Subarachnoid hemorrhage (SAH) is known to be associated with long-term cognitive deficits. Neurosurgical manipulation on the brain itself has been reported to have influence on neuropsychological sequelae. The following is a comparative study on perimesencephalic and aneurysmal subarachnoid hemorrhage patients as well as elective aneurysm patients that was carried out to determine the isolated and combined impact of surgical manipulation and hemorrhage, respectively, on long-term neuropsychological outcome. Inclusion criteria were good neurological recovery at discharge (modified Rankin Scale 0 or 1) without focal neurological deficit. Standardized psychological testing covered attention, memory, executive functions, and mood. Thirteen aneurysmal SAH patients, 15 patients undergoing elective clipping, and 14 patients with perimesencephalic SAH were analyzed. Standardized neuropsychological testing and social/professional history questionnaires were performed 2 years (mean) after discharge. Memory impairment and slower cognitive processing were found in the aneurysmal and perimesencephalic SAH groups, while elective aneurysm patients showed signs of impaired attention. However, compared with norm data for age-matched healthy controls, all groups showed no significant test results. In contrast, signs of clinical depression were seen in 9/42 patients, 45 % of all patients complained of stress disorders and 55 % of patients were unable to work in their previous professions. Nearly normal neuropsychological test results on long-term follow-up in SAH patients were unexpected. However, a 50 % rate of unemployment accompanied with stress disorders and depression manifests insufficient social and workplace reintegration. Therefore, even more specific rehabilitation programs are required following inpatient treatment to attain full recovery. PMID:23949148
Krajewski, Kara; Dombek, Susanne; Martens, Tobias; Köppen, Johannes; Westphal, Manfred; Regelsberger, Jan
Object Studies using the Nationwide Inpatient Sample (NIS), a large ICD-9-based (International Classification of Diseases, Ninth Revision) administrative database, to analyze aneurysmal subarachnoid hemorrhage (SAH) have been limited by an inability to control for SAH severity and the use of unverified outcome measures. To address these limitations, the authors developed and validated a surrogate marker for SAH severity, the NIS-SAH Severity Score (NIS-SSS; akin to Hunt and Hess [HH] grade), and a dichotomous measure of SAH outcome, the NIS-SAH Outcome Measure (NIS-SOM; akin to modified Rankin Scale [mRS] score). Methods Three separate and distinct patient cohorts were used to define and then validate the NIS-SSS and NIS-SOM. A cohort (n = 148,958, the "model population") derived from the 1998-2009 NIS was used for developing the NIS-SSS and NIS-SOM models. Diagnoses most likely reflective of SAH severity were entered into a regression model predicting poor outcome; model coefficients of significant factors were used to generate the NIS-SSS. Nationwide Inpatient Sample codes most likely to reflect a poor outcome (for example, discharge disposition, tracheostomy) were used to create the NIS-SOM. Data from 716 patients with SAH (the "validation population") treated at the authors' institution were used to validate the NIS-SSS and NIS-SOM against HH grade and mRS score, respectively. Lastly, 147,395 patients (the "assessment population") from the 1998-2009 NIS, independent of the model population, were used to assess performance of the NIS-SSS in predicting outcome. The ability of the NIS-SSS to predict outcome was compared with other common measures of disease severity (All Patient Refined Diagnosis Related Group [APR-DRG], All Payer Severity-adjusted DRG [APS-DRG], and DRG). Results The NIS-SSS significantly correlated with HH grade, and there was no statistical difference between the abilities of the NIS-SSS and HH grade to predict mRS-based outcomes. As compared with the APR-DRG, APSDRG, and DRG, the NIS-SSS was more accurate in predicting SAH outcome (area under the curve [AUC] = 0.69, 0.71, 0.71, and 0.79, respectively). A strong correlation between NIS-SOM and mRS was found, with an agreement and kappa statistic of 85% and 0.63, respectively, when poor outcome was defined by an mRS score > 2 and 95% and 0.84 when poor outcome was defined by an mRS score > 3. Conclusions Data in this study indicate that in the analysis of NIS data sets, the NIS-SSS is a valid measure of SAH severity that outperforms previous measures of disease severity and that the NIS-SOM is a valid measure of SAH outcome. It is critically important that outcomes research in SAH using administrative data sets incorporate the NIS-SSS and NIS-SOM to adjust for neurology-specific disease severity. PMID:24949676
Washington, Chad W; Derdeyn, Colin P; Dacey, Ralph G; Dhar, Rajat; Zipfel, Gregory J
An electronic literature search through August 2010 was performed to obtain articles describing fever incidence, impact, and\\u000a treatment in patients with subarachnoid hemorrhage. A total of 24 original research studies evaluating fever in SAH were identified,\\u000a with studies evaluating fever and outcome, temperature control strategies, and shivering. Fever during acute hospitalization\\u000a for subarachnoid hemorrhage was consistently linked with worsened outcome
V. Scaravilli; G. Tinchero; G. Citerio
Kerosene ingested, intentionally or accidentally, is toxic. Data is scarce on complications and outcomes of hydrocarbon poisoning following kerosene aspiration in adults and there has been no known case of bilateral hemorrhagic effusion occurring due to it in literature. We, hereby, report a case of a bilateral hemorrhagic pleural effusion secondary to hydrocarbon aspiration in a 40-year old adult.
Prasad, Rajendra; Karmakar, Saurabh; Sodhi, Rakhee; Karmakar, Shilpi
Two cases of subarachnoid hemorrhage from spontaneous anterior cerebral artery dissection : a case of simultaneous hemorrhage and ischemia without aneurysmal formation and another case of hemorrhage with aneurysmal formation.
Spontaneous anterior cerebral artery (ACA) dissection, although extremely rare, is often associated with severe morbidity and mortality. It could lead to cerebral hemorrhage, ischemic stroke, or, rarely, combination of hemorrhage and ischemia due to hemodynamic changes. Prompt and accurate diagnosis is essential for determining the appropriate management. However, the optimal treatment for ACA dissection remains controversial. Herein, we report on two rare cases of subarachnoid hemorrhage (SAH) caused by ACA dissection; a case presenting with simultaneous SAH and infarction without aneurysmal formation and another case presenting with SAH with fusiform aneurysmal formation. A review of the related literature is provided, and optimal treatments for each type of dissection are suggested. PMID:25045652
Im, Tae-Seop; Lee, Yoon-Soo; Suh, Sang-Jun; Lee, Jeong-Ho; Ryu, Kee-Young; Kang, Dong-Gee
Two Cases of Subarachnoid Hemorrhage from Spontaneous Anterior Cerebral Artery Dissection : A Case of Simultaneous Hemorrhage and Ischemia Without Aneurysmal Formation and Another Case of Hemorrhage with Aneurysmal Formation
Spontaneous anterior cerebral artery (ACA) dissection, although extremely rare, is often associated with severe morbidity and mortality. It could lead to cerebral hemorrhage, ischemic stroke, or, rarely, combination of hemorrhage and ischemia due to hemodynamic changes. Prompt and accurate diagnosis is essential for determining the appropriate management. However, the optimal treatment for ACA dissection remains controversial. Herein, we report on two rare cases of subarachnoid hemorrhage (SAH) caused by ACA dissection; a case presenting with simultaneous SAH and infarction without aneurysmal formation and another case presenting with SAH with fusiform aneurysmal formation. A review of the related literature is provided, and optimal treatments for each type of dissection are suggested.
Im, Tae-Seop; Suh, Sang-Jun; Lee, Jeong-Ho; Ryu, Kee-Young; Kang, Dong-Gee
A 78-year-old woman suffered sudden-onset left hemiparesis. There were no remarkable infectious findings. Computed tomography (CT) demonstrated a low-intensity area supplied by the right middle cerebral artery (MCA). The diagnosis was cerebral ischemia and she was conservatively treated with hyperosmotic fluids. Two days after the ischemic stroke she suddenly became comatose. CT showed diffuse subarachnoid hemorrhage (SAH) in the basal cistern associated with a right intra-Sylvian and a right frontal subcortical hematoma. Three-dimensional (3D)-CT angiography demonstrated occlusion of the M2 portion of the right MCA. Four days after the ischemic onset she died of brain herniation. Autopsy revealed arterial dissection in the intermediate membrane of the right MCA bifurcation and occlusion of the M2 portion of the thrombosed right MCA. Gram staining showed remarkable bacterial infection in the thrombus. SAH after an ischemic attack due to MCA dissection is extremely rare. We suspect that bacterial infection was involved in the formation of her fragile dissecting aneurysm. PMID:24140774
Saito, Atsushi; Kawaguchi, Tomohiro; Hori, Emiko; Kanamori, Masayuki; Nishimura, Shinjitsu; Sannohe, Seiya; Kaimori, Mitsuomi; Sasaki, Tatsuya; Nishijima, Michiharu
An outbreak of acute hemorrhagic conjunctivitis occurred in Delhi, India, during August and September 1996. The etiologic agent was confirmed as enterovirus type 70 by a modified centrifugation-enhanced culture method followed by immunofluorescence and neutralization tests. After nearly a decade, this virus is reemerging as a cause of acute hemorrhagic conjunctivitis in India.
