scholarly journals Intracerebral Hemorrhage in COVID-19 Patients with Pulmonary Failure: A Propensity Score-Matched Registry Study

2021 ◽  
Author(s):  
Corinna N. Lang ◽  
Johanna S. Dettinger ◽  
Michael Berchtold-Herz ◽  
Stefan Utzolino ◽  
Xavier Bemtgen ◽  
...  
Keyword(s):  
Propensity Score ◽  
Intracerebral Hemorrhage ◽  
Propensity Score Matching ◽  
Case Reports ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Therapeutic Anticoagulation ◽  
Intracerebral Hemorrhages ◽  
Ecmo Therapy ◽  
Vv Ecmo

Abstract Background Hypercoagulability in Coronavirus Disease 2019 (COVID-19) causes deep vein thrombosis and pulmonary embolism necessitating systemic anticoagulation. Case reports of intracerebral hemorrhages in ventilated COVID-19 patients warrant precaution. It is unclear, however, if COVID-19 patients with acute respiratory distress syndrome (ARDS) with or without veno-venous extracorporeal membrane oxygenation therapy (VV-ECMO) have more intracerebral hemorrhages (ICH) compared to other ARDS patients. Methods We conducted a retrospective observational single-center study enrolling all patients with ARDS from 01/2018 to 05/2020. PCR-positive SARS-CoV-2 patients with ARDS were allocated to the COVID-19 group. Propensity score matching was performed for age, VV-ECMO, and bleeding risk. Results A total of 163 patients with moderate or severe ARDS were identified, 47 (28.8%) in the COVID-19 group, and 116 (71.2%) in the non-COVID-19 group. In 63/163 cases (38.7%), VV-ECMO therapy was required. The ICU survival was 52.8%. COVID-19 patients were older, more often male, and exhibited a lower SOFA score, but the groups showed similar rates of VV-ECMO therapy. Treatments with antiplatelet agents (p = 0.043) and therapeutic anticoagulation (p = 0.028) were significantly more frequent in the COVID-19 patients. ICH was detected in 22 patients (13.5%) with no statistical difference between the groups (11.2 vs. 19.1% with and without SARS-CoV-2, respectively, p = 0.21). Propensity score matching confirmed similar rates of ICH in both groups (12.8 vs. 19.1% with and without SARS-CoV-2, respectively, p = 0.57), thus leveling out possible confounders. Conclusions Intracerebral hemorrhage was detected in every tenth patient with ARDS. Despite statistically higher rates of antiplatelet therapy and therapeutic anticoagulation in COVID-19 patients, we found a similar rate of ICH in patients with ARDS due to COVID-19 compared to other causes of ARDS.

scholarly journals Intracerebral hemorrhage in COVID-19 patients with pulmonary failure – a propensity score matched registry study

2020 ◽  
Author(s):  
Corinna N. Lang ◽  
Johanna S. Dettinger ◽  
Michael Berchtold-Herz ◽  
Stefan Utzolino ◽  
Xavier Bemtgen ◽  
...  
Keyword(s):  
Propensity Score ◽  
Intracerebral Hemorrhage ◽  
Propensity Score Matching ◽  
Case Reports ◽  
Vein Thrombosis ◽  
Artery Embolism ◽  
Intracerebral Hemorrhages ◽  
Pulmonary Artery Embolism ◽  
Deep Vein ◽  
Ecmo Therapy

Abstract Background: Hypercoagulopathy in coronavirus disease 2019 (COVID-19) causing deep vein thrombosis and pulmonary artery embolism necessitate systemic anticoagulation. Case reports of intracerebral hemorrhages in ventilated COVID-19 patients warrant precaution. It is unclear however, if COVID-19 patients with acute respiratory distress syndrome (ARDS) with and without extracorporeal membrane oxygenation therapy (ECMO) have more intracerebral hemorrhages (ICH) compared to other ARDS patients.Methods: We conducted a retrospective observational single center study enrolling all patients with ARDS from 01/2018-05/2020. Patients with ARDS positive for SARS-CoV2 PCR were allocated to the COVID-19 group. Propensity score matching was performed for age, ECMO and risk of bleeding according to HAS-BLED score.Results: A total of 163, mostly severe ARDS patients were identified, 116 (71.2%) without COVID-19 and 47 (28.8%) positive for SARS-CoV-2. The two groups were comparable concerning the main confounders of ICH including age, HAS-BLED score, need for ECMO-therapy as well as anticoagulation levels reported. In 63/163 cases (38.7%), veno-venous ECMO therapy was required and ICU survival was 52.8%. Although HAS-BLED-score on admission was generally low (1.6±1.3), intracerebral hemorrhage was detected in 22 patients (13.5%) with no statistical difference between the groups (11.2 vs. 19.1% with and without SARS-CoV-2, respectively, p=0.21). Propensity score matching confirmed similar intracerebral bleeding rates in both groups (12.8 vs. 19.1% with and without SARS-CoV-2, respectively, p=0.57). Conclusions: Intracerebral hemorrhage was detectable in every tenth patient with ARDS. We found no statistically significant increased bleeding rate in patients with ARDS due to COVID-19 compared to other causes of ARDS.

