Intracranial hemorrhages in patients with COVID-19: a systematic review of the literature, regarding six cases in an Amazonian population / Hemorragias intracranianas em pacientes com COVID-19: uma revisão sistemática da literatura, a propósito de seis casos na população amazônica

Abstract Background Coronavirus disease 2019 (COVID-19) has emerged as a public health emergency worldwide, predominantly affecting the respiratory tract. However, evidence supports the involvement of extrapulmonary sites, including reports of intracranial hemorrhages. Objective To describe six original cases and review the literature on intracranial hemorrhages in patients diagnosed with COVID-19 by molecular methods. Methods A systematic literature review was performed on MEDLINE, PubMed, and NCBI electronic databases to identify eligible studies. Of the total 1,624 articles retrieved, only 53 articles met the inclusion criteria. Results The overall incidence of intracranial hemorrhage in patients hospitalized for COVID-19 was 0.26%. In this patient group, the mean age was 60 years, and the majority were male (68%) with initial respiratory symptoms (73%) and some comorbidity. Before the diagnosis of hemorrhage, 43% of patients were using anticoagulants, 47.3% at therapeutic doses. The intraparenchymal (50%) was the most affected compartment, followed by the subarachnoid (34%), intraventricular (11%), and subdural (7%). There was a predominance of lobar over non-lobar topographies. Multifocal or multicompartmental hemorrhages were described in 25% of cases. Overall mortality in the cohort studies was 44%, while around 55% of patients were discharged from hospital. Conclusion Despite the unusual association, the combination of these two diseases is associated with high rates of mortality and morbidity, as well as more severe clinicoradiological presentations. Further studies are needed to provide robust evidence on the exact pathophysiology behind the occurrence of intracranial hemorrhages after COVID-19 infection.

Resumo Antecedentes A COVID-19 emergiu como uma emergência de saúde pública em todo o mundo, proporcionando lesão principalmente do trato respiratório. No entanto, várias evidências apontam para acometimento de sítios extrapulmonares, incluindo relatos de hemorragias intracranianas. Objetivo Descrever seis casos originais e revisar a literatura sobre hemorragias intracranianas em pacientes com diagnostico de COVID-19 por métodos moleculares. Métodos A revisão sistemática da literatura foi feita nas bases de dados eletrônicas da MEDLINE, PubMed e NCBI para identificar os estudos elegíveis. Do total de 1.624 artigos recuperados, apenas 53 artigos preencheram os critérios de inclusão. Resultados A incidência geral de hemorragia intracraniana nos pacientes internados por COVID-19 foi de 0,26%. A média de idade foi de 60 anos, e a maioria dos pacientes era do sexo masculino (68%) com sintomas respiratórios iniciais (73%) e alguma comorbidade. Antes do diagnóstico de hemorragia, 43% estavam em uso de anticoagulantes, 47,3% destes em doses terapêuticas. O compartimento mais acometido foi o intraparenquimatoso (50%), seguido do subaracnoideo (34%), intraventricular (11%) e subdural (7%). Houve predomínio de topografias lobares sobre as não-lobares. Hemorragias multifocais ou multicompartimentais foram descritas em 25% dos casos. A mortalidade geral nos estudos de coorte foi de 44%, enquanto houve alta hospitalar em cerca de 55% dos pacientes. Conclusão Apesar da associação incomum, a combinação dessas doenças está relacionada com altas taxas de mortalidade e morbidade, bem como apresentações clínico-radiológicas mais graves. Mais estudos são necessários para oferecer evidências robustas sobre a fisiopatologia exata por trás da ocorrência de hemorragias intracranianas após infecção por COVID-19.

Características de la trombosis venosa cerebral en pacientes de dos hospitales universitarios de Colombia en el período 2018-2020 / Characteristics of cerebral venous thrombosis in patients from two university hospitals in Colombia between 2018-2020

Introducción. La trombosis venosa cerebral es una causa infrecuente de enfermedad cerebrovascular que viene en aumento a nivel mundial. A pesar de ello, actualmente, en Colombia no se cuenta con estudios suficientes que nos permitan caracterizar epidemiológicamente la enfermedad en nuestra población para identificar los factores de riesgo y las complicaciones más frecuentes en nuestro medio. Objetivo. Describir las características clínicas, demográficas y radiológicas, y los factores de riesgo de una serie de pacientes con trombosis venosa cerebral de dos hospitales de Colombia. Materiales y métodos. Es un estudio descriptivo retrospectivo de pacientes hospitalizados, atendidos en el servicio de neurología de dos hospitales de Bogotá desde diciembre de 2018 hasta diciembre del 2020. Resultados. Se incluyeron 33 pacientes. Las frecuencias más altas correspondieron a mujeres en edad fértil, en puerperio (n=7; 33,3 %) y pacientes con patologías autoinmunes (n=10; 30,3 %). El síntoma inicial más común fue la cefalea (n=31; 93,9 %), seguido de focalización neurológica (n=9; 27,2%) y crisis epiléptica (n=8; 24,2 %). El 51 % (n=17) de los pacientes tuvo un examen físico normal. El infarto venoso cerebral se presentó en el 21,1 % (n=7), la hemorragia subaracnoidea en el 12,1 % (n=4) y el hematoma intraparenquimatoso en el 9 % (n=3) del total de pacientes. El 60,6 % (n=20) quedó con nivel independiente en la escala funcional de Barthel. Ningún paciente falleció. Conclusiones. Se encontraron características sociodemográficas, clínicas y radiológicas similares a lo reportado en la literatura mundial. Con respecto a las diferencias, se encontró en nuestro estudio compromiso de la circulación venosa cerebral profunda en un porcentaje ligeramente mayor a lo descrito, pero sin aumento de complicaciones, ni mortalidad.

