Intracranial hemorrhage in a patient with severe hemophilia — case report

Hemofilia jest dziedziczną, genetycznie uwarunkowaną skazą krwotoczną, spowodowaną niedoborem lub brakiem czynnika krzepnięcia VIII (hemofilia A) albo IX (hemofilia B). Leczenie krwawień w przebiegu choroby opiera się na substytucji czynników krzepnięcia. Powikłaniem leczenia substytucyjnego pogarszającym rokowanie i utrudniającym leczenie jest pojawianie się inhibitorów, które hamują aktywność czynnika VIII bądź IX. Krwotok do ośrodkowego układu nerwowego (OUN) to jedno z najcięższych powikłań hemofilii, wymagające intensywnego leczenia i monitorowania stanu chorego. Mężczyzna, lat 63, z ciężką postacią hemofilii A został przyjęty na Oddział Neurologii i Leczenia Udarów Mózgu z powodu bólu głowy i osłabienia siły mięśniowej lewych kończyn. W badaniu głowy metodą tomografii komputerowej (TK) uwidoczniono rozległe ognisko krwotoczne w okolicy ciemieniowo-skroniowej prawej wielkości 65 × 45 mm z obrzękiem prawej półkuli mózgu. W 1. dobie hospitalizacji aktywność czynnika krzepnięcia wynosiła 85,3%, a miano inhibitora — 1,3 jednostek Bethesda (jB./ml). Pomimo leczenia substytucyjnego dużymi dawkami koncentratu czynnika VIII w kontrolnym TK głowy stwierdzono powiększenie ogniska krwotocznego. Zadecydowano o włączeniu do leczenia koncentratów omijających inhibitor (BPA). Uzyskano poprawę stanu ogólnego i neurologicznego oraz zmniejszenie ogniska krwotocznego w kontrolnym badaniu TK.Hemophilia is a genetically inherited bleeding disorder, caused by deficiency or lack of clotting factor VIII (hemophilia A) or IX (hemophilia B). Treatment of bleeding in the course of the disease is based on the substitution of coagulation factors. The prognosis and treatment is more difficult in patients with elevated level of inhibitors of coagulation factor VIII or IX. Hemorrhage into the central nervous system (CNS) is one of the most serious complications of hemophilia, requiring intensive treatment and monitoring of the patient. Patient, 63 year old male with severe haemophilia A was admitted to the Department of Neurology and Stroke Treatment due to headaches and weakness of left limbs. We performed CT-scan and revealed hemorrhage in the right parieto-temporal region of brain, 65 × 45 mm in diameter, with edema of the right hemisphere. During the first day of hospitalization clotting factor activity was 85.3%, and the inhibitor activity — 1.3 Bethesda Units (BU/mL). Despite substitution treatment with high doses of concentrated factor VIII, in the control CT-scan of patients brain we found enlargement of the hemorrhage. It was decided to include bypassing agents (BPA) in the treatment. General and neurological condition of the patient improved and reduction of hemorrhage was revealed in the next CT-scan

A patient with ischemic stroke and myocardial infarction undergoing interventional treatment - a case report

The coexistence of acute ischemic stroke and acute myocardial infarction is rare. The reperfusion therapy used in the therapeutic window is the golden standard in the treatment of both diseases. We present a case of successful aspiration thrombectomy circumflex anterior artery and effective mechanical thrombectomy of the right internal carotid artery in a 49 - year-old female patient with myocardial infarction and ischemic stroke. When admitted in a neurological examination she received 16 points. on the NIHSS scale. The patient was discharged from the clinic as an independent, with slight hemiparesis (NIHSS 4 points). The result of recanalization was 3 points in the TICI scale. After intravascular treatment, the patient was advised to use anticoagulant therapy due to arterial thrombosis in two vascular areas and a high probability of thrombophilia until complete diagnostics. During the hospitalization, cardiovascular diseases were diagnosed. Transesophageal echocardiography showed a left-right flow through Botallio foramen width of 3 mm, with no visible reversal of leakage after contrast administration. After 3 months, tests were performed that did not confirm thrombophilia. The question of closing the surviving Botallio foramen, re-performing Holter and further genetic testing remains to be considered

