated with rt-PA. Our data show that rt-PA treatment is still safe in conjunction with selected anti-platelet therapies and pave the way for eagerly awaited additive treatment options in acute human stroke.
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Carandini T, Bozzano V, Scarpini E, Montano N, Solbiati M. Intensive versus standard lowering of blood pressure in the acute phase of intracranial haemorrhage: a systematic review and meta-analysis. Intern Emerg Med 2018; 13:95-105. [PMID: 28776173 DOI: 10.1007/s11739-017-1716-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/24/2017] [Indexed: 12/16/2022]
Abstract
The optimal target of blood pressure (BP) in the acute phase of intracranial haemorrhage (ICH) is still controversial. Our aim was to evaluate safety and efficacy of intensive BP lowering compared to standard BP treatment in ICH. We conducted a systematic review and meta-analysis of all available randomized controlled trials recruiting patients with elevated BP in acute spontaneous ICH to intensive or standard BP-lowering treatment. Our primary outcomes were 3-month mortality, disability (modified Rankin Scale 3-5) and combined death or disability. Secondary outcomes were early neurological deterioration at 24 h, substantial haematoma enlargement within 24-72 h and 3-month non-fatal serious adverse events. We included six studies for a total of 4385 patients (mean age 62 years, 62.3% men). No differences were detected between the two treatment groups in 3-month mortality (RR = 0.99, 95% CI 0.83-1.17), disability (RR = 0.96, 95% CI 0.89-1.03) and combined death and disability (RR = 0.97, 95% CI 0.90-1.03). The rate of patients with early neurological deterioration, substantial haematoma enlargement and non-fatal serious adverse events was similar in the two treatment groups (RR = 1.03, 95% CI 0.88-1.19, RR = 0.85, 95% CI 0.70-1.03, RR = 1.07, 95% CI 0.90-1.28, respectively). An intensive BP control in the acute phase of ICH is not beneficial and should not be recommended. Therefore, the systolic BP target of less than 140 mmHg that is now suggested by guidelines needs to be reconsidered.
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Affiliation(s)
- Tiziana Carandini
- Department of Neurology, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Viviana Bozzano
- Department of Internal Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, via Francesco Sforza 35, 20122, Milan, Italy.
| | - Elio Scarpini
- Department of Neurology, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Department of Internal Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, via Francesco Sforza 35, 20122, Milan, Italy
- Department of Emergency Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Monica Solbiati
- Department of Internal Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, via Francesco Sforza 35, 20122, Milan, Italy
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Shere A, Goyal H. Cannabis can augment thrombolytic properties of rtPA: Intracranial hemorrhage in a heavy cannabis user. Am J Emerg Med 2017; 35:1988.e1-1988.e2. [PMID: 28987516 DOI: 10.1016/j.ajem.2017.09.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/28/2017] [Indexed: 11/24/2022] Open
Abstract
Cannabis is one of the most commonly used illicit drugs in the United States and is considered to have several adverse health effects. There is evidence suggesting that its recreational use is associated with both increased cardio- and cerebrovascular events. Recently, multiple cases of ischemic and hemorrhagic strokes associated with cannabis use were reported in the literature (Goyal et al., 2017). It has been suggested that cannabis can affect cerebral auto-regulation and vascular tone leading to vasoconstriction and acute ischemic stroke. However, hemorrhagic strokes, which are often seen with sympathomimetic illicit drugs (e.g. cocaine and amphetamines), have rarely been reported due to cannabis. Many cellular mechanisms within non-ischemic tissue post stroke may be augmented by heavy cannabis use. Here, we describe a rapid development of hemorrhage following thrombolytic therapy in a patient with heavy cannabis use with an ischemic stroke.
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Affiliation(s)
- Amar Shere
- Medical Center Navicent Health, 790 1st Street, Macon, GA 31201, United States
| | - Hemant Goyal
- Mercer University School of Medicine, 707, Pine St, Macon, GA 31201, United States.
