Causes of death and mortality trends related to hemophilia in Brazil, 1999 to 2016

ABSTRACT Introduction Multiple cause of death methodology enhances mortality studies beyond the traditional underlying cause of death approach. Aim: This study aims to describe causes of death and mortality issues related to haemophilia with the use of multiple-cause-of-death methodology. Methods: Annual male haemophilia mortality data was extracted from the public multiple-cause-of-death databases of the Mortality Information System, searching deaths included in rubrics D66 "hereditary factor VIII deficiency" (haemophilia A), and D67 "hereditary factor IX deficiency" (Haemophilia B) of the International Classification of Diseases, Tenth Revision, and processed by the Multiple Cause Tabulator. Results: In Brazil, from 1999 to 2016, a total of 927 male deaths related to haemophilia occurred during the 18 year period, of which 418 (45,1 %) as underlying cause, and 509 (54,9 %) as associated cause of death. The leading associated cause of 418 deaths of haemophilia as underlying cause was hemorrhage (52.6%), half of which intracranial hemorrhage. Infectious and parasitic diseases accounted for 40,5% as the underlying causes of 509 deaths where haemophilia was an associated cause, where human immunodeficiency virus disease prevailed, however falling from 37,0% to 19.7%, and viral hepatitis increased from 6.0% to 7.9%; diseases of the circulatory system, increased from 13.5% to 18.4%, including intracranial hemorrhage from 5.7% to 7.0%, and neoplasms, from 8,5% to 13.2%, respectively from 1999-2007 to 2008-2016, followed as main underlying causes. Conclusion: Hemorrhages, mainly intracranial hemorrhage, human immunodeficiency virus disease, and viral hepatitis are the chief prevention goals aiming at the control of haemophilia mortality.

Malformaciones vasculares cerebrales de alto flujo en pediatría: experiencia en un hospital pediátrico de alta complejidad / High-flow vascular malformations of the brain in pediatrics: Experience in a tertiary care children's hospital

Introducción. Las malformaciones vasculares cerebrales de alto flujo son poco comunes en la edad pediátrica. El objetivo del trabajo es diferenciar y agrupar estas enfermedades según edad de debut, manifestaciones clínicas y angioarquitectura.Población y método. Se realizó un estudio retrospectivo y observacional. Se analizaron las historias clínicas, los estudios por imágenes y los protocolos de procedimientos de pacientes del Hospital J. P. Garrahan con diagnóstico de malformaciones vasculares cerebrales desde enero de 2010 hasta enero de 2020.Resultados. Ciento ochenta y tres pacientes cumplieron los criterios de inclusión. Se identificaron 131 pacientes con malformaciones arteriovenosas con nido (MAV) y 52 con fístulas directas (sin nido), entre los que se hallaron 19 malformaciones aneurismáticas de vena de Galeno, 23 fístulas piales y 10 fístulas durales. La edad promedio fue de 105 meses para las MAV, 1,7 meses para las malformaciones aneurismáticas de vena de Galeno, 60,5 meses para fístulas piales y 41 meses para fístulas durales.Conclusión. Según su angioarquitectura, las malformaciones vasculares cerebrales de alto flujo tuvieron nido (MAV) o fueron fístulas directas (malformaciones aneurismáticas de vena de Galeno, fístulas piales y fístulas durales). Las MAV se manifestaron a partir de la primera infancia, sobre todo, por hemorragia intracraneana. Las fístulas directas se expresaron en la primera etapa de la vida, frecuentemente, con insuficiencia cardíaca.

Introduction. High-flow vascular malformations of the brain are uncommon in pediatrics. The objective of this study is to establish the differences among these pathologies and group them by age at onset, clinical manifestations, and angioarchitecture.Population and method. This was a retrospective and observational study. The medical records, imaging studies, and procedure protocols of patients seen at Hospital J. P. Garrahan diagnosed with vascular malformations of the brain between January 2010 and January 2020 were analyzed.Results. A total of 183 patients met the inclusion criteria. It was possible to identify 131 patients with arteriovenous malformations with a nidus (AVMs) and 52 with direct fistulas (without a nidus), including 19 vein of Galen aneurysmal malformations, 23 pial fistulas, and 10 dural fistulas. The average age of patients was 105 months for AVMs, 1.7 months for vein of Galen aneurysmal malformations, 60.5 months for pial fistulas, and 41 months for dural fistulas.Conclusion. Based on their angioarchitecture, high-flow vascular malformations of the brain presented a nidus (AVMs) or direct fistulas (vein of Galen aneurysmal malformations, pial fistulas, and dural fistulas). AVMs were observed in early childhood, especially due to intracranial hemorrhage. Direct fistulas occurred in the first stage of life, commonly with heart failure.

