With the aging of the population, the number of people taking antithrombotic drugs is increasing. Few reports have described the clinical presentation, treatment, and outcomes of nontraumatic ...subarachnoid hemorrhage (SAH) in patients with preceding antithrombotic therapy. This study included 459 patients with nontraumatic SAH who had been treated between April 2009 and May 2021. Overall, 39 of the 459 patients with aneurysmal SAH were on antithrombotic therapy before ictus (8.5%). Therefore, we classified patients into two groups: Group A (n = 39), patients with preceding antithrombotic therapy and Group B (n = 420), patients without preceding antithrombotic therapy. Hunt and Kosnik (H&K) grade on admission was significantly higher in Group A than in Group B (p = 0.02). Patients in Group A more frequently received endovascular treatment. The rate of endovascular therapy for symptomatic vasospasm after SAH was significantly lower in Group A (2.6%) than in Group B (15.5%; p = 0.03). The outcomes at 3 months after onset were significantly poorer in Group A patients than in Group B patients (p = 0.03). Patients with preceding antithrombotic drugs tended to be at greater risk of unfavorable outcomes, but this difference was not significant in the univariate analysis. In the multivariate analysis, patient age, H&K grade ≥4, and subdural hematoma remained as risk factors for poor outcomes; however, preceding use of antithrombotic drugs was not a significant risk factor.
Warfarin remains crucially involved in the treatment of patients at thrombotic or thromboembolic risk. However, warfarin increases the mortality rate among patients with traumatic intracranial ...hemorrhage (TICH) through progressive hemorrhagic injury (PHI). Therefore, a rapid anticoagulation reversal could be required in patients with TICH to prevent PHI. Differences in the warfarin reversal effect between combination therapy of prothrombin complex concentrate (PCC) with vitamin K (VK) and VK monotherapy remain unclear. However, studies have reported that PCC has greater effectiveness and safety for warfarin reversal compared with fresh frozen plasma (FFP). This retrospective study aimed to evaluate the warfarin reversal effects of combination therapy of PCC with VK and VK monotherapy on TICH. We compared the clinical outcomes between the periods before and after the PCC introduction in our hospital. There were 13 and 7 patients who received VK monotherapy and PCC with VK, respectively. PHI predictors were evaluated using univariate regression analyses. Warfarin reversal using PCC had a significant negative association with PHI (odds ratio: 0.03, 95% confidence interval: 0.00–0.41, P = 0.004). None of the patients presented with thrombotic complications. Warfarin reversal through a combination of PCC with VK could be more effective for inhibiting post-trauma PHI compared with VK monotherapy. This could be attributed to a rapid and stable warfarin reversal. PCC should be administered to patients with TICH taking warfarin for PHI prevention.
Metastatic breast cancer in the bone rarely has a cystic appearance, and while it is common in the orbit, its metastasis to the orbitotemporal skull is rare. Consequently, it is difficult to diagnose ...it. We report and discuss a rare case of metastatic breast cancer with simple cyst appearance in the orbitotemporal region of the skull.
A 63-year-old woman presented with mild double vision only on left gaze that lasted for 2 months. Ten and a half years ago, the patient underwent surgery for tumor resection of a stage 3 breast adenocarcinoma, followed by radiotherapy and administration of anticancer therapy. Thereafter, she continued hormonal therapy with antiestrogen drugs, which was discontinued a half year ago because there was no recurrence during treatment. On admission, magnetic resonance imaging (MRI) showed a single and simple cystic lesion in the orbitotemporal region of the skull. The cyst was filled with fluid of different intensity, indicative of a hemorrhagic component. Additional gadolinium-contrasted MRI showed no enhancing effects in the lesion. The cyst was totally removed by surgery, and the histologic examination confirmed the diagnosis of breast adenocarcinoma. Intensity-modulated radiotherapy was then administered, and the patient started follow-up hormonal therapy with antiestrogen agents. No recurrence in the orbitotemporal region of the skull occurred during 6 months after the surgery.
Metastatic breast cancer should be considered in the differential diagnosis even if it appears as a simple cyst in the orbitotemporal bone after long-term remission.
Background
Postoperative rebleeding (PR) is one of the most severe complications of endoscopic surgery, often performed to remove spontaneous intracerebral hemorrhage (sICH). However, the risk ...factors for PR remain unclear.