Maitreyi, R. S.; Dar, L.; Muthukumar, A.; Vajpayee, M.; Xess, I.; Vajpayee, R. B.; Seth, P.; Broor, S.
A patient developed retroperitoneal hemorrhage after cardiac catheterization, initially thought to be a complication of the puncture. Diagnostic evaluation revealed the source to be spontaneous bleeding from a lumber artery, which was successfully embolized. Spontaneous hemorrhage is a recognized complication of anticoagulation therapy and must be considered in the differential diagnosis even in the face of a seemingly obvious source of bleeding.
Kalinowski, E. Anthony [Department of Medical Education, St. Vincent Hospital, 2001 W. 86 Street, and Indiana University School of Medicine, Indianapolis, IN 46260-1991 (United States); Trerotola, Scott O. [Department of Radiology, University Hospital 0279, Indiana University Medical Center, 550 N. University Blvd., Indianapolis, IN 46202-5252 (United States)
An outbreak of acute hemorrhagic conjunctivitis occurred in Delhi, India, during August and September 1996. The etiologic agent was confirmed as enterovirus type 70 by a modified centrifugation-enhanced culture method followed by immunofluorescence and neutralization tests. After nearly a decade, this virus is reemerging as a cause of acute hemorrhagic conjunctivitis in India. PMID:10221880
Maitreyi, R S; Dar, L; Muthukumar, A; Vajpayee, M; Xess, I; Vajpayee, R B; Seth, P; Broor, S
INTRODUCTION: Previous meta-analyses of magnesium sulphate infusion in the treatment of aneurysmal subarachnoid hemorrhage (SAH) have become outdated due to recently published clinical trials. Our aim was thus to perform an up-to-date systemic review and meta-analysis of published data on the use of magnesium sulphate infusion in aneurysmal SAH patients. METHODS: A systemic review and meta-analysis of the literature was
George KC Wong; Ronald Boet; Wai S Poon; Matthew TV Chan; Tony Gin; Benny CY Zee
The main objective of this thesis was to determine the role of serum magnesium\\u000ain the pathophysiology after subarachnoid hemorrhage (SAH) and to assess \\u000athe effect of magnesium treatment in reducing cerebral ischemia in experimental \\u000aSAH and in improving clinical outcome in patients with aneurysmal SAH. \\u000aIn Chapter 2 we reviewed the potentials of magnesium treatment in subarachnoid \\u000ahemorrhage by
W. M. van den Bergh
From the somewhat conflicting published data on apolipoprotein E (apoE) genotype in hemorrhage due to cerebral amyloid angiopathy (CAA), it is unclear whether apoE genotype influences the risk of CAA-related hemorrhage independently of its association with concomitant Alzheimer's disease (AD). We determined the apoE genotypes of 36 patients presenting with cerebral hemorrhage associated with histologically confirmed CAA. The frequency of apoE epsilon 2 was 0.25 and the frequency of apoE epsilon 4 was 0.18. Patients with CAA-related hemorrhage and concomitant AD pathology (CERAD criteria, n = 17) had a high apoE epsilon 4 frequency, close to that in AD cases without hemorrhage. Patients in whom CAA-related hemorrhage occurred in the absence of significant AD pathology (n = 13) had an apoE epsilon 4 frequency somewhat lower than non-AD controls without hemorrhage. However, in CAA-related hemorrhage, the apoE epsilon 2 frequency was high regardless of whether significant AD pathology was present. We conclude that whereas possession of apoE epsilon 2 may be a risk factor for cerebral hemorrhage due to CAA, apoE epsilon 4 is a risk factor for concomitant AD but not an independent risk factor for CAA-related hemorrhage. PMID:9189032
Nicoll, J A; Burnett, C; Love, S; Graham, D I; Dewar, D; Ironside, J W; Stewart, J; Vinters, H V
Introduction Celiac sprue most commonly presents with steatorrhea, abdominal pain, and weight loss. Celiac disease is now becoming more recognized for its atypical presentations. Anemia, osteoporosis, and childhood failure to thrive have been widely discussed. Objective In this paper, we present a case of nontraumatic intramuscular hemorrhage associated with prolongation of both prothrombin time and activated partial thromboplastin time. Main Results Coagulopathy, unmasked by the use of a nonsteroidal anti-inflammatory drug, was found to be attributable to vitamin K deficiency associated with malabsorption of multiple fat soluble vitamins. Celiac sprue was confirmed by small bowel biopsy. A review of the literature finds that, whereas asymptomatic prolongation of coagulation is relatively common in celiac sprue, clinical bleeding is a rare but described presentation. Conclusion This case emphasizes the importance of recognizing hemorrhage as an atypical manifestation of celiac disease and offers the opportunity to review the clinical and laboratory evaluation of a patient who presents with unexplained hemorrhage.
Cumbler, Ethan U.; Triebling, Andrzej T.
A 46-year-old woman presented with a sudden onset of non-traumatic periorbital hemorrhage, painless proptosis, conjunctival chemosis and injection as well as motility restriction of the right eye with double vision. Magnetic resonance imaging (MRI) revealed an extraconal mass in the medial orbit with lateral displacement of the medial rectus muscle and the eyeball without optic nerve involvement. A biopsy led to the diagnosis of non-specific inflammation. This case shows that sudden periorbital hemorrhages can be a sign for idiopathic orbital inflammation. PMID:22130730
Stingl, K; Schüttauf, F; Besch, D
The impact of acute brain injury and delayed neurological deficits due to cerebral vasospasm (CVS) are major determinants of outcomes after subarachnoid hemorrhage (SAH). Although hyperbaric oxygen (HBO) had been used to treat patients with SAH, the supporting evidence and underlying mechanisms have not been systematically reviewed. In the present paper, the overview of studies of HBO for cerebral vasospasm is followed by a discussion of HBO molecular mechanisms involved in the protection against SAH-induced brain injury and even, as hypothesized, in attenuating vascular spasm alone. Faced with the paucity of information as to what degree HBO is capable of antagonizing vasospasm after SAH, the authors postulate that the major beneficial effects of HBO in SAH include a reduction of acute brain injury and combating brain damage caused by CVS. Consequently, authors reviewed the effects of HBO on SAH-induced hypoxic signaling and other mechanisms of neurovascular injury. Moreover, authors hypothesize that HBO administered after SAH may “precondition” the brain against the detrimental sequelae of vasospasm. In conclusion, the existing evidence speaks in favor of administering HBO in both acute and delayed phase after SAH; however, further studies are needed to understand the underlying mechanisms and to establish the optimal regimen of treatment.
Ostrowski, Robert P.
