Trends in prior antithrombotic medication and risk of in-hospital mortality after spontaneous intracerebral hemorrhage: the J-ICH registry.

Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes, but the effects of direct oral anticoagulants (DOACs) remain unclear. This study aimed to clarify trends in prior antithrombotic use and to assess the associations between prior use of antithrombotics and in-hospital mortality using a multicenter prospective registry in Japan. In total, 1085 patients were analyzed. Prior antithrombotic medication included antiplatelets in 14.2%, oral anticoagulants in 8.1%, and both in 1.8%. Prior warfarin use was significantly associated with in-hospital mortality (odds ratio [OR] 5.50, 95% confidence interval [CI] 1.30-23.26, P < 0.05) compared to no prior antithrombotic use. No such association was evident between prior DOAC use and no prior antithrombotic use (OR 1.34, 95% CI 0.44-4.05, P = 0.606). Concomitant use of antiplatelets and warfarin further increased the in-hospital mortality rate (37.5%) compared to warfarin alone (17.2%), but no such association was found for antiplatelets plus DOACs (8.3%) compared to DOACs alone (11.9%). Prior use of warfarin remains an independent risk factor for in-hospital mortality after SICH in the era of DOACs. Further strategies are warranted to reduce SICH among patients receiving oral anticoagulants and to prevent serious outcomes.

Unusually elongated superior thyroid cornu associated with recurrent cerebral embolisms.

The superior thyroid cornu (STC) is a normal anatomic structure that forms part of the thyroid cartilage. Here, we report a patient with unusually elongated and ossified STC that might result in recurrent cerebral embolisms. During a second endovascular therapy for recurrent middle cerebral artery embolism, a segment with an irregular filling defect was noted in the internal carotid artery (ICA), at the C1 level. This defect was unnoticed during the initial endovascular procedure. Three-dimensional computed tomography angiography performed after the second endovascular procedure revealed an ICA segment located between the STC and C1 with a tortuous course and irregular wall of the ICA. Therefore, we assumed that STC compression of the ICA could have resulted in thrombus formation at the site and consequent cerebral embolism. The STC should be considered a structure responsible for cerebral embolism. Careful evaluation of the entire ICA course is imperative prior to performing an endovascular thrombectomy for acute embolic occlusion of the middle cerebral artery.

Cholesterol Crystals in the Retrieved Thrombus by Mechanical Thrombectomy for Cerebral Embolism: A Case Report and Literature Review.

There are only a few case reports in which cholesterol crystals were found in the thrombus retrieved by mechanical thrombectomy for cryptogenic stroke, leading to a definitive diagnosis. We herein report a case of aortogenic embolic stroke diagnosed by the presence of rich cholesterol crystals in the retrieved thrombus and review the previously reported cases. A woman in her 80s was transferred as an emergency due to consciousness disturbance, right conjugate deviation, and severe left hemiparesis. Magnetic resonance imaging showed occlusion of the right middle cerebral artery (MCA) and acute infarction in the territory. The MCA was recanalized by thrombectomy using an aspiration catheter and stent retriever, and the symptoms improved. Although the physiological examination did not detect the embolic source during hospitalization, pathological examination of the thrombus revealed atheroma with numerous cholesterol crystal clefts and intermixing of fibrin. Contrast-enhanced computed tomography performed based on the pathological results showed atheromatous lesions in the aortic arch as the embolic source. As a subsequent treatment, medications of a strong statin and an antiplatelet agent were continued, and the patient had no recurrence. The finding that the retrieved thrombus is a simple atheroma containing cholesterol crystals with poor hemocytes suggests embolism due to plaque rupture. Pathological examination of the thrombus obtained by thrombectomy is one of the useful diagnostic approaches for stroke etiology and the determination of its treatment.

Malignant Subdural Hematoma Associated with High-Grade Meningioma.

A 70-year-old man, who had previously undergone surgical resection of left parasagittal meningioma involving the middle third of the superior sagittal sinus (SSS) two times, presented with recurrence of the tumor. We performed removal of the tumor combined with SSS resection as Simpson grade II. After tumor removal, since a left dominant bilateral chronic subdural hematoma (CSDH) appeared, it was treated by burr hole surgery. However, because the CSDH rapidly and repeatedly recurred and eventually changed to acute subdural hematoma, elimination of the hematoma with craniotomy was accomplished. The patient unfortunately died of worsening of general condition despite aggressive treatment. Histopathology of brain autopsy showed invasion of anaplastic meningioma cells spreading to the whole outer membrane of the subdural hematoma. Subdural hematoma is less commonly associated with meningioma. Our case indicates the possibility that subdural hematoma associated with meningioma is formed by a different mechanism from those reported previously.

Comparative efficacy of granular and bagged formulations of the hemostatic agent QuikClot.

BACKGROUND: QuikClot is a zeolite-based dressing approved and deployed by military for the arrest of severe combat-induced hemorrhage. A novel formulation (bagged QuikClot [ACS]) of the original granular QuikClot (QC) has been proposed to facilitate the application of the hemostatic dressings under battlefield conditions. This study compares the hemostatic efficacy of ACS and QC in controlling blood loss and improving survival in a swine model of uncontrolled hemorrhage induced by complex groin injury. METHODS: After transection of the femoral vasculature, anesthetized Yorkshire pigs (n = 32) were hemorrhaged for 3 minutes and randomized into four groups: no treatment (NONE) or application of standard dressing (SD), QC, or ACS. At 15 minutes, resuscitation was initiated by infusion of 500 mL Hextend during a span of 30 minutes. Vital signs were continuously recorded throughout the 4-hour experimental period. In addition, blood loss and temperature at the dressing and tissue interface were continuously recorded. RESULTS: After 3 minutes, average blood loss was 44.7% +/- 11.9% estimated blood volume (EBV) for all animals (34.1 +/- 3.2 kg). Posttreatment blood loss was significantly higher (p < 0.01) for NONE- and SD-treated animals (31.5% +/- 21.8% and 22.3% +/- 12.6% EBV, respectively) as compared with animals treated with QC and ACS (7.4% +/- 7.1% and 10.3% +/- 6.9%, respectively). All NONE animals died at approximately 60 minutes. Times until death were slightly greater for animals treated with SD (96.8 minutes) and significantly greater for animals treated with QC (188 minutes) and ACS (194 minutes). Overall survival to 4 hours for SD (1 of 8, 12.5%) was significantly lower (p < 0.02) than for QC (6 of 8, 75%) and for ACS (6 of 8, 75%) treatments. Elevated temperatures at the dressing and tissue interface were seen in animals treated with QC and ACS (average at 8 minutes was 58.1 +/- 4.5 degrees C and 58.2 +/- 5.3 degrees C, respectively) compared with SD treated animals (38.8 +/- 2.7 degrees C). Histologic examination revealed more edema in muscular tissue of animals treated with ACS as compared with in QC-treated animals. CONCLUSIONS: ACS was as efficacious as original granular QC in inducing hemostasis and improving survival as compared with the efficacy of SD. Easier and more rapid application and complete removal of ACS may offer a distinct advantage in battlefield resuscitation efforts to enhance a clean wound site and eventual surgical repair.