Risk factors for intracranial hemorrhage and mortality in adult patients with severe respiratory failure managed using veno-venous extracorporeal membrane oxygenation / 中华医学杂志(英文版)

BACKGROUND@#Intracerebral hemorrhage (ICH) is one of the most severe complications during veno-venous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to determine the risk factors for ICH and mortality in such patients.@*METHODS@#We analyzed the clinical data of 77 patients who received VV-ECMO due to severe respiratory failure from July 2013 to May 2019 at China-Japan Friendship Hospital. Demographical data, laboratory indices, imaging characteristics, and other clinical information were collected. Multivariable logistic regression analyses were performed to identify risk factors for ICH and mortality.@*RESULTS@#Of 77 patients, 11 (14.3%) suffered from ICH, and 36 (46.8%) survived. The survival rate was significantly lower (18.2% [2/11] vs. 51.5% [34/66], P = 0.040) in patients with ICH than in those without ICH. Multivariable analysis revealed that factors independently associated with ICH were diabetes mellitus (adjusted odds ratio [aOR]: 12.848, 95% confidence interval [CI]: 1.129-146.188, P = 0.040) and minimum fibrinogen during ECMO (aOR: 2.557, 95% CI: 1.244-5.252, P = 0.011). Multivariable analysis showed that factors independently associated with mortality were acute hepatic failure during ECMO (aOR: 9.205, 95% CI: 1.375-61.604, P = 0.022), CO2 retention before ECMO (aOR: 7.602, 95% CI: 1.514-38.188, P = 0.014), and minimum platelet concentration during ECMO (aOR: 0.130, 95% CI: 0.029-0.577, P = 0.007).@*CONCLUSIONS@#Diabetes mellitus and minimum fibrinogen concentration during ECMO are risk factors for ICH in patients with severe respiratory failure managed using VV-ECMO. This indicated that anticoagulants use and nervous system monitoring should be performed more carefully in patients with diabetes when treated with VV-ECMO due to severe respiratory failure.

Hemorragia subaracnoidea posterior a descompresión Lumbar mínimamente invasiva. Presentación de un caso y revisión de la literatura / Subarachnoid hemorrhage after minimally invasive lumbar decompression. Case report and literature review

Introducción: Las lesiones durales son complicaciones frecuentes en la cirugía de columna. La fuga de liquidocefalorraquideo (LCR) puede originar hemorragia en todos los compartimientos del cerebro. La mayoría ocurre en venas ubicadas en región cerebelosa.Material y método: Se presenta un caso de hemorragia subaracnoidea posterior a una descompresión lumbar mínimamente invasiva asociada a desgarro dural. Resultados: Evoluciona en el postoperatorio con síntomas neurológicos de cefaleas y trastornos del sensorio por lo que se decide evaluarlo con estudios por imágenes vasculares cerebrales identificándose sangrado subaracnoideo.Discusión: El sitio más frecuente de hemorragia intracraneal posterior a una cirugía de columna es el cerebelo. El mecanismo de acción de este tipo de sangrados es desconocido y controversial, hay algunos reportes que sugieren que se trataría de un sangrado venoso. El síntoma más característico de este síndrome es la cefalea. Aunque se desconoce la etiología exacta, se postula que la pérdida de volumen de LCR causa una caída en la presión intracraneal, lo que lleva a un agrandamiento de los senos venosos durales que predisponen al paciente a un hematoma subdural espontáneoConclusión: La fuga de LCR, las alteraciones asociadas al edema cerebral en la hipotensión cerebral podría ser llave del mecanismo que desencadena una hemorragia subaracnoidea.

compartments of the brain. Most occur in veins located in the cerebellar region.Material and method: A case of subarachnoid hemorrhage after a minimally invasive lumbar decompression associated with dural tear is presented.Results: It evolves in the postoperative period with neurological symptoms of headaches and sensory disorders, so it is decided to evaluate it with studies by cerebral vascular images identifying subarachnoid bleeding.Discussion: The most frequent site of intracranial hemorrhage after spinal surgery is the cerebellum. The mechanism of action of this type of bleeding is unknown and controversial, there are some reports that suggest that it would be a venous bleeding. The most characteristic symptom of this syndrome is headache. Although the exact etiology is unknown, it is postulated that the loss of CSF volume causes a drop in intracranial pressure, which leads to an enlargement of the dural venous sinuses that predispose the patient to a spontaneous subdural hematomaConclusion: CSF leakage, alterations associated with cerebral edema in cerebral hypotension could be key to the mechanism that triggers a subarachnoid hemorrhage.