Pure agraphia is an isolated writing disturbance without intellectual impairment, aphasia, alexia, or apraxia. The authors report a case of pure agraphia following left thalamic hemorrhage. The patient showed impairment in the writing of both kanji and kana. The most frequent error in the writing of kanji was substitution (46%) followed by no reaction (23%) and partial omission or addition of characters (21%). The copying of kanji by hand was normal. Even when the patient was unable to write a kanji character, he understood the meaning and correctly recited the other readings. He complained that he could not recall the graphic image of the kanji. When we cued the patient by writing a part of a kanji he initially failed to recall, he correctly completed the character. The kanji and kana he was unable to write were inconsistent over time: in some cases he was unable to write words he had successfully written a week before, and vice versa. These findings suggested that the patient's pure agraphia resulted from combined impairments in recalling and selecting letters. While the thalamic lesion might have influenced the manifestation of pure agraphia, the dysfunction seemed to originate from the secondary negative effect of the lesion on the function of the left cerebral cortex. PMID:21319033
Toyokura, Minoru; Kobayashi, Ryouko; Aono, Kouji
KD-tree is one of the most efficient acceleration data structures for ray tracing. In this paper, we present a kd-tree construction algorithm that is precisely SAH-optimized and runs entirely on GPU. We construct the tree nodes in breadth-first order. In order to precisely evaluate the SAH cost, we design a parallel scheme based on the standard parallel scan primitive to
Zhefeng Wu; Fukai Zhao; Xinguo Liu
To clarify the clinical features and outcome of Stenotrophomonas maltophilia infection among hematopoietic SCT (HCT) recipients, we retrospectively reviewed the records of 1085 consecutive HCT recipients and identified 42 episodes in 31 HCT recipients with S. maltophilia infection. We compared these recipients with 30 non-HCT patients with S. maltophilia infection. The mortality rate in HCT recipients was significantly higher than that in non-HCT patients (relative risk 5.7, P=0.04), and we identified seven patients with pulmonary hemorrhage due to S. maltophilia, exclusively in the HCT cohort. Six of these latter seven patients died within 1 day from the onset of hemorrhage and the isolate was identified after death in most cases; one patient, who received empiric therapy for S. maltophilia and granulocyte transfusion, survived for more than 2 weeks. The patients with pulmonary hemorrhage had a more severe and longer duration of neutropenia, persistent fever despite of the use of broad-spectrum antibiotics, complication by pneumonia and higher C-reactive protein levels than those without pulmonary hemorrhage. In conclusion, S. maltophilia was associated with fulminant and fatal pulmonary hemorrhage in HCT recipients. Empiric therapy with antibiotics before the onset of pulmonary hemorrhage may be effective in HCT recipients who carry the conditions identified. PMID:22635245
Tada, K; Kurosawa, S; Hiramoto, N; Okinaka, K; Ueno, N; Asakura, Y; Kim, S-W; Yamashita, T; Mori, S-I; Heike, Y; Maeshima, A M; Tanosaki, R; Tobinai, K; Fukuda, T
Cerebral vasospasm of the major cerebral arteries, which is characterized by angiographic narrowing of those vessels, had been recognized as a main contributor to delayed cerebral ischemia (DCI) in subarachnoid hemorrhage (SAH) patients. However, the CONSCIOUS-1 trial revealed that clazosentan could not improve mortality or clinical outcome in spite of successful reduction of relative risk in angiographic vasospasm. This result indicates that the pathophysiology underlying DCI is multifactorial and that other pathophysiological factors, which are independent of angiographic vasospasm, can contribute to the outcome. Recent studies have focused on microcirculatory disturbance, such as microthrombosis and arteriolar constriction, as a factor affecting cerebral ischemia after SAH. Reports detecting microthrombosis and arteriolar constriction will be reviewed, and the role of the microcirculation on cerebral ischemia during vasospasm after SAH will be discussed.
Asano, Kenichiro; Ohkuma, Hiroki
Gallbladder perforation is a relatively uncommon complication of acute cholecystitis and may occur with or without gallstones. Prophylactic cholecystectomy has been recommended for patients with very large stones (>3 cm) due to an increased risk of gallbladder cancer. We present the case of a 68-year-old woman who died of hemorrhagic shock following gallbladder perforation due to very large gallstones. This case provides additional support for consideration of prophylactic cholecystectomy in patients with very large gallstones.
Soto, Luis R.; Levine, Harold R.; Celinski, Scott A.
Background Patients with aneurysmal subarachnoid hemorrhage (SAH) typically develop appetite loss. However, the mechanisms regulating appetite are not understood. Ghrelin and leptin, both of which signal nutritional status and energy storage levels to the hypothalamus, are essential elements of the appetite system. Thus, the goal of this study was to investigate the relationship between appetite and ghrelin and leptin concentrations in patients with SAH. Methods Blood plasma or serum profiles and appetite status were measured in 19 patients with SAH who underwent aneurysmal clipping within 48 hours of SAH onset. Appetite status was measured using dietary oral calorie intake. All outcome variables were measured at an early (day 3) and late (day 8) time point after SAH onset (day 0). Results Of the 19 patients studied, 6 (31.6%) showed lower dietary oral calorie intake at the late time point than at the early time point. In these patients with appetite loss, plasma hemoglobin (P < 0.02), albumin (P < 0.01), glucose (P < 0.01), plasma insulin (P < 0.04), and serum ghrelin (P < 0.03) concentrations were lower at the late time point than at the early time point. Serum leptin was higher at the late time point than at the early time point (P < 0.02). Conclusion In SAH patients, appetite loss may be induced by lower serum ghrelin and higher serum leptin concentrations resulting from high plasma glucose and insulin levels due to a catecholamine surge following SAH. PMID:24075245
Kubo, Yoshitaka; Koji, Takahiro; Kashimura, Hiroshi; Otawara, Yasunari; Ogawa, Akira; Ogasawara, Kuniaki
Extracorporeal membrane oxygenation (ECMO) is increasingly applied in adults with acute refractory respiratory failure that is deemed reversible. Bleeding is the most frequent complication during ECMO support. Severe pre-existing bleeding has been considered a contraindication to ECMO application. Nevertheless, there are cases of successful ECMO application in patients with multiple trauma and hemorrhagic shock or head trauma and intracranial hemorrhage. ECMO has proved to be life-saving in several cases of life-threatening respiratory failure associated with pulmonary hemorrhage of various causes, including granulomatosis with polyangiitis (Wegener's disease). We successfully applied ECMO in a 65-year-old woman with acute life-threatening respiratory failure due to diffuse massive pulmonary hemorrhage secondary to granulomatosis with polyangiitis, manifested as severe pulmonary-renal syndrome. ECMO sustained life and allowed disease control, together with plasmapheresis, cyclophosphamide, corticoids, and renal replacement therapy. The patient was successfully weaned from ECMO, extubated, and discharged home. She remains alive on dialysis at 17 months follow-up. PMID:23926421
Hohenforst-Schmidt, Wolfgang; Petermann, Arndt; Visouli, Aikaterini; Zarogoulidis, Paul; Darwiche, Kaid; Kougioumtzi, Ioanna; Tsakiridis, Kosmas; Machairiotis, Nikolaos; Ketteler, Markus; Zarogoulidis, Konstantinos; Brachmann, Johannes
Nearly all men with spinal cord injury suffer from neurogenic sexual dysfunction which is often treated with phosphodiesterase-5 (PDE5) inhibitors. We describe a case of subarachnoid hemorrhage due to autonomic dysreflexia (AD) caused by sexual stimulation. Nitrates are frequently used for acute treatment of AD; however, the use of these drugs in combination with PDE5 inhibitors is contraindicated. Therefore, meticulous information from patients and relatives on the risk of AD and possible drug interactions is of vital importance. PMID:23784679
Galiart, E; Baumberger, M; Pannek, J
Tentorial dural arteriovenous fistulas (tDAVF) clinically present usually with subarachnoid and\\/or intraparenchymal hemorrhage. Reported rates range from 58% to 92% and neurological deficits occur in 79% to 92% of patients. This is due to venous congestion resulting from retrograde leptomeningeal venous drainage, which rarely, can be clinically silent. A 69-year-old woman presented with vertigo, double vision and gait instability. Cerebral
V. Panagiotopoulos; O. Kastrup; I. Wanke
The outcome of patients with aneurysmal subarachnoid hemorrhage (SAH) has improved slowly over the past 25 years. This improvement may be due to early aneurysm repair by endovascular or open means, use of nimodipine, and better critical care management. Despite this improvement, mortality remains at about 40%, and many survivors have permanent neurologic, cognitive, and neuropsychologic deficits. Randomized clinical trials have tested pharmacologic therapies, but few have been successful. There are numerous explanations for the failure of these trials, including ineffective interventions, inadequate sample size, treatment side effects, and insensitive or inappropriate outcome measures. Outcome often is evaluated on a good-bad dichotomous scale that was developed for traumatic brain injury 40 years ago. To address these issues, we established the Subarachnoid Hemorrhage International Trialists (SAHIT) data repository. The primary aim of the SAHIT data repository is to provide a unique resource for prognostic analysis and for studies aimed at optimizing the design and analysis of phase III trials in aneurysmal SAH. With this aim in mind, we convened a multinational investigator meeting to explore merging individual patient data from multiple clinical trials and observational databases of patients with SAH and to create an agreement under which such a group of investigators could submit data and collaborate. We welcome collaboration with other investigators. PMID:23295631
Macdonald, R Loch; Cusimano, Michael D; Etminan, Nima; Hanggi, Daniel; Hasan, David; Ilodigwe, Don; Jaja, Blessing; Lantigua, Hector; Le Roux, Peter; Lo, Benjamin; Louffat-Olivares, Ada; Mayer, Stephan; Molyneux, Andrew; Quinn, Audrey; Schweizer, Tom A; Schenk, Thomas; Spears, Julian; Todd, Michael; Torner, James; Vergouwen, Mervyn D I; Wong, George K C
Magnesium offers theoretic vascular and neuroprotective benefits for patients with subarachnoid hemorrhage. An electronic literature search was conducted to identify original research studies describing intravenous magnesium treatment in patients with SAH published in English between January 1990 and October 2010. Seventeen articles were identified and reviewed, including one phase III randomized-controlled clinical trial and six phase II randomized-controlled trials. Study quality was low for most of the included studies, with the phase III trial considered to be of moderate quality. Due to inconsistently reported benefits and the occurrence of side effects, phase II data suggested that intravenous magnesium for SAH provided either no overall net benefit or uncertain trade-offs. Benefit was likewise not supported in the single phase III clinical trial. PMID:21748496
Suarez, Jose I
Background. Cerebral vasospasm is one of the leading courses for disability in aneurysmal subarachnoid hemorrhage. Effective treatment of vasospasm is therefore one of the main priorities for these patients. We report about a case series of continuous intra-arterial infusion of the calcium channel antagonist nimodipine for 1–5 days on the intensive care unit. Methods. In thirty patients with aneurysmal subarachnoid hemorrhage and refractory vasospasm continuous infusion of nimodipine was started on the neurosurgical intensive care unit. The effect of nimodipine on brain perfusion, cerebral blood flow, brain tissue oxygenation, and blood flow velocity in cerebral arteries was monitored. Results. Based on Hunt & Hess grades on admission, 83% survived in a good clinical condition and 23% recovered without an apparent neurological deficit. Persistent ischemic areas were seen in 100% of patients with GOS 1–3 and in 69% of GOS 4-5 patients. Regional cerebral blood flow and computed tomography perfusion scanning showed adequate correlation with nimodipine application and angiographic vasospasm. Transcranial Doppler turned out to be unreliable with interexaminer variance and failure of detecting vasospasm or missing the improvement. Conclusion. Local continuous intra-arterial nimodipine treatment for refractory cerebral vasospasm after aSAH can be recommended as a low-risk treatment in addition to established endovascular therapies.