Objective
This study retrospectively investigated whether increased preoperative plasma plasmin-α2-plasmin inhibitor complex (PIC) levels, indicating activation of fibrinolysis, are associated with PR.
Methods
A total of 101 patients underwent endoscopic surgery to evacuate sICH at our institution from January 2010 to June 2019, and 79 patients who underwent examinations of plasma PIC levels at admission with available radiographical data were included. Correlations between PR and increased plasma PIC levels were retrospectively evaluated.
Results
PR occurred in eight patients (10.1%), and high PIC levels (≥ 4 or 6 μg/ml) were significantly associated with PR. The sensitivities employing high PIC levels of ≥ 4 μg/ml and ≥ 6 μg/ml were both 0.63, and the specificities using the same PIC levels were 0.86 and 0.92, respectively. Multivariable analyses showed that high plasma PIC levels of ≥ 4 μg/ml (odds ratio (OR), 12.77; 95% confidence interval (CI), 1.65–98.77;
p
= 0.02) or ≥ 6 μg/ml (OR, 18.33; 95% CI, 2.32–144.82;
p
= 0.006) were independent predictors of PR.
Conclusions
This study found that increased plasma PIC levels were associated with PR following the endoscopic evacuation of sICHs, indicating that increased plasma PIC levels could be potentially used to predict PR. Further studies are needed to establish new surgical strategies and adjuvant treatments to improve surgical outcomes in patients with sICH prone to PR.
We report a case in which a central venous catheter (CVC) misplaced in the vertebral artery during insertion was surgically removed. A 70-year-old man was suspected of having a pancreatic abscess ...based on computed tomography (CT). The patient was initially treated for it at another department. Moreover, as part of the treatment, the CVC was placed under echocardiographic guidance. However, while placing the CVC, the catheter was erroneously inserted into the vertebral artery; therefore, he was referred to our department for retrieval. Magnetic resonance imaging (MRI) showed right thalamic and occipital cerebral infarctions. CT angiography (CTA) demonstrated that the catheter was inserted approximately 5 mm distal to the bifurcation of the brachiocephalic and vertebral arteries, and the catheter tip was located in the brachiocephalic artery. Removing the catheter posed risks such as hemorrhage, cerebral embolism, and arteriovenous fistulas. Therefore, to prevent the aforementioned risks, we chose a surgical intervention to remove the catheter using a microscope. The postoperative course was uneventful, and no complications occurred. This case demonstrates that surgical removal of CVC is effective and should be considered to avoid the risk of complications.
BACKGROUND Spinal extradural arachnoid cysts (SEACs) are rare and can cause spinal dysfunction. Total cyst removal and duraplasty via multiple laminectomies are commonly performed. However, to avoid ...postoperative spinal deformity and axial pain, a minimally invasive surgery via selective laminectomy may be optimal. Therefore, preoperative detection of the dural fistula site is required. OBSERVATIONS A 25-year-old male presented with a 2-month history of progressive gait disturbance and back pain. Conventional magnetic resonance imaging (MRI) revealed SEACs at the T9 to L2 level but did not reveal the dural fistula. Further examinations were performed using sagittal time-spatial labeling inversion pulse MRI and cone-beam computed tomography myelography with a spinal intrathecal catheter, which indicated a dural fistula on the left side at the T12 level. On the basis of these results, dural repair was performed via selective laminectomy. Furthermore, an intraoperative cerebrospinal fluid leakage test by intrathecally injecting saline via a spinal catheter confirmed complete closure of the dural fistula, with no other fistulas. LESSONS These comprehensive pre and intraoperative examinations may be useful for minimally invasive and selective surgeries in patients with SEACs.
Angiosarcoma is a malignant mesenchymal tumor derived from vascular endothelial cells in which a primary intracranial origin is extremely rare. Most previous reports of primary central nervous system ...(CNS) angiosarcoma have been solitary cases.
The authors report a case of primary CNS angiosarcoma that caused the development of multiple disseminated cerebral hemorrhagic lesions within a short period of time. This rapid progression of symptoms resulted in the death of the patient. During surgery, several nodules suggestive of a tumor were removed from just below the surface of the brain, mixed into the hematoma. A pathological examination revealed atypical cells mimicking blood vessels in the subarachnoid space that were positive for specific vascular endothelial markers.
In this case, multifocal angiosarcoma occurred on the brain surface and ventricles, suggesting cerebrospinal fluid dissemination. If multiple cerebral hemorrhages are found on the brain surface, multifocal angiosarcoma should also be considered.
