Neurología Vascular.artículos

Latin America Multidisciplinary Consensus Panel on Management of Severe Bleeding in the Anticoagulated Patient

2025-05-05T00:00:00Z

Latin America Multidisciplinary Consensus Panel on Management of Severe Bleeding in the Anticoagulated Patient Pontes-Neto, Octávio M.; Noble-Lugo, Alejandra; Montenegro Arenas, Ana Cristina; de Campos Guerra, Joao Carlos; Ceresetto, Jose Manuel; Rosales, Julieta Soledad; Colunga-Lozano, Luis Enrique; Meillon-Garcia, Luis Antonio; Vargas Tellez, Luis Eduardo; Dos Reis Rodrigues, Roseny; Gibler, W. Brian; Kreitzer, Natalie P. Background: Bleeding is the most important complication associated with anticoagulants. Patients experiencing bleeding while on an anticoagulation require proper risk stratification, which involves careful assessment of multiple factors, including hemodynamic stability, the origin of bleeding, and the extent of blood loss. Over the last several decades, important advances have been made in the field of anticoagulant therapy and reversal. Objectives: This manuscript provides a review of anticoagulant related hemorrhages, with particular emphasis on topics most relevant to Latin America. It offers an updated assessment of evidence-based strategies for managing major bleeding related to anticoagulation. We will also explore what happens to patients in real-life situations, where there are not specific reversal agents available. Discussion: While minor bleeding can usually be managed simply by discontinuing the anticoagulant, major bleeding is a medical emergency that may threaten life and require the administration of blood products and the utilization of specific antidotes. Fresh frozen plasma (FFP) or prothrombin complex concentrates (PCCs) can be administrated for major bleeding incidents linked to warfarin. Protamine sulfate is administrated for unfractionated heparin and partially for low-molecular-weight heparin (LMWH). Idarucizumab is the reversal agent for dabigatran, while andexanet alfa is approved for the reversal of oral factor Xa inhibitors. Conclusions: This review highlights the significance of appropriate risk stratification and management strategies for bleeding complications associated with anticoagulants. The manuscript emphasizes the need for adaptable management strategies in regions like Latin America, where resource limitations may impact the availability of specific reversal agents.

Initial Experience of Transarterial Embolization for Shoulder Musculoskeletal Pain Using an Ethiodized Oil-Based Emulsion: A Multicenter Study

2025-08-27T00:00:00Z

Initial Experience of Transarterial Embolization for Shoulder Musculoskeletal Pain Using an Ethiodized Oil-Based Emulsion: A Multicenter Study Sapoval, Marc; Stacoffe, Nicolas; Bertoni, Hernán Gabriel; Déan, Carole; Ghelfi, Julien; Jehanno, Pascal; Gremen, Emeric; Boeken, Tom Purpose: The study reports the initial experience in transarterial embolization (TAE) using an ethiodized oil-based emulsion for patients with refractory shoulder pain, focusing on safety, pain reduction, and functional improvement. Methods: This is a retrospective, multicenter study including 23 patients treated with TAE using an ethiodized oil-based emulsion between April 2021 and May 2024. Clinical outcomes were assessed using visual analog scale (VAS) scores for pain (0-100 mm) and QuickDASH (0-100) scores (Disability of the Arm, Shoulder and Hand) for functionality. Adverse events were recorded and classified. Results: The primary etiology of shoulder pain was adhesive capsulitis (61%), followed by bursitis (39%). Median follow-up was 87 days (range: 27-1088 days). Mean VAS score decreased from 65 mm (± 22) at rest, and 82 mm (± 13) during mobilization to 30 mm (± 27) at rest, and 36 mm (± 24) during mobilization at the last follow-up (p < 0.05). Mean QuickDASH score improved from 67 (± 17) pre-procedure to 43 (± 25) post-procedure (p < 0.05). No major complications occurred, and minor adverse events included one radial artery thrombosis (4%) and one puncture site hematoma (4%). Conclusion: TAE of the shoulder using an ethiodized oil-based emulsion is safe and effective, warranting further investigation in larger studies.

Outcomes After Reversible Cerebral Vasoconstriction Syndrome With Convexity Subarachnoid Hemorrhage: Individual Patient Data Analysis