Hemorragia intracraniana en un feto con trisomia 21 y rabdomiomas cardiacos: diagnostico diferencial de esclerosis tuberosa: estudio antenatal a propósito de un caso / Intracranian hemorrhage in a fetus with trisomy 21 and cardiac rhabdomyomas: differential diagnosis of tuberous sclerosis: antenatal study regarding a case

INTRODUCCIÓN: El Síndrome de Down (SD) es una de las aneuploidías más frecuentes. En Chile, la incidencia es de 2.2 por 1000 nv. La esclerosis tuberosa (ET) es una enfermedad genética autosómica dominante con una prevalencia de 1:600 a 1:10.000 nacidos vivos (nv) que se sospecha prenatalmente por la presencia de rabdomiomas cardiacos. Los tumores cardiacos fetales tienen una prevalencia de 1:10000 nv, los más prevalentes son los Rabdomiomas. El hallazgo de tumores intracraneanos son infrecuentes, dentro del diagnóstico diferencial es necesario descartar la Hemorragia Intraventricular (HIV). CASO CLÍNICO: Paciente de 29 años, M2, Derivada a nuestro centro a las 27+4 semanas para evaluación ecográfica. Entre los hallazgos se encuentran tumores intracardiacos en ventrículo derecho y marcadores blandos para alto riesgo de aneuploidía, por lo que se realiza cariotipo (amniocentesis genética: 47, XX+21). A las 32+0 semanas en una nueva evaluación presenta imagen hiperecogénica sugerente de tumor intracerebral. Se solicita resonancia magnética fetal que informa hemorragia intraventricular (HIV). El parto ocurre con un recién nacido de término, fenotipo concordante con Trisomía 21, ecocardiograma confirma dos tumores intracardiacos (Rabdomiomas) y ecografía cerebral confirma el diagnóstico de HIV Grado III derecho. Ante el diagnóstico diferencial de ET, se realiza ANGIO-TAC que resulta negativo para ET. DISCUSIÓN: En la evaluación ecográfica antenatal, la presencia de tumores intracardiacos asociados a tumor cerebral hace plantear el diagnóstico de una ET. El diagnóstico antenatal de tumores cerebrales vs HIV por ultrasonido es difícil. La resonancia es un examen complementario de gran ayuda, permitiendo un diagnóstico de certeza. La HIV fetal es un diagnóstico poco frecuente de diagnostico prenatal asociado a feto con trisomia 21.

INTRODUCTION: Down Syndrome (DS) is one of the most frequent aneuploidies. In our country its incidence is 2.2 every 1000 newborns. Tuberous sclerosis (TS) is a dominant autosomal genetic disease with a prevalence of 1:6000 to 1:10.000 newborns, this disease is suspected by the finding of cardiac rhabdomyomas. Rhabdomyomas are the most prevalent fetal heart tumors. Intracranial tumors are a rare prenatal finding in ultrasound the main differential diagnosis is Intraventricular Hemorrhage (IVH). The Objective of this paper is present a case report of a fetus with trisomy 21 plus rhabdomyomas and cranial tumors. CASE REPORT: 29 years old patient, referred for ultrasound at 27+4 week. Cardiac tumors and aneuploidy soft markers are found. Genetic amniocentesis is performed (Result: 47, XX+21). At 32+0 weeks ultrasound finding of intracranial tumor. Fetal MRI was performed which reports suspected IVH. Confirmed postnatally. Baby was delivered at term. Neonatal findings: Trisomy 21 phenotype, Echocardiogram with two cardiac tumors (Rhabdomyomas), neonatal brain ultrasound confirms Grade III - IVH. To rule out TS, an Angio-CT is performed which is negative for the disease. DISCUSSION: Cardiac Tumors associated to brain tumors in antenatal period make TS a possible diagnosis. Differentiate brain tumors and IVH by ultrasound is very difficult. MRI is a very helpful tool for an accurate diagnostic. IVH is a rare antenatal diagnosis. Not reported before in a baby with trisomy 21.

Comparison on cognitive performance among schoolchildren born prematurely according to the presence of intracranial hemorrhage in the neonatal period / Comparação do desempenho cognitivo entre escolares nascidos prematuros segundo presença de hemorragia intracraniana no período neonatal

Abstract Objectives: to compare the cognitive performance of schoolchildren born prematurely according to the presence of intracranial hemorrhage (ICH) during the neonatal period. Methods: a cross-sectional cohort study of schoolchildren between the ages of 6-8 years old, born prematurely with or without a history of neonatal ICH. Between January and December 2015, some children were followed up at the outpatient clinic of a tertiary hospital and underwent a cognitive evaluation by using the Wechsler Intelligence Scale for Children, Third Edition (WISC-III) and they were divided into two groups: those with no history of ICH (control group) and those with ICH (case group), confirmed by a transfontanelar ultrasound in the prenatal period. Results: 39 schoolchildren were included, 21 cases and 18 controls. There was no difference in gestational age or chronological age at evaluation between the groups. Also there was no significant difference in subtest scores between the groups. Conclusions: WISC-III evaluated the cognitive performance in children, born preterm, aged 6-8 years old, and had neonatal ICH did not differ from those of their peers without a history of ICH. These findings suggest that, in preterm infants, a neonatal diagnosis of ICH may not be associated with cognitive performance at school age and this should be investigated through a longitudinal study.

