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In a trial of minimally invasive cerebral hematoma removal within 24 hours after onset of hemorrhage, functional outcomes were better with surgery than with medical treatment, particularly among patients with lobar hemorrhages.

Patients with acute upper gastrointestinal bleeding were assigned to receive endoscopy within 6 hours or between 6 and 24 hours after gastroenterologic consultation. Mortality at 30 days was 8.9% in the former group and 6.6% in the latter group; earlier endoscopy did not lower mortality.

Background Intraventricular haemorrhage (IVH) is a common and severe complication of preterm birth, affecting nearly 500 neonates annually in the UK. Over 50% of infants with IVH develop post-haemorrhagic ventricular dilatation (PHVD), which is associated with significant long-term neurodevelopmental impairment. Current treatment strategies involve the use of temporary CSF diversion, through options such as ventricular access devices (VADs) or ventricular subgaleal shunts (VSGS). Neuroendoscopic lavage (NEL) is an emerging technique that aims to directly reduce the load of intraventricular blood and its breakdown products, potentially reducing the risk of secondary brain injury. The ENLIVEN-UK trial aims to assess whether the addition of NEL to standard temporising device placement improves neurodevelopmental outcomes at 2 years of corrected age compared to temporising device placement alone. Methods ENLIVEN-UK is a national, multicentre, parallel-group, assessor-blinded, superiority randomised controlled trial (RCT) that aims to enrol 100 preterm infants with severe IVH and PHVD across UK paediatric neurosurgical centres. Infants will be randomised in a 1:1 ratio to receive either standard temporising device placement or NEL in addition to temporising device placement. Randomisation will be performed using a secure online system (Sealed Envelope), with outcome assessors and statisticians blinded to treatment allocation. The primary outcome measure will be cognitive quotient (CQ) at 2 years of corrected age, assessed using the Bayley Scales of Infant and Toddler Development (4th edition, Bayley-IV). Secondary outcomes will include motor and language development, the requirement for permanent CSF diversion with a ventriculoperitoneal (VP) shunt, surgical complications, health-related quality of life (EQ-5D-5L, TAPQOL), and healthcare costs. Discussion This study aims to provide level 1 evidence regarding the efficacy and safety of NEL in preterm infants with IVH and PHVD. If successful, this trial has the potential to change the standard of care and improve long-term neurodevelopmental outcomes in this cohort of patients. Trial registration ISRCTN Trial Registration: ISRCTN14018410.

Craniotomy, according to the results from trials, does not improve functional outcome after intracerebral haemorrhage. Whether minimally invasive catheter evacuation followed by thrombolysis for clot removal is safe and can achieve a good functional outcome is not known. We investigated the safety and efficacy of alteplase, a recombinant tissue plasminogen activator, in combination with minimally invasive surgery (MIS) in patients with intracerebral haemorrhage. MISTIE was an open-label, phase 2 trial that was done in 26 hospitals in the USA, Canada, the UK, and Germany. We used a computer-generated allocation sequence with a block size of four to centrally randomise patients aged 18–80 years with a non-traumatic (spontaneous) intracerebral haemorrhage of 20 mL or higher to standard medical care or image-guided MIS plus alteplase (0·3 mg or 1·0 mg every 8 h for up to nine doses) to remove clots using surgical aspiration followed by alteplase clot irrigation. Primary outcomes were all safety outcomes: 30 day mortality, 7 day procedure-related mortality, 72 h symptomatic bleeding, and 30 day brain infections. This trial is registered with ClinicalTrials.gov, number NCT00224770. Between Feb 2, 2006, and April 8, 2013, 96 patients were randomly allocated and completed follow-up: 54 (56%) in the MIS plus alteplase group and 42 (44%) in the standard medical care group. The primary outcomes did not differ between the standard medical care and MIS plus alteplase groups: 30 day mortality (four [9·5%, 95% CI 2·7–22.6] vs eight [14·8%, 6·6–27·1], p=0·542), 7 day mortality (zero [0%, 0–8·4] vs one [1·9%, 0·1–9·9], p=0·562), symptomatic bleeding (one [2·4%, 0·1–12·6] vs five [9·3%, 3·1–20·3], p=0·226), and brain bacterial infections (one [2·4%, 0·1–12·6] vs zero [0%, 0–6·6], p=0·438). Asymptomatic haemorrhages were more common in the MIS plus alteplase group than in the standard medical care group (12 [22·2%; 95% CI 12·0–35·6] vs three [7·1%; 1·5–19·5]; p=0·051). MIS plus alteplase seems to be safe in patients with intracerebral haemorrhage, but increased asymptomatic bleeding is a major cautionary finding. These results, if replicable, could lead to the addition of surgical management as a therapeutic strategy for intracerebral haemorrhage. National Institute of Neurological Disorders and Stroke, Genentech, and Codman.