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Bengtson LGS, Lutsey PL, Chen LY, MacLehose RF, Alonso A. Comparative effectiveness of dabigatran and rivaroxaban versus warfarin for the treatment of non-valvular atrial fibrillation. J Cardiol 2017; 69:868-876. [PMID: 27889397 PMCID: PMC5411320 DOI: 10.1016/j.jjcc.2016.08.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 07/28/2016] [Accepted: 08/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Effectiveness data on novel oral anticoagulants (NOACs) versus warfarin for stroke prevention in non-valvular atrial fibrillation (NVAF) by prior warfarin use are limited. METHODS We used data from the US MarketScan databases from 2009 to 2012. NVAF patients initiating dabigatran or rivaroxaban were matched with up to 5 warfarin users. Propensity score-adjusted Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (95% CI) for relevant endpoints in NOACs versus warfarin users. Separate analyses were conducted to compare anticoagulant-naïve users of NOACs and those switching from warfarin. RESULTS Among 32,918 dabigatran, 3301 rivaroxaban, and 109,447 warfarin users with NVAF, 225 intracranial bleeds, 1035 ischemic strokes, 958 myocardial infarctions, and 1842 gastrointestinal bleeds were identified. Compared to warfarin users, patients initiating NOACs had similar ischemic stroke rates and lower intracranial bleeding rates, while the gastrointestinal bleeding rate was higher in dabigatran users than warfarin users. Associations of dabigatran with ischemic stroke risk differed between anticoagulant-naïve initiators and patients switching from warfarin; dabigatran was associated with lower ischemic stroke rates in naïve users (HR 0.65, 95% CI 0.52-0.82) but not in switchers (HR 1.20, 95% CI 0.95-1.51), compared to warfarin. Risk of stroke and bleeding was not different between rivaroxaban and warfarin users. CONCLUSIONS Real-world effectiveness of NOACs (compared to warfarin) for diverse outcomes was comparable to efficacy reported in published clinical trials. However, harms and benefits of switching from warfarin to dabigatran need to be evaluated.
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Affiliation(s)
- Lindsay G S Bengtson
- Health Economics and Outcomes Research, Life Sciences, Optum, Eden Prairie, MN, USA.
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Lin Y Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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Bundhun PK, Soogund MZS, Teeluck AR, Pursun M, Bhurtu A, Huang WQ. Bleeding outcomes associated with rivaroxaban and dabigatran in patients treated for atrial fibrillation: a systematic review and meta-analysis. BMC Cardiovasc Disord 2017; 17:15. [PMID: 28056795 PMCID: PMC5216587 DOI: 10.1186/s12872-016-0449-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023] Open
Abstract
Background Warfarin is commonly used as a secondary prevention of stroke in patients with atrial fibrillation (AF). However, limitations have been observed even with the use of this medication. Recently, several newer direct oral anticoagulants (DOACs) have been approved for use by the food and drug administrations. Unfortunately, these newer drugs have seldom been compared directly with each other. Therefore, this study aimed to compare the bleeding events associated with rivaroxaban and dabigatran in patients treated for non-valvular AF. Methods EMBASE, Medline (National Library of Medicine) and the Cochrane Central Registry of Controlled Trials were searched for studies comparing rivaroxaban with dabigatran using the terms ‘rivaroxaban, dabigatran and atrial fibrillation’. Primary endpoints were: any bleeding outcomes, intracranial bleeding and gastro-intestinal (GI) bleeding. Secondary outcomes included stroke/systemic embolism (SE)/transient ischemic attack (TIA), venous thromboembolism and mortality. Odds ratios (OR) with 95% confidence intervals (CIs) were calculated. The pooled analyses were carried out with RevMan 5.3 software. All the authors had full access to the data and approved the manuscript as written. Results A total number of 4895 patients were included. This analysis showed that rivaroxaban was not associated with a significantly higher bleeding event when compared to dabigatran (OR: 1.28, 95% CI: 0.95–1.72; P = 0.11). GI bleeding was similarly manifested between these two DOACs (OR: 0.98, 95% CI: 0.43–2.25; P = 0.97). Even if intracranial bleeding was higher with the use of rivaroxaban, (OR: 2.18, 95% CI: 0.51–9.25; P = 0.29), the result was not statistically significant. Moreover, stroke/SE/TIA and venous thromboembolism were also not significantly different (OR: 0.81, 95% CI: 0.53–1.23; P = 0.32) and (OR: 2.06, 95% CI: 0.73–5.82; P = 0.17) respectively. However, even if mortality favored dabigatran (OR: 1.42, 95% CI: 0.99–2.06; P = 0.06), this result only approached statistical significance. Conclusion Head to head comparison showed that rivaroxaban was not associated with significantly higher bleeding events compared to dabigatran. Intracranial bleeding, GI bleeding, stroke/SE/TIA, venous thromboembolism and mortality were also not significantly different between these two DOACs. However, due to the limited number of patients analyzed, and which were mainly obtained from observational studies, this hypothesis might only be confirmed in future randomized trials. Furthermore, the CHADS2-VASC and HAS-BLED score which might play an important role in predicting bleeding risks should also not be ignored.
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Affiliation(s)
- Pravesh Kumar Bundhun
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China
| | | | | | - Manish Pursun
- Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China
| | - Akash Bhurtu
- Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China
| | - Wei-Qiang Huang
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People's Republic of China.