Resumo Objetivos: comparar o desempenho cognitivo de escolares, nascidos prematuramente, segundo a presença de hemorragia intracraniana (HIC) no período neonatal. Métodos: corte transversal de uma coorte de escolares com idade entre seis e oito anos que nasceram prematuramente e apresentaram ou não HIC, realizado entre janeiro e dezembro de 2015, acompanhados em ambulatório de seguimento de hospital terciário e submetidos à avaliação cognitiva, através da Escala de Inteligência Wechsler para Crianças-3ª edição (WISC-III), que foram divididos em dois grupos: sem HIC (grupo controle - GC) e com HIC (grupo de casos - GH) comprovada através de exame ultrassonográfico transfontanelar no período perinatal. Resultados: foram incluídos 39 escolares, 18 no GC e 21 no GH. Não se observou dife-rença entre os grupos quanto à idade gestacional e idade cronológica na qual eles foram avaliados. Não foi encontrada diferença estatística entre os grupos estudados nos valores dos subtestes. Conclusões: o desempenho cognitivo de crianças nascidas pré-termo que tiveram HIC não difere daquele que não a apresentaram quando avaliadas pelo WISC-III na faixa etária de seis a oito anos. Sugere-se que o diagnóstico neonatal de HIC pode não estar associado ao desempenho cognitivo de prematuros, na idade escolar, o que deverá ser investigado através de estudo longitudinal.

Procalcitonin levels among patients with fever secondary to severe intracerebral infection. A cross-sectional study

ABSTRACT BACKGROUND: Making the differential diagnosis between central fever and infectious fever is critically important among intracerebral hemorrhage patients followed up in intensive care units (ICUs). Serum procalcitonin (PCT) has been found to be a promising biomarker for the initial diagnosis of infection, even before culturing results. OBJECTIVES: To investigate the relationship between PCT and both fever etiologies and C-reactive protein (CRP) levels among critically ill patients with suspected intracerebral hemorrhage. DESIGN AND SETTING: Cross-sectional study in a public university hospital in Elazig, Turkey. METHODS: ICU patients diagnosed with intracerebral hemorrhage and normal procalcitonin levels were included in this study. From clinical assessments and cultures, they were classified as presenting either infectious or central fever. The sensitivity and specificity of PCT and CRP for predicting infection were calculated using a receiver operating characteristic (ROC) curve. RESULTS: There were 98 ICU patients with diagnoses of intracerebral hemorrhage. The median (interquartile range) PCT levels of patients with infectious and central fever were 4 (0.9-11) and 0.1 (0.1-0.4) ng/ml, respectively, with a statistically significant intergroup difference (P < 0.001). The areas under the ROC curve for predicting infectious or central fever PCT and CRP were 0.958 (P < 0.001) and 0.816 (P < 0.001), respectively. A statistically significant positive correlation was detected between PCT and CRP levels in patients with infectious fever (rho: 0.461; P = 0.003), but not in patients with central fever. CONCLUSIONS: PCT can possibly be used as a biomarker to differentiate between infectious and central fever among ICU patients.

Bleeding risk of small intracranial aneurysms in a population treated in a reference center / Risco de sangramento de aneurismas intracranianos pequenos em uma população tratada em um centro de referência

ABSTRACT Large multicenter studies have shown that small intracranial aneurysms are associated with a minimal risk of bleeding. Nevertheless, other large series have shown that most ruptured aneurysms are, in fact, the smaller ones. In the present study, we questioned whether small aneurysms are indeed not dangerous. Methods: We enrolled 290 patients with newly-diagnosed aneurysms at our institution over a six-year period (43.7% ruptured). We performed multivariate analyses addressing epidemiological issues, cardiovascular diseases, and three angiographic parameters (largest aneurysm diameter, neck diameter and diameter of the nutrition vessel). Risk estimates were calculated using a logistic regression model. Aneurysm size parameters were stratified according to receiver operating characteristic (ROC) curves. Finally, we calculated odds ratios for rupture based on the ROC analysis. Results: The mean largest diameter for the ruptured versus unruptured groups was 13.3 ± 1.7 mm versus 22.2 ± 2.2 mm (p < 0.001). Multivariate analysis revealed a positive correlation between rupture and arterial hypertension (p < 0.001) and an inverse correlation with all three angiographic measurements (all p < 0.01). Aneurysms from the anterior cerebral artery bled more often (p < 0.05). According to the ROC curves, at the largest diameter of 15 mm, the sensitivity and specificity to predict rupture were 83% and 36%, respectively. Based on this stratification, we calculated the chance of rupture for aneurysms smaller than 15 mm as 46%, which dropped to 25% for larger aneurysms. Conclusion: In the population studied at our institution, small aneurysms were more prone to bleeding. Therefore, the need for intervention for small aneurysms should not be overlooked.

