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Venous thromboembolism (VTE) is a common complication after intracranial hemorrhage (ICH); the incidence has been reported to vary between 18% to 50% for deep vein thrombosis and between 0.5% to 5% for pulmonary embolism (PE). According to current clinical practice guidelines, patients with acute VTE should receive anticoagulant treatment for at least 3 months in the absence of contraindications. Anticoagulant treatment reduces mortality, prevents early recurrences and improves long-term outcome in patients with acute VTE. However, recent ICH is an absolute contraindication for anticoagulant treatment due to the potential increased risk of hematoma expansion or recurrent ICH. Hematoma expansion occurs in approximately a third of patients within 24 h following the diagnosis of a spontaneous ICH. The risk for recurrent ICH depends on patients' features as well as on the feature of index ICH. Limited evidence is available on the risks of therapeutic anticoagulation started shortly after ICH. Expert consensus around the introduction of therapeutic anticoagulation suggests delaying therapeutic anticoagulation for at least 2 weeks after spontaneous ICH, until the risk re-bleeding becomes acceptable. Vena cava filters should be inserted to reduce the risk for (non) fatal PE until therapeutic anticoagulation can be started; antithrombotic prophylaxis should be started as soon as possible to avoid recurrent VTE after vena cava filter insertion. For patients presenting PE with hemodynamic compromise, percutaneous embolectomy should be considered. Most patients will be able to receive anticoagulant treatment within 4 weeks following spontaneous ICH; direct oral anticoagulants are probably the treatment of choice for those ICH patients tolerating anticoagulant treatment.

Introduction: Moyamoya syndrome or disease is a very rare cerebrovascular disorder that predisposes affected individuals to transient or permanent ischemic attacks due to progressive stenosis of the internal carotid artery and its branches, which causes compensatory responses, a large number of smaller blood vessels begins to grow and proliferate. Method: systematic literature review of the quantitative type using the following platforms: PubMed, SciELO, Google Scholar, Revista Brasileira de Neurocirurgia and Jornal Americano de Neurocirurgia. Results and Discussion: Catheter-based diagnostic cerebral angiography is the gold standard for obtaining a diagnosis. One study observed the presence of genetic expectations and concluded that females are the most affected in families (DMMs). Genome and locus-specific studies were performed by Kamada et al. (RNF213) was found as the first susceptibility gene for (DMM). Therefore, (p.R4859K) was recorded as the founder of the missense mutation in (RNF213), patients usually develop symptoms of (stroke) due to cerebral ischemia. Angiogenesis of collateral vessels within the basal ganglia can lead to dyskinesia. MRI enabled rapid detection of acute ischemic stroke using weighted imaging. Conclusion: Moyamoya syndrome is an occlusive cerebrovascular disease that has the potential to cause stroke, epilepsy and neurological dysfunction in adults and children. however, surgical intervention can prevent an upward progression of the disease. Introducción: El síndrome o enfermedad de Moyamoya es un trastorno cerebrovascular muy raro que predispone a los individuos afectados a ataques isquémicos transitorios o permanentes debido a la estenosis progresiva de la arteria carótida interna y sus ramas, lo que provoca respuestas compensatorias, comienza a crecer una gran cantidad de vasos sanguíneos de menor tamaño. y proliferar. Método: revisión sistemática de la literatura de tipo cuantitativo utilizando las siguientes plataformas: PubMed, SciELO, Google Scholar, Revista Brasileira de Neurocirurgia y Jornal Americano de Neurocirurgia. Resultados y Discusión: La angiografía cerebral diagnóstica por catéter es el estándar de oro para obtener un diagnóstico. Un estudio observó la presencia de expectativas genéticas y concluyó que las hembras son las más afectadas en las familias (DMM). Los estudios de genoma y locus específicos fueron realizados por Kamada et al. (RNF213) se encontró como el primer gen de susceptibilidad para (DMM). Por lo tanto, (p.R4859K) se registró como el fundador de la mutación sin sentido en (RNF213), los pacientes suelen desarrollar síntomas de (accidente cerebrovascular) debido a la isquemia cerebral. La angiogénesis de los vasos colaterales dentro de los ganglios basales puede provocar discinesia. La resonancia magnética permitió la detección rápida del accidente cerebrovascular isquémico agudo utilizando imágenes ponderadas. Conclusión: El síndrome de Moyamoya es una enfermedad cerebrovascular oclusiva que tiene el potencial de causar accidente cerebrovascular, epilepsia y disfunción neurológica en adultos y niños. sin embargo, la intervención quirúrgica puede prevenir una progresión ascendente de la enfermedad. Introdução: A síndrome ou doença de Moyamoya é um distúrbio cerebrovascular bastante rara que predispõe os indivíduos afetados a ataques isquêmicos transitórios ou permanentes devido à estenose progressiva da artéria carótida interna e seus ramos, o que causa respostas compensatórias, um grande número de vasos sanguíneos menores começa a crescer e proliferar. Método: revisão sistemática da literatura do tipo quantitativo utilizando as seguintes plataformas: PubMed, SciELO, Google Scholar, Revista Brasileira de Neurocirurgia e o Jornal Americano de Neurocirurgia. Resultados e Discursão: A angiografia cerebral diagnóstica baseado em cateter é o padrão-ouro para obter um diagnóstico. Um estudo observou a presença de expectativas genéticas e concluiu que o sexo feminino é o mais afetado nas famílias (DMMs). Estudos do genoma e do locus específicos foram realizados por Kamada et al. Sendo encontrado o (RNF213) como o primeiro gene de suscetibilidade para (DMM). Portanto, foi registrado o (p.R4859K) como o fundador da mutação missense em (RNF213), os pacientes geralmente desenvolvem sintomatologia de (AVC) devido à isquemia cerebral. A angiogênese de vasos colaterais dentro dos gânglios da base pode levar à discinesia. A ressonância magnética possibilitou a detecção rápida de (AVC) isquêmico agudo usando imagens ponderadas. Conclusão: A síndrome de Moyamoya é uma doença cerebrovascular oclusiva que tem o potencial de causar acidente vascular cerebral, epilepsia e disfunção neurológica em adultos e crianças, a mesma, é doença crônica e progressiva sem opções de tratamento médico ou endovascular resolutivos; contudo, a intervenção cirúrgica pode impedir uma progressão ascendente da doença.

