Impact of Antithrombotic Medications and Reversal Strategies on the Surgical Management and Outcomes of Traumatic Acute Subdural Hematoma.

OBJECTIVE: Careful hematologic management is required in surgical patients with traumatic acute subdural hematoma (aSDH) taking antithrombotic medications. We sought to compare outcomes between patients with aSDH taking antithrombotic medications at admission who received antithrombotic reversal with patients with aSDH not taking antithrombotics. METHODS: Retrospective review identified patients with traumatic aSDH requiring surgical evacuation. The cohort was divided based on antithrombotic use and whether pharmacologic reversal agents or platelet transfusions were administered. A 3-way comparison of outcomes was performed between patients taking anticoagulants who received pharmacologic reversal, patients taking antiplatelets who received platelet transfusion, and patients not taking antithrombotics. Multivariable regressions, adjusted for injury severity, further investigated associations with outcomes. RESULTS: Of 138 patients who met inclusion criteria, 13.0% (n = 18) reported taking anticoagulants, 16.7% (n = 23) reported taking antiplatelets, and 3.6% (n = 5) reported taking both. Patients taking antiplatelets who received platelet transfusion had longer intraoperative times (P = 0.040) and higher rates of palliative care consultations (P = 0.046) compared with patients taking anticoagulants who received pharmacologic reversal and patients not taking antithrombotics. Across groups, no significant differences were found in frequency of in-hospital intracranial hemorrhage and venous thromboembolism, length of hospital stay, rate of inpatient mortality, or follow-up health status. In multivariable analysis, intraoperative time remained longest for the antiplatelets with platelet transfusion group. Other outcomes were not associated with patient group. CONCLUSIONS: Among surgical patients with traumatic aSDH, those taking antiplatelet medications who receive platelet transfusions experience longer intraoperative procedure times and higher rates of palliative care consultation. Comparable outcomes were observed between patients receiving antithrombotic reversal and patients not taking antithrombotics.

Melatonin Ameliorates Hemorrhagic Transformation via Suppression of ROS-Induced NLRP3 Activation after Cerebral Ischemia in Hyperglycemic Rats.

Melatonin is a strong antioxidant which beneficially protects against middle cerebral artery occlusion (MCAO) followed by hemorrhagic transformation in rats; protection includes the reduction of neurological deficits, infarction, and hematoma volume. The molecular mechanisms underlying these neuroprotective effects in the MCAO model have not been clearly identified. This study examined the influence and involved mechanism of melatonin on inflammation in hemorrhagic transformation following hyperglycemia MCAO rat model. Compared with the MCAO group, MCAO+dextrose (DX) group showed worse neurological function and higher infarction and hematoma volume. Interestingly, the protein expression of Nod-like receptor protein 3 (NLRP3) inflammasome increased in the MCAO+DX group compared with the MCAO group, which indicated that NLRP3 inflammasome may be involved in the DX-induced hemorrhagic transformation following MCAO. Then, three dosages of melatonin were intraperitoneally injected 2 h after MCAO induction. Melatonin treatment attenuated inflammatory response by inhibiting the reactive oxygen species (ROS) and NLRP3 inflammasome, alleviating neuronal injury, and reducing infarction and hematoma volume, finally improving neurological score. Melatonin also repressed cortical levels of proinflammatory cytokine IL-1ß, which were increased 24 h after hyperglycemia MCAO. In order to identify the potential mechanisms, we further revealed that nigericin administration reversed the neuroprotective effect of melatonin by promoting NLRP3 inflammasome activation. In general, this present study reveals that melatonin prevents the occurrence of hyperglycemia-enhanced hemorrhagic transformation, and this effect might be beneficial to attenuate neurological dysfunction via suppressing the inflammatory response after MCAO which possibly associated with the inhibition of the ROS/NLRP3 inflammasome pathway.

Low Risk of Traumatic Intracranial Hematoma Expansion with Factor Xa Inhibitors without Andexanet Reversal.

