Case fatality rate and fatal bleeding complication in patients with pulmonary embolism and patent foramen ovale

Objectives In patients with acute pulmonary embolism (PE), right atrial pressure is elevated, which increases risk for right-to-left shunt when patent foramen ovale (PFO) is present and thus potentially increases risk for paradoxical embolism. Little is known about the clinical outcome of patients with PE and concomitant PFO. Methods We analysed data on patient characteristics, treatments and in-hospital outcomes for all PE patients (ICD-code I26) with concomitant presence of PFO in Germany 2005–2018 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, and own calculations). Results Between January 2005 and December 2018, 1,174,235 patients with acute PE (53.5% females) were included in this analysis; of those, 5,486 (0.5%) had a concomitant diagnosis of PFO. Trends analysis demonstrating an increasing frequency of diagnosed PE with additional PFO from 2005 (n=299) to 2018 (n=556; p<0.001). While patients with PE and PFO presented more often with signs of haemodynamic compromise such RV dysfunction (37.6% vs. 28.5%) or shock (7.1% vs. 3.9%) as well as paradox arterial emboli (47.8% vs. 3.2%) or intracerebral bleeding (3.3% vs. 0.6%), PE patients with PFO died less often compared to PE patients without PFO (11.1% vs. 15.8%). Patients with PE and PFO were younger (65 [IQR 52–75] vs. 72 [60–80]; P<0.001) and were more often treated invasively with a reperfusion treatment approach like embolectomy (10.2% vs. 4.2%) or systemic thrombolysis (5.0% vs 0.1%). A multivariate logistic regression analysis revealed a 27.6-fold increased risk for paradox arterial emboli (OR, 27.6 [95% CI 26.1–29.1]; p<0.001) and a 3.9-fold increased risk for intracerebral bleeding events (OR, 3.9 [95% CI 3.3–4.54]; p<0.001) for patients with PE and concomitant PFO. In normotensive patients with RVD and PFO, embolectomy were not associated to affect the rate of intracerebral bleeding events (OR, 0.8 [95% CI 0.2–2.6]; p=0.720) compared to conventional non-reperfusion treatment; instead of systemic thrombolysis, which is associated with a higher risk of intracerebral bleeding (OR, 3.5 [95% CI 1.8–6.59]; p<0.001) compared to conventional non-reperfusion treatment. Conclusion Patients with acute PE and the concomitant presence of PFO are associated with a high risk for paradox arterial emboli and intracranial bleeding events. Especially in normotensive patients, the use of systemic thrombolysis should be considered with cautious. Thus, our findings may improve the clinical management of patients with PE and PFO. FUNDunding Acknowledgement Type of funding sources: None.

Management and Outcome of Traumatic Intracerebral Hemorrhage in 79 Infants and Children from a Single Level 1 Trauma Center

Objective: Traumatic brain injury is a leading form of pediatric trauma and a frequent cause of mortality and acquired neurological impairment in children. The aim of this study was to present the severity and outcomes of traumatic intracerebral bleeding in children and adolescence. Methods: Seventy-nine infants and children with intracerebral bleedings were treated between 1992 and 2020 at a single level 1 trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. The Glasgow Outcome Scale was used to classify the outcome at hospital discharge and at follow-up visits. CT scans of the brain were classified according to the Rotterdam score. Results: In total, 41 (52%) patients with intracerebral bleedings were treated surgically, and 38 (48%) patients were treated conservatively; in 15% of the included patients, delayed surgery was necessary. Patients presenting multiple trauma (p < 0.04), higher ISS (p < 0.01), poor initial neurological status (p < 0.001) and a higher Rotterdamscore (p = 0.038) were significantly more often treated surgically. Eighty-three percent of patients were able to leave the hospital, and out of these patients, about 60% showed good recovery at the latest follow-up visit. Overall, 11 patients (14%) died. Conclusion: The findings in this study verified intracerebral bleeding as a rare but serious condition. Patients presenting with multiple traumas, higher initial ISS, poor initial neurological status and a higher Rotterdamscore were more likely treated by surgery. Trial registration: (researchregistry 2686).

Abstract P345: Perfusion-Guided Bridging Therapy in Strokes With Unknown Time of Onset and Large Vessel Occlusion

