scholarly journals Risk of Subsequent Thrombosis in Patients with Isolated Heparin-Induced Thrombocytopenia

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3566-3566
Author(s):  
Heather R Wolfe ◽  
Yu-Min Shen
Keyword(s):  
Optical Density ◽  
Thrombotic Event ◽  
Serotonin Release ◽  
Short Term ◽  
Heparin Induced Thrombocytopenia ◽  
Significant Difference ◽  
Thrombotic Complications ◽  
Release Assay ◽  
Prophylactic Anticoagulation

Abstract Background: Heparin-Induced Thrombocytopenia (HIT) is one of the most important and commonly encountered immune-mediated drug reactions which can lead to significant morbidity and mortality. In up to 25% of patients, thrombosis can be the presenting finding of HIT. Isolated HIT occurs in patients without clinically evident thrombosis at the time of diagnosis. The management of HIT focuses on reducing the risk of thrombotic complications. In addition to prompt discontinuation of heparin products, anticoagulation is recommended. The risk of thrombosis is thought to remain high for up to 4 weeks due to persistent circulating PF4-heparin antibodies. Prior studies have shown that in patients with isolated HIT, the subsequent 30-day risk of thrombosis is up to 53%. Guidelines recommend 3 months of anticoagulation for patients with HIT-associated thrombosis. The optimal duration of anticoagulation in isolated HIT is unknown. Many experts recommend prophylactic anticoagulation for up to 4 weeks after diagnosis. However in the era of direct thrombin inhibitors, the need for prophylactic anticoagulation and risk of thrombosis beyond normalization of platelet count remains to be determined. The aim of this study was to determine the incidence of subsequent thrombosis in patients with isolated HIT. Methods: In this retrospective review, we identified patients with a documented positive HIT (heparin-PF4 antibody) enzyme immunoassay (ELISA) at our affiliated hospitals between January 2006 and December 2016. Laboratory data from these patients were reviewed. Patients who met criteria for HIT, defined as HIT ELISA optical density ≥ 2 or positive serotonin release assay were included in the analysis. From this cohort of patients with confirmed HIT, clinical data was extracted from the electronic medical record, including anticoagulation management and documented thrombotic events within 3 months of HIT diagnosis. Patients with evidence of thrombosis at the time of diagnosis were excluded in the final analysis as our focus was on patients with isolated HIT. The incidence of subsequent thrombosis was compared in patients who received anticoagulation versus those who did not receive anticoagulation. Results: A total of 403 charts were reviewed from patients with a documented positive HIT ELISA, defined as an optical density of > 0.4. Of the 403 patients, 49.5% (n = 107) met criteria for HIT, with an optical density > 2 or positive serotonin release assay. In patients with HIT, 48.6% (n = 52) did not have evidence of thrombosis at the time of diagnosis. Of these patients with isolated HIT, 14 patients (26.9%) received no prophylactic anticoagulation, 8 patients (15.4%) received prophylactic anticoagulation for at least 4 weeks but less than 3 months, and 30 patients (57.7%) were anticoagulated for 3 months or longer. The total incidence of subsequent thrombosis in isolated HIT was 7.7%. In the cohort of patients that did not receive prophylactic anticoagulation, two patients (14.3%) developed a thrombotic event in the 3 months following the HIT diagnosis. No documented thrombotic complications occurred in the eight patients that received prophylactic anticoagulation for at least 4 weeks but less than 3 months. Three patients (10%) who received long-term anticoagulation (≥3 months) developed a subsequent thrombotic event. There was no significant difference in the incidence of subsequent thrombosis in patients who did not receive prophylactic anticoagulation versus patients who received short-term prophylactic anticoagulation (p=0.141). In addition, there was no significant difference in the incidence of subsequent thrombosis in patients who did not receive prophylactic anticoagulation versus those who received long-term anticoagulation (p=0.701). Conclusions: The optimal duration of anticoagulation in patients with isolated HIT is unknown. Our incidence of thrombosis following the diagnosis of HIT was lower than previously described. Patients who did not receive prophylactic anticoagulation did not have a significantly higher incidence of thrombosis compared to patients who received short-term prophylactic or long-term anticoagulation. The study was limited by the retrospective nature and small sample size. Further studies are needed to better understand the ideal length of anticoagulation to prevent thrombotic complications without leading to unnecessary increased risk of bleeding. Disclosures No relevant conflicts of interest to declare.

