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BACKGROUND: Venous thromboembolic events, including deep vein thrombosis (DVT) and pulmonary embolism (PE), are frequent complications in patients with intracerebral hemorrhage (ICH). Various prophylactic strategies have been employed to mitigate this risk, such as heparin, intermittent pneumatic compression (IPC), and graduated compression stockings (GCS). The optimal thromboembolic prophylaxis approach remains uncertain due to the lack of randomized controlled trials (RCTs) comparing all interventions. AIMS: We conducted a network meta-analysis and meta-analysis to systematically review and synthesize evidence from RCTs and non-randomized studies on the efficacy and safety of thromboembolic prophylaxis strategies in hospitalized ICH patients. SUMMARY OF FINDINGS: Our study followed a registered protocol (PROSPERO CRD42023489217) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines incorporating the extension for network meta-analyses. Search for eligible studies was performed up to December 2023. We considered the occurrence of DVT, PE, hematoma expansion (HE), and all-cause mortality as outcome measures. A total of 16 studies, including 7 RCTs and 9 non-randomized studies, were included in the analysis. Network meta-analysis revealed that IPC demonstrated the highest efficacy in reducing DVT incidence (odds ratios (OR) 0.30, 95% confidence interval (CI) 0.08-1.16), particularly considering only RCTs (OR 0.33, 95% CI 0.16-0.67). GCS showed the highest safety profile for HE (OR 0.67, 95% CI 0.14-3.13), but without efficacy. Chemoprophylaxis did not reduce the risk of PE events (OR 1.10, 95% CI 0.17-7.19) with a higher occurrence of HE (OR 1.33, 95% CI 0.60-2.96), but the differences were not significant. CONCLUSION: Our study supports the use of IPC as the primary thromboembolic prophylaxis measure in ICH patients. Further research, including head-to-head RCTs, is needed to strengthen the evidence base and optimize clinical decision-making for thromboembolic prophylaxis in this vulnerable patient population.
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The basal ganglia, a complex of subcortical nuclei, form an important functional component of the brain. Spontaneous simultaneous bilateral basal ganglia haemorrhage (SSBBGH) is exceedingly uncommon and often associated with hypertension as a primary predisposing factor. We report a case of a 72-year-old female who presented to a local hospital following a dizzy spell and subsequent fall. Non-contrast CT brain revealed bilateral basal ganglia haemorrhage alongside central pontine haemorrhage. Subsequently, she was transferred to our tertiary-care specialist stroke unit where conservative management was pursued. She was discharged after brain imaging, multidisciplinary team (MDT) consultations, and follow-up plans. The MDT comprised stroke physicians, radiologists, physiotherapists, occupational therapists, and speech and language therapists. Given the limited number of documented cases of this rare occurrence (approximately 60 in the literature), we believe this report will contribute to the existing body of knowledge.
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Primary aldosteronism, the most common curable form of secondary hypertension, is associated with greater hypertension-related organ damage and cardiovascular complications compared to primary essential hypertension. The authors present a case involving a 41-year-old Black male admitted to the emergency department with left hemiparesis and blurred vision persisting for one hour, accompanied by markedly elevated blood pressure (220/140 mmHg). The patient was asymptomatic by then, and, aside from a history of tobacco smoking and occasional cannabis use, lacked significant medical comorbidities. Further investigations revealed a right acute hemorrhagic stroke, bilateral grade 4 hypertensive retinopathy, chronic kidney disease with end-stage renal disease, hypokalemia, and an elevated aldosterone/renin ratio. An abdominal CT scan showed bilateral adrenal hyperplasia. The patient was diagnosed with primary aldosteronism with extensive hypertension-mediated organ damage. This case highlights the significant harm caused by undiagnosed primary aldosteronism-induced secondary hypertension, emphasizing the importance of timely diagnosis and intervention to prevent organ damage.
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Between 2016 and 2018, twenty maternal deaths were associated with a stroke. The 20 deaths whose main cause was stroke represent 7.4% of all maternal deaths, i.e. a maternal mortality ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3). Among the 20 stroke deaths, it was hemorrhagic in 17 cases (85%), ischemic in 2 cases, and due to thrombophlebitis in 1 case. Stroke occurred during pregnancy in 8 women (40%) - one case before 12 weeks, 3 cases between 28 and 32 weeks, and 4 cases between 34 and 40 weeks; in 3 cases the stroke occurred intrapartum, and for the other 9 cases (45%) the stroke occurred postpartum between Day 1 and Day 15. Care was assessed as non-optimal in 10/19 (56%) of cases but mortality as possibly avoidable in 24% of cases (4/17 cases with conclusion established by the CNEMM) and not established in two cases. The potentially improvable elements identified were a delay in carrying out initial brain imaging in three cases (one case antepartum, two cases postpartum) and insufficient hemodynamic monitoring in intensive care in one case.