Ott, Stephanie; Jedlicka, Sheila; Wolf, Stefan; Peter, Mozes; Pudenz, Christine; Merker, Patrick; Schurer, Ludwig; Lumenta, Christianto Benjamin
The Rho/Rho-kinase pathway is considered important in the pathogenesis of sustained smooth muscle cell contraction during cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). The aims of this study were to investigate whether combination treatment, with pitavastatin as an inhibitor of RhoA and fasudil as an inhibitor of Rho-kinase, prevents the cerebral vasospasm. SAH was simulated using the double-hemorrhage rabbit model, and pitavastatin, or fasudil, or both (combination treatment) were administrated. The basilar artery (BA) cross-sectional area only in the combination treatment group was statistically larger than in the SAH group (p<0.05). BA Rho-kinase, as measured by ELISA, was statistically reduced only in the combination treatment group compared with the SAH group (p<0.05). In the other two treatment groups, pitavastatin or fasudil treatment group showed larger BA cross-sectional areas and lower value for BA Rho-kinase, but there were no statistically significant differences compared with the SAH group. The expression of endothelial nitric oxide synthase (eNOS), evaluated by immunohistochemistry in the pitavastatin group and the combination group, was higher than in the SAH group. Results indicate that combination treatment could extensively prevent cerebral vasospasm due to the synergic effect of combining pitavastatin and fasudil on the Rho/Rho-kinase pathway and on eNOS. PMID:23658597
Naraoka, Masato; Munakata, Akira; Matsuda, Naoya; Shimamura, Norihito; Ohkuma, Hiroki
Brain injury begins early after aneurysmal subarachnoid hemorrhage (SAH). Although cell death via apoptosis and necrosis is known to be present in brain 24 hours after SAH, it is not known how soon after SAH cell death begins. We have previously described structural changes in rat brain microvessels 10 minutes after induction of SAH by endovascular puncture. This study examined brain for evidence of cell death beginning 10 minutes after induction of SAH. Cleaved caspase-3 (cl-caspase-3) staining was evident in vascular and parenchymal cells at 10 minutes after SAH and was significantly greater than in time-matched, sham-operated controls. The number of cl-caspase-3 positive cells was increased further at 24 hour after SAH. TUNEL assay revealed apoptotic cells present at 10 minutes, with substantially more at 24 hours after SAH. Scattered Fluoro-Jade positive neurons appeared at 1 hour after SAH and their number increased with time. At 1 hour Fluoro-Jade positive neurons were present in cortical and subcortical regions but not in hippocampus; at 24 hours they were also present in hippocampus and were significantly greater in the hemisphere ipsilateral to the vascular puncture. No Fluoro-Jade staining was present in shams. These data demonstrate an early activation of endothelial and parenchymal cells apoptosis and neuronal necrosis after SAH and identifies endpoints that can be targeted to reduce early brain injury after SAH.
Friedrich, Victor; Flores, Rowena; Sehba, Fatima A.
Extrahepatic biliary atresia (EHBA) is a rare disease characterized by progressive and obliterative cholangiopathy in infants and is one of the major causes of secondary vitamin K deficiency bleeding (VKDB) due to cholestasis-induced fat malabsorption. Breast feeding increases the tendency of bleeding in EHBA patients because breast milk contains low amounts of vitamin K. A 2-month-old female infant unexpectedly died, with symptoms of vomiting and jaundice prior to death. She had been born by uncomplicated vaginal delivery and exhibited normal growth and development with breastfeeding. There was no history of trauma. She received vitamin K prophylaxis orally. In an emergency hospital, a CT scan showed a right intracranial hematoma and mass effect with midline shift to the left. In the postmortem examination, severe atresia was observed in the whole extrahepatic bile duct. Histologically, cholestasis, periductal fibrosis, and distorted bile ductules were noted. The gallbladder was not identified. A subdural hematoma and cerebellar tonsillar herniation were found; however, no traumatic injury in any part of the body was observed. Together, these findings suggest that the subdural hemorrhage was caused by secondary vitamin K deficiency resulting from a combination of cholestasis-induced fat malabsorption and breastfeeding. Subdural hemorrhage by secondary VKDB sometimes occurs even when vitamin K prophylaxis is continued. This case demonstrated that intrinsic factors, such as secondary VKDB (e.g., EHBA, neonatal hepatitis, chronic diarrhea), should also be considered in infant autopsy cases presenting with subdural hemorrhage. PMID:22607980
Miyao, Masashi; Abiru, Hitoshi; Ozeki, Munetaka; Kotani, Hirokazu; Tsuruyama, Tatsuaki; Kobayashi, Naho; Omae, Tadaki; Osamura, Toshio; Tamaki, Keiji
The purpose of this study was to determine the effects of subarachnoid hemorrhage (SAH) on cerebral blood flow and cerebral oxidative metabolism. Average total hemispheric flow was measured utilizing a polarographic technique and the metabolic consumption...