scholarly journals Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risks and benefits

2021 ◽  
Vol 9 (1) ◽  
Author(s):  
Bo Yu ◽  
Victor Perez Gutierrez ◽  
Alex Carlos ◽  
Gregory Hoge ◽  
Anjana Pillai ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Propensity Score ◽  
Propensity Score Matching ◽  
Major Bleeding ◽  
Risk Estimation ◽  
Large Population ◽  
Invasive Mechanical Ventilation ◽  
Bleeding Risk ◽  
Hospitalized Patients ◽  
Significant Difference

Abstract Background Hospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients. Methods We retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 5 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts. Results The analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345–0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110–1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114–3.729, p = 0.016). Conclusion Empiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

scholarly journals Impact of Preexisting Cognitive Impairment and Race/Ethnicity on Functional Outcomes Following Intracerebral Hemorrhage

Stroke ◽  
2021 ◽  
Vol 52 (2) ◽  
pp. 603-610
Author(s):  
Russell P. Sawyer ◽  
Eunji Yim ◽  
Elisheva Coleman ◽  
Stacie L. Demel ◽  
Padmini Sekar ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cognitive Impairment ◽  
Propensity Score ◽  
Intracerebral Hemorrhage ◽  
Propensity Score Matching ◽  
Scale Score ◽  
Functional Outcomes ◽  
Cognitively Impaired ◽  
Modified Rankin Scale ◽  
Race Ethnicity

Background and Purpose: In intracerebral hemorrhage (ICH), preexisting cognitive impairment has been identified as a risk factor for increased mortality and morbidity. However, previous studies examined predominantly White populations; therefore, the prevalence and effect of preICH cognitive impairment has not been studied in a multiethnic cohort. This limits the generalizability of previous findings. We sought to investigate the role of preexisting cognitive impairment in a multiethnic population on short-term mortality and functional outcomes after ICH. Methods: Patients with ICH were prospectively enrolled as cases for the GERFHS III (Genetic and Environmental Risk Factors for Hemorrhagic Stroke) Study and the Ethnic/Racial Variations of ICH (ERICH) Study. Cognitive impairment before ICH was defined as positive history of dementia or treatment with donepezil, galantamine, memantine, or rivastigmine on chart abstraction or baseline interview. Specific outcomes—modified Rankin Scale score at 3 months (0–2 versus ≥3), Barthel Index score (<100 versus 100) at 3 months, and withdrawal of care—were analyzed using multivariable logistic regression. Propensity score matching and analysis was done because of imbalances between cognitively impaired and cognitively intact groups. Results: Of the 3537 cases of ICH, 304 patients had cognitive impairment predating ICH. Cognitively impaired subjects were more likely to experience withdrawal of care during hospitalization, and for survivors, greater disability (modified Rankin Scale score of ≥3) and lower Barthel scores after ICH. After propensity score matching, preexisting cognitive impairment was associated with a lower modified Rankin Scale at 3 months in the White, Black, and Hispanic subgroups. Conclusions: Preexisting cognitive impairment was associated with loss of independence 3-month post-ICH, when matching for risk factors of cognitive impairment, in the White, Black, and Hispanic subgroups. This suggests that preexisting cognitive impairment has a negative effect in obtaining functional independence following ICH, irrespective of race/ethnicity.

scholarly journals Prognostic Significance of Admission Systemic Inflammation Response Index in Patients With Spontaneous Intracerebral Hemorrhage: A Propensity Score Matching Analysis

2021 ◽  
Vol 12 ◽  
Author(s):  
Junhong Li ◽  
Yunbo Yuan ◽  
Xiang Liao ◽  
Zhiyuan Yu ◽  
Hao Li ◽  
...  
Keyword(s):  
Propensity Score ◽  
Intracerebral Hemorrhage ◽  
Propensity Score Matching ◽  
Systemic Inflammation ◽  
Functional Outcomes ◽  
Prognostic Significance ◽  
Predictive Ability ◽  
Original Cohort ◽  
Inflammation Response ◽  
Response Index