2025-08-20T00:00:00Z

Outcomes After Reversible Cerebral Vasoconstriction Syndrome With Convexity Subarachnoid Hemorrhage: Individual Patient Data Analysis Hostettler, Isabel Charlotte; Ponciano, Ana; Wilson, Duncan; Ambler, Gareth; Singhal, Aneesh B.; Charidimou, Andreas; Arnold, Catherine Elizabeth; Ameriso, Sebastián Francisco; Eberbach, Federico; Phan, Thanh G.; Marchina, Sarah; Beitzke, Markus; Kleinig, Timothy John; Mourand, Isabelle; Parreira, Sara; Singhal, Shaloo; Ly, John; Ma, Henry H.; Geraldes, Ruth; Fonseca, Ana Catarina Background and objectives: The most common cause of convexity subarachnoid hemorrhage (cSAH) in younger patients (younger than 60 years) is reversible cerebral vasoconstriction syndrome (RCVS). Evidence on the long-term outcomes of future vascular events and functional outcome after cSAH due to RCVS is limited. We aimed to assess the rates and baseline predictors of our primary outcomes (cSAH, intracerebral hemorrhage (ICH), and ischemic stroke), functional outcome, and mortality after cSAH attributed to RCVS. Methods: Individual patient data pooled analysis in patients with cSAH attributed to RCVS. A systematic literature search was conducted in PubMed and EMBASE. Two independent reviewers screened studies and extracted data. Quality assessment was assessed using the Newcastle-Ottawa Scale. Early events during the accepted time frame of an RCVS episode (<3 months) were classified as progression rather than recurrence. Follow-up was truncated at 5 years. Primary outcomes were recurrent cSAH, ICH, and ischemic stroke. Secondary outcomes were mortality and functional status measured by modified Rankin Score (mRS). Results: We identified 21 eligible cohorts finally including 138 patients from 9 collaborative centers, which provided individual patient data. The mean age was 49.3 ± 12.1 years, and 110 (79.7%) were female. During a mean follow-up of 1.8 years, annual rates were cSAH recurrence 0.81% (95% CI 0.1-2.91), ICH 0.81% (95% CI 0.1-2.91), and ischemic stroke 0.81% (95% CI 0.1-2.91). Progression during the initial episode (shortly after admission) occurred in 10 patients for cSAH, 2 for ICH, and 8 for ischemic stroke, respectively. Of 106 patients (76.8%) with available outcome data, 100 (94.3%) achieve a mRS of ≤1 at follow-up, indicating no significant disability. Two patients died (annual rate 0.5%, 95% CI 0.09-2.9): one within 10 days and the other within 2 months of the cSAH. Discussion: Our data suggest a favorable prognosis for most patients after RCVS-associated cSAH with low rates of recurrent events and a high proportion achieving functional independence. Major limitations include retrospective data collection and potential selection bias from centers providing individual patient data. Nevertheless, these findings provide prognostic information to inform clinical practice.

Silk Vista Baby for the treatment of distal anterior cerebral artery aneurysms

2025-07-02T00:00:00Z

Silk Vista Baby for the treatment of distal anterior cerebral artery aneurysms Scarcia, Luca; Clarençon, Frédéric; Dmytriw, Adam A.; Shotar, Eimad; Jabbour, Pascal; Psychogios, Marios; Sporns, Peter; Puri, Ajit S.; Hassan, Ameer E.; Algin, Oktay; Möhlenbruch, Markus A.; Russo, Riccardo; Bergui, Mauro; Goren, Oded; Bankole, Nourou Dine A.; Boulouis, Gregoire; Morimoto, Takeshi; Pop, Raoul; Ho, Joanna Wk; Ferrario, Ángel; Pujol Lereis, Virginia Andrea Purpose: Treating small-caliber vessel aneurysms with flow diverters poses challenges due to narrow luminal diameters and tortuous vasculature, which complicate the navigation and deployment of conventional devices using standard microcatheters. The Silk Vista Baby (SVB, Balt, Montmorency, France) flow diverter was developed to treat intracranial aneurysms located in smaller vessels or more distal segments and is compatible with 0.017″ microcatheters. We present the largest multicenter analysis to date evaluating the outcomes of SVB use in unruptured distal anterior cerebral artery (DACA) aneurysms. Methods: Retrospective data from 20 centers were reviewed for patients with unruptured DACA aneurysms treated with the SVB. Demographic information, clinical presentation, radiographic characteristics, complications, and outcomes were recorded. Results: Seventy-nine patients (79 DACA aneurysms) were treated between January 2018 and December 2022; 59 were female (74.7%), and the median age was 61 years (IQR 53-67). Most aneurysms were saccular (89.9%), and 65.8% involved a branch. The median parent vessel diameter was 1.9 mm (IQR 1.7-2.1). A single stent was implanted in 97.5% of cases; 2.5% required two stents. The median imaging follow-up duration was 12 months (IQR 9.5-24). At the last follow-up, 76% of aneurysms showed complete or near-complete occlusion (O'Kelly-Marotta scale C or D, Raymond-Roy 1 or 2). Overall, thromboembolic or hemorrhagic complications occurred in 14% of patients, with two cases being symptomatic. The mortality rate was 0%, and the retreatment rate was 1.3%. Conclusion: In this multicenter series, the SVB flow diverter represented a valuable treatment option for distal anterior cerebral artery (DACA) aneurysms.