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Yee JN, Koht A, McCarthy RJ, Bebawy JF. Factors associated with blood transfusion during intracranial aneurysm surgery. J Clin Anesth 2016; 36:164-167. [PMID: 28183559 DOI: 10.1016/j.jclinane.2016.10.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/20/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE The purpose of this study was to identify risk factors associated with intraoperative blood transfusions in patients presenting for intracranial aneurysm surgery in the current era of more restrictive transfusion guidelines. DESIGN Retrospective observational cohort study with stepwise, multivariate binary logistic regression analysis. SETTING Tertiary care university teaching hospital. PATIENTS Four hundred seventy-one consecutive patients undergoing intracranial aneurysm surgery at Northwestern Memorial Hospital (Chicago, IL) from 2006 to 2012. INTERVENTION Red blood cell transfusion (retrospective observational). MEASUREMENTS Demographic data, medical comorbidities, hemoglobin levels, Hunt-Hess grades, intracranial aneurysm characteristics, presenting intracranial bleeding states, estimated blood losses, transfused red blood cells, and blood products. MAIN RESULTS Forty-six patients (9.5%) received intraoperative red blood cell transfusions. Preoperative risk factors associated with transfusions were highly related to aneurysm rupture, including such parameters as older age (P < .001), lower presenting hemoglobin level (P < .001), preoperative rupture (P < .001), and higher Hunt-Hess grade (P < .001). Intraoperative risk factors included larger aneurysm size (>10 mm; P = .03), intraventricular hemorrhage (P < .001), and intracerebral hematoma evacuation (P = .02). Binary logistic regression modeling identified age (P < .001), presenting hemoglobin level (P < .001), larger aneurysm size (>10 mm; P = .003), elevated Hunt-Hess grade (P = .021), and intraoperative rupture (P = .013) as independent predictors of intraoperative red blood cell transfusion. CONCLUSION The incidence of intraoperative red blood cell transfusion in intracranial aneurysm surgery in our patient cohort was 9.5%, and the most significant factors associated with transfusion were presenting hemoglobin level less than 11.7 g/dL and age greater than 52 years. It would seem advisable that these patients undergo routine type and cross-matching of red blood cells before intracranial aneurysm surgery.
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Affiliation(s)
- Jessica N Yee
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Antoun Koht
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - John F Bebawy
- Northwestern University Feinberg School of Medicine, Chicago, IL.
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Moustafa F, Saint-Denis J, Laporte S, Mismetti P, Schmidt J. Comparison of blood coagulation factors between patients with gastrointestinal or intracranial bleeding under vitamin K antagonists. Eur J Intern Med 2016; 33:e22-4. [PMID: 27209417 DOI: 10.1016/j.ejim.2016.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 11/27/2022]
Affiliation(s)
- F Moustafa
- Service des Urgences Adultes, CHU Gabriel Montpied, Clermont-Ferrand, France.
| | - J Saint-Denis
- Service des Urgences Adultes, CHU Gabriel Montpied, Clermont-Ferrand, France; Université d'Auvergne, Clermont-I, UFR de Médecine, Clermont-Ferrand, France
| | - S Laporte
- EA3065, Université Jean Monnet, Saint-Etienne, France; Unité de Recherche Clinique, Innovation, et Pharmacologie, Centre hospitalo-universitaire de Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - P Mismetti
- EA3065, Université Jean Monnet, Saint-Etienne, France; Unité de Recherche Clinique, Innovation, et Pharmacologie, Centre hospitalo-universitaire de Saint-Etienne, Hôpital Nord, Saint-Etienne, France; Service de Médecine interne et Thérapeutique, Centre hospitalo-universitaire de Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - J Schmidt
- Service des Urgences Adultes, CHU Gabriel Montpied, Clermont-Ferrand, France; Université d'Auvergne, Clermont-I, UFR de Médecine, Clermont-Ferrand, France
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Łukasik M, Zawilska K, Undas A. Intracranial bleedings in patients on long-term anticoagulant treatment: Benefits from oral thrombin and factor Xa inhibitors in clinical practice. Neurol Neurochir Pol 2015; 49:171-9. [PMID: 26048605 DOI: 10.1016/j.pjnns.2015.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/17/2015] [Accepted: 04/29/2015] [Indexed: 11/27/2022]
Abstract
Dabigatran, a direct thrombin inhibitor and activated factor X inhibitors, rivaroxaban and apixaban, used in the prevention of stroke or systemic embolism in patients with nonvalvular atrial fibrillation (AF), have several advantages over vitamin K antagonists (VKAs). The non-vitamin K oral anticoagulants (NOACs) have been shown to reduce the risk of intracranial bleedings by 50%. The current review summarizes the available data on the epidemiology, mechanisms and treatment of intracranial bleedings observed on oral anticoagulation with the focus on the specificity of NOACs in this context.
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Affiliation(s)
- Maria Łukasik
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland.
| | | | - Anetta Undas
- Institute of Cardiology, Jagiellonian University School of Medicine and John Paul II Hospital, Krakow, Poland.
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