Introduction. Cerebral venous thrombosis is an uncommon cause of cerebrovascular disease, which has been increasing worldwide. In Colombia, there are not enough recent studies that allow us to determine epidemiological characteristics of the disease in our population to identify more frequent risk factors and complications according to our living conditions. Objective. To describe clinical, demographic, and radiographic characteristics, and risk factors in a cohort of patients with cerebral venous thrombosis attended at two hospitals in Colombia. Materials and methods. Retrospective descriptive study with patients treated in the hospitalization neurology service of two hospitals in Bogotá, Colombia from December 2018 to December 2020. Results. Thirty-three patients were included. There was a higher incidence of cerebral venous thrombosis in women of childbearing age in the puerperium (n=7; 33.3%) and associated with autoimmune diseases (n=10; 30.3%). The most common initial symptom was headache (n=31; 93.9 %), followed by neurological focal signs (n=9; 27.2%) and seizures (n=8; 24.2%). Fifty-one percent (n=17) of the patients had a normal physical examination. Cerebral venous infarction occurred in 21.1 % (n=7), subarachnoid hemorrhage in 12.1 % (n=4), and intraparenchymal hematoma in 9 % (n=3) of all the patients. Sixty-point six percent (n=20) of the patients had a total independent Barthel functional scale. None of those died. Conclusions. We found similar sociodemographic, clinical, and radiography characteristics to those reported in the world literature. Regarding the differences, deep cerebral venous circulation was higher than that described in previous studies but without complications increase or mortality.

Effectiveness and safety of endovascular therapy for acute progressive stroke caused by large vessel occlusion / 国际脑血管病杂志

Objective:To investigate the effectiveness and safety of endovascular therapy for acute progressive stroke caused by large vessel occlusion (LVO).Methods:Patients with progressive stroke caused by LVO admitted to the Department of Neurology, Yueyang Central Hospital from January 2019 to February 2022 were retrospective included. Patients with an Alberta Stroke Program Early CT Score (ASPECTS) or posterior circulation ASPECTS (pc-ASPECTS) ≥6 after progression were selected for endovascular therapy, including mechanical thromboectomy, thrombus aspiration, balloon angioplasty, stenting, or a combination of the above methods. Patients in the time window (anterior circulation within 12 h and posterior circulation within 24 h) and outside the time window (anterior circulation >12 h, posterior circulation >24 h) as well as those in the anterior and posterior circulation were compared.Results:A total of 20 patients with progressive stroke caused by LVO received endovascular treatment were included. There were 17 males and 3 females, aged 59.45±12.06 years. Three patients (15%) developed asymptomatic intracranial hemorrhage, and 12 (60%) had a good outcome 3 months after procedure. There were no statistically significant differences in the rate of successful vascular recanalization, incidence of intracranial hemorrhage, and the rate of poor outcomes between patients within and outside the time window and between the patients with anterior and posterior circulation.Conclusion:Endovascular therapy may be safe and effective for patients with progressive stroke caused by LVO with ASPECTS or pc-ASPECTS scores ≥6.

Systemic immune-inflammation index predicts hemorrhagic transformation after intravenous thrombolysis in patients with acute ischemic stroke / 国际脑血管病杂志

Objective:To investigate the predictive value of systemic immune-inflammatory index (SII) for hemorrhagic transformation (HT) and symptomatic intracranial hemorrhage (sICH) after intravenous thrombolysis in patients with acute ischemic stroke (AIS).Methods:Patients with AIS received intravenous thrombolysis in the Department of Neurology, Huai’an First People’s Hospital from July 2019 to July 2022 were included retrospectively. The head CT was performed at 24 h after intravenous thrombolysis and determined whether HT existed. sICH was defined as brain parenchymal hematoma, and the National Institutes of Health Stroke Scale (NIHSS) scores increased by ≥4 compared with the baseline, or the patient died within 36 h after onset. Multivariate logistic regression analysis was used to determine the independent correlation between SII and HT and sICH after intravenous thrombolysis. The receiver operating characteristics (ROC) curve was used to evaluate the predictive value of SII for HT and sICH after intravenous thrombolysis. Results:A total of 352 patients with AIS received intravenous thrombolysis were enrolled, including 240 males (68.1%), aged 66.46±12.00 years. The median baseline NIHSS score was 8 (interquartile range, 5-13), and the median SII is 531.91×10 9/L (interquartile range, 351.20-896.91×10 9/L). HT occurred in 62 patients (17.6%) and sICH occurred in 27 patients (7.7%). Univariate analysis showed that the SII of the HT group was significantly higher than that of the non-HT group ( Z=–2.731, P=0.006), and the SII of the sICH group was significantly higher than that of non-sICH group ( Z=–4.125, P<0.01). Multivariate logistic regression analysis showed that the increased SII was the independent risk factor for HT (odds ratio [ OR] 1.001, 95% confidence interval [ CI] 1.000-1.001; P=0.004) and sICH ( OR 1.001, 95% CI 1.001-1.002; P<0.01). ROC curve analysis shows that the area under curve of SII predicting HT was 0.610 (95% CI 0.535-0.686; P=0.006), and the best cutoff value was 488.48×10 9/L. The corresponding sensitivity and specificity were 69% and 47% respectively. The area under the curve of SII predicting sICH was 0.739 (95% CI 0.636-0.842; P<0.01), and the best cutoff value was 846.56×10 9/L, the corresponding sensitivity and specificity were 70% and 77% respectively. Conclusion:The increased SII at admission can predict the risks of HT and sICH in patients with AIS after intravenous thrombolysis.