J. M. Fein
Purpose Moyamoya (meaning a “hazy puff of smoke” in Japanese) disease is a rare cerebrovascular occlusive disease. Moyamoya disease\\u000a may become symptomatic for the first time during pregnancy. We report a case of antepartum intracranial hemorrhage due to\\u000a unrecognized unilateral moyamoya disease, which was subsequently diagnosed as HELLP syndrome during the postpartum period.\\u000a \\u000a \\u000a \\u000a \\u000a Study design A case report of a 29-year-old Japanese
Jun Kakogawa; Miyuki Sadatsuki; Norio Masuya; Hideto Gomibuchi; Hiroyasu Ohno; Tetsuo Hara; Hiroko Oda; Akio Kimura; Shigeki Minoura
Subarachnoid blood has been reported as a cause of chronic spinal arachnoiditis. Although syringomyelia has been thought to be caused by spinal arachnoiditis, reports of syringomyelia following aneurysmal subarachnoid hemorrhage (SAH) are very rare. We describe two patients with syringomyelia associated with chronic spinal arachnoiditis following SAH. From January 2001 to December 2010, 198 patients with aneurysmal SAH were treated at Kinki University School of Medicine. Two of the 198 patients had syringomyelia following aneurysmal SAH; thus the rate of syringomyelia associated with aneurysmal SAH was 1.0%. Patient 1 was a 54-year-old woman who presented with back pain, back numbness and gait disturbance 20 months after SAH. Her MRI revealed syringomyelia of the spinal cord from C2 to T10. She underwent shunting of the syrinx to the subarachnoid space. Patient 2 was a 49-year-old man, who was admitted to the hospital with headache, diplopia, hoarseness, dysphagia and ataxia five months after SAH. MRI revealed syringomyelia from the medulla oblongata to C6, and an enlargement of the lateral and fourth ventricles. After foramen magnum decompression and C1 laminectomy, a fourth ventricle-subarachnoid shunt was placed by insertion of a catheter. Spinal arachnoiditis and spinal syringomyelia are rare but important chronic complications after SAH. PMID:22285478
Nakanishi, Kinya; Uchiyama, Takuya; Nakano, Naoki; Fukawa, Norihito; Yamada, Kimito; Yabuuchi, Tomonari; Kato, Amami
Objective\\u000a In patients with non-traumatic subarachnoid hemorrhage (SAH) and no evidence for a cerebral aneurysm on angiography, a frequent\\u000a cause of the hemorrhage is perimesencephalic hemorrhage or other cerebral vascular pathology. In some patients no cause is\\u000a found. The exact incidence of a spinal vascular malformation (SVM) as the origin for the SAH is not known. We assessed the\\u000a occurrence
M. R. Germans; F. A. Pennings; M. E. S. Sprengers; W. P. Vandertop
Tentorial dural arteriovenous fistulas (tDAVF) clinically present usually with subarachnoid and/or intraparenchymal hemorrhage. Reported rates range from 58% to 92% and neurological deficits occur in 79% to 92% of patients. This is due to venous congestion resulting from retrograde leptomeningeal venous drainage, which rarely, can be clinically silent. A 69-year-old woman presented with vertigo, double vision and gait instability. Cerebral digital subtraction angiography revealed a tDAVF with retrograde cerebellar venous drainage directed through the vein of Galen into the straight sinus. MRI showed extensive cerebellar edema due to venous congestion. Clinical manifestations of cerebellar and brainstem dysfunction resolved completely after transarterial embolization with N-butylcyanoacrylate. PMID:19091572
Panagiotopoulos, V; Kastrup, O; Wanke, I
The author reports the case of a 36 year old man with cervical cord injury in whom autonomic dysreflexia developed into intracerebral hemorrhage during inpatient rehabilitation. This patient showed complete quadriplegia (motor below C6 and sensory below C7) due to fracture of the 6th cervical vertebra. An indwelling urethral catheter had been inserted into the bladder for 3 months, diminishing bladder expansiveness. Bladder capacity decreased to 200 ml and the patient frequently experienced headaches whenever his bladder was full.To obtain smoother urine flow, a supra-pubic cystostomy was performed. The headaches were temporarily cured, but soon relapsed with extreme increases in blood pressure, representing typical symptoms of autonomic dysreflexia. However, no potential triggers were identified or removed, and lack of blood pressure management led to left putaminal hemorrhage. Despite operative treatment, the right upper extremity showed progressive increases in muscle tonus and finally formed a frozen shoulder with elbow flexion contracture. Two factors contributed to this serious complication: first, autonomic dysreflexia triggered by minor malfunction and/or irritation from the cystostomy catheter; and second, the medical staff lacked sufficient experience in and knowledge about the management of autonomic dysreflexia.It is of the utmost importance for medical staff engaging in rehabilitation of spinal patients to share information regarding triggers of autonomic dysreflexia and to be thorough in ensuring proper medical management. PMID:23774659
Context: Kashmir, a snow bound and mountain locked valley, is populated by about 7 million ethnic and non-migratory Kashmiris who have specific dietary and social habits than rest of the world. The neurological disorders are common in Kashmiri population. Aims: To study the prevalence and outcome of spontaneous intracranial subarachnoid hemorrhage (SAH) in Kashmir compared withother parts of the world. Settings and Design: A retrospective and hospital based study from 1982 to 2010 in the single and only Neurosurgical Centre of the State of Jammu and Kashmir. Materials and Methods: A hospital based study, in which, information concerning all Kashmiri patients was collected from the case sheets, patient files, discharge certificates, death certificates, and telephonic conversations with the help of Medical Records Department and Central Admission Register of Sher–i-Kashmir Institute of Medical Sciences, Kashmir India. Statistical Analysis: Analysis of variance and students T-test were used at occasions. Results: Incidence of SAH in Kashmiris is about 13/100,000 persons per year. SAH comprises 31.02% of total strokes and aneurysmal ruptures are cause of 54.35% SAHs. The female suffers 1.78 times more than the male. Total mortality of 36.60% was recorded against a good recovery of 14.99%. The familial SAHs and multiple aneurysms were also common. Intra-operative finding of larger aneurysmal size than recorded on pre-operative computed tomography (CT) angiogram of same patients was noteworthy. In 493 patients of SAH, the angiography revealed 705 aneurysms. Conclusion: Spontaneous intracranial subarachnoid hemorrhage, due to aneurysmal rupture, is common in Kashmir, with worst outcome. Food habits like “salt-tea twice a day”, group-smoking of wet tobacco like “Jejeer”, winter season, female gender, hypertension, and inhalation of “Kangri” smoke are special risk factorsof SAH, in Kashmiris. The plain CT brain and CT angiography are best diagnostic tools. The preventive measures for aneurysmal formation and rupture seems most promising management of future. The detachable endovascular aneurysmal occupying video assisted micro-camera capsules or plugs may be future treatment.
Bhat, Abdul Rashid; AfzalWani, Mohammed; Kirmani, Altaf R.
Annually, approximately 30,000 people suffer from aneurysmal subarachnoid hemorrhage (SAH) in the United States. In an estimated 5% of these patients, the hemorrhage is difficult to diagnose using conventional methods. Clini- cians must rely upon a combination of clinical history, Computerized Tomography (CT) scan evidence and lumbar punc- ture results to diagnose and differentiate SAH from a traumatic spinal tap
Prashant R. Bhadri; Vasant A. Salgaonkar; Gail J. Pyne-Geithman; James J. Caffery Jr; Rakesh Shukla; Fred R. Beyette Jr; Joseph F. Clark
Subarachnoid hemorrhage (SAH) is a unique disorder commonly occurring when an aneurysm ruptures, leading to bleeding and clot formation, with a higher incidence in females. To evaluate the influence of 17-? estradiol (E2) in the outcome of subarachnoid hemorrhage, SAH was induced by endovascular puncture of the intracranial segment of internal carotid artery in 15 intact females (INT), 19 ovariectomized
Shao-Hua Yang; Zhen He; Samuel S. Wu; Yun-Ju He; Jason Cutright; William J. Millard; Arthur L. Day; James W. Simpkins
Objective: We describe a rare case of a patient with subarachnoid hemorrhage (SAH) due to a ventral dissecting mid-basilar aneurysm that was treated surgically. One week after surgery, the patient experienced sudden deterioration due to a new SAH caused by the development of a new aneurysm of the basilar trunk distinct from the previously clipped aneurysm. Case Description: A 54-year-old woman with acute subarachnoid hemorrhage was found to have a small, broad-based aneurysm arising from the ventral aspect of the mid-basilar artery. This complicated lesion was treated with a microsurgical clipping via a translabyrinthine pre-sigmoidal sub-temporal approach. One week postoperatively, the patient suffered a new SAH and was found to have developed a distinct basilar artery aneurysm. The patient was returned to the Operating Room for microsurgical clipping via the previous craniotomy. After surgery, the patient made a slow, but steady, recovery. She underwent repeated angiographic imaging, demonstrating a stable appearance. Two years post surgery, the patient had returned to work and had no obvious neurological deficit, with the exception of unilateral iatrogenic hearing loss. Conclusion: We describe a rare case of multiple aneurysms originating in relation to a mid-basilar dissection, resulting in multiple episodes of SAH. These are difficult and dangerous lesions that can be treated with open microsurgical reconstruction or possibly via an endovascular approach. The intricate location of the lesions poses a particular challenge to neurosurgeons attempting to directly treat mid-basilar lesions.
Defillo, Archie; Nussbaum, Eric S.; Zelensky, Andrea; Nussbaum, Leslie
Sildenafil citrate (Viagra®; Pfeizer US Pharmaceutical Group, New York, NY, USA) is a potent vasodilating agent to treat male erectile dysfunction. Among its adverse effects, hemorrhagic stroke has not been widely reported yet. We present a case of a 33-year-old healthy man who ingested 50 mg sildenafil a half hour before onset of headache, nervousness and speech disturbance. Head computed tomogram of this stuporous man showed huge intracerebral hemorrhage and thick subarachnoid hemorrhage, but angiography failed to disclose any vascular anomalies. Subsequent surgical procedure was followed, and rehabilitation was provided thereafter. Sildenafil seems to act by redistributing arterial blood flow, and concurrent sympathetic hyperactivity, which lead to such hemorrhagic presentation. Extreme caution should be paid on even in a young adult male patient wven without known risk factors.