Incidence of Thrombosis in Serotonin Release Assay Negative Patients and Correlation with Pretest Heparin-Induced Thrombocytopenia Scoring System.

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 1816-1816 ◽  
Author(s):  
Christopher Hueser ◽  
Anjali J Patel ◽  
John N Allan
Keyword(s):  
Platelet Count ◽  
Scoring System ◽  
Thrombotic Event ◽  
Study Groups ◽  
Serotonin Release ◽  
Single Institution ◽  
Heparin Induced Thrombocytopenia ◽  
Significant Difference ◽  
Release Assay ◽  
4T Score

Abstract Introduction: Heparin-induced thrombocytopenia (HIT) is an immune mediated, adverse effect related to both unfractionated heparin (UFH) and low-molecular weight heparin (LMWH). HIT may result in significant morbidity and mortality. The serotonin release assay (SRA) is utilized in conjunction with clinical information to diagnosis HIT. Employment of the pretest clinical scoring system, known as the “4Ts”, classifies patients as having a low, intermediate or high probability for developing HIT. Previous investigators have reported clinically diagnosed HIT in patients with a negative SRA. However, there is no systematic study evaluating such a group of patients. We determined the frequency of thromboses in SRA negative patients and determined the correlation between the 4T score in patients with and without thromboses. Methods: We report a descriptive, single institution, retrospective study of 181 consecutive samples over the course of one year sent to the Coagulation Laboratory of St. Louis University for the work up of suspected HIT. A total of 142 patients were eligible. Patients with SRA negative samples were evaluated for evidence of thrombosis. Diagnosis of a thrombotic event was made by computed tomography (CT), venous Doppler ultrasonography (US), and ventilation-perfusion scanning (V/Q). Defined patient study groups were: all evalulable patients (PALL), patients with thromboses (TPOS) and patients without thromboses (TNEG). Analyses, between each patient group, the 4T score, mean platelet count prior to heparin therapy, and mean platelet nadirs were performed. Results: The overall incidence of proven thromboses in evaluable SRA negative patients was 14.8% (n=21). Of the 21 thromboses, 17(81.0%) were deep venous thromboses (DVT), 3(14.3%) were DVT and pulmonary embolus (PE), and 1(0.7%) was an isolated PE. A significant difference in 4T score was observed between TPOS vs PALL (p<0.0001) and TPOS vs TNEG (p<0.0001) groups. There was no difference between the patient groups PALL vs TNEG (p=0.985). No statistically significant difference between the study groups was seen for either initial platelet averages (TPOS vs PALL [p=0.8923], TPOS vs TNEG [p=0.2091], PALL vs TNEG [p=0.2550]) or nadirs (TPOS vs PALL [p=0.4664], TPOS vs TNEG [p=0.3763], PALL vs TNEG [p=0.7860]). Total Evaluable Patients (PALL) Patients without Thrombosis (TNEG) Patients with Thrombosis (TPOS) * Missing data was included in calculations for patients without thrombosis n 142 (100%) 110 (77.46)/121(85.2%)* 21(14.8%) Avg. 4T Score 3.23 (±1.81) 2.79 (±1.61)* 5.50 (±0.83) Avg. Initial Platelet Count (1X10 9 /L) 198.98 (±97.19) 194.16 (±99.39)* 223.90 (±79.31) Avg. Platelet Nadir (1X10 9 /L) 75.02 (±48.57) 73.41 (±46.47)* 82.86 (±59.42) Avg. Platelet Drop (1X10 9 /L) 123.96 (62.30%) 94.77 (48.81%)* 141.04 (62.99%) NO Data* 11 11(7.75%)* NA Conclusions: A higher incidence of thrombotic events in SRA negative patients was seen compared to historical data. A strong positive and negative correlation exists between high and low 4T scores, respectively, and the probability of thromboses from HIT. Prospective data are needed to address the incidence of thrombosis for patients in whom the pretest probability of HIT is high and in whom the SRA is negative. Studies evaluating the utility of serial SRA testing in such patients may lead to earlier identification of those at high risk for thromboses. Limitations of this study were the retrospective design, single institution, and the lack of serial SRA testing.

