Endovascular Treatment of Acute MI Occlusions Due To Underlying Intracranial Atherosclerotic Severe Stenosis

Objective: Endovascular treatment (EVT) for acute ischemic stroke with an occlusion of the M1 segment due to intracranial atherosclerotic severe stenosis (ICASS) remains challenging. This study aimed to evaluate the safety and efficacy of EVT for ICASS-related M1 acute occlusion.Methods: We retrospectively reviewed all patients with an ICASS-related M1 acute occlusion underwent EVT at our institution between January 2015 and December 2020. Clinical presentation, baseline characteristics, angiographic and clinical results, technical feasibility, perioperative complications, and follow-up results were evaluated.Results: Twenty-two patients with ICASS-related M1 acute occlusion were included. Eight patients (36.4%) received bridging therapy and the other 14 patients (63.6%) directly underwent EVT. Fifteen patients (68.2%) treated with balloon dilations and stenting as rescue treatment. Six patients (27.3%) received single balloon angioplasty and 5 of these patients treated with staged stenting. One case (4.5%) failed recanalization at the first EVT and successful revascularization was achieved a month later. The mean procedure time was 67.2±20.8 min. Successful revascularization (mTICI≥2b) was achieved in 95.5% (21/22) of patients. Perioperative complications developed in two patients (9.1%) including one hemorrhagic event and one thromboembolic event. Anangiographic follow-up was available in 20 patients (90.9%) at an average of 8.6±3.0 months. The degree of stenosis was worse (10%-30%) in 6 cases (30%) compared with the initial outcomes. The favorable outcomes (mRS≤2) at 3 months follow-up was achieved in 19 patients (86.4%).Conclusions: ICASS-related occlusion in the M1 segment often required a rescue therapy including balloon angioplasty with/without stenting, and this treatment strategy was safe and effective. But single balloon angioplasty at the first EVT generally cannot achieve satisfactory results and often needed staged stenting treatment.

Hemorrhagic Events in Patients Receiving Heparin or Enoxaparin in Combination With Oral Antithrombotics, NSAIDs, and Antiplatelet Medications: A Multi-Center Case-Series Study

Background: Hemorrhagic events are amongst the significant adverse effects of injectable anticoagulants such as heparin and enoxaparin. This undesirable effect needs close monitoring of their use for clinically relevant drug-drug interactions. Objectives: To study the rate of hemorrhagic events, the anatomical site, and the severity of the bleeding in patients receiving heparin or enoxaparin in combination with clopidogrel, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), and warfarin. Methods: We designed a prospective, multi-center, case-series study. Patients admitted to two teaching hospitals who received either an NSAID, or warfarin, or clopidogrel were evaluated. Any hemorrhagic event was recorded by Yellow Card Scheme. Also, the Naranjo scale was utilized for causality assessment.Results: A total of 123 patients were eligible for inclusion. They were admitted between November 2014 and April 2015. Sixty-five patients (52.5%) received heparin and 58 patients (47.2%) received enoxaparin. Of 123 patients, 115 patients (93.5%) received aspirin, 69 (56.1%) warfarin, 34 (27.6%) an antiplatelet medication, and 121 (98.4%) NSAIDs in combination with heparin or enoxaparin. Overall, 26 cases (21.1%) of the hemorrhagic incident were reported, of whom six cases (4.9%) were categorized as major bleeding. Patients receiving heparin constituted the largest proportion among all 26 hemorrhagic incidents (57.7%). All patients with the hemorrhagic incident had aspirin in their medication regimen, while 19 patients (73.0%) were concomitantly receiving warfarin as well. Hematuria (46.2%), hematoma in the injection site (38.5%), and hematoma (34.6%) were the top three types of hemorrhagic events. In Naranjo scale analysis, 19 patients scored more than 9 points, indicating a definite Adverse Drug Reaction (ADR) causality. Moreover, seven patients scored 5 to 8, affirming a possible association with ADR. Conclusion: The risk of hemorrhagic can be influenced by undesirable drug-drug interactions. Close monitoring of high-risk patients is advised to prevent adverse hemorrhagic reactions. Further studies to detect the explanatory factors associated with the hemorrhagic events are recommended.

Subarachnoid Hemorrhage as a Consequence of Pleomorphic Xanthoastrocytoma: A Case Report

BACKGROUND AND IMPORTANCE Pleomorphic xanthoastrocytoma (PXA) is a rare World Health Organization (WHO) grade II lesion considered to portend a good prognosis. However, the literature contains several references of serious intracranial hemorrhages associated with PXAs, although the etiology is poorly understood. CLINICAL PRESENTATION We present the case of a young woman with a Hunt and Hess V, Fisher 4 subarachnoid hemorrhage associated with a right cavernous sinus PXA. The case provides rare baseline angiographic imaging prior to a presenting hemorrhagic event and reveals progressive loss of structural vascular integrity at proximal large vessels. CONCLUSION This case provides insight into the natural history of this entity, tropism for catastrophic vascular injury, and informs surgical management with an emphasis on preoperative vascular imaging and preparation for proximal vascular control with cervical exposure.