Monocyte-to-high-density lipoprotein cholesterol ratio predicts early neurological deterioration and hemorrhagic transformation after intravenous thrombolytic therapy in patients with acute ischemic stroke / 国际脑血管病杂志

Objective:To investigate the predictive value of monocyte-to-high-density lipoprotein cholesterol ratio (MHR) for early neurological deterioration (END) and hemorrhagic transformation (HT) after intravenous thrombolysis in patients with acute ischemic stroke (AIS).Methods:Patients with AIS received IVT in Hefei Second People's Hospital from May 2020 to January 2022 were retrospectively enrolled. Blood collection was completed and MHR was calculated before intravenous thrombolysis. END was defined as an increase of ≥2 from the baseline in the National Institutes of Health Stroke Scale (NIHSS) score or ≥1 from the baseline in motor function score at any time within 7 d after admission. HT was defined as intracranial hemorrhage newly found by CT/MRI within 24 h after intravenous thrombolysis. Multivariate logistic regression analysis was used to determine the independent predictors of END and HT, and the receiver operating characteristic (ROC) curve was used to analyze the predictive value of MHR for END and HT. Results:A total of 186 patients with AIS treated with IVT were included, of which 50 (26.9%) had END and 31 (16.7%) had HT. The median MHR was 0.43. The MHR in the END group was significantly higher than that in the non-END group (0.49 vs. 0.40; P=0.008), and the MHR in the HT group was significantly higher than that in the non-HT group (0.52 vs. 0.40; P=0.013). All patients were divided into 4 groups (MHR1, MHR2, MHR3 and MHR4) according to the MHR quartile from low to high. Multivariate logistic regression analysis showed that after adjusting for confounding factors, taking MHR1 as a reference, MHR3 (odds ratio [ OR] 6.317, 95% confidence interval [ CI] 1.465-27.237; P=0.013) and MHR4 ( OR 8.064, 95% CI 1.910-34.051; P=0.005) were the significant independent predictors of END; Taking MHR1 as a reference, MHR4 ( OR 5.147, 95% CI 1.194-22.182; P=0.028) was the significant independent predictor of HT. The ROC curve analysis showed that the area under the curve of MHR for predicting END was 0.628 (95% CI 0.554-0.698; P=0.008). When the optimal MHR cutoff value was 0.41, its sensitivity and specificity for predicting END was 74.0% and 53.7% respectively. The area under the curve of MHR for predicting HT was 0.642 (95% CI 0.569-0.711; P=0.013). When the best cutoff value was 0.44, the sensitivity and specificity of MHR for predicting HT were 77.4% and 58.1% respectively. Conclusion:Higher MHR is a risk factor for END and HT after intravenous thrombolysis in patients with AIS, but the predictive value of MHR for END and HT is limited.

Prediction of hemorrhagic transformation after reperfusion therapy in patients with acute ischemic stroke / 国际脑血管病杂志

Reperfusion therapy, including intravenous thrombolysis and endovascular therapy, is an effective treatment for acute ischemic stroke. As a common complication after reperfusion therapy, hemorrhagic transformation is closely associated with the poor outcomes of patients. Early evaluation of clinical features, imaging and blood biomarkers can predict the risk of hemorrhagic transformation, so as to better guide the reperfusion treatment in patients with acute ischemic stroke.

Predictive score of the outcomes after intravenous thrombolysis in patients with acute ischemic stroke / 国际脑血管病杂志

Stroke has become the leading cause of disability and death in China. At present, intravenous thrombolysis is one of the most effective treatment for acute ischemic stroke, but not all patients can benefit from intravenous thrombolysis. In recent years, the exploration of predictive models for the outcomes after intravenous thrombolysis in patients with acute ischemic stroke has attracted increasing attention. This article systematically reviews the scoring models for predicting the functional outcome, death and symptomatic intracranial hemorrhage after intravenous thrombolysis in patients with acute ischemic stroke, with the aim of screening the scoring system suitable for clinical application and providing reference for the clinical diagnosis, evaluation and treatment of acute ischemic stroke.

Research progress in portable diagnosis devices for traumatic intracranial hematoma / 中华创伤杂志

Traumatic intracranial hematoma progresses rapidly and may cause quick increase of intracranial pressure and even brain hernia, ultimately leading to coma or death. Therefore, traumatic intracranial hematoma needs prompt treatment, but the prerequisite of treatment is early examination and diagnosis. Due to the limited transportation and other reasons, the existing large-scale detection devices such as CT and MRI cannot be deployed on the rescue site or during patient transportation. Instead, the portable diagnosis devices have the characteristics of miniaturization and high flexibility, which is conducive to promoting early detection, assisting diagnosis and further guiding the formulation of treatment plans. At present, more and more attention has been paid to the portable diagnosis devices in the diagnosis of intracranial hematoma. The authors summarized the conventional diagnosis methods and application of portable diagnosis devices for traumatic intracranial hematoma, aiming to provide a reference for the diagnosis of traumatic intracranial hematoma.