Correlation Of Heparin Confirmatory Test (HCT) With Optical Density (OD) and Serotonin Release Assay (SRA) In The Diagnosis Of Heparin Induced Thrombocytopenia (HIT)

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 4754-4754 ◽  
Author(s):  
Ravneet Thind ◽  
Danielle Heidemann ◽  
Sundara Raman ◽  
Philip Kuriakose
Keyword(s):  
Optical Density ◽  
Predictive Value ◽  
Serotonin Release ◽  
Thrombin Inhibitors ◽  
Confirmatory Test ◽  
Functional Assay ◽  
Heparin Induced Thrombocytopenia ◽  
Laboratory Confirmation ◽  
Confirmation Test ◽  
Release Assay

Introduction Heparin-induced thrombocytopenia (HIT) is a potentially fatal, thrombotic complication of heparin therapy mediated by antibodies to complexes between platelet factor 4 (PF4) and heparin. Accurate and rapid diagnosis with prompt commencement of therapy are imperative as delays in treatment are associated with an increasing risk of thrombosis, amputation, or death. On the flip side, initiation of therapy with direct thrombin inhibitors without laboratory confirmation carries a significant risk of bleeding. Two types of laboratory tests are available for detection of these antibodies: a widely available immunoassay (ELISA), which is very sensitive to the presence of anti-heparin/PF4 antibodies, but is less specific to the clinical syndrome of HIT because of detection of non-pathological antibodies. The Serotonin Release Assay (SRA) is a functional assay that is now considered the gold standard for confirmatory diagnosis of HIT due to its high specificity. However, the downside of SRA is the cost involved, limited availability and a turnaround time of 5-7 days. As such, a heparin confirmatory test (HCT) with excess heparin has been in use since mid 2011 on positive ELISA samples in our laboratory to improve test specificity. This test is more cost and time efficient, with a turnover time of no more than 48 hours. As noted in prior studies, inhibition of a positive ELISA result by 50% or more in the presence of excess heparin is considered confirmatory of heparin-dependent antibodies. Likewise a negative confirmatory test is defined as a decrease of 50% or less in antibody binding in the presence of heparin. Aim a) Correlation of Heparin Confirmatory test (HCT) with strength of HIT ELISA, vis-à-vis optical density (OD) of 0.4 - 0.99 and OD of >/= 1.0. b) Correlation of HCT results with SRA, to see if the latter can be replaced by the heparin confirmatory test. Patients and Methods A retrospective chart review of adult patients hospitalized at our institution with suspected HIT from July 2011 until January 2013 was done. There were 101 such patients. All patients who had a positive HIT ELISA, then had HCT as per our standard lab practice, with an SRA test done for diagnosis/confirmation of HIT, as per standard clinical practice. Historically, the major strength of SRA assay is its specificity. The optical density on HIT ELISA and SRA results were then compared with the Heparin Confirmatory test to establish clinical significance. Results Of the 101 patients tested for HIT ELISA, 49 were positive. HCT and SRA were performed on all 49 samples, 1 out of which was reported as indeterminate. Hence 48 samples were used for primary analysis, comparing HCT to the OD as well as the SRA results. Out of 48 patients, 6 had positive SRA with Heparin inhibition of >50% (sensitivity 6/6 = 100%). Remaining 42 patients had negative SRA, 7 out of which had Heparin inhibition of <50% (specificity 7/42 = 16.6%). All 7 patients with a negative HCT had a negative SRA, making the negative predictive value of the HCT 100%; however positive predictive value was only 14.6% (6/41). There was no correlation between the OD and Heparin Confirmation test. Conclusions Although there is data suggesting that there might be some value to the Heparin Confirmation test, we were unable to show a significant correlation between HCT and OD or between HCT and SRA. The prospect of having a cost effective and rapid assay for laboratory confirmation of HIT will always be a relevant need. We feel that a larger, prospective study should be conducted to definitively assess the relationship between HCT and SRA. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Clinical Significance of the Serotonin Release Assay and Platelet Count Monitoring After Cardiac Surgery

