INTRODUCTION: Intraventricular hemorrhage (IVH) as an extension of spontaneous intracerebral hemorrhage is an independent predictor of mortality. The Clot Lysis: Evaluating Accelerated Resolution of IVH phase 3 (CLEAR III) trial is a randomized, double-blinded, placebocontrolled, multiregional trial recently conducted to determine whether external ventricular drainage (EVD) plus intraventricular recombinant tissue plasminogen activator (rtPA, alteplase) improved outcome, in comparison to EVD plus saline. This study is an application of the rationale and principles of management in CLEAR III trial and related literature. METHODS: There are five patients described in this case series. Report followed the PROCESS guidelines. RESULTS: 30-day mortality in this series is 2 out of 5 while actual allcause mortality is 4 out of 5. Modified Graeb scores and IVH scores of all subjects have decreased after the intervention. However, good functional status defined as modified Rankin scale (mRS) score of 0-3 has not been achieved with the intervention. Efficacy of completely resolving IVH and hydrocephalus has been achieved in 2 out of 5 which translated to a benefit of survival to one of the two. Shunt dependence has been avoided by the subjects except for the one with the caudate intracerebral hemorrhage. Complications related to the intervention have been noted and discussed CONCLUSION In this single-institution study, patients for which rtPA was used for intraventricular fibrinolysis of IVH clot in addition to EVD as surgical treatment for hydrocephalus resulted to a 30-day survival of 3 out of 5 in this series, while actual survival is 1 out of 5. The intervention was efficacious in decreasing the Modified Graeb scores and IVH scores of all study subjects at end of treatment. Functional status of mRS 5 is the highest score achieved among survivors.
Fibrinolysis

BACKGROUND & PURPOSE: Fibrinoeptide-A (FpA) and D-dimer have been well known as hematologic parameters for activation of the coagulation and the endogeneous fibrinolysis system during acute phase of ischemic stroke. We measured the levels of FpA and D-dimer in acute progressive and non-progressive ischemic strokes to assess whether these markers are valuable as a predictor of stroke progression during acute phase. METHODS: FpA (RIA method) and D dimer (ELISA method) were determined in 54 patients, 9 with acute progressive and 45 with non-progressive within acute stage(< 48 hours of onset) of cerebral infarction. RESULTS: Levels of FpA in patients with acute progressive stroke were significantly higher than those in patients with non-progressive stroke, indicating activation of the coagulation system (P = 0.013). And, levels of D-dimer in patients with acute progressive stroke were also higher than those in patients with non-progressive stroke but statistically insignificant(P-0.071). CONCLUSIONS: These findings suggest that the coagulation system is more enhanced in progressive stroke than non-progressive one during acute stage of ischemic stroke. Higher levels of FpA are thought to be useful markers to predict stroke in progression.
Cerebral Infarction ; Fibrinolysis ; Humans ; Stroke*

BACKGROUND: Thromboelastography (TEG) measures the viscoelastic properties of clotting blood, displaying a visual trace of all phases of coagulation and fibrinolysis. When performing a TEG, it is commonly recommended to store whole blood at 37oC with only a 3-6 min delay after sampling. However, it is difficult to actually keep this recommend time and temperature. The purpose of this study is to investigate the effects on TEG by inadvertent technical errors due to inappropriate measurement time and temperature. METHODS: Twenty healthy male volunteers were studied. TEG measurements were performed at: stat, 4 min, and 8 min at room temperature, and 4 min and 8 min at 37 degrees C. Parameters used were: reaction time (R), clot formation time (K), maximal amplitude (MA), clot formation velocity (alpha-angle), clot lysis 60 min (LY60) and TEG index. RESULTS: When compared with the routine recommendation, 4 min lag time at 37 degrees C, R and K were shortened and alpha angle and LY60 were increased at 8 min after the sample. However, temperature differences did not significantly affect TEG parameters. CONCLUSIONS: Inappropriate measurement temperature does not result in significant changes of TEG parameters, but, delayed storage resulted in a false hypercoagulation state and increased fibrinolysis.
Fibrinolysis ; Humans ; Male ; Reaction Time ; Thrombelastography ; Volunteers