Instrumento predictivo de rotura de aneurismas intracraneales en pacientes de Sancti Spiritus, Cuba

Fundamento: la estratificación del riesgo de rotura de los aneurismas intracraneales es importante para decidir la conducta ante aquellos pacientes con aneurismas que son incidentales o asintomáticos. No existe consenso para determinar la realización de intervención quirúrgica o seguimiento médico de estos pacientes. Objetivo: elaborar un instrumento predictivo de rotura de aneurismas intracraneales incidentales. Métodos: se incluyó una muestra de 152 pacientes con diagnóstico, mediante angiografía por tomografía axial computarizada, de aneurismas intracraneales saculares rotos (n=138) y no rotos(n=22). Se trabajó con 160 imágenes de aneurismas intracraneales. Los 152 pacientes fueron divididos, al azar, en un grupo de desarrollo que corrrespondió a 95 pacientes, 100 imágenes de aneurismas y un grupo de validación que incluyó 57 pacientes con 60 imágenes de aneurismas. Se realizaron mediciones y segmentaciones de los aneurismas; se obtuvieron nueve factores morfológicos. Se realizó una combinación multivariante, mediante regresión logística múltiple, que expresó seis factores demográficos, clínicos y mofológicos predictivos obtenidos de los expedientes clínicos de los pacientes. La selección para inclusión de los factores fue realizada a partir de un consenso de 15 expertos con más de 15 años de experiencia en el tema. Se confeccionó un nomograma representativo del modelo con los predictores significativos. Se evaluó la calibración y la precisión del instrumento predictivo representado por un modelo y su nomograma. Resultados: el instrumento quedó conformado por cinco predictores que resultaron estadísticamente significativos asociados con la rotura en el análisis multivariado: el sexo femenino, la razón de aspecto, el mayor ancho del domo, el volumen, y el índice de no esfericidad. El nomograma mostró una buena calibración y discriminación (grupo de entrenamiento: área bajo la curva = 99 %; grupo de validación área bajo la curva=99 % ). Conclusiones: el instrumento predictivo, validado y representado por el nomograma es un modelo útil para estratificar el riesgo de rotura de aneurismas. Puede emplearse para el seguimiento de aneurismas considerados de menor riesgo.

Background: the stratification of the intracranial aneurysms rupture risk is important to decide the strategy before those patients with aneurysms that are incidental or asymptomatic. There is no consensus to determine the performance of surgical intervention or medical follow-up of these patients. Objective: to develop a predictive instrument for incidental intracranial aneurysm rupture. Methods: a sample of 152 patients diagnosed by computed tomography angiography of ruptured (n=138) and unruptured (n=22) saccular intracranial aneurysms was included. The 160 images of intracranial aneurysms were studied. The 152 patients were randomly divided into a development group consisting of 95 patients, 100 aneurysm images, and a validation group consisting of 57 patients, 60 aneurysm images. Measurements and segmentations of the aneurysms were performed; nine morphological factors were obtained. A multivariate combination was performed, using multiple logistic regression, which expressed six predictive demographic, clinical and morphological factors obtained from the clinical records of the patients. The selection for inclusion of the factors was made from a consensus of 15 experts with more than 15 years of experience in the subject. A representative nomogram of the model with the significant predictors was made. Calibration and accuracy of the predictive instrument represented by a model and its nomogram were evaluated. Results: the instrument was made up of five predictors that were statistically significant associated with breakage in the multivariate analysis: female sex, aspect ratio, the greatest width of the dome, volume, and non-sphericity index. The nomogram showed good calibration and discrimination (training group: area under the curve = 99%; validation group area under the curve = 99% ). Conclusions: the predictive instrument, validated and represented by the nomogram, is a useful model to stratify the risk of aneurysm rupture. It can be used to monitor aneurysms considered to be of lower risk.

Clinical and imaging analysis on meningiomas initially manifesting as intracranial hemorrhage in 19 cases / 中国基层医药

Objective:To investigate the main clinical characteristics, imaging features, diagnosis, and treatment of meningiomas initially manifesting as spontaneous intracranial hemorrhage.Methods:The clinical characteristics, imaging features, treatment, and follow-up data of 19 patients with meningiomas initially manifesting as spontaneous intracranial hemorrhage who received treatment in The First Affiliated Hospital of Shantou University Medical College from January 2011 to December 2020 were retrospectively analyzed.Results:Among the 19 patients, there were 6 males and 13 females, with an average age of (53 ± 14) years. The onset manifestations were sudden and severe headache and vomiting in 6 cases, progressive coma in 4 cases, and hemiplegia in 9 cases. Among the 19 patients, 15 patients showed irregular tumor shape and mixed hyperintense signal in CT, and 4 patients showed a homogeneous hyperintense signal. Eighteen patients showed peritumoral edema. Three patients showed intratumoral calcification. One patient showed an intratumoral fluid level. Fourteen patients showed isointense to hypointense signals on T1WI images and isointense to hyperintense signals on T 2WI images. Five patients showed mixed isointense and hyperintense signals on T 1WI images and mixed hypointense and hyperintense signals on T 2WI images. Heterogeneous enhancement was found in 18 patients, intratumoral cystic necrosis was found in 15 patients, and the meningeal tail sign was found in 16 patients. Preoperative imaging misdiagnosis occurred in 4 patients. Before surgery, all patients underwent surgery to resect the tumor and remove the hematoma. No patients died because of surgery. After surgery, muscle strength was improved compared with that before surgery. The average follow-up time was (46.5 ± 28.4) months. Tumor recurrence occurred in two patients. The Karnofsky Performance Scale score at the last follow-up, at discharge, and before surgery was (73.7 ± 3.4) points, (61.1 ± 5.5) points, and (49.5 ± 5.6) points, respectively ( F = 21.06, P < 0.01). The Karnofsky Performance Scale score at the last follow-up was significantly increased compared with that at discharge and before surgery ( F = 13.13, P < 0.01). Conclusion:Spontaneous hemorrhagic meningioma is rare and has a sudden onset. It is easily misdiagnosed before surgery. Skull CT, skull CT angiography, and enhanced magnetic resonance imaging examination in combination can increase the preoperative diagnosis rate. Early surgical resection of tumors and removal of hematoma can acquire good clinical efficacy.

