Background: Surgical treatment demonstrated a reduction in mortality among patients suffering from severe spontaneous intracerebral hemorrhage (SSICH). However, which SSICH patients could benefit from surgical treatment was unclear. This study aimed to establish and validate a decision tree (DT) model to help determine which SSICH patients could benefit from surgical treatment. Materials and methods: SSICH patients from a prospective, multicenter cohort study were analyzed retrospectively. The primary outcome was the incidence of neurological poor outcome (modified Rankin scale as 4–6) on the 180th day posthemorrhage. Then, surgically-treated SSICH patients were set as the derivation cohort (from a referring hospital) and validation cohort (from multiple hospitals). A DT model to evaluate the risk of 180-day poor outcome was developed within the derivation cohort and validated within the validation cohort. The performance of clinicians in identifying patients with poor outcome before and after the help of the DT model was compared using the area under curve (AUC). Results: One thousand two hundred sixty SSICH patients were included in this study (middle age as 56, and 984 male patients). Surgically-treated patients had a lower incidence of 180-day poor outcome compared to conservatively-treated patients (147/794 vs. 128/466, P<0.001). Based on 794 surgically-treated patients, multivariate logistic analysis revealed the ischemic cerebro-cardiovascular disease history, renal dysfunction, dual antiplatelet therapy, hematoma volume, and Glasgow coma score at admission as poor outcome factors. The DT model, incorporating these above factors, was highly predictive of 180-day poor outcome within the derivation cohort (AUC, 0.94) and validation cohort (AUC, 0.92). Within 794 surgically-treated patients, the DT improved junior clinicians’ performance to identify patients at risk for poor outcomes (AUC from 0.81 to 0.89, P<0.001). Conclusions: This study provided a DT model for predicting the poor outcome of SSICH patients postsurgically, which may serve as a useful tool assisting clinicians in treatment decision-making for SSICH.

Background: Despite the capability of emergency surgery to reduce the mortality of severe spontaneous intracranial hemorrhage (SSICH) patients, the effect and safety of surgical treatment for severe spontaneous intracranial hemorrhage (SSICH) patients receiving long-term oral antiplatelet treatment (LOAPT) remains unclear. In consideration of this, the cohort study is aimed at figuring out the effect and safety of emergency surgery for SSICH patients on LOAPT.Methods: As a multicenter and prospective cohort study, it will be conducted across 7 representative clinical centers. Starting in September 2019, the observation is scheduled to be completed by December 2022, with a total of 450 SSICH patients recruited. The information on clinical, radiological, and laboratory practices will be recorded objectively. All of the patients will be monitored until death or 6 months after the occurrence of primary hemorrhage.Results: In this study, two comparative cohorts and an observational cohort will be set up. The primary outcome is the effect of emergency surgery, which is subject to assessment using the total mortality and comparison in the survival rate of SSICH patients on LOAPT between surgical treatment and conservative treatment. The second outcome is the safety of surgery, with the postoperative hemorrhagic complication which is compared between the operated SSICH patients on and not on LOAPT. Based on the observation of the characteristics and outcome of SSICH patients on LOAPT, the ischemic events after discontinuing LOAPT will be further addressed, and the coagulation function assessment system for operated SSICH patients on LOAPT will be established.Conclusions: In this study, we will investigate the effect and safety of emergency surgery for SSICH patients on LOAPT, which will provide an evidence for management in the future.Ethics and dissemination: The research protocol and informed consent in this study were approved by the Institutional Review Board of Beijing Tiantan Hospital (KY2019-096-02). The results of this study are expected to be disseminated in peer-reviewed journals in 2023.Trial registration: Name: Effect and safety of surgical intervention for severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet treatment.ChiCTR1900024406. Date of registration is July 10, 2019.

Isolated traumatic supraclinoid internal carotid artery (ICA) dissection is a rare complication of blunt craniomaxillofacial trauma, and differentiation from atherosclerosis is the key factor for confirming the diagnosis. A 53-year-old man was admitted because of blunt trauma to his head and face. His primary manifestations were disability of abduction of the left eye on day 2, recurrent epistaxis and a blowing murmur in the left ear on day 4. Neurological physical examination showed bilateral normal pupil diameter, a corrected visual acuity of 0.6 in the right eye and 0.3 in the left eye, and loss of abduction of the left eye. Craniofacial computed tomography scans revealed multiple craniomaxillofacial fractures mainly including a LeFort III injury of the left maxilla, fractures of the left ramus of the mandible, fractures of the left orbital apex, fractures of the sellar turcica, etc. Brain magnetic resonance (MR) findings showed multifocal lacunar infarcts in the left hemisphere. Cerebral angiography demonstrated severe intraluminal stenosis of the left supraclinoid ICA, which was highly suspicious of arterial dissection. A high-resolution vessel wall MR imaging performed on day 7 showed proximal intramural subacute haemorrhage and two distal intimal flaps at the injured region, both of which facilitated the exclusion of atherosclerosis and thus, confirmation of isolated arterial dissection. The patient underwent treatment with endovascular stent placement and antiplatelet agents two weeks later and had no ictus of symptomatic stroke during the next half-year duration. HR vw-MRI is able to assist in the diagnosis of isolated traumatic supraclinoid dissection complicated with underlying atherosclerosis.

Background: Upper-extremity deep vein thrombosis (UEDVT) is not uncommon in neurocritical patients with indwelling peripherally inserted central catheters (PICCs). Pharmacological anticoagulation following UEDVT poses a clinical challenge for these patients. Here, we present a rare mechanism contributing to UEDVT: distortion and deformation of a PICC line. A stepwise anticoagulation strategy was implemented while the PICC remained in situ . Case report: A 79-year-old man underwent an urgent craniotomy to remove a massive traumatic subdural hematoma. A 4 Fr single-lumen PICC was inserted after surgery via the right basilic vein using ultrasound guidance. The catheter tip was correctly positioned, and the PICC line remained stable for the 1 week. In the 2 week, the patient experienced recurrent seizures. Subsequently, progressive swelling of the right upper limb developed, attributed to the formation of right UEDVT due to a reverse S-shaped distortion of the proximal PICC, which further induced systemic hypoalbuminemia and generalized gravity-dependent pitting edema. The PICC was patent and left in place. A cautious anticoagulation strategy was adopted, starting with nadroparin calcium at 4,100 IU once daily, then twice daily, and later switched to enoxaparin at 6,000 IU twice daily. Upon recanalization of the thrombus, the regimen was sequentially transitioned to rivaroxaban 20 mg once daily and maintained until discharge. No intracranial bleeding was observed during the anticoagulation therapy. Conclusions: Epilepsy after traumatic brain injury can cause unexpected PICC distortion, markedly increasing UEDVT risk. If the catheter is still required and keeps patent, maintaining it in situ with carefully escalated anticoagulation may be a safe management strategy.