Berlin Heart EXCOR® (BHE) ventricular assist device (VAD) (Berlin Heart, Berlin Heart AG, Berlin, Germany) implantation is prevalent in patients with severe heart failure. However, clinical outcomes of pediatric patients on long-term BHE support remain mainly unknown. This study aimed to report our clinical experience with long-term support of pediatric patients with severe heart failure supported by BHE VAD. Clinical outcomes of 11 patients (median age 8.4 months; two male), who underwent LVAD implantation of the Berlin Heart EXCO® (BHE) VAD (Berlin Heart, Berlin Heart AG, Berlin, Germany) between 2013 and 2017 at our institution were reviewed. The median support period was 312 (range 45-661) days and five patients were supported for more than 1 year. The longest support duration was 661 days. No mortality occurred, and six patients were successfully bridged to heart transplantation, while three patients were successfully weaned off the device. Two patients are currently on BHE support while they await heart transplantation. Four patients had cerebral bleeding or infarction, but only one case of persistent neurological deficit occurred. No fatal device-related infection occurred during LVAD support. BHE VAD can provide long-term support for pediatric patients with severe heart failure with acceptable mortality and morbidity rates with long-term support.

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A 78-year-old male with a history of a cardiac embolic stroke due to persistent AF and cerebral bleeding (CHADS2 score 4, HAS-BLED score 4) was referred to our hospital to implant a left atrial appendage (LAA) closure (LAAC) device. A trans esophageal echocardiography was performed and a high echoic lesion that was difficult to differentiate the spontaneous echo contrast or thrombus was found in the LAA cavity. After isoproterenol infusion, a high echoic lesion disappeared and we confirmed that it was not an LAA thrombus. Successful LAAC device implantation was performed without any thromboembolic events.