Microsurgery for ruptured intracranial dural arteriovenous fistula: a retrospective case series of 8 patients / 国际脑血管病杂志

Objective:To investigate the emergency surgical effect of ruptured intracranial dural arteriovenous fistula (DAVF).Methods:Patients with ruptured intracranial DAVF underwent microsurgery in the Department of Neurosurgery, Nanping First Hospital Affiliated to Fujian Medical University from May 2013 to July 2022 were retrospectively included. The clinical, imaging and follow-up data were collected, and the clinical characteristics, selection of surgical methods and treatment effects of patients were summarized.Results:A total of 8 patients with DAVF were enrolled. Their age ranged from 11 to 60 years (average, 48 years). There were 7 males and 1 female. All 8 patients suffered from intracranial hemorrhage, manifested as headache and vomiting in 2 cases, simple conscious disturbance in 2 cases, conscious disturbance with cerebral hernia in 3 cases, and conscious disturbance with limb paralysis in 1 case. The fistula was located in the anterior fossa in 4 cases (including 2 cases with aneurysms), the middle fossa in 2 cases (including 1 case with moyamoya disease), the transverse sinus in 1 case, and the anterior 1/3 area of the sagittal sinus in 1 case. Cognard classification: 7 patients were type Ⅲ and 1 was type Ⅳ. After admission, all patients underwent emergency craniotomy and microsurgery to remove hematoma. Among them, 4 patients underwent decompressive craniectomy at the same time, 1 patient with moyamoya disease underwent dural turnover and temporalis muscle application at the same time, and 2 patients with aneurysms at the same location were clipped at the same time. Postoperative re-examination of head CT showed that the hematoma was cleared satisfactorily and the midline was no shift in all 8 patients. CT angiography (CTA) showed that the fistula disappeared within 2 weeks. Seven patients were followed up within 1-12 months after operation. CTA or digital subtraction angiography showed no recurrence of DAVF. Two patients with aneurysms did not have residual or recurrent aneurysms. All patients had no new neurological symptoms, and the Glasgow Outcome Scale score in 2 patients increased by 1 compared with that at discharge.Conclusion:Emergency microsurgery is an effective method for the treatment of ruptured intracranial DAVF, especially for patients with special parts or complicated hematoma, cerebral hernia, and other vascular diseases.

Diffusion-weighted imaging and fluid-attenuated inversion recovery mismatch guide intravenous thrombolysis in patients with ischemic stroke beyond a 4.5-h time window / 国际脑血管病杂志

Objective:To investigate the efficacy and safety of using diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) mismatch to guide intravenous thrombolysis in patients with ischemic stroke beyond a 4.5-h time window.Methods:Patients with acute ischemic stroke received intravenous thrombolysis with alteplase in the Stroke Center of Hefei Second People's Hospital from July 2019 to June 2021 were retrospectively enrolled. According to the time of onset, they were divided into the time window group and the beyond time window group. The demographic and baseline clinical data of both groups were recorded and compared. The primary outcome measure was the clinical outcome assessed by the modified Rankin Scale (mRS) at 90 d after onset. 0-2 points were defined as good outcome, and >2 were defined as poor outcome. The secondary outcome measure was symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis was used to determine the independent risk factors for poor outcomes. Results:A total of 244 patients with acute ischemic stroke were enrollded, including 146 males (58.8%), aged 61.4±8.47 years. The median time from onset to thrombolysis was 142 min, and the median baseline National Institutes of Health Stroke Scale (NIHSS) score was 7. Thirty-six (14.8%) patients exceeded the 4.5 h time window, and 69 (28.3%) patients had poor outcomes. There were no significant differences in the good outcome rate (71.2% vs. 75.0%; χ2=0.224, P=0.636), any intracranial hemorrhage (9.6% vs. 13.9%; χ2=0.233, P=0.629) and the incidence of sICH (5.3% vs. 5.6%; χ2=0.000, P=1.000) between the time window group and the beyond time window group. Univariate analysis showed that the proportion of patients with atrial fibrillation or cardiogenic embolism and the baseline NIHSS score in the poor outcome group were significantly higher than those in the good outcome group (all P<0.05), while there was no statistical difference in the proportion of patients receiving intravenous thrombolysis beyond the time window. Multivariate logistic regression analysis showed that only the baseline NIHSS score was an independent risk factor for poor outcomes (odds ratio 1.681, 95% confidence interval 1.457-1.940; P<0.001). Conclusions:Compared with the patients who received intravenous thrombolysis within 4.5 h after onset, intravenous thrombolysis in patients with acute ischemic stroke beyond the 4.5 h time window guided by DWI-FLAIR mismatch results in similar clinical outcomes, and does not increase the incidence of intracranial hemorrhage.