Acute pulmonary embolism (PE) ranges from asymptomatic to often fatal, incidentally discovered emboli to massive embolism causing immediate death. Acute PE may occur rapidly and unpredictably and may be difficult to diagnose. Mortality and complications can be reduced by prompt diagnosis and therapy. Untreated PE is associated with a mortality rate of approximately 30 percents. Most patients with PE have endogenous fibrinolysis, although it is not effective enough to prevent PE. A case of spontaneous remission of untreated acute PE has not previously been reported. Here we present a case of spontaneously resolved acute PE without any treatment.
Embolism ; Fibrinolysis ; Humans ; Pulmonary Embolism ; Remission, Spontaneous

Atherothrombotic complications are important causes of morbidity and mortality in diabetic patients. Diabetes has been considered to be a prothrombotic status. Several factors contribute to the prothrombotic condition, such as increasing coagulation, impaired fibrinolysis, endothelial dysfunction, and platelet hyperreactivity. Among the factors that contribute to the prothrombotic status in diabetes, altered platelet function plays a crucial role. Although understanding platelet function abnormalities in diabetes still remains as a challenge, more attention should be focused on platelet function for effective management and the prediction of atherothrombotic events in diabetic patients. This review will provide an overview on the current status of knowledge of platelet function abnormalities and clinical marker of platelet hyperreactivity in patients with diabetes.
Biomarkers* ; Blood Platelets* ; Diabetes Mellitus* ; Fibrinolysis ; Humans ; Mortality

BACKGROUND: Recent studies have produced conflicting results on the influence of hemodilution on the coagulation system. Furthermore, only a few clinical studies have been conducted regarding actual blood loss and associated hemodilution. The purpose of this study was to investigate changes in thromboelastograph (TEG) findings after moderate bleeding-induced hemodilution in patients undergoing radical hysterectomy. METHODS: 23 patients scheduled for radical hysterectomy were included. No patient had a preoperative coagulation abnormality or was receiving anticoagulant or antiplatelet medication. TEG findings 15 min after induction of anesthesia and after an estimated blood loss equaling 15% of the estimated blood volume were compared. Only crystalloid solution was administered until the second blood sampling for TEG analysis in order to produce a hemodilution state. RESULTS: After hemodilution R time, K time and coagulation time (r + k) showed significant reductions, and alpha angle and TEG index showed significant increases (P < 0.01), and increased coagulability. MA increased after hemodilution, but this was not statistically significant. A60 and CL60 also increased, showing decreased fibrinolysis (P < 0.05). CONCLUSIONS: Moderate bleeding-induced hemodilution increased coagulability according to TEG compared to pre-hemodilution findings. We recommend that the decision to replace coagulation factors and/or platelets should not be based on empirically derived, arbitrary standards.
Anesthesia ; Blood Coagulation Factors ; Blood Volume ; Fibrinolysis ; Hemodilution* ; Humans ; Hysterectomy*

Dry socket, also termed fibrinolytic osteitis or alveolar osteitis, is a complication of tooth exodontia. A dry socket lesion is a post-extraction socket that exhibits exposed bone that is not covered by a blood clot or healing epithelium and exists inside or around the perimeter of the socket or alveolus for days after the extraction procedure. This article describes dry socket lesions; reviews the basic clinical techniques of treating different manifestations of dry socket lesions; and shows how microscope level loupe magnification of 6× to 8× or greater, combined with co-axial illumination or a dental operating microscope, facilitate more precise treatment of dry socket lesions. The author examines the scientific validity of the proposed causes of dry socket lesions (such as bacteria, inflammation, fibrinolysis, or traumatic extractions) and the scientific validity of different terminologies used to describe dry socket lesions. This article also presents an alternative model of what causes dry socket lesions, based on evidence from dental literature. Although the clinical techniques for treating dry socket lesions seem empirically correct, more evidence is required to determine the causes of dry socket lesions.
Bacteria ; Diagnosis* ; Dry Socket* ; Epithelium ; Fibrinolysis ; Inflammation ; Lighting ; Osteitis ; Tooth