The main objective of our study was to carry out a statement of the knowledge and the management of the VKA by the General Practitioners (GPs) of Normandy and to evaluate their experience of the use of DOA with a questionnaire; 471 of the 1951 GPs requested responded. When the INR was stable in a patient affected with atrial fibrillation, the GPs participating dosed it again 4 weeks later, modified the dosage when the INR was below 1.9 or upper 3.2. The risk of stroke was overestimated to 6.2% per year with fluindione and to 31.5% without curative anticoagulation. The mean TTR was overstated to 84%. When the INR was at 4.4, the risk of serious cerebral bleeding was overestimated at 12.4%. 80.26% of the GPs skipped the next dose and 11.25% controlled the INR the day after. So, few GPs used the HAS protocol. After the INR decreased to 3.6, the GPs diminished the dose of 14.62%. 70% of the GPs, responded using only their experience for AVK management. Fluindione was the most to use VKA by 52.7% of them although 24.42% thought it was the most effective. The majority of GPs thought the DOA were a least as effective than the VKA, without being responsible of more bleeding (77.92%) and improved the quality of life of the patients (88.54%). Although the DOA's prescriptions increase, the improvement of the VKA management have to stay a concern for the GPs.

Zusammenfassung Anamnese und klinischer Befund Aufnahme eines 82-jährigen Patienten mit Verdacht auf zerebrale Blutung nach häuslichem Sturz unter Dauerantikoagulation mit Dabigatran wegen Vorhofflimmern. Untersuchungen Die kraniale Computertomografie zeigte beidseitige chronische Subduralhämatome mit frischen Blutanteilen eines ausgedehnten, linksseitigen Subduralhämatoms und Mittellinienverlagerung. Die Laboranalyse ergab eine nur mäßig hohe Dabigatran-Konzentration bei durchlaufender Thrombinzeit. Diagnose Sturzbedingte intrazerebrale Blutung und chronisches Subduralhämatom unter Antikoagulation. Therapie und Verlauf Präoperative Gabe von Idarucizumab zur Antagonisierung von Dabigatran und neurochirurgische Hämatom-Evakuation mit rückläufiger Mittellinienverlagerung. Heparinisierung und Wiederaufnahme der Dabigatran-Behandlung nach Rehabilitation in klinisch stabilem Verlauf bei neurologisch geringgradigen Residuen.

Objective: In this study, we present the design, fabrication, and evaluation of a curved-array-based photoacoustic imaging system designed for imaging vasculatures inside human finger joints with multispectral strategy. Methods: The transducers were fabricated with polyvinylidene fluoride (PVDF) film with a size of 30 mm × 2.8 mm and a curvature radius of 82 mm. A detailed comparison between the PVDF transducer and commercial piezoelectric ceramic transducers was performed. In addition, phantom and in vivo mouse experiments were carried out to evaluate the system performance. Furthermore, we recruited healthy volunteers and did multispectral photoacoustic imaging of blood vessels in finger joints. Results: The transducers have an average center frequency of 6.6 MHz and a mean bandwidth of 95%. The lateral and axial resolutions of the system are 110 and 800 μ m, respectively, and the diameter of the active imaging is larger than 50 mm. We successfully captured the drug-induced cerebral bleeding spots in intact mouse brains, and recovered both morphology and oxygen saturation of the blood vessels in human finger joints. Conclusions: The PVDF transducer has a better performance in bandwidth compared with commercial transducers. The curved design of the transducer offers a better sensitivity and a higher axial resolution compared with the flat design. Significance: Based on the phantom, animal, and human experiments, the proposed system has the potential to be used in clinical diagnosis of early-stage arthritis.

Direct oral anticoagulants (DOACs) represent an innovation because they avoid periodic laboratory monitoring, and also reduce cerebral bleeding. An examination of the performance of DOACs versus warfarin in randomized clinical trials dedicated to atrial fibrillation would reveal the poor performance of warfarin because the percentage of major bleeding is always above 3%; however, the percentage of major bleeding is less than half of that when the management is done in anticoagulation clinics (ACs). Several years ago, a common opinion was that ACs would disappear as soon as DOACs enter the market. We proposed then that ACs could be transformed into thrombosis centres (TCs) because we envisaged many new activities in terms of diagnostic tools and therapeutic choices. After the introduction of DOACs, the role of the ACs has been re-evaluated because their role may be crucial in selecting both the most appropriate diagnostic approach and the best therapeutic option (including anti-vitamin K drugs) for the single patient. TCs can organize a regular follow-up to improve patient adherence to DOACs. Marketing might have a role in the decision making of the single doctor. Efforts should be made for limiting the relationships between doctors and pharmaceutical companies. It seems reasonable to better prepare doctors, during their university courses, for them to develop a greater scientific culture that would enable them to critically read clinical studies and acquire an independent opinion. Ideally, an expert in haemostasis and thrombosis should handle new and old anticoagulants.

