Spontaneous Haematomas in Anticoagulated Covid-19 Patients: Diagnosis and Treatment by Embolization.

PURPOSE: To assess the safety and efficacy of embolization for spontaneous bleeding in anticoagulated patients with COVID-19. MATERIAL AND METHODS: Single center retrospective study in 9 patients with COVID-19 who experienced bleeding complications following anticoagulation. The study included 8 men and 1 woman aged from 48 to 80 years (mean 69.7 years), who had a total of 10 soft tissue haematomas: 1 in the thigh, 1 in the anterior abdominal wall, 6 retroperitoneal and 2 thoracic haematomas. All patients were referenced for vascular embolization, mostly with Onyx-18. RESULTS: A total of 10 haematomas were embolized in 9 patients. Technical success was achieved in all patients. No complications or adverse events were noted. One patient required percutaneous drainage of an infected haematoma 88 days after embolization. The mean hemoglobin level before embolization was 8,64 mg/dL and increased to 9,08 mg/dL after embolization (p = 0,3). After embolization all patients recovered haemodynamic stability and blood pressure levels improved. Seven patients resumed anticoagulation therapy after embolization. There were no recurrences or new bleedings in all treated patients. No patients required any additional invasive therapies or surgery. Mean intensive unit care and hospital stay was 6.7 and 35.2 days, respectively. All patients were discharged and were well at follow-up clinic visits 2-7 months after embolization. Seven patients performed a control CT scan 1-6 months after embolization, showing complete resolution of the haematoma. CONCLUSION: Embolization is safe and effective to treat spontaneous haematomas in anticoagulated patients with COVID-19, allowing to resume anticoagulation therapy. Level of evidence IV Level 4, case-series.

Fibrin-Platelet Clots in Acute Ischemic Stroke. Predictors and Clinical Significance in a Mechanical Thrombectomy Series.

Introduction: The histological composition of the clot influences its mechanical properties, affects the efficacy of endovascular treatment (EVT), and could determine the clinical outcome of patients with acute ischemic stroke (AIS). Insights into clot composition may guide therapeutic decision-making prior to EVT and facilitate revascularization therapies. Material and Methods: Consecutive patients with AIS recorded in a prospective single-center reperfusion registry from December 2015 to December 2019 and treated with EVT were included. Baseline, laboratory [including post-procedural C-reactive protein (CRP)], radiological, and angiographic variables were analyzed. We aimed to study the relationship between histological composition of the clot with basal neuroimaging, laboratory markers, and recanalization technique. The secondary outcome was to analyze the correlation between clot composition and functional outcome at 3 months assessed by the modified Rankin scale (mRS). Results: From the study period, 360 AIS patients treated with EVT were included, of whom 189 (53%) fulfilled the inclusion criteria. One hundred (53%) cases of fibrin-predominant clot (FPC) were recorded. Full recanalization in FPC cases was achieved with higher probability when stent retrievers (SR) were selected as the first-line device (68.2%, p = 0.039). Patients with FPC had higher levels of CRP (p = 0.02), lower frequency of the hyperdense middle cerebral artery (HMCA) in baseline imaging (p = 0.039), and higher rates of mortality (p = 0.012). The multivariate analysis showed that the absence of HMCA (OR = 0.420; 95% CI 0.197-0.898; p = 0.025) and higher levels of CRP (OR = 1.01; 95% CI 1.003-1.019; p = 0.008) were predictors of FPC. Leukocytes and platelet counts were not associated with clot histology. Conclusions: The absence of HMCA and higher levels of CRP were markers of FPC. In patients with FPC, complete recanalization was most likely to be achieved when a SR was selected as first line of treatment. Mortality was higher in patients within this histologic group.

Comaneci device-assisted embolization of wide-necked carotid aneurysms with an unfavorable ratio.

BACKGROUND: Endovascular treatment is the technique of choice for most intracranial aneurysms. However, the treatment of morphologically complex wide-necked aneurysms with an unfavorable anatomy is still a therapeutic challenge. The purpose of the study is to describe the initial experience with the Comaneci embolization assist device for the treatment of wide-necked aneurysms with an unfavorable ratio for direct embolization. METHODS: We report a retrospective single-center analysis taken from a prospective database of consecutive aneurysms of the anterior circulation treated using the Comaneci device in the period from March 2017 to March 2019. RESULTS: Eighteen aneurysms were collected from 16 patients (9 women and 7 men) treated using the Comaneci device. The mean age was 48.4 years (range 36-81). Twelve patients had SAH, three were incidental aneurysms and one had compressive symptoms. A complete asymptomatic occlusion rate of 88.8% was obtained. The major complication rate was 5.55%. CONCLUSION: The Comaneci embolization assist device is a safe, effective option for endovascular treatment of complex aneurysms with an unfavorable ratio.

Endovascular management of an unsual case of spontaneous Retroperitoneal Haemorrhage due to Fibromuscular Dysplasia.