RESUMO Grandes estudos multicêntricos demostram que aneurismas intracranianos pequenos são associados a risco de sangramento mínimo. Outras grandes séries têm evidenciado que aneurismas rotos são em sua maioria os pequenos. Neste estudo questionamos até que ponto os aneurismas pequenos não são perigosos. Métodos: Avaliamos 290 novos casos de aneurismas tratados em nossa instituição durante 6 anos (43,7% rotos). Realizamos análises multivariadas com aspectos epidemiológicos dos pacientes, doenças cardiovasculares e três parâmetros angiográficos: maior diâmetro, diâmetro do colo e diâmetro do vaso nutridor do aneurisma. Estimativas de risco foram calculadas utilizando-se modelo de regressão logística. Parâmetros do tamanho aneurismático foram estratificados de acordo com curvas ROC. Também calculamos a razão de chances (odds ratios) de ruptura baseadas nas análises das curvas ROC. Resultados: O maior diâmetro médio para os grupos de aneurismas rotos e não-rotos foi 13.3 ± 1.7mm e 22.2 ± 2.2 (p < 0.001). Análises multivariadas revelaram uma correlação positiva entre ruptura aneurismática e hipertensão arterial (p < 0.001) e uma correlação inversa entre ruptura e as três medidas angiográficas (p < 0.01). Aneurismas da artéria cerebral anterior foram os que mais sangraram (p < 0.05). Análises das curvas ROC demonstram que no maior diâmetro de 15mm, a sensibilidade e especificidade para se predizer ruptura são de 83% e 36%. Baseando-se nessas estratificações, calculamos uma chance de ruptura para aneurismas menores de 15mm de 46% e de 25% para aneurismas maiores. Conclusão: Na população estudada, aneurismas pequenos são mais propensos a romper. Desta forma, a necessidade de intervenção para aneurismas pequenos não deve ser relevada.

The safety and efficacy of tPA intravenous thrombolysis for treating acute ischemic stroke patients with a history of cerebral hemorrhage

Alteplase (tPA) intravenous thrombolysis is an effective treatment for acute ischemic stroke (AIS) when administered within 4.5 h of initial stroke symptoms. Here, its safety and efficacy were evaluated among AIS patients with a previous history of cerebral hemorrhage. Patients who arrived at the hospital within 4.5 h of initial stroke symptoms and who were treated with tPA intravenous thrombolysis or conventional therapies were analyzed. The 90-day modified Rankin scale (90-d mRS) was used alongside mortality and incidence of symptomatic intracerebral hemorrhage (SICH) rates to evaluate the curative effect of these therapies. Among 1,694 AIS patients, 805 patients were treated with intravenous thrombolysis, including patients with (n=793) or without (n=12) a history of cerebral hemorrhage, and the rate of incidence of SICH significantly differed between them (8.3 vs 4.3%, P=0.039). No significant difference was found in 90-d mRS measurements (41.7 vs 43.6%, P=0.530) and 90-d mortality rates (8.3 vs 6.5%, P=0.946). A total of 76 AIS patients with a history of cerebral hemorrhage received tPA thrombolytic therapy (n=12) or conventional therapy (n=64), and a significant difference was noted in the 90-d mRS scores between the two groups (41.7 vs 23.4%, P=0.029), while no significant difference was found in SICH measurements (8.3 vs 4.6%, P=0.610) and 90-d mortality rates (8.3 vs 9.4%, P=0.227). A history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy; tPA intravenous thrombolysis does not increase SICH measurements and mortality rates in patients with a history of cerebral hemorrhage, and they may benefit from thrombolytic therapy.

Caracterización epidemiológica de pacientes con enfermedad cerebral vascular aguda en un hospital de Chile en base a registros de grupos relacionados al diagnóstico / An epidemiological characterization of patients with acute stroke in a single Chilean hospital using diagnosis-related group registers