Introduction: We previously reported that oral Streptococcus mutans expressing a collagen binding protein Cnm was associated with deep cerebral microbleeds (CMBs) and intracranial hemorrhage (ICH). Approximately 20% of S. mutans strains have the cnm gene, raising the risk of cerebral bleeding. However, the positive correlation between cnm -positive S. mutans and CMBs has been shown only in cross-sectional studies and long-term effects of cnm -positive S. mutans still remain unknown. Purpose: To determine whether cnm -positive S. mutans facilitates cerebral bleeding. Methods: In our retrospective longitudinal study, 92 stroke survivors who underwent serial 3.0 T-MRI scans at intervals of more than 6 months and received analysis of oral bacteria were consecutively enrolled. Patients without oral harboring S. mutans were excluded. The cnm gene in S. mutans isolated from dental plaque was screened using PCR techniques. CMBs were illustrated by MRI T2*-weighted GRE method (TR 550 ms, TE 12 ms, flip angle 20°, slice thickness 4.0 mm). CMBs were classified into the deep, lobar, and subtentorial CMBs. After evaluation of serial MRI scans, the number of newly evoked CMBs per 6 months was compared between cnm -positive S. mutans group ( cnm+ group) and cnm -negative S. mutans group ( cnm - group). Results: Twenty-two patients were enrolled in the cnm+ group and 70 in the cnm - group (mean age±SE 69.7±2.8 vs. 69.2±1.5 p=0.56). The two groups were not different in the mean observational period (1.37±0.13 vs. 1.46±0.08 years p=0.84) or in the prevalence of vascular risk factors, including hypertension. Total and deep CMBs significantly increased in number in the cnm + group compared to the cnm - group (mean±SD per 6 months, 0.88±1.30 vs. 0.16±0.45 for total CMBs, p=0.01; 0.47±0.80 vs. 0.03±0.15 for deep CMBs, p=0.003), while lobar and subtentorial CMBs did not increase significantly (0.22±0.50 vs. 0.07±0.32 for lobar CMBs, p=0.10; 0.19±0.61 vs. 0.06±0.17 for subtentorial CMBs, p=0.24). Two (9.1%) in the cnm + group but only one (1.6%) in the cnm - group had symptomatic cerebral hemorrhage during the observational period. Conclusions: Oral cnm -positive S. mutans facilitated formation of CMBs. Brain-oral axis may be a novel therapeutic target for cerebral bleeding.

Purpose We previously reported experimental advantages of new titanium mesh wrapped inflow cannula for left ventricular assist device (LVAD) to avoid wedge thrombus formation. There was no thrombus formation in any of the explanted LVAD system and around the outside of the inflow cannula after 2 months from LVAD implantation in calves. We had applied this newly developed inflow cannula into the clinical arena with EVAHEART LVAD since 2013. We had clinically evaluated experience of this inflow cannula and showed the clear induction of autologous neointima avoiding wedge thrombus formation for over 5 years from LVAD implantation. Methods Retrospective data were analyzed from 19 patients who underwent EVAHEART LVAD implantation using newly inflow cannula as a bridge to transplant since September 2013 at Tokyo Women's Medical University. Results All patients achieved hospital discharge on LVAD support. 9 patients underwent heart transplantation and 3 of 9 patients were supported over 5 years (5.12-5.45 years) from LVAD implantation. Thromboembolic complications in these patients included 1 cerebral bleeding event, 1 cerebral infarction and 2 transit ischemic attack. In macroscopically findings were no thrombus formation around the inflow cannula. The titanium mesh was completely enveloped with white neointima tissue that appeared to have grown from the ventricular endocardium (Figure). Conclusion The titanium mesh inflow cannula induces autologous neointima avoiding wedge thrombus formation in clinical experience for over 5 years after LVAD implantation.

Traumatic intracranial aneurysms are rare lesions that occur after blunt or primarily penetrating mechanisms. These are extremely fragile vessel injuries associated with significant morbidity and mortality, especially after rupture. Disease natural history, surveillance strategies, and management are based on small case series. Here we present a case of a 29-year-old male with a large epidural hematoma after blunt trauma, who underwent emergent surgical intervention. Three months postoperatively, he presented with unusual cerebral bleeding. Clinical suspicion prompted a conventional angiogram, which diagnosed a ruptured cortical traumatic intracranial aneurysm. The patient was urgently treated by surgical clipping with a good outcome.