2017 ◽  
Vol 24 (6) ◽  
pp. 944-949 ◽  
Author(s):  
Shinya Motohashi ◽  
Takefumi Matsuo ◽  
Hidenori Inoue ◽  
Makoto Kaneko ◽  
Shunya Shindo
Keyword(s):  
Cardiac Surgery ◽  
Platelet Count ◽  
Clinical Course ◽  
Serotonin Release ◽  
Enzyme Linked Immunosorbent Assay ◽  
Heparin Induced Thrombocytopenia ◽  
Release Assay ◽  
Immunological Assays ◽  
Platelet Count Monitoring ◽  
The Relationship

Heparin-induced thrombocytopenia (HIT) is one of the serious complications in patients who undergo cardiac surgery. However, there remains a major problem in diagnosing HIT because the current immunological assays for detection of HIT antibody have limitations. Furthermore, the clinical course of thrombocytopenia in this surgery makes it increasingly difficult to diagnose HIT. We investigated the relationship between platelet count and HIT antibody in 59 patients who underwent cardiac surgery using cardiopulmonary bypass (CPB). The number of postoperative HIT antibody-positive patients evaluated using enzyme-linked immunosorbent assay kit (polyanion IgG/IgA/IgM complex antibodies/antiplatelet factor 4 enhanced) was 37 (62.7%). In contrast, platelet activation by HIT antibody was evaluated using the serotonin release assay (SRA). More than 20% and 50% release of serotonin was obtained from 12 patients (20.3%) and 8 patients (13.6%), respectively. The levels of d-dimer were significantly different on postoperative day 14 between SRA-positive and SRA-negative groups; however, postoperative thrombus complication was not detected using sonography in the patients with positive serotonin release at all. After being decreased by the operation, their platelet count recovered within 2 weeks in both groups equally. In our study, although the patients were positive in the platelet activating HIT antibody assay, they remained free from thrombosis and their platelet count recovered after early postoperative platelet decrease. Therefore, in addition to the SRA, monitoring of platelet count might be still considered an indispensable factor to facilitate the prediction of HIT thrombosis prior to manifestation in the patients undergoing cardiac surgery using CPB.

scholarly journals Combined Androgen Blockade in Localized Prostate Cancer Treated With Definitive Radiation Therapy

2019 ◽  
Vol 17 (12) ◽  
pp. 1497-1504
Author(s):  
Lucas K. Vitzthum ◽  
Chris Straka ◽  
Reith R. Sarkar ◽  
Rana McKay ◽  
J. Michael Randall ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Radiation Therapy ◽  
High Risk ◽  
Cox Proportional Hazards ◽  
Hazard Ratio ◽  
Short Term ◽  
Combined Androgen Blockade ◽  
Significant Difference ◽  
Androgen Blockade