Resumen Introducción Las enfermedades cerebrales vasculares son la primera causa específica de muerte y discapacidad en Chile. Objetivo Analizar características epidemiológicas de pacientes hospitalizados con diagnóstico de accidentes vasculares cerebrales en el Complejo Asistencial Víctor Ríos Ruiz. Metodología Estudio observacional, transversal. Se analizaron los egresos hospitalarios con diagnóstico de accidentes vasculares cerebrales entre 2014 y 2017. Se recolectaron datos sobre el diagnóstico de accidentes vasculares cerebrales mediante registro CIE 10, datos demográficos, tipo de accidentes vasculares cerebrales y datos respecto de la letalidad y estadía intrahospitalaria. Las variables cuantitativas fueron expresadas mediante promedios y desviación estándar (± DS) mientras que las variables categóricas fueron evaluadas mediante frecuencias absolutas y relativas. Las diferencias entre las variables fueron analizadas mediante T de Student y ANOVA de un factor. Se consideraron resultados significativos los valores p < 0,05. Resultados Se caracterizó un total de 1856 egresos, 58,6% fueron hombres, edad media de 66,9 (± 13,9) años y estadía media de 10,4 (± 16,7) días. En mujeres, la edad media fue 69,9 (± 16) años y estadía media 11,1 (± 16,5) días. El 55,5% correspondió a accidentes vasculares cerebrales isquémicos y 17,4% accidentes vasculares cerebrales hemorrágicos. Los principales factores de riesgo fueron hipertensión arterial (72%) y diabetes mellitus (33%). La letalidad intrahospitalaria global fue de 10,6%. Tanto la letalidad y estadía prolongada estuvieron asociadas a hemorragia subaracnoidea y accidentes vasculares cerebrales hemorrágicos (valor p < 0,05). Conclusiones La prevalencia de accidentes vasculares cerebrales es similar en hombres y mujeres. La hipertensión arterial fue el factor de riesgo más prevalente. A pesar de que el accidente vascular cerebral isquémico fue el más frecuente, la hemorragia subaracnoidea y el accidente cerebral vascular hemorrágico fueron relacionados con una mayor letalidad y estadía prolongada.

Abstract Introduction Stroke is the leading cause of death and disability in Chile. Objective To analyze the epidemiological characteristics of hospitalized patients with a diagnosis of stroke in our hospital unit (Complejo Asistencial Víctor Ríos Ruiz). Methods We performed an observational, cross-sectional study. We included patients who were discharged from our hospital with a diagnosis of stroke between 2014 and 2017. We extracted data on stroke-related ICD codes, demographic variables, types of stroke, case fatality rates, and hospital stay. Quantitative variables were expressed as averages with standard deviation (± SD), and categorical variables were expressed as absolute and relative frequencies. Differences were analyzed using Student t-distribution and ANOVA. We defined a p-value of < 0.05 as statistically significant. Results In total, 1856 patients were discharged of which 58.6% were male, with an average age of 66.9 (± 13.9) years, and an average stay of 10.4 (± 16.7) days. In the female population, the average age was 69.9 (± 16), and the average hospitalization was 11.1 (± 16.5) days. 55.5% of stroke cases was ischemic, and 17.4% was hemorrhagic. The main risk factors were hypertension (72%) and type 2 diabetes (33%). We found an overall in-hospital case fatality rate of 10.6%. Both the case fatality rate and prolonged in-hospital stay were associated with subarachnoid hemorrhage and hemorrhagic stroke (p < 0.05). Conclusions Prevalence of stroke is similar in both men and women. Hypertension was the leading risk factor associated with acute stroke. Although ischemic stroke was the most frequent diagnosis, both subarachnoid hemorrhage and hemorrhagic stroke were related to an increased case fatality rate and a more extended hospital stay.

Hemorrhagic stroke following viper bites and delayed antivenom administration: three case reports from the Western Brazilian Amazon

Abstract Snakebites were included by the World Health Organization in their list of neglected diseases. In Latin America, most snakebites are caused by species of the Viperidae family, notably by the genus Bothrops. Bothrops atrox accounts for 90% of the cases of envenoming in the Brazilian Amazon. In this report, we present a series of three cases of snakebites that evolved with hemorrhagic stroke due to delays in the access to antivenom in the Brazilian Amazon, being fundamental for diagnosis to validate the clinical suspicion and make decisions that would improve the treatment and prognosis of the patients.

Evacuación de hematoma subdural crónico: hemorragia de Duret postoperatoria y restitución ad-integrum. A propósito de un caso / Evacuation of chronic subdural hematoma: postoperative Duret hemorrhage and ad-integrum replacement. About a case

El tratamiento de elección para la evacuación de hematoma subdural crónico es la evacuación mediante orificio de trépano. Las complicaciones más frecuentes son recurrencia, neumoencefalo, convulsiones, hemorragia intracraneal y en otros sitios. La hemorragia del tronco cerebral secundaria a la cirugía es extremadamente rara. Aquí presentamos un paciente masculino de 72 años, que ingresa con GSC 9/15, hemiparesia izquierda 2/5. Con HSD crónico bilateral con desplazamiento de línea media de 1.5 cm. hacia izq. Al cual se realiza evacuación de HSD derecho. Y en el POP se detecta GSC 12/15, lado izquierdo fuerza 5/5, con hemiparesia derecha a predominio braquial. TC control POP: adecuada evacuación de HSD y lesión hiperdensa protuberancial. Es externado al 6to día POP con GSC 14/15 sin déficit motor. Este reporte, además de abordar la bibliografía actual y fisiopatología; agrega otro caso para reafirmar la posibilidad de pronóstico favorable en ésta patología