Neuroimaging features of hemorrhagic transformation after intravenous thrombolysis in patients with acute ischemic stroke / 国际脑血管病杂志

Objective:To investigate the neuroimaging features of hemorrhagic transformation (HT) after intravenous thrombolysis in patients with acute ischemic stroke.Methods:Patients with acute ischemic stroke received intravenous thrombolysis with a standard dose of alteplase in the Department of Neurology, Ninghe District Hospital from April 2018 to May 2022 and had HT within 24 h after treatment were retrospectively included. Demography, clinical data and neuroimaging findings of HT were recorded. The clinical data of symptomatic intracerebral hemorrhage (sICH) group and asymptomatic intracerebral hemorrhage (asICH) group, as well as HT in the infarct group and HT outside the infarct group were compared. Multivariate logistic regression analysis was used to determine independent risk factors for HT types. Results:A total of 63 patients with HT were enrolled (40 males and 23 females, aged 73.5±8.95 years). There were 42 patients with sICH (66.7%), 21 (33.3%) with asICH, 37 (58.7%) with HT in the infarct (ECASS classification: hemorrhagic infarction [HI]-1, 5 cases [7.9%]; HI-2, 6 cases [9.5%]; parenchymal hematoma [PH]-1, 11 cases [17.5%]; PH-2, 15 cases [23.8%]), 17 (27.0%) with HT outside the infarct, and 9 cases (14.3%) with HT both inside and outside the infarct. Heidelberg classification: 1a HI-1, 5 cases (7.9%); 1b HI-2, 6 cases (9.5%); 1c PH-1, 11 cases (17.5%); 2, 15 cases (23.8%); 3a, 14 cases (22.2%); 3b, 6 cases (9.5%); 3c, 4 cases (6.3%); and 3d, 2 cases (3.2%). Multivariate logistic regression analysis showed that lower baseline National Institutes of Health Stroke Scale (NIHSS) score (odds ratio [ OR] 1.413, 95% confidence interval [ CI] 1.216-1.447; P=0.001), small vessel occlusion ( OR 1.378, 95% CI 1.134-1.429; P=0.002), minor stroke ( OR 1.447, 95% CI 1.120-1.467; P<0.001), and HT outside the infarct ( OR 1.335, 95% CI 1.131-1.363; P=0.007) were independently associated with sICH. Higher baseline NIHSS scores ( OR 1.737, 95% CI1.102-1.801; P<0.001), cardiogenic embolism ( OR 1.789, 95% CI 1.095-1.881; P<0.001), and severe stroke ( OR 1.648, 95% CI 1.110-1.672; P<0.001) were independently associated with HT in the infarct. Conclusions:The most common neuroimaging feature of HT after intravenous thrombolysis in patients with acute ischemic stroke is PH in the infarct, while HT outside the infarct and HT both inside and outside the infarct are rare. For patients with cardiogenic embolism with higher baseline NIHSS score, the HT after thrombolysis was mostly asICH, and its imaging features were mostly multiple punctuate hemorrhage in the infarct. In patients with small vessel occlusion with lower baseline NIHSS score, most of the HT after thrombolytic therapy is sICH, and their imaging features are mostly PH outside the infarct.

Risk factors of intracranial hemorrhage with 125I seeds for the treatment of brain tumors / 中华内科杂志

Objective:To analyze the risk factors of intracranial hemorrhage after implanting 125-iodine seeds for brain tumors.Methods:A total of 234 patients with intracranial tumors receiving treatment of 125-iodine seeds from March, 2013 to November, 2020 were retrospectively analyzed. Patients were divided into bleeding group and non-bleeding group according to whether postoperative intracranial hemorrhage was reported. Univariate and multivariate analysis was performed by logistic regression to determine the independent risk factors of intracranial hemorrhage.Result:A total of 22 cases (9.4%) reported postoperative intracranial hemorrhage in 234 patients treated with 125-iodine seeds. Univariate analysis showed that the type of tumor and the history of anti-angiogenic drug within one month were possible risk factors ( P<0.1). Multivariate logistic regression analysis showed that anti-angiogenic drug within one month was the independent risk factor for intracranial hemorrhage ( P<0.05). Conclusions:The application of anti-angiogenic drugs within one month is the independent risk factor of intracranial hemorrhage with 125-iodine seeds for the treatment of brain tumors.

Predictors of intracranial hemorrhage in patients with cerebral venous sinus thrombosis / 国际脑血管病杂志

Objective:To investigate the predictors of intracranial hemorrhage in patients with cerebral venous sinus thrombosis (CVST).Methods:Patients with CVST treated in Drum Tower Hospital Affiliated to Medical School of Nanjing University from January 2008 to March 2021 were retrospectively enrolled. The risk factors, clinical manifestations, imaging examination and 90 d follow-up data were collected. The complicated intracranial hemorrhage group and non-intracranial hemorrhage group were compared. Multivariate logistic regression analysis was used to determine the independent predictors of intracranial hemorrhage in patients with CVST. Results:A total of 104 patients with CVST were enrolled, including 42 males and 62 females. Their age was 35.24 ± 10.92 years old (range 22-68 years). Thirty-eight patients (36.84%) were complicated with intracranial hemorrhage, including 34 hemorrhagic cerebral infarction and 4 complicated subarachnoid hemorrhage. Univariate analysis showed that compared with the non-intracerebral hemorrhage group, the intracranial hemorrhage group was more common in puerperal/pregnant patients (60.52% vs. 48.48%; P=0.012), with more acute onset (57.89% vs. 48.48%; P=0.004), focal neurological signs (47.37% vs. 19.70%; P=0.003) and seizure (39.47% vs. 18.18%; P=0.017), and the site of thrombosis was more common in the superior sagittal sinus (57.89% vs. 36.36%; P=0.033). Multivariate logistic regression analysis showed that puerperium/pregnancy (odds ratio 2.857, 95% confidence interval 1.095-7.453; P=0.031) and superior sagittal sinus thrombosis (odds ratio 2.847, 95% confidence interval 1.110-7.302; P=0.027) were the independent predictors of intracranial hemorrhage in patients with CVST. The analysis at 90 d after onset showed that there was no significant difference in the good outcome rate between the intracranial hemorrhage group and the non-intracranial hemorrhage group (86.84% vs. 89.39%; P=0.695). Conclusions:Puerperium/pregnancy and superior sagittalsinus thrombosis are the independent risk factors for intracranial hemorrhage in patients with CVST. However, complicated with intracranial hemorrhage is not associated with 90-day clinical outcomes.

