Delays in Intracerebral Hemorrhage Management Is Associated with Hematoma Expansion and Worse Outcomes: Changes in COVID-19 Era

Purpose@#The coronavirus disease 2019 (COVID-19) pandemic disrupted the emergency medical care system worldwide. We analyzed the changes in the management of intracerebral hemorrhage (ICH) and compared the pre-COVID-19 and COVID-19 eras. @*Materials and Methods@#From March to October of the COVID-19 era (2020), 83 consecutive patients with ICH were admitted to four comprehensive stroke centers. We retrospectively reviewed the data of patients and compared the treatment workflow metrics, treatment modalities, and clinical outcomes with the patients admitted during the same period of pre-COVID-19 era (2017–2019). @*Results@#Three hundred thirty-eight patients (83 in COVID-19 era and 255 in pre-COVID-19 era) were included in this study. Symptom onset/detection-to-door time [COVID-19; 56.0 min (34.0–106.0), pre-COVID-19; 40.0 min (27.0–98.0), p=0.016] and median door to-intensive treatment time differed between the two groups [COVID-19; 349.0 min (177.0–560.0), pre-COVID-19; 184.0 min (134.0–271.0), p<0.001]. Hematoma expansion was detected more significantly in the COVID-19 era (39.8% vs. 22.1%, p=0.002). At 3-month follow-up, clinical outcomes of patients were worse in the COVID-19 era (Good modified Rankin Scale; 33.7% in COVID-19, 46.7% in pre-COVID-19, p=0.039). @*Conclusion@#During the COVID-19 era, delays in management of ICH was associated with hematoma expansion and worse outcomes.

Delays in Intracerebral Hemorrhage Management Is Associated with Hematoma Expansion and Worse Outcomes: Changes in COVID-19 Era

Purpose@#The coronavirus disease 2019 (COVID-19) pandemic disrupted the emergency medical care system worldwide. We analyzed the changes in the management of intracerebral hemorrhage (ICH) and compared the pre-COVID-19 and COVID-19 eras. @*Materials and Methods@#From March to October of the COVID-19 era (2020), 83 consecutive patients with ICH were admitted to four comprehensive stroke centers. We retrospectively reviewed the data of patients and compared the treatment workflow metrics, treatment modalities, and clinical outcomes with the patients admitted during the same period of pre-COVID-19 era (2017–2019). @*Results@#Three hundred thirty-eight patients (83 in COVID-19 era and 255 in pre-COVID-19 era) were included in this study. Symptom onset/detection-to-door time [COVID-19; 56.0 min (34.0–106.0), pre-COVID-19; 40.0 min (27.0–98.0), p=0.016] and median door to-intensive treatment time differed between the two groups [COVID-19; 349.0 min (177.0–560.0), pre-COVID-19; 184.0 min (134.0–271.0), p<0.001]. Hematoma expansion was detected more significantly in the COVID-19 era (39.8% vs. 22.1%, p=0.002). At 3-month follow-up, clinical outcomes of patients were worse in the COVID-19 era (Good modified Rankin Scale; 33.7% in COVID-19, 46.7% in pre-COVID-19, p=0.039). @*Conclusion@#During the COVID-19 era, delays in management of ICH was associated with hematoma expansion and worse outcomes.

Endovascular Treatment to Stop Life-threatening Bleeding from Branches of the External Carotid Artery in Patients with Traumatic Maxillofacial Fracture

OBJECTIVE: The purpose of this study was to report our preliminary experience with endovascular treatment (EVT) for life-threatening bleeding from branches of the external carotid artery (ECA) in patients with traumatic maxillofacial fractures. MATERIALS AND METHODS: A total of 12 patients seen between March 2010 and December 2014 were included in this study. All subjects met the following criteria: 1) presence of maxillofacial fracture; 2) continuous blood loss from oronasal bleeding; and 3) EVT to stop bleeding. Various clinical factors were recorded for each patient and the correlations between those factors and clinical outcome (Glasgow Outcome Scale, GOS) were evaluated. RESULTS: Four patients were injured in traffic accidents, five in falls, and three by assaults. Mean initial Glasgow Coma Scale (GCS) was 6.9 ± 2.1 and the lowest hemoglobin measured was mean 6.3 ± 0.9 g/dL. GOS at discharge was 4 in five patients, 3 in three patients, and 1 (death) in four patients. GOS on follow-up (mean 13.7 months) was 5 in two patients, 4 in three patients, and 3 in three patients. Initial GCS (p = 0.016), lowest systolic blood pressure (p = 0.011), and lowest body temperature (p = 0.012) showed a significant positive correlation with good clinical outcomes. The number of units of red blood cells transfused (p = 0.030), the number of units of fresh frozen plasma transfused (p = 0.013), and the time from arrival to groin puncture (p < 0.001) showed significant negative correlation with good clinical outcomes. CONCLUSION: It might be suggested that rapid transition to EVT could be preferable to struggling with other rescue strategies to stop life-threatening bleeding from branches of the ECA in patients with traumatic maxillofacial fractures.