ABSTRACT The treatment of choice for the evacuation of chronic subdural hematoma is evacuation through a trepan orifice. The most frequent complications are recurrence, re-accumulation of the hematoma, pneumoencephalus, seizures, intracranial hemorrhage and elsewhere. Brainstem hemorrhage secondary to surgery is extremely rare. Here we present a 72-year-old male patient, admitted with GSC 9/15, left hemiparesis 2/5. Without obeying orders. With bilateral chronic HSD with midline displacement of 1.5 cm. to left; to which evacuation of right HSD is performed. And in the POP GSC 12/15 is detected, left side force 5/5, with right hemiparesis to brachial predominance. POP control CT: adequate evacuation of HSD and hyperdense pontine lesion. It is extership to the 6th day POP with GSC 14/15 without motor deficit. This report, besides addressing the current bibliography and physiopathology; adds another case to reaffirm the possibility of favorable prognosis in this pathology

The Effects of Balloon-Guide Catheters on Outcomes after Mechanical Thrombectomy in Acute Ischemic Strokes: A Meta-Analysis

OBJECTIVE: Mechanical thrombectomies with balloon-guide catheters (BGC) are thought to improve successful recanalization rates and to decrease the incidence of distal emboli compared to thrombectomies without BGC. We aimed to assess the effects of BGC on the outcomes of mechanical thrombectomy in acute ischemic strokes.METHODS: Studies from PubMed, EMBASE, and the Cochrane library database from January 2010 to February 2018 were reviewed. Random effect model for meta-analysis was used. Analyses such as meta-regression and the “trim-and-fill” method were additionally carried out.RESULTS: A total of seven articles involving 2223 patients were analyzed. Mechanical thrombectomy with BGC was associated with higher rates of successful recanalization (odds ratio [OR], 1.632; 95% confidence interval [CI], 1.293–2.059). BGC did not significantly decrease distal emboli, both before (OR, 0.404; 95% CI, 0.108–1.505) and after correcting for bias (adjusted OR, 1.165; 95% CI, 0.310–4.382). Good outcomes were observed more frequently in the BGC group (OR, 1.886; 95% CI, 1.564–2.273). Symptomatic intracranial hemorrhage and mortality did not differ significantly with BGC use.CONCLUSION: Our meta-analysis demonstrates that BGC enhance recanalization rates. However, BGC use did not decrease distal emboli after mechanical thrombectomies. This should be interpreted with caution due to possible publication bias and heterogeneity. Additional meta-analyses based on individual patient data are needed to clarify the role of BGC in mechanical thrombectomies.

Hemorrhagic Moyamoya Disease : A Recent Update

Moyamoya disease (MMD) is a progressive cerebrovascular disease with unknown etiology, characterized by bilateral stenoocclusive changes at the terminal portion of the internal carotid artery and an abnormal vascular network formation at the base of the brain. MMD has an intrinsic nature to convert the vascular supply for the brain from internal carotid (IC) system to the external carotid (EC) system, as indicated by Suzuki’s angiographic staging. Insufficiency of this ‘IC-EC conversion system’ could result not only in cerebral ischemia, but also in intracranial hemorrhage from inadequate collateral anastomosis, both of which represent the clinical manifestation of MMD. Surgical revascularization prevents cerebral ischemic attack by improving cerebral blood flow, and recent evidence further suggests that extracranial-intracranial bypass could powerfully reduce the risk of re-bleeding in MMD patients with posterior hemorrhage, who were known to have extremely high re-bleeding risk. Although the exact mechanism underlying the hemorrhagic presentation in MMD is undetermined, most recent angiographic analysis revealed the characteristic angio-architecture related to high re-bleeding risk, such as the extension and dilatation of choroidal collaterals and posterior cerebral artery involvement. We sought to update the current management strategy for hemorrhagic MMD, including the outcome of surgical revascularization for hemorrhagic MMD in our institute. Further investigations will clarify the optimal surgical strategy to prevent hemorrhagic manifestation in patients with MMD.