Byoun, Hyoung-Soo; Lee, Young-Joon
A 31-year-old woman with epigastric pain was given a diagnosis of a pseudocyst associated with pancreatitis. Despite treatment, symptoms did not completely improve and she was referred to our hospital. Since imaging examinations demonstrated findings characteristic of mucinous cystic neoplasm, the lesion was resected. Histopathologic examinations revealed mucinous cystic adenoma. Remains of intracystic hemorrhage were evident and short-term morphological changes were presumed to be associated with hemorrhage. PMID:19966522
Hayashi, Tsuyoshi; Ishiwatari, Hirotoshi; Yoshida, Makoto; Ihara, Hideyuki; Muramatsu, Hirohito; Kato, Junji; Kimura, Yasutoshi; Hasegawa, Tadashi
Delayed cerebral ischemia after subarachnoid hemorrhage (SAH) may be affected by a number of factors, including cerebral blood flow and oxygen delivery. Anemia affects about half of patients with SAH and is associated with worse outcome. Anemia also may contribute to the development of or exacerbate delayed cerebral ischemia. This review was designed to examine the prevalence and impact of anemia in patients with SAH and to evaluate the effects of transfusion. A literature search was made to identify original research on anemia and transfusion in SAH patients. A total of 27 articles were identified that addressed the effects of red blood cell transfusion (RBCT) on brain physiology, anemia in SAH, and clinical management with RBCT or erythropoietin. Most studies provided retrospectively analyzed data of very low-quality according to the GRADE criteria. While RBCT can have beneficial effects on brain physiology, RBCT may be associated with medical complications, infection, vasospasm, and poor outcome after SAH. The effects may vary with disease severity or the presence of vasospasm, but it remains unclear whether RBCTs are a marker of disease severity or a cause of worse outcome. Erythropoietin data are limited. The literature review further suggests that the results of the Transfusion Requirements in Critical Care Trial and subsequent observational studies on RBCT in general critical care do not apply to SAH patients and that randomized trials to address the role of RBCT in SAH are required. PMID:21769459
Le Roux, Peter D
We report a case of significant pulmonary hemorrhage developing shortly after commencing ticagrelor and aspirin therapy and requiring coronary artery bypass grafting to safely cease the antiplatelet therapy. Lung biopsy findings were consistent with drug-induced lung injury. Clinicians should be aware of this significant adverse event with this drug class. PMID:24590025
Whitmore, Timothy J; O'Shea, John P; Starac, Diana; Edwards, Mark G; Waterer, Grant W
A man aged 65 receiving low-dose anticoagulant therapy for a previous myocardial infarction suddenly developed a bilateral femoral nerve palsy. An abdominal CT scan showed small hemorrhages in both iliac muscles with consequent compression of the femoral nerves. The case is reported for its exceptional bilaterality.
F. Barontini; M. Macucci
For survivors of aneurysmal subarachnoid hemorrhage (SAH), somatic and cognitive deficits can affect long-term outcomes. We were interested in comparing the deficits identified in SAH patients, including cognitive deficits, at discharge by neurosurgeons and deficits identified by neurologists upon admission to the rehabilitation unit on the same day. The assessment of deficits might have an impact on referring patients to rehabilitation. This retrospective study included 494 SAH patients treated between 2005 and 2010. Of these, 50 patients were discharged to an affiliated rehabilitation unit. Deficits were grouped into 18 categories and summarized into three groups: major somatic, minor somatic, and cognitive deficits. Major somatic deficits were identified in 16 and 20 patients (p = 0.53), minor somatic deficits in 16 and 44 (p < 0.0001) patients, and cognitive deficits in 36 and 45 (p < 0.04) patients by neurosurgeons and neurologists, respectively. The absolute number of deficits in daily activities identified by the neurosurgeon and neurologist were 21 and 31 major somatic deficits (p = 0.2), 18 and 97 minor somatic deficits (p < 0.0001), and 61 and 147 cognitive deficits (p < 0.0001), respectively. Significant differences in assessment of cognitive and minor somatic deficits between neurosurgeons and neurologists exist. Based on these findings, it is evident that for the neurosurgeon, there needs to be an increased awareness of the assessment of cognitive deficits and a more routine interdisciplinary approach, including the use of neuropsychological evaluations, to ensure a better triage of patients to rehabilitation or for discharge home. PMID:22527224
Fung, Christian; Beck, Jürgen; Lauber, Lara; Müri, René; Raabe, Andreas; Nyffeler, Thomas
We report the case of a 55–year–old man, hypertensive, who presented to the Emergency Room with intense occipital cephaleea, nausea, vomiting and disturbance of balance. The peculiarity of this case was given by the simultaneous presence of two brain hemorrhagic lesions and an unusual hypodensity with digitiform borders at cerebral CT scan, which suggested a different etiology than hypertension and leaded us to further investigations, which confirmed the diagnosis of lung cancer with multiple brain metastases.
Ghitoiu, A; Rusu, CM; Slavoaica, D; Aigyul, E
Background Intrapleural fibrinolytics have been used successfully worldwide for the management of complicated pleural effusions and empyema. Bleeding complications are usually mentioned as rare side effects, but there is no clear information in the literature addressing the alarming outcome that might result following the use of alteplase as a fibrinolytic in the management of complicated parapneumonic effusions. We present a rare, if not unique, case of intrapleural hemorrhage requiring transfusion after alteplase use as a fibrinolytic in a 6-year-old male with complicated parapneumonic effusion. Methods A search of the PubMed database was carried out, using a combination of the following terms: alteplase, fibrinolytic, intrapleural hemorrhage, and side effects. Results The majority of studies found in the search concentrated on the efficacy of intrapleural fibrinolytics in the management of pleural effusion, but very few of the reports addressed the bleeding complications which may be caused by the treatment. Conclusion Although intrapleural and systemic hemorrhage are rare side effects of intrapleural fibrinolytic use, the health care provider must be watchful for these potentially life-threatening complications. Further studies are needed to understand not only the efficacy of fibrinolytics but also their safety, especially in children.
Hendaus, Mohamed A; Abushahin, Ahmad
Background Postpartum hemorrhage (PPH) represents a serious problem for women and obstetricians. Because of its association with hemorrhagic shock and predisposition to disseminated coagulopathy, it is a leading cause of maternal deaths worldwide. Furthermore, the jeopardy of PPH is rising with the secondary form of PPH occurring between 24 hours and 6 weeks postpartum, when women are already discharged home. The causes of this pathology are severe inflammation (endometritis), inherited coagulation disorders, consumptive coagulopathy, and retained products of conceptions. Others are of rare occurrence, such as vessel subinvolution (VSI) of the placental implantation site, uterine artery pseudoaneurysm, or trauma. Case presentation We present a rare form of recurrent secondary postpartum hemorrhage in a woman after uncomplicated cesarean delivery, with review of the literature linked to the management of this situation originating in the rare local VSI in the placental implantation site, defective decidual homeostasis, and coagulopathy confined to the uterus. Conclusion The placental site VSI is one of the rare causes of secondary PPH, and this situation is frequently underdiagnosed by clinicians. The histological confirmation of dilated “clustered”-shaped myometrial arteries partially occluded by thrombi of variable “age” together with the presence of endovascular extravillous trophoblasts confirms the diagnosis.
Chronic communicating hydrocephalus is a significant health problem affecting up to 20% of survivors of spontaneous subarachnoid hemorrhage (SAH). The development of new treatment strategies is hampered by the lack of well characterized disease models. This study investigated the incidence of chronic hydrocephalus by evaluating the temporal profile of intracranial pressure (ICP) elevation after SAH, induced by endovascular perforation in rats. Twenty-five adult male Sprague-Dawley rats (260–320g) were subjected to either endovascular perforation or sham surgery. Five animals died after SAH induction. At 7, 14 and 21 days after surgery ICP was measured by stereotaxic puncture of the cisterna magna in SAH (n=10) and SHAM (n=10) animals. On day 21 T-maze test was performed and the number of alterations and latency to decision was recorded. On day 23, samples were processed for histological analyses. The relative ventricle area was evaluated in coronal Nissl stained sections. On day 7 after surgery all animals showed normal ICP. The absolute ICP values were significantly higher in SAH compared to SHAM animals on day 21 (8.26±4.53 mmHg versus 4.38±0.95 mmHg) but not on day 14. Observing an ICP of 10mmHg as cut-off, 3 animals showed elevated ICP on day 14 and another animal on day 21. The overall incidence of ICP elevation was 40% in SAH animals. On day 21, results of T-maze testing were significantly correlated with ICP values, i.e. animals with elevated ICP showed a lower number of alterations and a delayed decision. Histology yielded a significantly higher (3.59 fold increased) relative ventricle area in SAH animals with ICP elevation compared to SAH animals without ICP elevation. In conclusion, the current study shows that experimental SAH leads to chronic hydrocephalus, which is associated with ICP elevation, behavioral alterations and ventricular dilation in about 40% of SAH animals.
Lackner, Peter; Vahmjanin, Alexander; Hu, Qin; Krafft, Paul R.; Rolland, William; Zhang, John H.