Correlation between serum uric acid level and symptomatic intracranial hemorrhage and outcomes in elderly patients with acute anterior circulation ischemic stroke treated with endovascular therapy / 国际脑血管病杂志

Objective:To investigate the correlation between serum uric acid level and symptomatic intracranial hemorrhage (sICH) and outcomes after endovascular therapy (EVT) in elderly patients with anterior circulation acute ischemic stroke (AIS).Methods:Elderly patients with AIS (aged ≥65 years) received EVT in Beijing Geriatric Hospital and Xuanwu Hospital from December 2017 to December 2020 were retrospectively enrolled. sICH was defined as cerebral parenchymal hemorrhage revealed by CT within 72 h after admission and the Naitonal Institutes of Health Stroke Scale score increased by ≥4 compared with the baseline. At 90 d after onset, the clinical outcome was evaluated by the modified Rankin Scale. 0-2 was a good outcome and 3-6 was a poor outcome. The clinical data of the sICH group and non-sICH group, as well as the good outcome group and poor outcome group were compared. Multivariate logistic regression analysis was used to determine the independent correlation between serum uric acid level and sICH and poor outcomes. Results:A total of 122 patients were enrolled, their age was 73.89±6.24 years, and 73 (59.8%) were male. Fifty-two patients (42.6%) had hemorrhagic transformation, 27 (22.1%) had sICH, and 28 (23.8%) had a good outcome at 90 d after onset. The serum uric acid in the sICH group was significantly lower than that in the non-sICH group ( P=0.002), while the serum uric acid in the good outcome group was similar to that in the poor outcome group ( P=0.510). Multivariate logistic analysis showed that the lower serum uric acid was an independent risk factor for sICH (odds ratio 0.994, 95% confidence interval 0.990-0.998; P=0.011). Conclusion:The lower serum uric acid level was an independent risk factor for sICH after EVT in elderly patients with AIS, but it was not associated with the outcomes.

Factor VIII prophylactic therapy reduces neurological complications in patients with Hemophilia A / Terapia profilática com Fator VIII reduz complicações neurológicas em paciente com Hemofilia A

ABSTRACT Background: Bleeding in hemophiliacs can cause complications in the central and peripheral nervous system (CNS and PNS). The incidence of intracranial hemorrhage has reduced after the introduction of prophylactic treatment with factor VIII or IX, but the benefits of this therapy have not yet been evaluated on PNS complications. Objective: The aim of this study was to determine the prevalence of neurological complications in hemophiliacs and verify the effect of prophylactic therapy in these patients, including PNS disorders. Methods: We retrospectively evaluated the prevalence of CNS and PNS disorders caused by bleeding in hemophiliacs seen at the Hemocentro Regional Norte, Ceará, Brazil, from 1992 to 2018, and we compared the incidence in different periods (before and after the introduction of prophylactic treatment in 2011). Results: Of 75 hemophilia A patients evaluated (4.61/100.000 population), 13.3% (n=10) had either CNS (n=5) or PNS (n=5) disorders secondary to bleeding. Patients submitted to factor VIII replacement prophylactic therapy were less likely to have CNS events: from 1992 to 2011, 5 of 63 patients had CNS disease, while from 2011 to 2018, there were no new cases (p=0.0181). From 2011 to 2018, 5 PNS events occurred in patients without prophylactic therapy, whereas none occurred in those covered by prophylactic therapy (5/20 versus 0/29, p=0.0081). Conclusions: The prevalence of neurological complications in hemophiliacs in our cohort is similar to other studies. Similar to CNS, prophylactic therapy also reduces the risk of PNS complications. This is the first report in the literature showing this benefit.

RESUMO Antecedentes: O sangramento em hemofílicos causa complicações no sistema nervoso central e periférico (SNC e SNP). A incidência de hemorragia intracraniana diminuiu após a introdução da profilaxia com fator VIII ou IX, entretanto esse benefício ainda não foi avaliado no SNP. Objetivo: O objetivo deste estudo foi determinar a prevalência de complicações neurológicas em hemofílicos, verificando o efeito da terapia profilática também no SNP. Métodos: Avaliamos retrospectivamente a prevalência de complicações neurológicas causadas ​​por sangramentos em hemofílicos atendidos no Hemocentro Regional Norte, Ceará, Brasil, de 1992 a 2018, comparando a incidência em diferentes períodos (antes e depois da introdução do tratamento profilático em 2011). Resultados: Foram avaliados 75 pacientes com hemofilia A (4,61/100 mil habitantes). Deles, 13,3% (n=10) tinham distúrbios do SNC (n=5) ou do SNP (n=5) secundários a hemorragias. Os pacientes submetidos à terapia profilática com fator VIII apresentaram menor probabilidade de eventos do SNC: de 1992 a 2011, cinco de 63 pacientes apresentaram hemorragia no SNC, enquanto de 2011 a 2018 não ocorreram novos casos (p=0,0181). De 2011 a 2018, cinco eventos no SNP ocorreram entre pacientes sem terapia profilática, e nenhum ocorreu entre aqueles cobertos pela profilaxia (5/20 × 0/29, p=0,0081). Conclusões: A prevalência de complicações neurológicas em hemofílicos em nossa coorte é similar à de outros estudos. Assim como no SNC, a terapia profilática também reduz o risco de complicações no SNP. Este é o primeiro relato na literatura a mostrar esse benefício.