AB0778 VENOUS THROMBOSIS IN UNUSUAL SITES

Background:Unusual site venous thrombosis (USVT), which includes venous thromboses of the upper limbs, digestive tract, cellar and brain, are rarely observed compared to those of the lower limbs and require both an etiological approach and a rigorous management.Objectives:Our objective is to identify the epidemiological, clinical, therapeutic and evolutionary characteristics of USVT.Methods:Retrospective study including 33 patients files with USVT followed in The Internal Medicine Departments at Tahar Sfar University Hospital Mahdia TUNISIA over a period of 10 years.Results:They were 21 females (63.6 %) and 12 males (36.4%) with an average age of 45.2 ± 18 years. Cerebral venous thrombosis was the most frequent localization identified in 10 patients (30.3%), followed by gastrointestinal thrombosis in 9 cases (27.3%), vena cava thrombosis in 9 cases (27.3%) and upper limb thrombosis in 5 cases (15.2%). The risk factors were respectively: age (42.4%), obesity (42.4%), smoking (30%), prolonged downtime (24.2%), surgical interventions (6.1%) and pregnancy (3%). An etiology was identified in 21 patients (66.6%), dominated by constitutional thrombophilia (27.3%), followed by BVL (15.1%) and Behçet’s disease (16.4%). Rare causes were neoplasia in one case (3%), scleroderma in one case (3%) and inflammatory bowel disease in one case (3%). The etiological investigation was negative in 36.3% of cases. Treatment was based on heparin therapy followed by vitamin K therapy. Progression was favourable without accident or recurrence in 25 patients (75.5%). Complications were dominated by recurrence in 12.1% of cases, post-thrombotic disease in 6% of cases and pulmonary embolism in 3% of cases. We reported one death related to a hemorrhagic event.Conclusion:USVT is a multifactorial pathology that involves both acquired and constitutional risk factors. Heparin therapy with an early relay by antivitamin K remains the treatment of choice today. The duration of treatment depend on the etiology, the recurrence of venous thrombosis and the risk of hemorrhagic complications.Disclosure of Interests:None declared

Antithrombotic Management and Long-Term Outcomes of Patients with Atrial Fibrillation. Insights from CRAFT Trial

Background: We aimed to compare long-term outcomes in Polish patients with atrial fibrillation (AF) according to oral anticoagulation (OAC) type and to evaluate the predictive value of common thromboembolic and bleeding risk scores. Methods: Data from the CRAFT trial (NCT02987062) were included. The primary study endpoint was major adverse event (MAE; all-cause death, thromboembolic and hemorrhagic event) during the mean four-year follow-up period. Results: Out of 2983 patients with available follow-up data, 1686 (56%) were prescribed with vitamin K antagonist (VKA), 891 (30%) with rivaroxaban and 406 (14%) with dabigatran. Predominance of elderly and female patients with previous history of thromboembolic and hemorrhagic events was observed within rivaroxaban (vs. other OAC) group. Higher rate of MAEs and its components was observed in patients on VKA followed by rivaroxaban as compared to patients on dabigatran (43% vs. 42% vs. 31%, p < 0.01). After group matching based on clinical characteristics, higher risk of hemorrhagic events in VKA (vs. dabigatran) and rivaroxaban (vs. dabigatran) group were observed. The available thromboembolic (CHA2DS2-VASs, ATRIA, R2CHADS2) and bleeding (HAS-BLED, ATRIA, ORBIT) risk scores showed poor prediction value. Conclusions: Despite no difference in the thromboembolic event rate, treatment with VKA and rivaroxaban was associated with a significant increase in the risk of hemorrhagic events.

Anti-Xa activity and hemorrhagic events under extracorporeal membrane oxygenation (ECMO): a multicenter cohort study