Introduction Cardiac abnormalities that have been reported after subarachnoid hemorrhage (SAH) include the release of cardiac biomarkers,\\u000a electrocardiographic changes, and left ventricular (LV) systolic dysfunction. The mechanisms of cardiac dysfunction after\\u000a SAH remain controversial. The aim of this study was to determine the prevalence of LV regional wall motion abnormalities (RWMA)\\u000a after SAH and to quantify the independent effects of specific
Avinash Kothavale; Nader M. Banki; Alexander Kopelnik; Sirisha Yarlagadda; Michael T. Lawton; Nerissa Ko; Wade S. Smith; Barbara Drew; Elyse Foster; Jonathan G. Zaroff
The neuroprotective effect of alpha lipoic acid (ALA; 100 mg\\/kg, po), a dithiol antioxidant, on experimentally induced subarachnoid\\u000a hemorrhage (SAH) was assessed in Wistar albino rats. Neurological examination scores recorded at the 48th h of SAH induction\\u000a were increased in SAH groups, which were accompanied with significant increases in the formation of reactive oxygen species,\\u000a DNA fragmentation ratios, malondialdehyde levels and myeloperoxidase
Mehmet ErsahinHale; Hale Z. Toklu; ?ule Çetinel; Meral Yüksel; Can Erzik; M. Zafer Berkman; Berrak Ç. Ye?en; Göksel ?ener
Object Aneurysmal subarachnoid hemorrhage (SAH) causes devastating rates of mortality and morbidity. Accumulating studies indicate that early brain injury (EBI) greatly contributes to poor outcomes after SAH and that oxidative stress plays an important role in the development of EBI following SAH. Astaxanthin (ATX), one of the most common carotenoids, has a powerful antioxidative property. However, the potential role of ATX in protecting against EBI after SAH remains obscure. The goal of this study was to assess whether ATX can attenuate SAH-induced brain edema, blood-brain barrier permeability, neural cell death, and neurological deficits, and to elucidate whether the mechanisms of ATX against EBI are related to its powerful antioxidant property. Methods Two experimental SAH models were established, including a prechiasmatic cistern SAH model in rats and a one-hemorrhage SAH model in rabbits. Both intracerebroventricular injection and oral administration of ATX were evaluated in this experiment. Posttreatment assessments included neurological scores, body weight loss, brain edema, Evans blue extravasation, Western blot analysis, histopathological study, and biochemical estimation. Results It was observed that an ATX intracerebroventricular injection 30 minutes post-SAH could significantly attenuate EBI (including brain edema, blood-brain barrier disruption, neural cell apoptosis, and neurological dysfunction) after SAH in rats. Meanwhile, delayed treatment with ATX 3 hours post-SAH by oral administration was also neuroprotective in both rats and rabbits. In addition, the authors found that ATX treatment could prevent oxidative damage and upregulate the endogenous antioxidant levels in the rat cerebral cortex following SAH. Conclusions These results suggest that ATX administration could alleviate EBI after SAH, potentially through its powerful antioxidant property. The authors conclude that ATX might be a promising therapeutic agent for EBI following SAH. PMID:24724856
Zhang, Xiang-Sheng; Zhang, Xin; Zhou, Meng-Liang; Zhou, Xiao-Ming; Li, Ning; Li, Wei; Cong, Zi-Xiang; Sun, Qing; Zhuang, Zong; Wang, Chun-Xi; Shi, Ji-Xin
Summary Potassium channels play an important role in the regulation of arterial tone and decreased activity of these ion channels has been linked to pial artery vasospasm after subarachnoid hemorrhage (SAH). Our previous work has shown that acute application of a blood component, oxyhemoglobin, caused suppression of voltage-gated K+ (KV) channels through heparin-binding epidermal growth factor-like growth factor (HB-EGF) mediated activation of epidermal growth factor receptor (EGFR). Using patch clamp electrophysiology, we have now examined whether this pathway of KV channel suppression is activated in parenchymal arteriolar myocytes following long-term in vivo exposure to subarachnoid blood. We have found that KV currents, but not large conductance Ca2+ activated or inwardly rectifying K+ channel currents, were decreased in parenchymal arteriolar myocytes freshly isolated from Day-5 SAH model rabbits. Interestingly, parenchymal arteriolar myocytes from control animals were more sensitive to exogenous HB-EGF (IC50: 0.2 ± 0.4 ng/mL) compared to pial arterial myocytes (IC50: 2.4 ±1.3 ng/mL). However, HB-EGF and oxyhemoglobin failed to decrease KV currents in parenchymal arteriolar myocytes from SAH animals, consistent with EGFR activation and KV current suppression by SAH. These data suggest that HB-EGF/EGFR pathway activation contributes to KV current suppression and enhanced parenchymal arteriolar constriction after SAH.
Koide, Masayo; Wellman, George C.
Background and Study Aims?Perimesencephalic subarachnoid hemorrhage (PMSAH) was previously defined as a variant of subarachnoid hemorrhage (SAH) associated with a relatively benign clinical presentation and better outcomes than aneurysmal SAH. However, several prior studies have shown complications associated with PMSAH including vasospasm and hydrocephalus, and the need for follow-up imaging. We therefore reviewed our experience to further characterize the clinical consequences of PMSAH. Materials and Methods?Eighty-eight consecutive patients who sustained spontaneous intracranial SAH and whose cerebral angiograms did not show any obvious source for SAH were retrospectively studied to characterize their prognosis and outcome based on SAH pattern. Glasgow Coma Scale and Hunt-Hess scores on admission, the incidence of vasospasm or hydrocephalus, the need for an external ventricular drain, and shunt dependence, along with Glasgow outcome score (GOS) at discharge and follow-up, were used to draw comparisons between perimesencephalic and diffuse SAH patient populations. Results?Patients with perimesencephalic SAH differed statistically (p?0.05) from patients with diffuse SAH in regard to age, Hunt-Hess score on presentation, hospital length of stay, GOS at discharge, and incidence of hydrocephalus, angiographic vasospasm, and clinical vasospasm. Conclusion?Our data demonstrate that although the patients with perimesencephalic SAH fared better than those with diffuse SAH, their outcomes were worse than those of similar patients with PMSAH who have been previously reported in the literature. PMID:24554610
Patel, Neal B; Patel, Amrita D; Wilkinson, Jared; Gianaris, Nicholas G; Payner, Troy D; Leipzig, Thomas J; Ansari, Shaheryar; Cohen-Gadol, Aaron A
The clinical picture of hemorrhagic type Moyamoya disease was analyzed in 20 cases. Hematoma at the basal ganglia was noted in 40% of cases, intraventricular hemorrhage (IVH) in 30%, thalamic hemorrhage with ventricular rupture in 15% and subcortical hemorrhage in 5%. The location was undetermined in two cases (10%) due to bleeding in the pre-computed tomography (CT) era. The frequencies
Naokatsu Saeki; Susumu Nakazaki; Motoo Kubota; Akira Yamaura; Seiichirou Hoshi; Souichi Sunada; Kenro Sunami
A major reason for the recent advancements in ray tracing perfor- mance is the use of optimized acceleration structures, namely kd- trees based on the surface area heuristic (SAH). Though algorithms exist to build these search trees in O(nlogn), the construction times for larger scenes are still high and do not allow for rebuilding the kd-tree every frame to support
Stefan Popov; MPI Informatik; Hans-Peter Seidel; Philipp Slusallek
Seven young men developed acute pulmonary hemorrhage and edema from the inhalation of powder or fumes of a bisphenol epoxy resin containing tri-mellitic anhydride (TMA) while working in a steel pipe-coating plant. The illness was characterized by cough, hemoptysis, dyspnea, fever, weakness and nausea or vomiting. Chest roentgenograms showed either a bilateral or unilateral pulmonary infiltrate. All patients had a normochromic type of anemia. Pulmonary function studies demonstrated a restrictive defect, hypoxemia, and increased A-a DO2 gradients. Light and electron microscopic studies of lung tissue revealed extensive bleeding into alveoli but no basement membrane deposits were seen and no antiglomerular basement membrane antibodies were detected. The patients improved quickly without treatment. Follow-up studies of six patients three weeks to one year after their illness revealed apparent recovery. A detailed medical survey carried out on all 29 workers currently employed in the plant revealed five additional men had experienced severe recurrent pulmonary problems. PMID:498827
Herbert, F A; Orford, R
A 61-year-old woman had suffered from severe headache and nausea over 20 times during the last 43 years. An subarachnoid hemorrhage (SAH) was detected by spinal puncture in some other hospitals, but the source of hemorrhage remained unknown in spite of repeated angiography. At the age of 61, she was diagnosed as having normal pressure hydrocephalus, and received a ventriculo-peritoneal shunt. She suffered from sudden headache 12 days after surgery. A CT scan showed a SAH and enlargement of the pineal mass. The tumor was totally removed via the occipital interhemispheric transtentorial approach and was diagnosed histologically as a pineocytoma. She has been free from SAH for three years since removal of the tumor. Pineal apoplexy should be considered as a cause of SAH. PMID:18341015
Ogiwara, Toshihiro; Kakizawa, Yukinari; Yomo, Shoji; Wada, Naomichi; Goto, Tetsuya; Tanaka, Yuichiro; Hongo, Kazuhiro; Kaneko, Tomoki
Background: Protein S100B has proven to be a useful biomarker for cerebral damages. Increased levels of serum and cerebrospinal fluid (CSF) S100B have been shown in patients suffering subarachnoid hemorrhage (SAH), severe head injury and stroke. In patients with SAH, the course of S100B levels has been correlated with neurological deficits and outcome. Cerebral vasospasm is a major contributor to morbidity and mortality. The primary aim of this study was to investigate the potential of S100B protein as a predictor of cerebral vasospasm in patients with severe SAH. Materials and Methods: Patients with SAH, Fisher grade 3 and 4, were included in the study. Five samples of CSF and serum S100B were collected from each patient. The first sample (baseline sample) was drawn within the first 3?days following ictus and the following four samples, once a day on days 5–8, with day of ictus defined as day 1. Clinical suspicion of cerebral vasospasm confirmed by computed tomography angiography was used to diagnose cerebral vasospasm. Results: A total of 18 patients were included. Five patients (28%) developed cerebral vasospasm, two (11%) developed ventriculitis. There were no significant differences between S100B for those with and without vasospasm. Serum S100B levels in patients with vasospasm were slightly lower within the first 5?days following ictus, compared to patients without vasospasm. Two out of five patients had elevated and increasing serum S100B prior to vasospasm. Only one showed a peak level of S100B 1?day before vasospasm could be diagnosed. Due to the low number of patients in the study, statistical significance could not be reached. Conclusion: Neither serum nor CSF S100B can be used as predictor of cerebral vasospasm in patients suffering from SAH.