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Muerte Materna , Accidente Cerebrovascular , Embarazo , Femenino , Humanos , Mortalidad Materna , Muerte Materna/etiología , Periodo Posparto , Francia/epidemiologíaRESUMEN
Introduction Understanding when and how systemic complications can occur after an acute stroke is crucial. It is important to identify patients who are at higher risk for these complications. Early and effective treatment based on this knowledge can significantly improve patient outcomes. The objective of this study was to identify the risk factors associated with neurological and extra-neurological complications and mortality in stroke patients treated at a secondary care hospital. Methods Of a total of 170 patients diagnosed with hemorrhagic/ischemic stroke and transient cerebral ischemia at a secondary care hospital in Mexico, the records of 125 were reviewed and of these, 86 were included in the study. The study group comprised 86 adult patients (> 18 years of age) diagnosed with ischemic or hemorrhagic stroke or transient cerebral ischemia. Their demographics, clinical characteristics, in-hospital complications, and mortality were retrospectively analyzed. Results Of the 86 patients examined, 34.9% experienced complications, regardless of the type of stroke. The most significant factor associated with mortality and complications during hospitalization in patients with stroke was previous diseases. Other factors that were linked to higher mortality were pre-existing medical conditions. The most common neurological complication among patients with stroke during hospitalization was intracranial hypertension (3.5%). As for extra-neurological complications, pressure ulcers and nosocomial pneumonia had an occurrence rate of 4.7%. Conclusions The main neurological complication during hospitalization of patients with stroke was intracranial hypertension, while the extra neurological complications were pressure ulcers and nosocomial pneumonia.
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Introduction Spontaneous intracerebral hemorrhage (sICH) carries a high mortality burden. Limited data are available on early mortality (EM) and sICH. This study attempted to identify the independent predictors of EM and analyze the mortality characteristics for mechanically ventilated patients with sICHs at a tertiary care hospital over a period of five years. Methods An Institutional Review Board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPPA)-compliant retrospective analysis was performed on sICH patients admitted at the University of Mississippi Medical Center Neuroscience Intensive Care Unit between January 1, 2013, to December 31, 2017. Patients were divided into two cohorts: EM cohort (death within seven days of admission) versus survivor cohort (alive more than seven days after admission). Demographic, comorbidity, clinical, and radiographic data were collected for each patient. Outcomes were compared utilizing student t-test or Mann-Whitney U tests for continuous variables. Logistic regression analysis was performed to determine independent predictors of EM. Results A total of 204 mechanically ventilated patients with sICHs, with a mean age of 59.73 (SD ±14.30), mostly African American (137, 67%), were included in the study. The characteristics of the two cohorts were comparable except the EM cohort had a lower proportion of patients with hypertension and end-stage renal disease; lower median Glasgow Coma Score (GCS) on admission; lower proportion of surgical evacuation and external ventricular drain (EVD) placement; higher proportion of lobar hemorrhage, brainstem involvement, midline shift, hydrocephalus, intraventricular hemorrhage component, and right-sided intracerebral hemorrhage (ICH); higher median ICH score; and higher ICH volume compared to the survivor cohort. Overall, the mortality of mechanically ventilated sICH patients in this institution was 53% (N=109), with 47% (N=96) not surviving beyond seven days. Logistic regression analysis revealed that ICH volume and brainstem involvement increased the odds of EM, while a history of hypertension, surgical evacuation, and EVD placement decreased the odds of EM. Conclusions This study on mechanically ventilated sICH patients identified ICH volume and brainstem involvement as independent predictors of increased EM. History of hypertension, EVD placement, and surgical evacuation decreased its odds. Further studies should be conducted to explore potentially modifiable processes that can improve patient outcomes, most importantly EM, especially in this cohort of patients.
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Autoimmune-associated vasculitis is related to conditions like granulomatosis with polyangiitis (GPA) and eosinophilic polyangiitis with granulomatosis (EGPA), among many others. An unlikely scenario is patients with the above conditions presenting with ischemic strokes before any renal or pulmonary pathology. These conditions are associated with increased antineutrophillic cytoplasmic antibodies (C-ANCA) levels in the blood, and its decline after treatment is directly proportional to the recovery of the patient. We present a case of a previously healthy 38-year-old male patient who presented with acute/subacute ischemic stroke with elevated C-ANCA levels; his MRI brain images revealed multiple posterior circulation infarcts with hemorrhagic transformation. With pulse steroid therapy, he had significant improvement in neurological functions. This case report highlights the importance of maintaining a high degree of suspicion and providing early treatment for autoimmune strokes in young patients with no clear etiology for such a presentation.
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BACKGROUND: The varicella zoster virus (VZV) is a highly neurotropic virus that, after the primary infection, remains latent in the nerve cells and can reactivate many years later, resulting in various conditions affecting the central nervous system, such as vasculopathy and stroke. METHODS: We report on a review of the published literature that included all case reports identified via PubMed and an additional unpublished case of VZV vasculopathy. All epidemiological, clinical, laboratory, imaging, virologic, treatment and outcome data collected are described. RESULTS: Of the 62 patients, 41.6% were immunocompromised. Ischemic stroke occurred in 77.2% of the patients, comprising cases of isolated (37.1%) and multifocal stroke (17.7%). Multifocal, ischemic and hemorrhagic stroke was only described in the newly reported case. The magnetic resonance imaging results were normal in 2.9% of the cases. The vascular studies (angiography and magnetic resonance angiography [MRA]) revealed signs of angiitis in 74.4% of the cases; the small arteries were involved in 38.5% of the cases, large arteries in 17.7% and mixed in 43.5%. For 95.2% of the patients, the cerebrospinal fluid (CSF) was positive for VZV IgG antibodies, and for 46.1% of the patients, the CSF was positive for polymerase chain reaction (PCR); however, the diagnosis was confirmed in only 3 of 6 biopsies. DISCUSSION: VZV vasculopathy can occur in both immunocompetent and immunosuppressed patients. Neuroimaging can reveal stroke and angiitis, and the detection of VZV-specific IgG antibodies in the CSF is a reliable and highly sensitive diagnostic tool. The multifocal nature of VZV vasculopathy makes biopsy a test with low sensitivity and high morbidity.