Background Two implantable continuous-flow left ventricular assist devices (LVADs), DuraHeart (Terumo Heart, Ann Arbor, MI, USA) and EVAHEART (Sun Medical, Nagano, Japan), were approved in Japan in April 2011. We analyzed the midterm outcome of patients implanted with these implantable LVADs at the University of Tokyo Hospital. Methods and results A total of 31 patients who underwent implantation of LVADs (10 DuraHeart, 21 EVAHEART) as a bridge to transplantation at our institution between April 2011 and August 2013 were retrospectively reviewed. All patients were followed up through December 2013. Seven patients underwent conversions from NIPRO paracorporeal LVAD (Nipro, Osaka, Japan) to an implantable LVAD. The mean observation period was 483 ± 239 days (41.0 patient years). Eight patients were transplanted and one patient showed functional recovery with subsequent LVAD explantation. Four patients died due to cerebrovascular accident, empyema, or device malfunction due to pump thrombosis after cerebral bleeding. Kaplan–Meier analysis revealed 6-, 12-, and 24-month survival rates of 93%, 86%, and 86%, respectively. The rates of freedom from cerebrovascular accidents and device-related infections at 1 year after LVAD implantation were 65% and 36%, respectively. Twenty-nine patients were discharged home after LVAD implantation. During the period of this study, there were 59 readmissions (53 urgent, 6 elective) among 22 patients (76%). The overall and urgent readmission rates were 1.66 and 1.49 per patient year, respectively. The common reason for readmission was device-related infection (31%), followed by cerebrovascular accidents (17%). The total out-of-hospital time after the primary discharge was 90%. Conclusions Our midterm survival rate after LVAD implantation is satisfactory. However, patients undergoing LVAD support were often readmitted with adverse events.

In chronic cardiomyopathy, mechanical circulatory support (MCS) plays an increasingly important role for children as the shortage of suitable donor hearts increases waiting time on the transplant list. We report our experience with the paracorporal Berlin Heart EXCOR System (Berlin Heart AG, Berlin, Germany) used as a biventricuclar assist device (BVAD). Nine patients with a BVAD EXCOR system were treated between 2006 and 2012; out of these patients, four were less than 18 years old (6, 14, 14, and 17 years old). Their diagnoses were postcardotomy failure (n = 1), dilatative cardiomyopathy (n = 2), and terminal heart failure (n = 1). Overall survival, waiting time for heart transplantation (HTx) and complication profile for the BVAD were analyzed retrospectively. Thirty days' mortality was 25% (n = 1). One child died after 84 days on support due to cerebral bleeding. Mean support time was 218.75 days (4, 84, 262, and 525 days). Pump chamber exchange was necessary three times due to pump chamber thrombosis (n = 2) and partial pump chamber membrane rupture (n = 1). Complications included: sepsis (n = 1), drive line infection requiring intravenous antibiotics (n = 2), and recurrent epistaxis (n = 3). Two children were successfully transplanted after 262/525 days on BVAD; they are currently at home (follow-up: 1.9 and 2.3 years). The EXCOR is a life-saving MCS system suitable for long-term paracorporeal biventricular assistance.

Objective: Several studies have shown that rates of cerebrovascular events in HIV-infected patients are increased in comparison to uninfected individuals. In addition, cerebral bleeding represents a serious complication in hemophilia patients. Recently, asymptomatic cerebral microbleeds (CMBs), which can be detected by highly sensitive techniques such as T2*-weighted magnetic resonance imaging (MRI), have emerged as an important marker for predicting symptomatic cerebral bleeding. The aim of the present study was to investigate the prevalence of CMBs in HIVinfected hemophilia patients and to evaluate the association between HIV infection and cerebral bleeding. Methods: All HIV-infected hemophilia patients (HIV+ HemPts) who visited our hospital from January 2015 to December 2016 were enrolled in this study. In addition, all HIV-uninfected hemophilia patients (HIV- HemPts) who visited our hospital in the same period were enrolled as controls. CMBs were assessed using T2*-weighted MRI. The relationship between cerebral bleeding and the patients’ clinical factors was examined. Results: Two HIV+ HemPts had symptomatic cerebral bleedings during the study period. Twenty-one asymptomatic HIV+ HemPts and 13 HIV- HemPts underwent T2*-weighted MRI. CMBs were observed in 7 HIV+ HemPts (30.4%) and 1 HIV- HemPts (7.7%). In the multivariate logistic regression analysis, HIV infection was the factor most closely related to cerebral bleeding (odds ratio: 9.78, p-value: 0.08). Conclusion: This is the first report to investigate the prevalence of CMBs in HIV-infected patients. The prevalence of CMBs or symptomatic cerebral bleeding in HIV+ HemPts was high in comparison to that in HIV- HemPts. The brain screening test by T2*-weighted MRI seems to be meaningful for HIV+ HemPts.