BACKGROUND: Andexanet alfa, a novel anticoagulation reversal agent for factor Xa inhibitors, was recently approved. Traumatic intracranial hemorrhage presents a prime target for this drug. The Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors study established the efficacy of andexanet alfa in reversing factor Xa inhibitors. However, the association between anticoagulation reversal and traumatic intracranial hemorrhage progression is not well understood. The objective of this study was to determine progression rates of patients with traumatic intracranial hemorrhage on factor Xa inhibitors prior to hospitalization who were managed without the use of andexanet alfa. METHODS: A retrospective cohort study was performed between 2016 and 2019 at a single institution. An institutional traumatic brain injury (TBI) registry was queried. Patients with recorded use of apixaban or rivaroxaban <18 hours before injury were included. The primary study outcome was <35% increase in hemorrhage volume or thickness on repeated head computed tomography (CT) scans. RESULTS: We identified 25 patients meeting the inclusion criteria. Two patients were excluded because of a lack of necessary CT data. Twelve patients (52%) were receiving apixaban, and 11 were (48%) on rivaroxaban. On admission CT scan, 14 patients had subdural hematoma, 6 had traumatic intraparenchymal hemorrhage, and 3 had subarachnoid hemorrhage. Anticoagulation reversal was attempted in 17 patients (74%), primarily using 4-factor prothrombin complex concentrate. Twenty patients (87%) were adjudicated as having excellent or good hemostasis on repeat imaging. CONCLUSIONS: Our results indicate that patients on factor Xa inhibitors with complicated mild TBI have a similar intracranial hemorrhage progression rate to patients who are not anticoagulated or anticoagulated with a reversible agent. The hemostatic outcomes in our cohort were similar to those reported after andexanet alfa administration.

Intracranial Subdural Hematoma after Spinal Anesthesia: Report of Two Cases with different Outcomes

Spinal anesthesia is a technique commonly used for local anesthesia and in obstetric surgeries. Rarely, the formation of an intracranial subdural hematoma (SDH) may result from spinal anesthesia, constituting a serious condition that often leads to severe neurological deficits. The presentation and course of this pathology may occur in a completely different way, which makes its diagnosis and management difficult. In the present article, the authors report two cases of patients with intracranial SDH after spinal anesthesia with completely different presentations and outcomes, demonstrating the variability of the manifestations of this condition. A quick review of key points of its pathophysiology, symptomatology, diagnosis, and treatment was also performed.

Review of the Management of Infected Subdural Hematoma.

OBJECTIVE: Infection of a subdural hematoma is an unusual cause of subdural empyema, with fewer than 50 cases reported in the literature. The appropriate surgical option for this entity has not been determined because of its rarity. We present a case report of a post-traumatic subdural hematoma infected with Escherichia coli that was successfully treated with craniotomy. In addition, we performed a PubMed search to comprehensively illustrate the causative organism, source of infection, clinical picture, surgical treatment, and outcome for this condition. This article presents an update on the condition. CASE DESCRIPTION: A 55-year-old man was admitted to our hospital complaining of headache, seizure, and urinary incontinence. He had a history of alcoholism and several hospitalizations for mild head trauma. Neuroimaging studies revealed a chronic hematic collection in the left frontal-parietal region. Laboratory tests showed increased C-reactive protein levels. In addition, surgical results revealed an infected subdural hematoma. A bacterial culture of the purulent specimen identified E. coli. In view of the urinary complaint and leukocyturia, the cause of the infected subdural hematoma was postulated as a urinary tract infection. CONCLUSIONS: Infected subdural hematoma is an unusual disorder. We must keep in mind the possibility of this complication when seeing a patient who presents with any of the 3 most common symptoms in this review. In these patients, craniotomy should be the method of surgical drainage, especially in adults. It ensures maximal drainage of the loculated pus and allows the total removal of the infected hematoma capsule.

Delayed left ventricular apical thrombus formation following discontinuation of dual anti-platelet therapy.

Delayed de novo left ventricular apical thrombus following a distant antero-apical myocardial infarction has to our knowledge not been previously reported. Herein we describe a patient who developed an apical thrombus 18 months after his initial infarct following cessation of dual anti-platelet therapy for a traumatic subdural haematoma requiring surgical evacuation.

Intracranial hematoma as the cause of headache after subarachnoid anesthesia for cesarean section--a case report.