BACKGROUND: Fibromuscular dysplasia (FMD) is an uncommon vascular disease that results in stenosis, dissection or aneurysmal degeneration. However, it can sometimes manifest atypically, as we show in this case. CASE PRESENTATION: A 24-year old patient with no relevant medical history with severe left hypochondrium pain. The physical examination showed blood pressure levels of 160/90 mmHg. An abdominopelvic CT evidenced left retroperitoneal haematoma associated with active bleeding and left renal artery stenosis. Given these findings, it was decided to perform an endovascular treatment. Significant stenosis was seen during the arteriography in both renal arteries, suggesting fibromuscular dysplasia and development of a collateral neovascular network responsible for the retroperitoneal haematoma. It was embolised in association with angioplasty of the left renal artery. The patient had a favourable outcome; however, high blood pressure levels persisted. A new bilateral renal angioplasty was performed, which returned blood pressure values to normal. The patient was discharged without needing antihypertensives. CONCLUSIONS: FMD is a rare disease that can show multiple clinical presentations and need individualized treatment options. Endovascular techniques are in the first therapeutic line regarding fibromuscular dysplasia.

Embolismo arterial gaseoso paradójico tras una herida incisa craneal directa / Paradoxical arterial gas embolism following a direct incisive injury to the skull

Introducción. El embolismo arterial gaseoso se define como la presencia de aire en la circulación arterial. Se trata de una causa extremadamente rara de ictus que se ha descrito en multitud de escenarios clínicos, generalmente relacionados con procesos yatrógenos. Se aporta un caso clínico en el que el embolismo arterial gaseoso sucedió tras un traumatismo craneoencefálico, y se revisan los aspectos más relevantes del diagnóstico y la etiopatogenia. Caso clínico. Mujer de 52 años que presentaba herida incisa craneofacial tras una agresión con un hacha. La tomografía computarizada inicial objetivó fractura en los arcos cigomático, esfenoidal y maxilar izquierdos, así como neumoencéfalo en los senos cavernosos y el canal carotídeo derecho. Una hora más tarde, la paciente mostró un déficit neurológico hemisférico derecho, por lo que se solicitó de forma urgente una nueva tomografía computarizada craneal con estudio vascular multimodal, que objetivó la movilización del neumoencéfalo y descartó una oclusión arterial de gran vaso. Un estudio de shunt mediante Doppler transcraneal y ecocardiografía comprobó la presencia de un foramen oval permeable como causa de comunicación arteriovenosa que justificaba un embolismo arterial gaseoso. La tomografía computarizada de control a las 48 horas confirmó la aparición de una lesión isquémica parietal derecha. Conclusión. En este caso queda reflejada la presencia simultánea de aire en la circulación cerebral arterial y venosa y la comunicación periférica a través de un foramen oval permeable. Este mecanismo de producción está escasamente documentado en la bibliografía

Introduction. An arterial gas embolism is defined as the presence of air in the arterial circulation. This is an extremely rare cause of stroke that has been described in a multitude of clinical scenarios, generally related to iatrogenic processes. A clinical case is reported in which the arterial gas embolism occurred after a traumatic brain injury, and the most relevant aspects of diagnosis and aetiopathogenesis are reviewed. Case report. We report the case of a 52-year-old woman with an open craniofacial wound resulting from an attack with an axe. The initial CT scan found fractures in the left zygomatic, sphenoidal and maxillary arches, as well as pneumocephalus in the cavernous sinuses and the right carotid canal. One hour later, the patient showed a neurological deficit in the right hemisphere, and so a new cranial computed tomography scan with multimodal vascular study was urgently requested, which revealed the mobilisation of the pneumocephalus and ruled out a large vessel arterial occlusion. A shunt study using transcranial Doppler and echocardiography showed the presence of a patent foramen ovale to be the cause ofarteriovenous communication that justified an arterial gas embolism. The follow-up CT scan at 48 hours confirmed the appearance of a right parietal ischaemic lesion. Conclusion. This case reflects the simultaneous presence of air in the arterial and venous circulation of the brain, as well as the peripheral communication through a patent foramen ovale. This production mechanism is poorly documented in the literature

Embolización de arterias intercostales en un hemotórax iatrogénico / Embolization of intercostal arteries in iatrogenic haemothorax

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Focalidad neurológica en paciente anticoagulado / Focal neurologic signs in an anticoagulated patient

Presentamos el caso de una mujer de 63 años que acude a urgencias por dificultad en la emisión del lenguaje y debilidad en extremidades derechas de instauración súbita. Entre sus antecedentes personales encontramos una fibrilación auricular (FA) crónica insuficientemente anticoagulada. El primer diagnóstico a tener en cuenta es el de ictus isquémico agudo de origen cardioembólico. La enfermedad vascular cerebral es la segunda causa de mortalidad en el mundo. El tiempo entre el inicio del ictus y el tratamiento de revascularización, bien sea farmacológico (intravenoso o intraarterial) o mecánico, nos marcará la evolución y pronóstico del paciente (AU)

We report the case of a 63 year old woman who came to the emergency department due to difficulty in expressing herself linguistically and right limb weakness of sudden onset. She had a history of chronic atrial fibrillation (AF) and being insufficiently anticoagulated. The first diagnosis to consider is acute ischemic stroke of cardioembolic origin. Cerebrovascular disease is the second cause of death worldwide. The time between the onset of stroke and revascularization, either pharmacological (intravenous or intraarterial) or mechanical, will determine the patient's evolution and prognosis (AU)