Recently, mixed phenotype acute leukemia (MPAL) with t (9; 22) (q34; q11.2); bcr-abl1 was described as one kind of acute leukemia of ambiguous lineage in the 2008 World Health Organization Classification of Tumors of Hematopoietic and Lymphoid Tissues. However, treatment strategy remains difficult for this uncommon MPAL. In addition, this type of MPAL is at high risk of tumor lysis syndrome (TLS) because of high chemo-sensitivity. Here, we report a MPAL with t (9; 22) (q34; q11.2); bcr-abl1 case that suffered from life-threatening cerebral bleeding associated with disseminated intravascular coagulation (DIC) with TLS after bcr-abl positive acute lymphoblastic leukemia (ALL) type induction therapy who was successfully treated with recombinant human thrombomodulin (rhTM). This case reached complete remission without additive cerebral bleeding. In conclusion, bcr-abl positive ALL type induction therapy was effective for MPAL with t (9; 22) (q34; q11.2); bcr-abl1 and rhTM was effective against DIC with TLS.

Objectives Left ventricular assist device (LVAD) exchange is becoming a standard surgical procedure. The exchange procedure is an opportunity to upgrade patients to a new generation pump that offers advanced reduction of adverse events or longer battery hours. Methods We performed an analysis of 6 consecutive patients who underwent LVAD exchange to HeartMate 3 either from a HeartWare or HeartMate (HM) II device. Minimally invasive operations were performed through a lateral thoracotomy. Follow-up time was 6 months after LVAD exchange. Results We present 4 patients with the HM II and 2 patients with the HeartWare ventricular assist device (HVAD) who underwent LVAD exchange to HM III. The average age was 57.5 years. At the time of the LVAD exchange, all patients were classified as Interagency Registry for Mechanically Assisted Circulatory Support level 3. In 5 cases, LVAD infection led to LVAD exchange (83%, 5/6). The remaining patient underwent LVAD exchange due to pump thrombosis (16%, 1/6). The 6-month survival rate after LVAD exchange was 100% (6/6). None of the patients was postoperatively supported by extracorporeal membrane oxygenation. No patient experienced postoperative relevant bleeding. One patient suffered minor cerebral bleeding (16.6%, 1/6). At the 6-month follow-up examination, 1 patient reported a single syncope and several low-flow alarms (1/6). The remaining 5 patients showed no adverse events or technical malfunctions of the VAD (5/6). Conclusions LVAD exchanges from HM II as well from HVAD to HM 3 are proven to be technically feasible. Due to the advantages and technical improvements of the new-generation pumps, this procedure is an excellent opportunity to give patients access to a superior generation of assist device.

We read with interest the recent study by Hafez et al1 titled “Matrix Metalloprotease 3 Exacerbates Hemorrhagic Trans formation and Worsens Functional Outcomes in Hyperglycemic Stroke.” The authors performed a study to investigate a potential role and mechanism of matrix metalloproteinase 3 (MMP3) during the acute phase in hyperglycemic stroke, which could provide treatment option to for reducing cerebral bleeding and improving clinical outcomes in …

Systemic fibrinolytic therapy is effective in dissolving chronic arterial occlusions. In the present study, ultra-high streptokinase short-term lysis was the treatment of choice. It consisted of one to three infusion series of 9 million IU SK over 6 hours each. In about 50% of patients, a subsequent catheter dilation was carried out either for widening residual stenoses or for clearance of vessels still occluded. Patients treated were 176 younger than 65 years and 165 older. Targets of therapy were iliac and femoral occlusions; iliac occlusions were removed more often in older patients and femoral occlusions more often in younger patients. The rate of cerebral bleeding was 1.14% in the younger and 0.606% in the older patient group. No age-related differences existed for streptokinase plasma concentrations and streptokinase half-life. Plasminogen, on the other hand, which fell during streptokinase infusion to below 10% recovered more slowly in the older than in the younger patients.