Impact of bundle implementation on the incidence of peri/intraventricular hemorrhage among preterm infants: a pre-post interventional study

ABSTRACT BACKGROUND: Peri/intraventricular hemorrhage (PIVH) is a frequent cause of death and morbidity among preterm infants. Few studies have addressed the use of bundles for preventing PIVH. OBJECTIVE: To evaluate the efficacy of a bundle of interventions designed to decrease the incidence of intraventricular hemorrhage at hospital discharge among preterm infants. DESIGN AND SETTING: Pre-post interventional study with retrospective and prospective data collection performed before and after bundle implementation in the neonatal intensive care unit of a university hospital. METHODS: Infants with gestational age < 32 weeks without malformations, who survived > 6 days were included. The bundle consisted of the following actions during the first 72 hours of life: maintenance of head in neutral position with the body in supine position, minimal handling, including delay of lumbar puncture until after 72 hours and absence of respiratory therapy maneuvers. Cranial ultrasound was performed on days 3, 7 and 28, or later if needed. The effect of the bundle was analyzed through logistic regression and results were adjusted for confounding variables. RESULTS: 167 infants met the inclusion criteria; 146 (87%) were analyzed. Bundle implementation was associated with decreased chances of PIVH at hospital discharge (odds ratio 0.29; 95% confidence interval 0.13-0.65). Cerebrospinal fluid collection within the first 72 hours increased the odds of PIVH of any grade during the hospital stay fourfold, after adjustment for all variables included in the model. CONCLUSION: Implementation of a bundle of interventions to avoid intraventricular hemorrhage was effective for decreasing the incidence of all grades of PIVH in preterm infants.

Evaluation of CT value with dual-energy CT in predicting cerebral hemorrhagic transformation after endovascular treatment in patients with acute ischemic stroke / 中华神经科杂志

Objective:To evaluate the value of dual-energy CT (DECT) mixed images CT in predicting hemorrhagic transformation (HT) after endovascular therapy (EVT) of acute ischemic stroke (AIS).Methods:From October 2018 to January 2020, the immediate dual-energy CT images of intracranial high attenuation (HA) regions in patients with AIS after endovascular treatment in Wuhan No.1 Hospital were retrospectively analyzed. According to the diagnostic criteria of CT or diffusion weighted image in 72 hours of follow-up, they were classified into HT group and non-HT group. The CT value of mixed images, contrast media, and virtual non-enhancement (VNC) and iodine concentration in the highest attenuation areas were measured. Intragroup correlation coefficient was used to evaluate the consistency among the readers; Mann-Whitney U test was used to compare the difference between the two groups of quantitative parameters; Spearman correlation analysis was uesd for evaluating correlation between mixed images CT value and contrast media CT value, VNC CT value, and iodine concentration. The receiver operating characteristic curve was used to analyze the quantitative parameters to predict the diagnostic efficacy of HT. Results:A total of 154 cases were enrolled, with 65 cases in the HT group and 89 cases in the non-HT group. The intraclass correlation coefficient of CT values of mixed images was 0.861 ( P<0.05). Comparing the non-HT group and the HT group,the CT value of mixed images [59.40(54.84, 63.05) HU vs 100.10(79.90, 122.40) HU, Z=-10.87, P<0.001],contrast agent CT value [24.90(20.75, 30.05) HU vs 66.60(47.10, 84.15) HU, Z=-10.85, P<0.001] and iodine concentration [1.10(1.00, 1.30) mg/ml vs 2.90(2.05, 3.65) mg/ml, Z=-10.85, P<0.001] both increased in the HT group, but there was no significant difference in VNC CT values between the two groups [33.60(31.80, 35.70) HU vs 34.30(30.90, 38.00) HU, Z=-0.50, P=0.62]. There was a highly significant correlation between the CT value of mixed images and iodine concentration ( r=0.99, P<0.01). Using CT value>72.60 HU as the diagnostic cutoff value for predicting HT, the sensitivity and specificity were 89.23% and 95.51%, respectively. Conclusions:The CT value of DECT mixed images after EVT can be used to predict HT within 72 hours. When DECT was not available, conventional CT scan′s intracranial HA density over 72.60 HU can be selected as the cutoff value for predicting HT.

Relationship between cerebral small vessel disease and the outcome after intravascular thrombectomy in patients with acute ischemic stroke / 国际脑血管病杂志

Endovascular thrombectomy (EVT) has become an effective treatment for acute large vessel occlusive ischemic stroke. Because there are many common etiologies and pathogenesis between cerebral small vessel disease (CSVD) and large vessel disease, patients with large vessel occlusive ischemic stroke are often accompanied by imaging manifestations of CSVD. In recent years, with the wide application of EVT in the treatment of acute ischemic stroke, more and more studies have investigated the relationship between CSVD and the outcome of patients treated with EVT. This article reviews the relationship between various imaging phenotypes of CSVD and the outcome of acute ischemic stroke patients treated with EVT and its possible mechanism.