We studied intraoperative changes of transurethral resection of the prostate in blood coagulation-fibrinolysis system by thromboelastography (TEG) in 31 patients with benign prostatic hyperplasia. As TEG parameters reaction time (R), clot formation time (K), maximum amplitude (MA), coagulation time (R+K), clot lysis index after 60 minutes (Ly60) were measured. The coagulability was evaluated by R and R+K, the absolute strength of clot by MA, and fibrinolysis by Ly60. Coagulation time (R+K) was shortened in patients with decreased platelet count under 30,000 u/L (p<0.05), irrigating fluid volume over 20,000 ml (p<0.05) and had a tendency of shortening in patient with resection time over 50minutes (p=0.078). MA had a tendency of increasing but significant contributing factor was not detected. The mean value of Ly60 was increased significantly but the change was in normal range. Irrigating fluid volume (r=-0.407, p<0.05) and resection time (r=-0.456, p<0.05) showed negative correlation significantly with the change of R + K. There was no significant correlation between resected prostatic weight and TEG parameters. We concluded that coagulability is increased during TURP suggesting a possible role in postoperative clot retention, but the risk of fibrinolysis is not increased in patients with normal coagulation-fibrinolysis system.
Fibrinolysis ; Humans ; Platelet Count ; Prostate* ; Prostatic Hyperplasia ; Reaction Time ; Reference Values ; Thrombelastography* ; Transurethral Resection of Prostate

The volume of hip arthroplasty is stiffly increasing because of excellent clinical outcomes, however it has not been shown to decrease the incidence of transfusions due to bleeding related to this surgery. This is an important consideration since there are concerns about the side effects and social costs of transfusions. First, anemia should be assessed at least 30 days before elective hip arthroplasty, and if the subject is diagnosed as having anemia, an additional examination of the cause of the anemia should be carried and steps taken to address the anemia. Available iron treatments for anemia take 7 to 10 days to facilitate erythropoiesis, and preoperative iron supplementation, either oral or intravenous, is recommended. When using oral supplements for iron storage, administer elemental iron 100 mg daily for 2 to 6 weeks before surgery, and calculate the dose using intravenous supplement. Tranexamic acid (TXA) is a synthetic derivative of the lysine component, which reduces blood loss by inhibiting fibrinolysis and clot degradation. TXA is known to be an effective agent for reducing postoperative bleeding and reducing the need for transfusions in primary and revision total hip arthroplasties. Patient blood management has improved the clinical outcome after hip arthroplasty through the introduction and research of various agents, thereby reducing the need for allogeneic blood transfusions and reducing the risk of transfusion-related infections and the duration of hospitalizations.
Anemia ; Arthroplasty* ; Blood Transfusion ; Consensus* ; Erythropoiesis ; Fibrinolysis ; Hemorrhage ; Hip* ; Hospitalization ; Humans ; Incidence ; Iron ; Lysine ; Tranexamic Acid

PURPOSE: To evaluate the efficacy of superselective intra-arterial fibrinolysis for acute cerebral stroke and the usefulness of pre- and postfibrinolysis diffusion-weighted MRI (DWI). MATERIALS AND METHODS: In 41 patients with acute ischemic stroke whose treatment involved intra-arterial fibri-nolysis, the occlusion site, degree of recanalization, and clinical results were compared. In 12 patients, diffusion weighted MRI was performed before fibrinolysis, and eight of these also underwent diffusion-weighted MRI after fibrinolysis. Using diffusion-weighted MRI, neurological outcomes were compared with signal intensity ratio (SIR, or the average signal intensity within the region of interest divided by that in the contralateral, nonischemic, homologous region). RESULTS: Twenty patients showed complete recanalization, nine partial recanalization, and in twelve there was no recanalization. Fourteen patients (34 %) improved neurologically. No relationship existed between occlusion sites, degree of recanalization, and clinical outcome. Among 12 patients who underwent DWI before fibrinolysis, complete recanalization was noted in eight. Neurological improvement was seen in four patients with low SIR(<1.55),while in four with high SIR(>1.7 ), neurological outcome was poor despite complete recanalization. CONCLUSION: Although superselective intra-arterial fibrinolysis for acute cerebral stroke is a good therapeutic method for recanalization, the clinical outcome can be disappointing. We therefore suggest that in cases of acute cerebral ischemic infaret, SIR-as seen on DWI-might be useful for predicting the benefits of recanalization. In such cases, further investigation of the use of DWI prior to fibrinolysis is therefore needed.
Diffusion Magnetic Resonance Imaging ; Diffusion* ; Fibrinolysis* ; Humans ; Magnetic Resonance Imaging ; Stroke