Mechanical thrombectomy in acute stroke – Five years of experience in Poland

Objectives Mechanical thrombectomy (MT) is not reimbursed by the Polish public health system. We present a description of 5 years of experience with MT in acute stroke in Comprehensive Stroke Centers (CSCs) in Poland. Methods and results We retrospectively analyzed the results of a structured questionnaire from 23 out of 25 identified CSCs and 22 data sets that include 61 clinical, radiological and outcome measures. Results Most of the CSCs (74%) were founded at University Hospitals and most (65.2%) work round the clock. In 78.3% of them, the working teams are composed of neurologists and neuro-radiologists. All CSCs perform CT and angio-CT before MT. In total 586 patients were subjected to MT and data from 531 of them were analyzed. Mean time laps from stroke onset to groin puncture was 250±99min. 90.3% of the studied patients had MT within 6h from stroke onset; 59.3% of them were treated with IV rt-PA prior to MT; 15.1% had IA rt-PA during MT and 4.7% – emergent stenting of a large vessel. M1 of MCA was occluded in 47.8% of cases. The Solitaire device was used in 53% of cases. Successful recanalization (TICI2b–TICI3) was achieved in 64.6% of cases and 53.4% of patients did not experience hemorrhagic transformation. Clinical improvement on discharge was noticed in 53.7% of cases, futile recanalization – in 30.7%, mRS of 0–2 – in 31.4% and mRS of 6 in 22% of cases. Conclusion Our results can help harmonize standards for MT in Poland according to international guidelines

Mechanical thrombectomy in acute stroke : five years of experience in Poland

Objectives: Mechanical thrombectomy (MT) is not reimbursed by the Polish public health system. We present a description of 5 years of experience with MT in acute stroke in Comprehensive Stroke Centers (CSCs) in Poland. Methods and results: We retrospectively analyzed the results of a structured questionnaire from 23 out of 25 identified CSCs and 22 data sets that include 61 clinical, radiological and outcome measures. Results: Most of the CSCs (74%) were founded at University Hospitals and most (65.2%) work round the clock. In 78.3% of them, the working teams are composed of neurologists and neuro-radiologists. All CSCs perform CT and angio-CT before MT. In total 586 patients were subjected to MT and data from 531 of them were analyzed. Mean time laps from stroke onset to groin puncture was 250 99 min. 90.3% of the studied patients had MT within 6 h from stroke onset; 59.3% of them were treated with IV rt-PA prior to MT; 15.1% had IA rt-PA during MT and 4.7% - emergent stenting of a large vessel. M1 of MCA was occluded in 47.8% of cases. The Solitaire device was used in 53% of cases. Successful recanalization (TICI2b–TICI3) was achieved in 64.6% of cases and 53.4% of patients did not experience hemorrhagic transformation. Clinical improvement on discharge was noticed in 53.7% of cases, futile recanalization - in 30.7%, mRS of 0–2 - in 31.4% and mRS of 6 in 22% of cases. Conclusion: Our results can help harmonize standards for MT in Poland according to international guideline

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry

BACKGROUND AND OBJECTIVES: COVID-19 related inflammation, endothelial dysfunction and coagulopathy may increase the bleeding risk and lower efficacy of revascularization treatments in patients with acute ischemic stroke. We aimed to evaluate the safety and outcomes of revascularization treatments in patients with acute ischemic stroke and COVID-19. METHODS: Retrospective multicenter cohort study of consecutive patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021, tested for SARS-CoV-2 infection. With a doubly-robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS: Of a total of 15128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19. 5848 (38.7%) patients received IVT-only, and 9280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted odds ratio [OR] 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour (OR 2.47; 95% CI 1.58-3.86) and 3-month mortality (OR 1.88; 95% CI 1.52-2.33).COVID-19 patients also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION: Patients with acute ischemic stroke and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 treated patients. Current available data does not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in COVID-19 patients, or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring and establishing prognosis

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry.

BACKGROUND AND OBJECTIVES COVID-19 related inflammation, endothelial dysfunction and coagulopathy may increase the bleeding risk and lower efficacy of revascularization treatments in patients with acute ischemic stroke. We aimed to evaluate the safety and outcomes of revascularization treatments in patients with acute ischemic stroke and COVID-19. METHODS Retrospective multicenter cohort study of consecutive patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021, tested for SARS-CoV-2 infection. With a doubly-robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS Of a total of 15128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19. 5848 (38.7%) patients received IVT-only, and 9280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted odds ratio [OR] 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour (OR 2.47; 95% CI 1.58-3.86) and 3-month mortality (OR 1.88; 95% CI 1.52-2.33).COVID-19 patients also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION Patients with acute ischemic stroke and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 treated patients. Current available data does not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in COVID-19 patients, or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring and establishing prognosis