BACKGROUND: Intracranial subdural hematoma is an exceptionally rare but life-threating complication of epidural and spinal anesthesia. The diagnosis is rather difficult because the initial symptoms mimic post-dural puncture headache. CASE REPORT: A 33-year-old primipara was admitted to the hospital at 38 weeks gestation for a cesarean section due to premature rupture of membranes and meconium stained amniotic fluid. During the procedure a single puncture between L2 and L3 vertebrae was made with the use of a 26-gauge, pencil-point needle. The amount of 2.8 ml of analgesic solution was administered in order to obtain subarachnoid analgesia at the level of Th4 and Th5 vertebrae. Postpartum recovery was uneventful for the first two days. On the third day the patient developed strong headache in the forehead area and tinnitus. An anesthesiologist diagnosed post-dural puncture headache (PDPH). The patient received 1 g of Paracetamol every 6 hours intravenously together with 3000 ml of crystalloid solution for 24 hours. As a result, the patient recovered and was discharged home with her infant. Five days later the patient presented at the neurology clinic because of strong and chronic temporal lobe headache. No other complaints were reported. Upon admission, the patient had a head CT followed by an MRI examination, which revealed cranial hematomas localized bilaterally in the area of the frontal, temporal and parietal lobes, spreading from the cranial vault to the skull base. The width of the hematomas was: 3-4 mm on the left and 5-6 mm on the right side. Hematomas infiltrated the anterior part of the medial longitudinal fissure. Magnetic resonance angiography showed normal images of the arteries, veins, and the dural venous sinuses. No vascular malformations, which may be a source of intracranial hemorrhage, were found. Other tests showed normal results. Patient condition during hospitalization was stable. Conservative treatment was implemented, i.e. fluids administered intravenously anti-edematous drugs, analgesic medications and bed rest. All pain complaints subsided and a control CT scan showed that hematomas evolved as expected i.e. their HU density decreased. About 6 weeks later the patient had a CT head scan, performed in outpatient settings, which showed complete absorption of extravasated blood. CONCLUSION: The presented case shows headaches in obstetric patients require thorough diagnostic examinations and appropriate management. In addition to the most typical PDPH, it may be the first sign of life-threatening intracranial pathology

[Local fibrinolysis in treatment of non-traumatic intracerebral hematomas and ventricular hemorrhages].

Local fibrinolysis and aspiration in treatment of spontaneous intracerebral hematomas (SIH) and ventricular hemorrhages (VH) have become a wide spread technique in dedicated cerebrovascular centers. Forty four patients treated in Burdenko NSI in 2007-2011 were evaluated. Local fibrinolysis for SIH were perfomed in 30 pt., for isolated VH in 14. Puroplazan, a prourokinaze based derivative (mean dose - 50 000 ME) were used in 36 cases, Actilyse (tPA) (2.0 g mean) in 8 cases. Status at discharge was improved in 66.7% of patients with SIH and 57.1% of patients with isolated VH. Mortality comprised to 10 and 28.6% correspondingly. Local hematoma aspiration and fibrinolysis is an effective minimally-invasive method of primary and secondary non-traumatic SIH and VH evacuation. Dose of fibrinolytic agent should be selected individually and depends on hematoma volume. Applied dose clinically-wise should be decreased along with reducing of hematoma size and number of injections to minimize recurrent hemorrhage risk.

Post-traumatic interemispheric subdural hematoma: report of two cases and review of the literature.

The interhemispheric subdural hematomas (ISHs) are located along the whole interhemispheric scissure. The ISHs are a rare complication of head traumas. Possible predisposing factors such as coagulopathies, alcohol abuse or anticoagulant therapy are favouring factors. ISHs are rarely accompanied by changes in consciousness and it usually manifests itself with signs of "Falx Syndrome" (controlateral monoparesis of lower extremity or controlateral hemiparesis with lower limb weakness predominating). The treatment can consist of conservative observation or craniotomy and is dictated by the neurological evolution. In literature are described 140 cases since 1940 including our two conservatively managed patients. The salient aspects of ISHs are discussed in an analysis of the pertinent literature.

Outcome of long-term prophylaxis after cerebral hemorrhage in a patient with severe hemophilia B.

Reports of intracerebral hemorrhage (ICH) in patients with hemophilia B are relatively rare. We describe the first clinical results of the use of a monoclonal antibody purified factor IX (FIX) concentrate (Mononine) after an ICH and the long-term outcome of prophylaxis with this product to prevent recurrences. A 44-year-old male with severe hemophilia B was referred to our department because of nausea, vomiting, left lower limb hemiplegia, and left arm paresis. Computed tomography (CT) revealed a right frontal intraparenchymal bleed. The patient was treated with replacement therapy with FIX for 40 days. Computed tomography scans performed on day 40 after the event showed complete disappearance of the cerebral hematoma from the parenchymal tissue. Subsequently, the patient received 25.6 IU/kg(-1) of FIX twice a week. At the 48-month follow-up visit, no more major or minor bleeding events had occurred. Long-term prophylaxis after ICH is recommended.