The relationship between noncontrast computed tomography (CT) markers, which predict the expansion of spontaneous intracerebral hemorrhage (sICH) under conservative treatment, and postoperative ...rebleeding (PR) after treatment by directly removing the sICH is unknown. This study investigated the relationship between noncontrast CT markers and PR in patients with sICH treated by endoscopic surgery.
The study population included 92 patients with available data who underwent endoscopic surgery for sICH at our institution from January 2010 to September 2018. The correlations between PR and preoperative noncontrast CT markers, including the blend sign, hypodensities, black hole sign, heterogeneous density, and island signs, were retrospectively evaluated.
In 5 of the 18 patients (27.8%) with the blend sign, PR developed, whereas only 5 of 74 patients (6.8%) without the blend sign developed PR. In the univariate regression analyses, manifestation of hydrocephalus (odds ratio OR, 8.75; 95% confidence interval CI, 2.15–35.68; P = 0.002), presence of the blend sign (OR, 5.31; 95% CI, 1.34–20.97; P = 0.02), and insertion of external ventricular drainage (OR, 13.88; 95% CI, 3.22–59.77; P < 0.001) were significant risk factors. The other radiographic markers were not associated with PR. In a multivariate analysis, the presence of the blend sign (OR, 22.07; 95% CI, 2.18–223.60; P = 0.009) was the only independent predictor of PR.
The blend sign is likely to be a strong predictor for PR in patients who undergo endoscopic surgery for sICH. To improve the prognosis of patients with sICH, further studies are needed to establish new treatment strategies and surgical procedures.
Abstract With the aging of the population, the number of people taking antithrombotic drugs is increasing. Few reports have described the clinical presentation, treatment, and outcomes of ...nontraumatic subarachnoid hemorrhage (SAH) in patients with preceding antithrombotic therapy. This study included 459 patients with nontraumatic SAH who had been treated between April 2009 and May 2021. Overall, 39 of the 459 patients with aneurysmal SAH were on antithrombotic therapy before ictus (8.5%). Therefore, we classified patients into two groups: Group A (n = 39), patients with preceding antithrombotic therapy and Group B (n = 420), patients without preceding antithrombotic therapy. Hunt and Kosnik (H&K) grade on admission was significantly higher in Group A than in Group B (p = 0.02). Patients in Group A more frequently received endovascular treatment. The rate of endovascular therapy for symptomatic vasospasm after SAH was significantly lower in Group A (2.6%) than in Group B (15.5%; p = 0.03). The outcomes at 3 months after onset were significantly poorer in Group A patients than in Group B patients (p = 0.03). Patients with preceding antithrombotic drugs tended to be at greater risk of unfavorable outcomes, but this difference was not significant in the univariate analysis. In the multivariate analysis, patient age, H&K grade >- 4, and subdural hematoma remained as risk factors for poor outcomes; however, preceding use of antithrombotic drugs was not a significant risk factor.
Abstract Warfarin remains crucially involved in the treatment of patients at thrombotic or thromboembolic risk. However, warfarin increases the mortality rate among patients with traumatic ...intracranial hemorrhage (TICH) through progressive hemorrhagic injury (PHI). Therefore, a rapid anticoagulation reversal could be required in patients with TICH to prevent PHI. Differences in the warfarin reversal effect between combination therapy of prothrombin complex concentrate (PCC) with vitamin K (VK) and VK monotherapy remain unclear. However, studies have reported that PCC has greater effectiveness and safety for warfarin reversal compared with fresh frozen plasma (FFP). This retrospective study aimed to evaluate the warfarin reversal effects of combination therapy of PCC with VK and VK monotherapy on TICH. We compared the clinical outcomes between the periods before and after the PCC introduction in our hospital. There were 13 and 7 patients who received VK monotherapy and PCC with VK, respectively. PHI predictors were evaluated using univariate regression analyses. Warfarin reversal using PCC had a significant negative association with PHI (odds ratio : 0.03, 95% confidence interval : 0.00-0.41, P = 0.004). None of the patients presented with thrombotic complications. Warfarin reversal through a combination of PCC with VK could be more effective for inhibiting post-trauma PHI compared with VK monotherapy. This could be attributed to a rapid and stable warfarin reversal. PCC should be administered to patients with TICH taking warfarin for PHI prevention.
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