Background Hemorrhagic events remain a major concern in patients under extracorporeal membrane oxygenation (ECMO) support. We tested the association between anticoagulation levels and hemorrhagic events under ECMO using anti-Xa activity monitoring. Methods We performed a retrospective multicenter cohort study in three ECMO centers. All adult patients treated with veno-venous (VV)- or veno-arterial (VA)-ECMO in 6 intensive care units between September 2017 and August 2019 were included. Anti-Xa activities were collected until a hemorrhagic event in the bleeding group and for the duration of ECMO in the non-bleeding group. All dosages were averaged to obtain means of anti-Xa activity for each patient, and patients were compared according to the occurrence or not of bleeding. Results Among 367 patients assessed for eligibility, 121 were included. Thirty-five (29%) presented a hemorrhagic complication. In univariate analysis, anti-Xa activities were significantly higher in the bleeding group than in the non-bleeding group, both for the mean anti-Xa activity (0.38 [0.29–0.67] vs 0.33 [0.22–0.42] IU/mL; p = 0.01) and the maximal anti-Xa activity (0.83 [0.47–1.46] vs 0.66 [0.36–0.91] IU/mL; p = 0.05). In the Cox proportional hazard model, mean anti-Xa activity was associated with bleeding (p = 0.0001). By Kaplan–Meier analysis with the cutoff value at 0.46 IU/mL obtained by ROC curve analysis, the probability of survival under ECMO without bleeding was significantly lower when mean anti-Xa was > 0.46 IU/mL (p = 0.0006). Conclusion In critically ill patients under ECMO, mean anti-Xa activity was an independent risk factor for hemorrhagic complications. Anticoagulation targets could be revised downward in both VV- and VA-ECMO.

Prevalence of traumatic brain hemorrhages in brain death patients

Background: Considering the significant burden of brain death and its leading cause in emergency clinical settings, head traumatic intracranial hemorrhage, the most prevalent type of hemorrhagic event in these scenarios, will help us predict the possibility of consequent development of a vegetative state. Methods: This study aimed to assess the prevalence of other intracranial hemorrhages in patients with brain death. 70 head traumatic brain dead patients referred to Masih Daneshvari hospital underwent CT scan assessment to determine the prevalence of major intracranial hemorrhage types and their complications. Results: Subarachnoid (SAH) and subdural (SDH) hemorrhages consisted of the most prevalent intracranial hemorrhage types among patients with brain dead; 45.7 % and 40%, respectively. Overall, hemorrhagic events led to a midline shift in 14.3% and Edema in 12.9% of cases. We noticed midline shift more in SAH subjects while Edema was of higher prevalence among subarachnoid hemorrhages SDH patients. Conclusion: This study found Subarachnoid (SAH) and subdural (SDH) hemorrhages as the most prevalent types of intracranial hemorrhage among head traumatic brain-dead patients.

Ticagrelor versus Clopidogrel in Stent-assisted Coil Embolization of Unruptured Intracranial Aneurysms

Background: In order to prevent thromboembolic events, dual antiplatelet therapy (DAPT) is widely used in stent-assisted coil embolization (SACE) for unruptured intracranial aneurysms (UIAs). Compared to clopidogrel associated with aspirin, knowledge of the safety and efficacy of ticagrelor are lacking in large studies to this date.Methods: A retrospective cohort study from January 2016 to December 2018 with at least one year follow in a single institution and systemic review.Results: Altogether 153 patients with UIA receiving SACE were separated into two groups: 113 patients receiving clopidogrel plus aspirin and 40 patients receiving ticagrelor plus aspirin. Acute in-stent thrombosis events were noted in 2 patients in the clopidogrel group (1.77%) and none in the ticagrelor group (0%). Another 1 patient (0.88%) in the clopidogrel group had an early ischemic stroke (<3 months). Delayed ischemic stroke was noted in 6 patients (5.31%) in the clopidogrel group and 3 patients (7.50%) in the ticagrelor group. There was no major hemorrhagic event in either group. The two groups had no significant differences with regard to ischemic stroke or hemorrhagic stroke.Conclusion: Compared to the clopidogrel based regimen, ticagrelor can reduce thromboembolic events without increasing bleeding tendency for stent-assisted coil embolization of unruptured intracranial aneurysms. Ticagrelor plus aspirin is a safe and effective alternative option for SACE.

Severe Aplastic Anemia as First Manifestation of Classical Hodgkin Lymphoma

Autoimmune cytopenia, a known paraneoplastic complication of lymphoid neoplasms, may occur before, concurrently, at relapse, or even years after completion of lymphoma treatment. In the case of Hodgkin lymphoma (HL), it is thought that immune dysregulation, typical of this neoplasm, may be involved in the genesis of these manifestations. We report a 57-year-old male presenting with stage IIIA, International Prognostic Score (IPS) 4, nodular sclerosis HL, and severe AA (SAA) confirmed on the histologic exam of the bone marrow that showed severe marrow hypoplasia due to a decrease in the elements of the three cell linages with left shift of the myeloid maturation. Immunosuppression with steroids and cyclosporine A was started. Eltrombopag and G-CSF were also added. In spite of prompt initiation of immunosuppressive therapy, the patient presented an unfavorable outcome with progressive pancytopenia and severe acute cerebral hemorrhagic event. The patient died 59 days after admission. Although autoimmune disorders are described in HL, its concomitant diagnosis is extremely rare. Our case shows a rare instance of SAA as the first manifestation of HL.