Factors influencing the Effectiveness of Hemodilution Therapy for Patients with Ruptured Cerebral Aneurysm

We operated on 621 patients with subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysm from 1979 to 1987. All the patients were operated on within 72 hours after the rupture of aneurysm. From 1979 to 1983, 312 patients with ruptured intracranial aneurysm were treated without postoperative hemodilution therapy (No-Hemodilution). From 1984 to 1987, 309 patients were treated with hemodilution therapy (Hemodilution). We have performed the hemodilution therapy for the prevention of cerebral ischemia due to vasospasm following SAH since January, 1984. Indication for the hemodilution therapy was the hematocrit value of above 30.0-33.0 % at Day 7 after onset. In the No-Hemodilution period (1979-1983), the mean value of hematocrit of 253 patients was 36.7 % and in the Hemodilution period (1984-1987) , the value of 150 patients was 31.9 %. The difference in these values is statistically significant. From the viewpoint of over-all outcome, the rate of Good Recovery was higher and that of Death was lower in the Hemodilution period (p < 0.001). 1. The correlation of the age and outcome: The mortality was higher with increasing age especially in patients over 60 years (p < 0.001). This result seemed to be due to the vulnerability of the brain by cerebral ischemia in the old age. 2. The correlation of the sites of ruptured aneurysm and outcome: In the ruptured aneurysm of the anterior cerebral artery, the mortality was higher than that of other sites (p < 0.001). Generally, the symptoms of ischemia in the anterior cerebral artery terri tory are more severe than those of other sites. By the hemodilution therapy the symptoms of ische mia in the anterior cerbral artery territory seemed to be prevented. 3. The correlation of the preoperative grade and outcome: The mortality and morbidity were higher especially in the preoperative grade (p < 0.001). In the preoperative grade Id the outcome has a tendency to be determined by the severity of cerebral vasospasm. By the hemodilution therapy the occurrence of ischemia is decreased. We conclude that the hemodilution therapy is effective for the prevention and treatment of cerebral ischemia due to vasognasm

Anchor-wire technique for multiple plastic biliary stents to prevent stent dislocation

In endoscopic placement of multiple plastic biliary stents (PBSs), we sometimes experience proximal dislocation of the first PBS at the time of subsequent PBS insertion. We describe the case of a 79-year-old male with obstructive jaundice caused by cholangiocarcinoma who needed to receive multiple PBS placements for management of cholangitis. Although proximal dislocation of the first PBS was observed, we prevented the dislocation via our technique of using guidewire inserted from the distal end of the first PBS to the side hole as the anchor-wire. We could complete this technique only by inserting guidewire through the side hole of the first PBS during the process of releasing the first PBS and pulling out the guidewire and the inner sheath. It did not matter whether the anchor-wire went towards the third portion of the duodenum or the duodenal bulb. Here we introduce this “anchor-wire technique”, which is useful for the prevention of PBS proximal dislocation in placing multiple PBSs

Factors influencing the Effectiveness of Hemodilution Therapy for Patients with Ruptured Cerebral Aneurysm

We operated on 621 patients with subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysm from 1979 to 1987. All the patients were operated on within 72 hours after the rupture of aneurysm. From 1979 to 1983, 312 patients with ruptured intracranial aneurysm were treated without postoperative hemodilution therapy (No-Hemodilution). From 1984 to 1987, 309 patients were treated with hemodilution therapy (Hemodilution). We have performed the hemodilution therapy for the prevention of cerebral ischemia due to vasospasm following SAH since January, 1984. Indication for the hemodilution therapy was the hematocrit value of above 30.0-33.0 % at Day 7 after onset. In the No-Hemodilution period (1979-1983), the mean value of hematocrit of 253 patients was 36.7 % and in the Hemodilution period (1984-1987) , the value of 150 patients was 31.9 %. The difference in these values is statistically significant. From the viewpoint of over-all outcome, the rate of Good Recovery was higher and that of Death was lower in the Hemodilution period (p < 0.001). 1. The correlation of the age and outcome: The mortality was higher with increasing age especially in patients over 60 years (p < 0.001). This result seemed to be due to the vulnerability of the brain by cerebral ischemia in the old age. 2. The correlation of the sites of ruptured aneurysm and outcome: In the ruptured aneurysm of the anterior cerebral artery, the mortality was higher than that of other sites (p < 0.001). Generally, the symptoms of ischemia in the anterior cerebral artery terri tory are more severe than those of other sites. By the hemodilution therapy the symptoms of ische mia in the anterior cerbral artery territory seemed to be prevented. 3. The correlation of the preoperative grade and outcome: The mortality and morbidity were higher especially in the preoperative grade (p < 0.001). In the preoperative grade Id the outcome has a tendency to be determined by the severity of cerebral vasospasm. By the hemodilution therapy the occurrence of ischemia is decreased. We conclude that the hemodilution therapy is effective for the prevention and treatment of cerebral ischemia due to vasognasm

Risk for Major Bleeding in Patients Receiving Ticagrelor Compared With Aspirin After Transient Ischemic Attack or Acute Ischemic Stroke in the SOCRATES Study (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes)