Background: The addition of androgen deprivation therapy to radiation therapy (RT) improves survival in patients with intermediate- and high-risk prostate cancer (PCa), but it is not known whether combined androgen blockade (CAB) with a gonadotropin-releasing hormone agonist (GnRH-A) and a nonsteroidal antiandrogen improves survival over GnRH-A monotherapy. Methods: This study evaluated patients with intermediate- and high-risk PCa diagnosed in 2001 through 2015 who underwent RT with either GnRH-A alone or CAB using the Veterans Affairs Informatics and Computing Infrastructure. Associations between CAB and prostate cancer–specific mortality (PCSM) and overall survival (OS) were determined using multivariable regression with Fine-Gray and multivariable Cox proportional hazards models, respectively. For a positive control, the effect of long-term versus short-term GnRH-A therapy was tested. Results: The cohort included 8,423 men (GnRH-A, 4,529; CAB, 3,894) with a median follow-up of 5.9 years. There were 1,861 deaths, including 349 resulting from PCa. The unadjusted cumulative incidences of PCSM at 10 years were 5.9% and 6.9% for those receiving GnRH-A and CAB, respectively (P=.16). Compared with GnRH-A alone, CAB was not associated with a significant difference in covariate-adjusted PCSM (subdistribution hazard ratio [SHR], 1.05; 95% CI, 0.85–1.30) or OS (hazard ratio, 1.02; 95% CI, 0.93–1.12). For high-risk patients, long-term versus short-term GnRH-A therapy was associated with improved PCSM (SHR, 0.74; 95% CI, 0.57–0.95) and OS (SHR, 0.82; 95% CI, 0.73–0.93). Conclusions: In men receiving definitive RT for intermediate- or high-risk PCa, CAB was not associated with improved PCSM or OS compared with GnRH alone.

Incidence of Heparin-Induced Thrombocytopenia in Patients With Newly Implanted Mechanical Circulatory Support Devices

2021 ◽  
pp. 106002802110387
Author(s):  
Long To ◽  
Dana Attar ◽  
Brittany Lines ◽  
Melissa McCarty ◽  
Hassan Nemeh ◽  
...  
Keyword(s):  
Negative Predictive Value ◽  
Predictive Value ◽  
Mechanical Circulatory Support ◽  
Serotonin Release ◽  
Circulatory Support ◽  
Anticoagulation Management ◽  
Heparin Induced Thrombocytopenia ◽  
Mechanical Circulatory Support Devices ◽  
High Negative Predictive Value ◽  
Release Assay

Background: Heparin exposure and device-related thrombocytopenia complicate the diagnosis of heparin-induced thrombocytopenia (HIT) in patients receiving mechanical circulatory support (MCS). To improve anticoagulation management for patients with newly implanted MCS devices, incidence of confirmed HIT needs to be further characterized. Objectives: The purpose of this study is to describe the incidence of HIT and clinical utility of the 4Ts score in patients with newly implanted MCS devices. Methods: This is a retrospective analysis of MCS patients receiving unfractionated heparin from 2014 to 2017. The primary end point was incidence of laboratory-confirmed HIT. Strong positive, likely positive, low probability, and negative HIT categories were established based on heparin-induced platelet antibody (HIPA) and serotonin release assay (SRA). Secondary end points include characterization of platelet trends, argatroban use, incidence of HIT among each of the MCS devices, and utility of 4Ts score. Results: A total of 342 patient encounters met inclusion criteria, of which 68 HIPA tests and 25 SRAs were ordered. The incidence of HIT was 0.88% (3/342) and 4.4% (3/68) in patients with suspected HIT. Of the 68 HIPA tests, 3 (4.4%) were considered strong positive and 3 of the 25 SRAs were positive. Median 4Ts score was 4 [2.5-4] and optical density 0.19 [0.11-0.54]. The positive predictive value for the 4Ts score was 0.15 (CI = 0.03-0.46) and negative predictive value, 0.93 (CI = 0.82-0.98). Conclusion and Relevance: HIT occurs infrequently with newly implanted MCS devices. The 4Ts score appears to have a high negative predictive value for ruling out HIT.

Pathophysiology of Heparin-Induced Thrombocytopenia

2000 ◽  
Vol 124 (11) ◽  
pp. 1657-1666 ◽  
Author(s):  
Fabrizio Fabris ◽  
Sarfraz Ahmad ◽  
Giuseppe Cella ◽  
Walter P. Jeske ◽  
Jeanine M. Walenga ◽  
...  
Keyword(s):  
Platelet Activation ◽  
Serotonin Release ◽  
Platelet Factor 4 ◽  
Thrombin Inhibitors ◽  
Platelet Factor ◽  
Cellular Activation ◽  
Heparin Induced Thrombocytopenia ◽  
New Information ◽  
Study Selection ◽  
Release Assay