The long-term management of paracorporeal biventricular assist devices (BiVAD) is difficult because of significant risks of bleeding, thrombosis, and infection. Here we report the case of a 41-year-old woman with severe dilated cardiomyopathy who developed serious cerebral bleeding after receiving a paracorporeal BiVAD but recovered well after treatment. She eventually underwent cardiac transplantation 17 months after implantation of the paracorporeal BiVAD.

Eine 67-jährige Patientin erlitt einen Herzinfarkt. In der Koronarangiographie fand sich thrombotisches Material in Koronararterien. Ursache dafür war eine paroxysmale nächtliche Hämoglobinurie, ein Stammzelldefekt, welcher durch komplementvermittelte hämolytische Schübe mit thromboembolischen Ereignissen gekennzeichnet ist. Wegen der koronaren Thrombosen wurden eine Antikoagulation und eine Antiaggregation eingeleitet. Darunter kam es zu einer intrazerebralen Massenblutung, an der die Patientin trotz zweimaliger neurochirurgischer Kraniektomie schließlich verstarb. Dieser tragische Fall zeigt, dass eine antithrombotische Behandlung immer wieder eine Gratwanderung mit ungewissem Ausgang ist.

Zusammenfassung: Es wird uber einen Autopsiefall einer ungewohnlichen disse-minierten Mucormykose in der Neonatal-periode bei einem unreifen Fruhgeborenen mit einem Atemnotsyndrom berichtet. Ausgehend von einer pulmonalen Zygomyceten-Infektion war es zu einer hama-togenen Streuung in das Herz, die Leber, die Milz, das Mediastinum und das Ge-hirn gekommen. Im Gewebe lag ein Di-morphismus des Erregers mit Hyphen und Rundformen vor, wie er bisher nur aus Kulturen in CO2-Atmosphare bekannt war. Der Tod trat am 9. Lebenstag nach frischer intrazerebraler Blutung auf. Summary: An autopsy case with an unusual disseminated mucormycosis in the neonatal period is reported in a premature infant with a respiratory distress syndrome. Starting from pulmonary zygomycete infection, hematogenous dissemination was seen in the heart, the liver, the spleen, the mediastinum and the brain. In the tissue there was a dimorphism of the pathogen with hyphae and globose forms. This dimorphism had previously only been observed in cultures under a CO2 atmosphere. Death occured on the 9th day after cerebral bleeding.

SummaryOptimal timing for restarting anticoagulant therapy after intracranial bleeding is a critical issue. The purpose of this systematic review is to summarize published studies on the management of oral anticoagulant therapy after intracranial bleeding secondary to the use of vitamin K antagonists in patients with a mechanical heart valve. A computer-assisted search of the MEDLINE and EMBASE electronic databases till January 2008 was performed. Two investigators independently performed study selection and completed a predefined quality assessment and data extraction form. Main inclusion criterion was the enrolment of patients with a mechanical heart valve and intracranial haemorrhage during oral anticoagulant treatment. Any randomised controlled trial, observational cohort study, case series and reports was included. No randomised controlled trials were identified. Six observational cohort studies were included in the final analysis. All studies were of low quality. A total of 120 patients were enrolled. Anticoagulation was restarted within a broad time range (2 days to 3 months). Four ischaemic strokes and two recurrent cerebral haemorrhages occurred after anticoagulation was restarted after a mean follow-up of 7.9 months. Eighteen patients were described in the selected case reports. Anticoagulant therapy was restarted within four days to eight weeks. Two patients had a recurrent haemorrhagic event, and no ischaemic events were reported. In conclusion, restarting oral anticoagulant therapy few days and, indirectly, stopping anticoagulant therapy for a few days (even for 7–14 days) after the occurrence of cerebral haemorrhage are both safe. However, well-designed studies are strongly recommended to provide better evidence.