Background and purposeIntraventricular extension of intracerebral haemorrhage (ICH) predicts poor outcome, but the significance of delayed intraventricular haemorrhage (dIVH) is less well defined. We determined the prognostic significance of dIVH in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trials (INTERACT 1 and 2).MethodsPooled analyses of the INTERACT CT substudies—international, multicentre, prospective, open, blinded end point, randomised controlled trials of patients with acute spontaneous ICH and elevated systolic blood pressure (SBP)—randomly assigned to intensive (<140 mm Hg) or guideline-based (<180 mm Hg) SBP management. Participants had blinded central analyses of baseline and 24 h CTs, with dIVH defined as new intraventricular haemorrhage (IVH) on the latter scan. Outcomes of death and major disability were defined by modified Rankin Scale scores at 90 days.ResultsThere were 349 (27%) of 1310 patients with baseline IVH, and 107 (11%) of 961 initially IVH-free patients who developed dIVH. Significant associations of dIVH were prior warfarin anticoagulation, high (≥15) baseline National Institutes of Health Stroke Scale score, larger (≥15 mL) ICH volume, greater ICH growth and higher achieved SBP over 24 h. Compared with those who were IVH-free, dIVH had greater odds of 90-day death or major disability versus initial IVH (adjusted ORs 2.84 (95% CI 1.52 to 5.28) and 1.87 (1.36 to 2.56), respectively (p trend <0.0001)).ConclusionsAlthough linked to factors determining greater ICH growth including poor SBP control, dIVH is independently associated with poor outcome in acute small to moderate-size ICH.Trial registration numbersNCT00226096 and NCT00716079.

After atrial fibrillation ablation, left atrial appendage closure was associated with a lower risk of bleeding than oral anticoagulation and was noninferior to oral anticoagulation with respect to clinical outcomes at 36 months.

In a trial of percutaneous coronary intervention or conservative treatment in patients undergoing TAVI, PCI was associated with a lower risk of a composite of death, MI, or urgent revascularization at a median of 2 years.

In a placebo-controlled trial involving patients undergoing cesarean delivery, prophylactic use of tranexamic acid did not lead to a significantly lower risk of a composite outcome of maternal death or blood transfusion.