Abstract Objective.—This review of heparin-induced thrombocytopenia (HIT), the most frequent and dangerous side effect of heparin exposure, covers the epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment of this disease syndrome. Data Sources and Study Selection.—Current consensus of opinion is given based on literature reports, as well as new information where available. A comprehensive analysis of the reasons for discrepancies in incidence numbers is given. The currently known mechanism is that HIT is mediated by an antibody to the complex of heparin–platelet factor 4, which binds to the Fc receptor on platelets. New evidence suggests a functional heterogeneity in the anti-heparin-platelet factor 4 antibodies generated to heparin, and a “superactive” heparin-platelet factor 4 antibody that does not require the presence of heparin to promote platelet activation or aggregation has been identified. Up-regulation of cell adhesion molecules and inflammatory markers, as well as preactivation of platelets/endothelial cells/leukocytes, are also considered to be related to the pathophysiology of HIT. Issues related to the specificity of currently available and new laboratory assays that support a clinical diagnosis are addressed in relation to the serotonin-release assay. Past experience with various anticoagulant treatments is reviewed with a focus on the recent successes of thrombin inhibitors and platelet GPIIb/IIIa inhibitors to combat the platelet activation and severe thrombotic episodes associated with HIT. Conclusions.—The pathophysiology of HIT is multifactorial. However, the primary factor in the mediation of the cellular activation is due to the generation of an antibody to the heparin-platelet factor 4 complex. This review is written as a reference for HIT research.

scholarly journals Can a simple, short-term memory task help to screen dyslexia?

2019 ◽  
Author(s):  
Nick Perham ◽  
Toni Howell ◽  
Andy Watt
Keyword(s):  
High Frequency ◽  
Short Term Memory ◽  
Memory Task ◽  
Compulsory Education ◽  
Low Frequency ◽  
Short Term ◽  
Term Order ◽  
Significant Difference ◽  
Support Students

AbstractFunding to support students with dyslexia in post-compulsory education is under pressure and more efficient assessments may offset some of this shortfall. We tested potential tasks for screening dyslexia: recall of adjective-noun, compared to noun-adjective, pairings (syntax) and recall of high versus low frequency letter pairings (bigrams). Students who reported themselves as dyslexic failed to show a normal syntax effect (greater recall of adjective-noun compared to noun-adjective pairings) and no significant difference in recall between the two types of bigrams whereas students who were not dyslexic showed the syntax effect and a bias towards recalling high frequency bigrams. Findings are consistent with recent explanations of dyslexia suggesting that those affected find it difficult to learn and utilise sequential long-term order information (Szmalec et al. Journal of Experimental Psychology: Learning, Memory & Cognition, 37(5) ,1270-1279, 2011). Further, ROC curve analyses revealed both tasks showed acceptable diagnostic properties as they were able to discriminate between the two groups of participants.

Does meloxicam provide adequate pain management as a post-operative analgesic in canine ovariohysterectomy patients?

2020 ◽  
Vol 11 (4) ◽  
pp. 192-197
Author(s):  
Gavin Goldsbrough ◽  
Helen Reynolds
Keyword(s):  
Pain Management ◽  
Pain Score ◽  
Pain Scale ◽  
Short Term ◽  
Post Surgery ◽  
Pain Scores ◽  
Significant Difference ◽  
Time Frames ◽  
Adequate Pain Management