Intracerebral hemorrhage (ICH) accounts for ~15% of all strokes and is associated with high mortality and disability rates. The systemic inflammation response index (SIRI) is a novel systemic inflammatory marker based on peripheral neutrophil, monocyte, and lymphocyte counts. This study aimed to evaluate the prognostic significance of admission SIRI in patients with spontaneous ICH and compare its predictive ability with that of the neutrophil-to-lymphocyte ratio (NLR). This retrospective study was conducted based on a prospectively collected database of patients with ICH between June 2016 and January 2019. Propensity score matching (PSM) was conducted to adjust for potential imbalances in the clinical parameters. A total of 403 patients were included in the original cohort. The optimal SIRI cut-off value was 2.76. After 1:1 PSM based on potential confounding variables, a new cohort containing 262 patients was established for further analysis. In the original cohort, SIRI served as an independent predictor of 3-month functional outcome [odds ratio (OR), 1.302; 95% CI, 1.120–1.512; p = 0.001] and 1-month mortality (OR, 1.072; 95% CI, 1.020–1.126; p = 0.006), while NLR was independently associated with only 3-month functional outcomes (OR, 1.051; 95% CI, 1.004–1.100; p = 0.031) and not 1-month mortality. The same applied to the PSM cohort. Receiver operating characteristic analyses and predictive models indicated that in most instances, SIRI was superior to NLR and their components in predicting the outcomes of patients with ICH. Our study found that SIRI is determined to be an independent predictive indicator for ICH patients in 3-month functional outcomes and 1-month mortality. The prognostic predictive ability of SIRI was stronger than that of NLR.

scholarly journals Empiric use of Anticoagulation in Hospitalized Patients with COVID-19: A Propensity Score-Matched Study of Risks and Benefits

2021 ◽  
Author(s):  
Bo Yu ◽  
Victor Perez Gutierrez ◽  
Alex Carlos ◽  
Gregory Hoge ◽  
Anjana Pillai ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Propensity Score ◽  
Propensity Score Matching ◽  
Major Bleeding ◽  
Risk Estimation ◽  
Large Population ◽  
Invasive Mechanical Ventilation ◽  
Bleeding Risk ◽  
Hospitalized Patients ◽  
Significant Difference

Abstract Background: Hospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients. Methods: We retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 15 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts. Results: The analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345-0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110-1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114-3.729, p = 0.016). Conclusion: Empiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

scholarly journals Conventional Craniotomy Versus Conservative Treatment in Patients With Minor Spontaneous Intracerebral Hemorrhage in the Basal Ganglia

2020 ◽  
Author(s):  
Ning Wang ◽  
Xuanhao Zhu ◽  
Qi Tu ◽  
Daqian Zhu ◽  
Shuai Qu ◽  
...  
Keyword(s):  
Basal Ganglia ◽  
Treatment Group ◽  
Propensity Score ◽  
Conservative Treatment ◽  
Intracerebral Hemorrhage ◽  
Propensity Score Matching ◽  
Primary Outcome ◽  
Clinical Status ◽  
Spontaneous Intracerebral Hemorrhage ◽  
Surgery Group

Abstract Background: The treatment for spontaneous intracerebral hemorrhage (ICH) is still controversial, especially for hematomas in the basal ganglia. A retrospective case-control study with propensity score matching was performed to compare the outcomes of conventional craniotomy and conservative treatment for patients with minor ICH in the basal ganglia.Methods: We retrospectively collected the data of consecutive patients with minor basal ganglia hemorrhage from January 2018 to August 2019. We compared clinical outcomes of two groups using propensity score matching. The extended Glasgow outcome scale obtained by phone interviews based on questionnaires at 12 months follow-up was used as the primary outcome measure. On the basis of their clinical status at admission, patients were divided into good and poor prognosis groups to obtain a dichotomized (favorable or unfavorable) outcome as the primary outcome. Secondary outcomes included hospitalized complications, mortality and modified Rankin score at 12 months.Results: A total of 54 patients were analyzed, and the baseline characteristics of patients in the surgery and conservative treatment groups were well matched. The primary favorable outcome at 12 months was significantly higher in the conservative treatment group than in the surgery group (81% vs 44%; OR 1.833, 95% CI 1.159–2.900; P=0.005). The incidence of pneumonia in the surgery group was significantly higher than that in the conservative treatment group (p=0.005).Conclusions: It is not recommended to undertake conventional craniotomy for patients with a minor hematoma (25–40 ml) in the basal ganglia. An open craniotomy might induce worse long-term functional outcomes than the conservative treatment.

Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review

2019 ◽  
Vol 36 (03) ◽  
pp. 204-212
Author(s):  
Vasanth S. Kotamarti ◽  
Eric Shiah ◽  
Kristen M. Rezak ◽  
Ashit Patel ◽  
Joseph A. Ricci
Keyword(s):  
Systematic Review ◽  
Case Reports ◽  
Free Tissue Transfer ◽  
Bleeding Risk ◽  
Bleeding Complications ◽  
Tissue Transfer ◽  
Therapeutic Anticoagulation ◽  
Risk Patients ◽  
Postoperative Thrombosis ◽  
Thrombotic Complications

Abstract Background Despite improvements in microsurgical techniques, hypercoagulable patients remain a reconstructive challenge. Thrombophilias are a relatively common problem with potentially catastrophic results including free flap loss. The aim of this study was to assess the available literature on free tissue transfer in patients with known hypercoagulability to develop recommendations for management. Methods A systematic review of the PubMed, EBSCO, and Cochrane databases was performed in June 2018. Inclusion criteria were assessment of outcomes of free tissue transfer in patients with established hypercoagulability. Exclusion criteria were review articles, case reports, and studies lacking detailed discussion of anticoagulation regimens and surgical outcomes. Data collected included the number of hypercoagulable patients, anticoagulation regimens, thrombotic complications, flap success, and bleeding complications. Statistical analysis was performed using independent samples t-tests. Results Of 147 total results, four articles were included for analysis. One relevant article published after search completion was included. In total, 185 free tissue transfers were performed in 155 thrombophilic patients. Anticoagulation regimens varied widely but often included intraoperative continuous heparin, with or without additional bolus, followed by postoperative and outpatient anticoagulation. Hypercoagulable patients often developed late postoperative thromboses. Of the intraoperative thromboses, 36.4% were successfully salvaged. No flaps with postoperative thrombosis were salvaged. Preemptive therapeutic anticoagulation improved outcomes but increased the bleeding risk. Conclusion Free tissue transfer may be successful in hypercoagulable patients. High-risk patients identified preoperatively should receive therapeutic anticoagulation initiated intraoperatively unless contraindicated. Salvage after postoperative thrombosis is poor. Ultimately, the benefits of free tissue transfer must be considered with the potential morbidity of bleeding complications on a case-by-case basis when developing a reconstructive plan. Initiating anticoagulation based on the presence of intraoperative risk factors may prevent unnecessary intervention.

scholarly journals Intraarterial Versus Intravenous Tirofiban as an Adjunct to Endovascular Thrombectomy for Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (10) ◽  
pp. 2925-2933
Author(s):  
Jianhong Yang ◽  
Yuefei Wu ◽  
Xiang Gao ◽  
Andrew Bivard ◽  
Christopher R. Levi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Propensity Score ◽  
Intracerebral Hemorrhage ◽  
Acute Ischemic Stroke ◽  
Propensity Score Matching ◽  
Death Rate ◽  
Hospital Death ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Significant Difference

Background and Purpose: This study aimed to evaluate the treatment effect of intraarterial versus intravenous tirofiban during endovascular thrombectomy in acute ischemic stroke. Methods: This study retrospectively examined 503 patients with acute ischemic stroke with large vessel occlusion who received endovascular thrombectomy within 24 hours of stroke onset. Patients were divided into 3 groups: no tirofiban (n=354), intraarterial tirofiban (n=79), and intravenous tirofiban (n=70). The 3 groups were compared in terms of recanalization rate, symptomatic intracerebral hemorrhage, in-hospital death rate, 3-month death, and 3-month outcomes measured by modified Rankin Scale score (good clinical outcome of 0–2, poor outcome of 5–6). The comparison was statistically assessed by propensity score matching, followed by Freidman rank-sum test and pairwise Wilcoxon signed-rank test with Bonferroni correction. Results: The propensity score matching resulted in 92 matched triplets. Compared with the no-tirofiban group, the intravenous tirofiban group showed significantly increased recanalization (96.7% versus 64.1%, P <0.001), an increased rate of 3-month good outcome (69.5% versus 51.2%, P =0.034), and a lower rate of 3-month poor outcome (12.2% versus 41.4%, P <0.001). There was no significant difference between the tirofiban intravenous and no-tirofiban groups in terms of symptomatic intracerebral hemorrhage (2.2% versus 0%, P =1.000). However, symptomatic intracerebral hemorrhage was significantly increased in the intraarterial-tirofiban group compared with the no-tirofiban group (19.1% versus 0%, P <0.001), with an increased rate of in-hospital death (23.6% versus 0% P <0.001), and increased rate of 3-month death (26.8% versus 11.1%, P =0.021). The intraarterial-tirofiban and no-tirofiban group showed no significant difference in recanalization rate (66.3% versus 64.1%, P =1.000). Conclusions: As an adjunct to endovascular thrombectomy, intravenous tirofiban is associated with high recanalization rate and good outcome, whereas intraarterial tirofiban is associated with high hemorrhagic rate and death rate.

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