Meta-Analysis of Endovascular Treatment for Acute M2 Occlusion

OBJECTIVE: Endovascular treatment (EVT) outcomes for acute M2 segment of middle cerebral artery occlusion remains unclear because most results are obtained from patients with large artery occlusion in the anterior circulation. The objective of this study was to assess procedural outcomes for acute M2 occlusion and compare outcomes according to thrombus location (M1 vs. M2).METHODS: A systematic review was performed for online literature published from January 2004 to December 2016. Primary outcome was successful recanalization rate and symptomatic intracranial hemorrhage (S-ICH) after the procedure. A fixed effect model was used if heterogeneity was less than 50%.RESULTS: Eight articles were included. EVT showed successful recanalization rate of 69.1% (95% confidence interval [CI], 54.9–80.4%) and S-ICH rate of 6.1% (95% CI, 4.5–8.3%). The rates of good clinical outcome at 3 months and mortality were 59.4% (95% CI, 49.9–68.2%) and 14.9% (95% CI, 11.4–19.3%), respectively. According to thrombus location (M1 vs. M2), successful recanalization (odds ratio [OR], 1.539; 95% CI, 0.293–8.092; p=0.610) and S-ICH (OR, 1.313; 95% CI, 0.603–2.861; p=0.493) did not differ significantly. Good clinical outcome was more evident in M2 occlusion after EVT than that in M1 occlusion (OR, 1.639; 95% CI, 1.135–2.368; p=0.008). However, mortality did not differ significantly according to thrombus location (OR, 0.788; 95% CI, 0.486–1.276; p=0.332).CONCLUSION: EVT seems to be technically feasible for acute M2 occlusion. Direct comparative studies between EVT and medical treatment are needed further to find specific beneficiary group after EVT in patient with M2 occlusion.

Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease

OBJECTIVE: To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).METHODS: A single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation.RESULTS: Forty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications.CONCLUSION: Hybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.

Cost-Effectiveness of Rivaroxaban Compared to Warfarin for Stroke Prevention in Atrial Fibrillation

BACKGROUND AND OBJECTIVES: Rivaroxaban is noninferior to warfarin for preventing stroke or systemic embolism in patients with high-risk atrial fibrillation (AF) and is associated with a lower rate of intracranial hemorrhage (ICH). We assessed the cost-effectiveness of rivaroxaban compared to adjusted-dose warfarin for the prevention of stroke in patients with nonvalvular AF. METHODS: We built a Markov model using the Korean Health Insurance Review & Assessment Service database. The base-case analysis assumed a cohort of patients with prevalent AF who were aged 18 years or older without contraindications to anticoagulation. RESULTS: Number of patients with CHA2DS2-VASc scores 0, 1 and ≥2 were 56 (0.2%), 1,944 (6.3%) and 28,650 (93.5%), respectively. In patients with CHA2DS2-VASc scores ≥2, the incidence rate of ischemic stroke was 3.11% and 3.76% in warfarin and rivaroxaban groups, respectively. The incidence rates of ICH were 0.42% and 0.15%, and those of gastrointestinal bleeding were 0.32% and 0.15% in warfarin and rivaroxaban, respectively. Patients with AF treated with rivaroxaban lived an average of 11.8 quality-adjusted life years (QALYs) at a lifetime treatment cost of $20,886. Those receiving warfarin lived an average of 11.4 QALYs and incurred costs of $17,151. Patients with rivaroxaban gained an additional 0.4 QALYs over a lifetime with an additional cost of $3,735, resulting in an incremental cost-effectiveness ratio of $9,707 per QALY. CONCLUSIONS: Patients who had been treated with rivaroxaban may be a cost-effective alternative to warfarin for stroke prevention in Korean patients with AF.

The Effects of Balloon-Guide Catheters on Outcomes after Mechanical Thrombectomy in Acute Ischemic Strokes: A Meta-Analysis

OBJECTIVE: Mechanical thrombectomies with balloon-guide catheters (BGC) are thought to improve successful recanalization rates and to decrease the incidence of distal emboli compared to thrombectomies without BGC. We aimed to assess the effects of BGC on the outcomes of mechanical thrombectomy in acute ischemic strokes. METHODS: Studies from PubMed, EMBASE, and the Cochrane library database from January 2010 to February 2018 were reviewed. Random effect model for meta-analysis was used. Analyses such as meta-regression and the “trim-and-fill” method were additionally carried out. RESULTS: A total of seven articles involving 2223 patients were analyzed. Mechanical thrombectomy with BGC was associated with higher rates of successful recanalization (odds ratio [OR], 1.632; 95% confidence interval [CI], 1.293–2.059). BGC did not significantly decrease distal emboli, both before (OR, 0.404; 95% CI, 0.108–1.505) and after correcting for bias (adjusted OR, 1.165; 95% CI, 0.310–4.382). Good outcomes were observed more frequently in the BGC group (OR, 1.886; 95% CI, 1.564–2.273). Symptomatic intracranial hemorrhage and mortality did not differ significantly with BGC use. CONCLUSION: Our meta-analysis demonstrates that BGC enhance recanalization rates. However, BGC use did not decrease distal emboli after mechanical thrombectomies. This should be interpreted with caution due to possible publication bias and heterogeneity. Additional meta-analyses based on individual patient data are needed to clarify the role of BGC in mechanical thrombectomies.