Background: Meloxicam is an analgesic agent with anti-inflammatory properties, commonly used in veterinary practices to treat a variety of different long-term medical conditions and is also used as a short-term pain relief following particularly traumatic surgeries. Aims: An observational study was conducted to determine whether meloxicam provides adequate pain management as a post-operative analgesic for canine ovariohysterectomies. Methods: 13 canines were admitted for ovariohysterectomy. Each patient was assessed using the Glasgow composite pain scale (CMPS) prior to surgery during the admission procedure, 15 minutes post-operatively, at discharge and at their post-operative check (POC) 3–5 days after surgery. Results: Data were statistically analysed to determine the overall effectiveness of meloxicam in reducing pain following canine ovariohysterectomy. The results showed a statistically significant difference (Kruskal-Wallis test: H3 =12.98, p=0.005) in pain scores between admission, 15 minutes post operatively, discharge and 3–5 days POC. The greatest decrease in pain score was between 15 minutes post-operatively and POC (Mann-Whitney U test: W=236, n=13, 13, p=0.0014) and between discharge and POC (Mann-Whitney U test: W=227, n=13, 13, p=0.0060). Overall, this demonstrated that there was an improvement in pain suggesting meloxicam is effective between these time frames. In addition, 69.2% (n=9) of patients in the study showed a pain score of 0, indicating an absence of pain, on their final POC. Statistical analysis was also used to determine if there was any difference in pain score between the 3, 4 or 5 day POC pain score. The results show there was no significant difference (Kruskal-Wallis test: H2 =0.090, p=0.638) suggesting that meloxicam's effectiveness was similar across this range of time post surgery. Conclusion: The results from the study indicate that meloxicam is an effective post-operative analgesic for canine patients undergoing an ovariohysterectomy.

Postoperative hemorrhage during the acute phase after direct or combined revascularization for moyamoya disease: risk factors, prognosis, and literature review

2020 ◽  
Vol 133 (5) ◽  
pp. 1450-1459
Author(s):  
Yu Chen ◽  
Li Ma ◽  
Junlin Lu ◽  
Xiaolin Chen ◽  
Xun Ye ◽  
...  
Keyword(s):  
Risk Factors ◽  
Acute Phase ◽  
Moyamoya Disease ◽  
Disease Risk ◽  
Propensity Score Analysis ◽  
Postoperative Hemorrhage ◽  
Posterior Circulation ◽  
Short Term ◽  
Significant Difference

OBJECTIVEPostoperative hemorrhage during the acute phase is rarely observed after revascularization surgery for moyamoya disease (MMD) but can have severe complications. Its risk factors and outcomes are still unclear. The aim of this study was to investigate the predictors of postoperative hemorrhage during the acute phase in MMD and examine the outcomes of the hemorrhage.METHODSThe authors reviewed the preoperative clinical characteristics and radiographic features of 465 consecutive MMD cases (518 procedures) that had undergone direct or combined bypass surgery at their institution between 2009 and 2015. Patients with postoperative intracerebral hemorrhage (ICH) or ICH plus intraventricular hemorrhage (IVH) during the acute phase were screened, and then the incidence, location, and risk factors of hemorrhage in these patients were analyzed. Short-term and long-term outcomes (modified Rankin Scale scores) for these patients were also collected. Outcomes were compared between patients with and those without postoperative ICH using propensity score analysis to reduce the between-group differences in baseline characteristics.RESULTSPostoperative hemorrhage occurred in 11 (2.1%; ICH = 9, IVH = 2) of 518 procedures (mean patient age 39.82 ± 8.8 years). Hemorrhage occurred in the first 24 hours after the operation in 8 cases (72.7%). In the ICH group, most of the hemorrhage sites (77.8%) were located beneath the anastomosed area, and the mean hematoma volume was 16.98 ± 22.45 ml (range 3–57 ml). One case from the ICH group required hematoma evacuation. Among the adult patients (463 procedures [89.4%]), preoperative hypertension (p = 0.008), CT perfusion (CTP) stage > III (p = 0.013), and posterior circulation involvement (p = 0.022) were significantly associated with postoperative ICH. No significant differences between the postoperative ICH group and the no-hemorrhage group were detected in terms of postoperative neurofunctional status at discharge (p = 0.569) or at the last follow-up (p = 1.000). Neither was there a significant difference in future stroke risk (p = 0.538) between these two groups.CONCLUSIONSPreoperative hypertension, CTP stage > III, and posterior circulation involvement are independent risk factors for postoperative ICH after direct or combined revascularization for MMD. After appropriate perioperative management, postoperative ICH has no significant correlations with the postoperative short-term and long-term neurofunctional status.

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