International audienc

Risk for Major Bleeding in Patients Receiving Ticagrelor Compared With Aspirin After Transient Ischemic Attack or Acute Ischemic Stroke in the SOCRATES Study (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes)

Abstract: Background: Patients with minor acute ischemic stroke or transient ischemic attack are at high risk for subsequent stroke, and more potent antiplatelet therapy in the acute setting is needed. However, the potential benefit of more intense antiplatelet therapy must be assessed in relation to the risk for major bleeding. The SOCRATES trial (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes) was the first trial with ticagrelor in patients with acute ischemic stroke or transient ischemic attack in which the efficacy and safety of ticagrelor were compared with those of aspirin. The main safety objective was assessment of PLATO (Platelet Inhibition and Patient Outcomes)\u2013defined major bleeds on treatment, with special focus on intracranial hemorrhage (ICrH). Methods: An independent adjudication committee blinded to study treatment classified bleeds according to the PLATO, TIMI (Thrombolysis in Myocardial Infarction), and GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definitions. The definitions of ICrH and major bleeding excluded cerebral microbleeds and asymptomatic hemorrhagic transformations of cerebral infarctions so that the definitions better discriminated important events in the acute stroke population. Results: A total of 13 130 of 13 199 randomized patients received at least 1 dose of study drug and were included in the safety analysis set. PLATO major bleeds occurred in 31 patients (0.5%) on ticagrelor and 38 patients (0.6%) on aspirin (hazard ratio, 0.83; 95% confidence interval, 0.52\u20131.34). The most common locations of major bleeds were intracranial and gastrointestinal. ICrH was reported in 12 patients (0.2%) on ticagrelor and 18 patients (0.3%) on aspirin. Thirteen of all 30 ICrHs (4 on ticagrelor and 9 on aspirin) were hemorrhagic strokes, and 4 (2 in each group) were symptomatic hemorrhagic transformations of brain infarctions. The ICrHs were spontaneous in 6 and 13, traumatic in 3 and 3, and procedural in 3 and 2 patients on ticagrelor and aspirin, respectively. In total, 9 fatal bleeds occurred on ticagrelor and 4 on aspirin. The composite of ICrH or fatal bleeding included 15 patients on ticagrelor and 18 on aspirin. Independently of bleeding classification, PLATO, TIMI, or GUSTO, the relative difference between treatments for major/severe bleeds was similar. Nonmajor bleeds were more common on ticagrelor. Conclusions: Antiplatelet therapy with ticagrelor in patients with acute ischemic stroke or transient ischemic attack showed a bleeding profile similar to that of aspirin for major bleeds. There were few ICrHs. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01994720.Abstract: BACKGROUND: Patients with minor acute ischemic stroke or transient ischemic attack are at high risk for subsequent stroke, and more potent antiplatelet therapy in the acute setting is needed. However, the potential benefit of more intense antiplatelet therapy must be assessed in relation to the risk for major bleeding. The SOCRATES trial (Acute Stroke or Transient Ischemic Attack Treated With Aspirin or Ticagrelor and Patient Outcomes) was the first trial with ticagrelor in patients with acute ischemic stroke or transient ischemic attack in which the efficacy and safety of ticagrelor were compared with those of aspirin. The main safety objective was assessment of PLATO (Platelet Inhibition and Patient Outcomes)-defined major bleeds on treatment, with special focus on intracranial hemorrhage (ICrH). METHODS: An independent adjudication committee blinded to study treatment classified bleeds according to the PLATO, TIMI (Thrombolysis in Myocardial Infarction), and GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definitions. The definitions of ICrH and major bleeding excluded cerebral microbleeds and asymptomatic hemorrhagic transformations of cerebral infarctions so that the definitions better discriminated important events in the acute stroke population. RESULTS: A total of 13 130 of 13 199 randomized patients received at least 1 dose of study drug and were included in the safety analysis set. PLATO major bleeds occurred in 31 patients (0.5%) on ticagrelor and 38 patients (0.6%) on aspirin (hazard ratio, 0.83; 95% confidence interval, 0.52-1.34). The most common locations of major bleeds were intracranial and gastrointestinal. ICrH was reported in 12 patients (0.2%) on ticagrelor and 18 patients (0.3%) on aspirin. Thirteen of all 30 ICrHs (4 on ticagrelor and 9 on aspirin) were hemorrhagic strokes, and 4 (2 in each group) were symptomatic hemorrhagic transformations of brain infarctions. The ICrHs were spontaneous in 6 and 13, traumatic in 3 and 3, and procedural in 3 and 2 patients on ticagrelor and aspirin, respectively. In total, 9 fatal bleeds occurred on ticagrelor and 4 on aspirin. The composite of ICrH or fatal bleeding included 15 patients on ticagrelor and 18 on aspirin. Independently of bleeding classification, PLATO, TIMI, or GUSTO, the relative difference between treatments for major/severe bleeds was similar. Nonmajor bleeds were more common on ticagrelor. CONCLUSIONS: Antiplatelet therapy with ticagrelor in patients with acute ischemic stroke or transient ischemic attack showed a bleeding profile similar to that of aspirin for major bleeds. There were few ICrHs