Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH)

Research Question:  Will platelet transfusion compared to standard of care reduce death or dependence in patients who present with ICH who took antiplatelet drugs within 7 days?


  • multicenter, open-label, randomized trial
  • 60 hospitals in Netherlands, UK and france
  • Inclusion: supratentorial ICH, antiplatelets for 7 days, GCS at least 8
  • standard of care vs standard of care + platelet transfusion within 90 minutes of CT scan
  • primary outcome: shift towards death or dependence on mRS at 3 months


  • 190 participants (97 treatment, 93% standard of care)
  • death or dependence at 3 months:  adjusted OR 2.05 95% CI 1.18-3.56; p=0.0114
  • serious adverse event:  42% vs 29%
  • deaths during hospital stay:  29% vs 24%





Subgroup analysis:




Baharoglu, M Irem et al. “Platelet Transfusion Versus Standard Care After Acute Stroke Due To Spontaneous Cerebral Haemorrhage Associated With Antiplatelet Therapy (PATCH): A Randomised, Open-Label, Phase 3 Trial”. The Lancet 387.10038 (2016): 2605-2613.


NEJM has been parceling out the results of the ANNEXA studies like the Harry Potter movie series.  I can’t wait for the final verdict on Xa-inhibitor reversals and the subgroup analysis on intracranial bleeds.  But for now, here is the study methodology:


  • bolus over 15-30 minutes + 2-hour infusion
  • For Apixaban or Rivaroxaban >7h before
    • 400mg bolus, 480mg infusion
  • For Enoxaparin, Edoxaban, Rivaroxaban <7h before or unknown time
    • 800mg bolus, 960mg infusion


Anti–Factor Xa Activity and Percent Change from Baseline in Patients Receiving Rivaroxaban and Apixaban (Efficacy Population).




Subgroup Analysis:




Connolly, Stuart J. et al. “Andexanet Alfa For Acute Major Bleeding Associated With Factor Xa Inhibitors”. New England Journal of Medicine (2016).

Semantic Paraphasia

meaning of the word is related to that of the intended word

6 different types:


  • Coordinate semantic paraphasias  – same category (tiger for lion)
  • Associate semantic paraphasias – related but not the same category (shoe for foot)
  • Superordinate semantic paraphasias – replaces specific with generalized (fruit for pear)
  • Subordinate semantic paraphasias – replace target word with one that is more specific (rose for flower)
  • Part-whole semantic paraphasias – replace the whole with the part (finger for hand) or part with the whole (leg for foot)
  • Visual semantic paraphasia – replace word with another word that shares same visual features (knife for nail)



Restricted diffusion in occipital lobe with extension to left pulvinar nucleus, with ADC correlation.The typical symptoms of thalamic aphasia consist of fluent output, semantic paraphasias, impairment of comprehension, and normal repetition.



Bruzzone, M. et al “Teaching Neuroimages: Aphasia after infarction of the left pulvinar nucleus.  Neurology 2016 August 23, 87 (8): e82.



Bicaudate Index

Diagram showing the method for measuring the bicaudate index (A / B). A = the width of the frontal horns at the level of the caudate nuclei; B = the diameter of the brain at the same level.





The bicaudate index is a commonly used linear measure of the lateral ventricles. To account for the natural changes in the size of ventricles with aging, BCI is then divided by the upper limits of ‘normal’ for age to calculate the relative bicaudate index.

Diagnosis of hydrocephalus is established when RBCI is >1. Normative values determined from subjects without neurological disease, in the mid to late 1970s.


Divide the width of the frontal horns, at the level of the caudate nuclei, by the corresponding diameter of the brain. Perform measurement on the cut which included the Foramen of Monro.  If the foramen of Monroe is in between two cute, use mean value for of the two cuts.


Bicaudate index plotted against age. The density ellipsoid includes 95% of the data points.



Normal BCI values, stratified by age group, in a cohort of SAH patients without co-existing hydrocephalus.




Gijn, Jan van et al. “Acute Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage”. Journal of Neurosurgery 63.3 (1985): 355-362.

Dupont, Stefan and Alejandro A Rabinstein. “CT Evaluation Of Lateral Ventricular Dilatation After Subarachnoid Hemorrhage: Baseline Bicaudate Index Balues”. Neurological Research 35.2 (2013): 103-106.