Endovascular Treatment to Stop Life-threatening Bleeding from Branches of the External Carotid Artery in Patients with Traumatic Maxillofacial Fracture

OBJECTIVE: The purpose of this study was to report our preliminary experience with endovascular treatment (EVT) for life-threatening bleeding from branches of the external carotid artery (ECA) in patients with traumatic maxillofacial fractures. MATERIALS AND METHODS: A total of 12 patients seen between March 2010 and December 2014 were included in this study. All subjects met the following criteria: 1) presence of maxillofacial fracture; 2) continuous blood loss from oronasal bleeding; and 3) EVT to stop bleeding. Various clinical factors were recorded for each patient and the correlations between those factors and clinical outcome (Glasgow Outcome Scale, GOS) were evaluated. RESULTS: Four patients were injured in traffic accidents, five in falls, and three by assaults. Mean initial Glasgow Coma Scale (GCS) was 6.9 ± 2.1 and the lowest hemoglobin measured was mean 6.3 ± 0.9 g/dL. GOS at discharge was 4 in five patients, 3 in three patients, and 1 (death) in four patients. GOS on follow-up (mean 13.7 months) was 5 in two patients, 4 in three patients, and 3 in three patients. Initial GCS (p = 0.016), lowest systolic blood pressure (p = 0.011), and lowest body temperature (p = 0.012) showed a significant positive correlation with good clinical outcomes. The number of units of red blood cells transfused (p = 0.030), the number of units of fresh frozen plasma transfused (p = 0.013), and the time from arrival to groin puncture (p < 0.001) showed significant negative correlation with good clinical outcomes. CONCLUSION: It might be suggested that rapid transition to EVT could be preferable to struggling with other rescue strategies to stop life-threatening bleeding from branches of the ECA in patients with traumatic maxillofacial fractures.

Preliminary Experience with Vascular Plugs for Parent Artery Occlusion of the Carotid or Vertebral Arteries

OBJECTIVE: The purpose of this study was to report the authors' preliminary experience using the Amplatzer Vascular Plug (AVP) (St. Jude Medical, Plymouth, MN, USA) for parent artery occlusion of the internal carotid artery (ICA) or vertebral artery (VA). MATERIALS AND METHODS: Between September 2008 and December 2015, we performed 52 therapeutic parent artery occlusions (PAOs) by an endovascular technique. Among them, 10 patients underwent PAO of the carotid or vertebral arteries using AVPs. Clinical and radiographic data of these patients were retrospectively reviewed. RESULTS: The devices were used for VA dissection that presented with subarachnoid hemorrhage (SAH) in five patients, traumatic arteriovenous fistula (AVF) in two patients, spontaneous AVF in one patient, recurrence of carotid-cavernous fistula (CCF) in one patient, and symptomatic unruptured giant ICA aneurysm in one patient. The devices were used in conjunction with detachable and/or pushable coils and in the extracranial segments of the ICA or VA. Complete occlusion of the parent artery was achieved in all patients. There was one intra-procedural rupture of the VA dissection during coiling prior to using the device. CONCLUSION: Results from the current series suggest that the AVP might be used for therapeutic PAO in the extracranial segments of the ICA or VA.

Neurological Deterioration after Decompressive Suboccipital Craniectomy in a Patient with a Brainstem-compressing Thrombosed Giant Aneurysm of the Vertebral Artery

We experienced a case of neurological deterioration after decompressive suboccipital craniectomy (DSC) in a patient with a brainstem-compressing thrombosed giant aneurysm of the vertebral artery (VA). A 60-year-old male harboring a thrombosed giant aneurysm (about 4 cm) of the right vertebral artery presented with quadriparesis. We treated the aneurysm by endovascular coil trapping of the right VA and expected the aneurysm to shrink slowly. After 7 days, however, he suffered aggravated symptoms as his aneurysm increased in size due to internal thrombosis. The medulla compression was aggravated, and so we performed DSC with C1 laminectomy. After the third post-operative day, unfortunately, his neurologic symptoms were more aggravated than in the pre-DSC state. Despite of conservative treatment, neurological symptoms did not improve, and microsurgical aneurysmectomy was performed for the medulla decompression. Unfortunately, the post-operative recovery was not as good as anticipated. DSC should not be used to release the brainstem when treating a brainstem-compressing thrombosed giant aneurysm of the VA.