IntroductionDelayed cerebral ischemia (DCI), which describes a new neurologic deficit or infarction arising 3–14 days after aneurysmal subarachnoid hemorrhage (aSAH), contributes to long-term disability and mortality following aSAH. While vasospasm is commonly implicated, coagulation abnormalities may also contribute to its pathophysiology. Thromboelastography (TEG), which provides dynamic assessment of clot formation and breakdown, has been used in trauma and transplant settings to assess coagulopathy. This study evaluates whether TEG parameters can predict DCI development in aSAH patients.MethodsA prospective cohort study was conducted in patients with aSAH confirmed by CTA. TEG parameters—including reaction time (R), clot kinetics (K), alpha angle (α), maximum amplitude (MA), 30-minute lysis (LY30), and coagulation index (CI)—were measured upon presentation and again during the peak vasospasm window (days 6–10). Changes in TEG parameters from admission to vasospasm window were calculated. DCI was determined clinically. Statistical comparisons of mean TEG parameters between patients with and without DCI were performed using t-tests; binomial logistic regressions were used to evaluate the odds ratio (OR) of TEG parameters.ResultsFifty patients (mean age 60, 15 male) were enrolled, with 14 (28%) developing DCI. A total of 110 TEG measurements (2.2 per patient) were collected. Alpha angle was significantly lower on TEG at admission but not on TEG in the vasospasm window among patients who later developed DCI (t = –2.3, p = 0.05). This was corroborated on linear regression analysis (OR = 0.81, p = 0.02). LY30 was also significantly lower at admission (t = -2.8 p = 0.01) but not in the vasospasm window. While not significant, there was also a trend towards lower maximum amplitude and coagulation index on the initial draw. No other TEG parameters differed significantly between groups at either time point or predicted DCI in regression.Discussion/ConclusionThis prospective study of 50 patients with aSAH identified two TEG parameters present on admission that were associated with later development of DCI: decreased alpha angle and reduced LY30. Alterations in TEG parameters manifested on admission and later normalized. It is possible that these differences reflect a worse initial injury due to a greater hemorrhage burden, which would explain a higher rate of DCI. Future directions for this study include matching subjects for Hunt Hess and modified Fisher grading to control for hemorrhage severity.Abstract O-059 Table 1On Admission (n=32)Vasospasm Window (n=41)TEG ParameterNo DCI (N=24)Mean (SD)DCI (N=8)Mean (SD)tpNo DCI (N=30)Mean (SD)DCI (N=11)Mean (SD)tpR3.9 (±1.3)4.1 (±1.1)0.50.645.3 (±0.9)5.7 (±1.1)0.60.39K1.4 (±0.5)1.7 (±0.3)1.80.081.2 (±0.4)1.3 (±0.4)1.30.81α71.7 (±4.1)64.1 (±8.3)-2.30.0571.4 (±5.5)69.4 (±10.8)-0.20.60MA65.3 (±7.1)62.5 (±4.1)-1.40.1970.7 (±5.4)72.3 (±8.3)-1.50.58LY300.8 (±1.0)0.2 (±0.3)-2.80.010.9 (±0.8)0.5 (±0.6)1.40.12CI2.5 (±1.4)1.5 (±1.4)-1.90.092.4 (±1.4)2.3 (±2.2)-1.70.84DisclosuresS. Susa: None. N. Dogra: None. R. Rahmani: None. N. Ellens: None. B. Santonastaso: None. M. Gatchell: None. S. Akkipeddi: None. D. Schartz: None. S. Mendoza-Ayus: None. M. Refaai: None. T. Mattingly: None. T. Bhalla: None. M. Bender: None. G. Vates: None.

Background Concomitant acute ischemic lesions are detected in up to a quarter of patients with spontaneous intracerebral hemorrhage (ICH). Influence of bleeding pattern and intraventricular hemorrhage (IVH) on risk of ischemic lesions has not been investigated. Methods Retrospective study of all 500 patients enrolled in the CLEAR III randomized controlled trial of thrombolytic removal of obstructive IVH using external ventricular drainage. The primary outcome measure was radiologically confirmed ischemic lesions, as reported by the Safety Event Committee and confirmed by two neurologists. We assessed predictors of ischemic lesions including analysis of bleeding patterns (ICH, IVH and subarachnoid hemorrhage) on computed tomography scans (CT). Secondary outcomes were blinded assessment of mortality and modified Rankin scale (mRS) at 30 and 180 days. Results Ischemic lesions occurred in 23 (4.6%) during first 30 days after ICH. Independent risk factors associated with ischemic lesions in logistic regression models adjusted for confounders were higher IVH volume ( p  = 0.004) and persistent subarachnoid hemorrhage on CT scan ( p  = 0.03). Patients with initial IVH volume ≥ 15 ml had five times the odds of concomitant ischemic lesions compared to IVH volume < 15 ml. Patients with ischemic lesions had significantly higher odds of death at 1 and 6 months (but not poor outcome; mRS 4–6) compared to patients without concurrent ischemic lesions. Conclusions Occurrence of ischemic lesions in the acute phase of IVH is not uncommon and is significantly associated with increased early and late mortality. Extra-parenchymal blood (larger IVH and visible subarachnoid hemorrhage) is a strong predictor for development of concomitant ischemic lesions after ICH.