Fixed Versus Variable Dosing of Prothrombin Complex Concentrate in Vitamin K Antagonist-Related Intracranial Hemorrhage:A Retrospective Analysis

Millions of patients receive vitamin K antagonist (VKA) therapy worldwide. Annually 0.2-1 % of all VKA users develops an intracranial hemorrhage (ICH). Prothrombin complex concentrate (PCC) is administered to restore the INR In a before and after design, we compared successful achievement of an INR A median dosage of 1750 IU was given per patient in the variable dose group (n = 25) versus 1000 IU in the fixed dose group (n = 28). In the intention-to-treat analysis, 96 % achieved an INR The fixed dose protocol necessitates additional PCC infusions more frequently to achieve a target IN

Ultra-Early and Short-Term Tranexamic Acid Treatment in Patients With Good- and Poor-Grade Aneurysmal Subarachnoid Hemorrhage

The results of the ULTRA trial showed that ultra-early and short-term treatment with tranexamic acid (TXA) does not improve clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH). Possibly, the lack of a beneficial effect in all patients with aSAH is masked by antagonistic effects of TXA in certain subgroups. In this post hoc subgroup analysis, we investigated the effect of TXA on clinical outcome in patients with good-grade and poor-grade aSAH

Second intravenous immunoglobulin dose in patients with Guillain-Barre syndrome with poor prognosis (SID-GBS):a double-blind, randomised, placebo-controlled trial

Background Treatment with one standard dose (2 g/kg) of intravenous immunoglobulin is insufficient in a proportion of patients with severe Guillain-Barre syndrome. Worldwide, around 25% of patients severely affected with the syndrome are given a second intravenous immunoglobulin dose (SID), although it has not been proven effective. We aimed to investigate whether a SID is effective in patients with Guillain-Barre syndrome with a predicted poor outcome. Methods In this randomised, double-blind, placebo-controlled trial (SID-GBS), we included patients (>= 12 years) with Guillain-Barre syndrome admitted to one of 59 participating hospitals in the Netherlands. Patients were included on the first day of standard intravenous immunoglobulin treatment (2 g/kg over 5 days). Only patients with a poor prognosis (score of >= 6) according to the modified Erasmus Guillain-Barre syndrome Outcome Score were randomly assigned, via block randomisation stratified by centre, to SID (2 g/kg over 5 days) or to placebo, 7-9 days after inclusion. Patients, outcome adjudicators, monitors, and the steering committee were masked to treatment allocation. The primary outcome measure was the Guillain-Barre syndrome disability score 4 weeks after inclusion. All patients in whom allocated trial medication was started were included in the modified intention-to-treat analysis. Findings Between Feb 16, 2010, and June 5, 2018, 327 of 339 patients assessed for eligibility were included. 112 had a poor prognosis. Of those, 93 patients with a poor prognosis were included in the modified intention-to-treat analysis: 49 (53%) received SID and 44 (47%) received placebo. The adjusted common odds ratio for improvement on the Guillain-Barre syndrome disability score at 4 weeks was 1.4 (95% CI 0.6-3.3; p=0.45). Patients given SID had more serious adverse events (35% vs 16% in the first 30 days), including thromboembolic events, than those in the placebo group. Four patients died in the intervention group (13-24 weeks after randomisation). Interpretation Our study does not provide evidence that patients with Guillain-Barre syndrome with a poor prognosis benefit from a second intravenous immunoglobulin course; moreover, it entails a risk of serious adverse events. Therefore, a second intravenous immunoglobulin course should not be considered for treatment of Guillain-Barre syndrome because of a poor prognosis. The results indicate the need for treatment trials with other immune modulators in patients severely affected by Guillain-Barre syndrome. Funding Prinses Beatrix Spierfonds and Sanquin Plasma Products. Copyright (C) 2021 Elsevier Ltd. All rights reserved

Response to Letter to the Editor Regarding “Yield of Computed Tomography (CT) Angiography in Patients with Acute Headache, Normal Neurological Examination, and Normal Non Contrast CT : A Meta-Analysis.”

Neuro Imaging Researc

Yield of Computed Tomography (CT) Angiography in Patients with Acute Headache, Normal Neurological Examination, and Normal Non Contrast CT : A Meta-Analysis

BACKGROUND: Patients with acute severe headache, normal neurological examination, and a normal noncontrast head computed tomography (NCCT) may still have subarachnoid hemorrhage, cerebral venous thrombosis (CVT), cervical arterial dissection, or reversible cerebral vasoconstriction syndrome (RCVS). Computed tomography angiography (CTA) is used increasingly in the emergency department for evaluating this, but its added value remains controversial. METHODS: We retrospectively collected data on the diagnostic yield of CTA in patients with acute severe headache, normal neurological examination, and normal NCCT who received additional CTA in the acute phase in 2 secondary referral centers for vascular neurology. We combined data of our patients with those from the literature and performed a meta-analysis. RESULTS: We included 88 patients from our hospital files and 641 patients after literature search. Of 729 patients 54 had a vascular abnormality on CTA (7.4%; 95% confidence interval [CI] 5.5%-9.3%). Abnormalities consisted of aneurysms (n = 42; 5.4%; 95% CI 3.8%-7.0%), CVT (n = 3, .5%), RCVS (n = 4, .5%), Moyamoya syndrome (n = 2, .3%), arterial dissection (n = 2, .3%), and ischemia (n = 1, .1%). Because most of the aneurysms were probably incidental findings, only 12 (1.6%) patients had a clear relation between the headache and CTA findings. The number needed to scan to find an abnormality was 14 overall, and 61 for an abnormality other than an aneurysm. CONCLUSION: Diagnostic yield of CTA in patients with acute headache, normal neurological examination, and normal NCCT is low, but because of the possible therapeutic consequences, its use might be justified in the emergency setting. Prospective studies confirming these results including cost-effectiveness analyses are needed

Mortality after chronic subdural hematoma is associated with frailty

Purpose Chronic subdural hematoma (CSDH) is a common neurological disease often affecting the elderly. Long-term excess mortality for patients after CSDH has been suggested but causes of death are unknown. We hypothesize that excess mortality of CSDH patients is related to frailty. In this article, we describe mortality rates and causes of death of CSDH patients compared with the general population and assess the association of frailty with mortality. Methods A cohort study in which consecutive CSDH patients were compared to the general population regarding mortality rates. Furthermore, the association of six frailty indicators (cognitive problems, frequent falling, unable to live independently, unable to perform daily self-care, use of benzodiazepines or psychotropic drugs, and number of medications) with mortality was assessed. Results A total of 1307 CSDH patients were included, with a mean age of 73.7 (SD +/- 11.4) years and 958 (73%) were male. Median follow-up was 56 months (range: 0-213). Compared with controls CSDH patients had a hazard ratio for mortality of 1.34 (95% CI: 1.2-1.5). CSDH patients more often died from cardiovascular diseases (37% vs. 30%) and falls (7.2% vs. 3.7%). Among CSDH patients frequent falling (HR 1.3; 95% CI: 1.0-1.7), inability to live independently (HR 1.4, 95% CI: 1.1-1.8), inability to perform daily self-care (HR 1.5; 95% CI: 1.1-1.9), and number of medications used (HR 1.0; 95% CI: 1.0-1.1) were independently associated with mortality. Conclusions CSDH patients have higher mortality rates than the general population. Frailty in CSDH patients is associated with higher mortality risk. More attention for the frailty of CSDH patients is warranted

External validation of computed tomography decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands

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