Introduction: Endovascular treatment (EVT) is the therapy of choice, in patients with unknown stroke onset (unwitnessed and wake-up strokes) and large vessel occlusion (LVO) with a favorable perfusion pattern. Whether bridging therapy (intravenous thrombolysis (IVT) and EVT) is superior to EVT alone remains unknown. Material and Methods: We retrospectively included all patients admitted to the Geneva University Hospital from 01.2016 to 06.2020 with i) stroke of unknown onset, due to ii) anterior circulation occlusion, with iii) favorable CT perfusion pattern based on the DEFUSE criteria (ischemic core volume< 70ml; mismatch ratio >= 1.8 and mismatch volume >= 15ml), and iv) treated < 4.5 hours after symptom recognition. As a standard of care, the patients fulfilling these inclusion criteria were treated with EVT and IVT or EVT alone when IVT was contraindicated. Outcome measures were any intracerebral bleeding (symptomatic or asymptomatic), mortality and favorable outcome (mRS 0-1) at three months. Results: 32 patients were included (17 treated with EVT alone and 15 with EVT and IVT). Mean age was 69±18 yo. Median NIHSS was 16 (IQR 12-20) and median time from symptom recognition to treatment was 184 (146-226) minutes. Median hypoperfused tissue volume (Tmax > 6s) was 119 ml (80-151) and infarcted core (CBF ratio <30%) 8 ml (0-27). After propensity score weighting, bridging therapy was not associated with an increased risk of intracerebral bleeding (p=0.72) or mortality (p=0.55). The proportion of favorable outcomes at three months was similar between treatment groups (p=0.78). Conclusion: These results suggest that IVT before EVT is a safe therapeutic option in patients with unknown stroke onset selected on perfusion imaging and treated <4.5 hours after symptom recognition. Early administration of IVT may be particularly relevant before interhospital transfer to a comprehensive stroke center for EVT.

Bleeding risk with rivaroxaban compared with vitamin K antagonists in patients aged 80 years or older with atrial fibrillation

ObjectiveDirect oral anticoagulants have been evaluated in the general population, but proper evidence for their safe use in the geriatric population is still missing. We compared the bleeding risk of a direct oral anticoagulant (rivaroxaban) and vitamin K antagonists (VKAs) among French geriatric patients with non-valvular atrial fibrillation (AF) aged ≥80 years.MethodsWe performed a sequential observational prospective cohort study, using data from 33 geriatric centres. The sample comprised 908 patients newly initiated on VKAs between September 2011 and September 2014 and 995 patients newly initiated on rivaroxaban between September 2014 and September 2017. Patients were followed up for up to 12 months. One-year risks of major, intracerebral, gastrointestinal bleedings, ischaemic stroke and all-cause mortality were compared between rivaroxaban-treated and VKA-treated patients with propensity score matching and Cox models.ResultsMajor bleeding risk was significantly lower in rivaroxaban-treated patients (7.4/100 patient-years) compared with VKA-treated patients (14.6/100 patient-years) after multivariate adjustment (HR 0.66; 95% CI 0.43 to 0.99) and in the propensity score–matched sample (HR 0.53; 95% CI 0.33 to 0.85). Intracerebral bleeding occurred less frequently in rivaroxaban-treated patients (1.3/100 patient-years) than in VKA-treated patients (4.0/100 patient-years), adjusted HR 0.59 (95% CI 0.24 to 1.44) and in the propensity score–matched sample HR 0.26 (95% CI 0.09 to 0.80). Major lower bleeding risk was largely driven by lower risk of intracerebral bleeding.ConclusionsOur study findings indicate that bleeding risk, largely driven by lower risk of intracerebral bleeding, is lower with rivaroxaban than with VKA in stroke prevention in patients ≥80 years old with non-valvular AF.

Fibrin-Specific Thrombolytic Therapy for Acute CVA within 6 Hours of Onset, Systematic Review and Meta-analysis

Objective: Cerebrovascular Accident (CVA) remains a major cause of disability and death and fibrinolytic agents might reduce long-term disability. We sought to determine whether patients receiving fibrin-specific thrombolytic agents acutely (within 6 h) following CVA had improved functional outcome, or decreased mortality or increased intracerebral bleeding at 6-months than patients receiving placebo. Materials and Methods: We conducted a systematic review of randomized controlled clinical trials that assessed 6-months functional outcome, mortality and intracranial hemorrhage and compared thrombolytic therapy with placebo in patients randomized within the first 6 hours following CVA. We searched these databases: MEDLINE (1990-2018), Cochrane Central Register of Controlled Trials, and Cochrane Database for Systematic Reviews. Two blinded reviewers reviewed the eligible articles and rated study quality using the Jadad score. We calculated pooled Odds Ratios (ORs) using a random effect model. Results: We included 9 studies with 6523 enrolled participants and had 673 deaths. Compared with placebo, thrombolytic therapy within 6 hours of CVA did not result in a statistically significant reduction in 6-month mortality (OR 1.21, 95% confidence interval [CI] 0.94–1.55). More patients in the thrombolytic therapy group had favorable functional outcome (OR 1.20 confidence interval [CI] 1.07–1.35). Thrombolytic therapy caused more fatal intracerebral bleeding than placebo (OR 5.61 confidence interval [CI] 3.40-9.24). Conclusion: Fibrin-Specific thrombolytic within 6 hours of CVA improves functional outcome at the expense of increasing symptomatic and fatal intracerebral bleed. Future studies are required before extending the thrombolytic window to 6-hours.

Bilateral Traumatic Thalamic Hemorrhage: A Rare Clinical Presentation

Bilateral traumatic thalamic hemorrhage is a very rare occurrence, especially after head trauma, and is limited to case reports. The authors present a 27-year-old man, admitted for head trauma causing bilateral thalamic bleeding. Posttraumatic intracerebral bleeding is caused by focal or diffuse axonal injury. Bilateral traumatic thalamic hemorrhage is a rare clinical and radiologic presentation.