Amiri, Moshgan; Astrand, Ramona; Romner, Bertil
Subarachnoid hemorrhage (SAH) represents a considerable health problem with an incidence of 6–7 per 100.000 individuals per year in Western society. We investigated the long-term consequences of SAH on behavior, neuroinflammation and gray- and white-matter damage using an endovascular puncture model in Wistar rats. Rats were divided into a mild or severe SAH group based on their acute neurological score at 24 h post-SAH. The degree of hemorrhage determined in post-mortem brains at 48 h strongly correlated with the acute neurological score. Severe SAH induced increased TNF-?, IL-1?, IL-10, MCP-1, MIP2, CINC-1 mRNA expression and cortical neutrophil influx at 48 h post-insult. Neuroinflammation after SAH was very long-lasting and still present at day 21 as determined by Iba-1 staining (microglia/macrophages) and GFAP (astrocytes). Long-term neuroinflammation was strongly associated with the degree of severity of SAH. Cerebral damage to gray- and white-matter was visualized by immunohistochemistry for MAP2 and MBP at 21 days after SAH. Severe SAH induced significant gray- and white-matter damage. MAP2 loss at day 21 correlated significantly with the acute neurological score determined at 24 h post-SAH. Sensorimotor behavior, determined by the adhesive removal task and von Frey test, was affected after severe SAH at day 21. In conclusion, we are the first to show that SAH induces ongoing cortical inflammation. Moreover, SAH induces mainly cortical long-term brain damage, which is associated with long-term sensorimotor damage.
Kooijman, Elke; Nijboer, Cora H.; van Velthoven, Cindy T. J.; Mol, Wouter; Dijkhuizen, Rick M.; Kesecioglu, Jozef; Heijnen, Cobi J.
An 81-year-old man was admitted to a primary care hospital due to bloody diarrhea. The findings of abdominal computed tomography indicated ischemic colitis, so conservative therapy was started. On the 4th hospital day, the patient was transferred to our hospital because of renal dysfunction. Physical examination showed clouding of consciousness and abdominal distention. Abdominal computed tomography revealed massive ascites and thickening of the whole colonic wall. With a diagnosis of acute abdomen, an emergent laparotomy was performed. Extended right hemicolectomy was performed because of severe ischemic change and necrosis of the right side of the colon. In the stool culture before the operation, Escherichia coli O157 and verotoxin were found, so this case was diagnosed as hemorrhagic colitis with hemolytic uremic syndrome and acute encephalopathy due to Escherichia coli O157 infection. Postoperatively, the hemolytic uremic syndrome and acute encephalopathy were prolonged. However, with intensive care, the patient recovered and was discharged on the 33rd postoperative day.
Tominaga, Tetsuro; Oikawa, Masahiro; Takeshita, Hiroaki; Kunizaki, Masaki; Tou, Kazuo; Abo, Takafumi; Hidaka, Shigekazu; Nanashima, Atsushi; Sawai, Terumitsu; Nagayasu, Takeshi
\\u000a Delayed ischemic neurological deficit or clinical vasospasm remained a major cause for delayed neurological morbidity and\\u000a mortality for patients with aneurysmal subarachnoid hemorrhage (SAH). Magnesium is a cerebral vasodilator. In experimental\\u000a model of drug or SAH-induced vasospasm, magnesium blocks voltage-dependent calcium channels and reverses cerebral vasoconstriction.\\u000a Furthermore, its antagonistic action on N-methyl-D-aspartate receptor in the brain prevents glutamate stimulation and
George Kwok Chu Wong; Matthew Tai Vai Chan; Tony Gin; Wai Sang Poon
We present an efficient algorithm for building an adaptive bounding volume hierarchy (BVH) in linear time on commodity graphics\\u000a hardware using CUDA. BVHs are widely used as an acceleration data structure to quickly ray trace animated polygonal scenes.\\u000a We accelerate the construction process with auxiliary grids that help us build high quality BVHs with SAH in O(k?n). We partition scene
Kirill Garanzha; Simon Premoze; Alexander Bely; Vladimir Galaktionov
A major reason for the recent advancements in ray tracing performance is the use of optimized acceleration structures, namely kd-trees based on the surface area heuristic (SAH). Though algorithms exist to build these search trees in O(n log n), the construction times for larger scenes are still high and do not allow for rebuilding the kd-tree every frame to support
Stefan Popov; J. Gunther; Hans-Peter Seidel; Philipp Slusallek
Spontaneous, nontraumatic intracerebral hemorrhage (ICH) is defined as bleeding within the brain parenchyma. Intracranial hemorrhage includes bleeding within the cranial vault and encompasses ICH, subdural hematoma, epidural bleeds, and subarachnoid hemorrhage (SAH). This review will focus only on ICH. This stroke subtype accounts for about 10% of all strokes. The hematoma locations are deep or ganglionic, lobar, cerebellar, and brain stem in descending order of frequency. Intracerebral hemorrhage occurs twice as common as SAH and is equally as deadly. Risk factors for ICH include hypertension, cerebral amyloid angiopathy, advanced age, antithrombotic therapy and history of cerebrovascular disease. The clinical presentation is “stroke like” with sudden onset of focal neurological deficits. Noncontrast head computerized tomography (CT) scan is the standard diagnostic tool. However, newer neuroimaging techniques have improved the diagnostic yield in terms of underlying pathophysiology and may aid in prognosis. Intracerebral hemorrhage is a neurological emergency. Medical care begins with stabilization of airway, breathing function, and circulation (ABCs), followed by specific measures aimed to decrease secondary neurological damage and to prevent both medical and neurological complications. Reversal of coagulopathy when present is of the essence. Blood pressure management can be key and continues as an area of debate and ongoing research. Surgical evacuation of ICH is of unproven benefit though a subset of well-selected patients may have improved outcomes. Ventriculostomy and intracranial pressure (ICP) monitoring are interventions also used in this patient population. To date, hemostatic medications and neuroprotectants have failed to result in clinical improvement. A multidisciplinary approach is recommended, with participation of vascular neurology, vascular neurosurgery, critical care, and rehabilitation medicine as the main players.
Aguilar, Maria I.; Brott, Thomas G.
The neuroprotective effect of magnesium sulphate infusion has been confirmed in experimental models. Pilot clinical trials using magnesium sulphate in patients with acute aneurysmal subarachnoid hemorrhage (SAH) have reported a trend toward a reduction in clinical deterioration due to delayed cerebral ischemia (DCI) and an improvement in clinical outcomes. However, our recent multicenter trials and systemic review failed to confirm benefit in neurological outcome. In post hoc analysis, data also did not support that a higher dose of magnesium sulphate infusion might improve clinical outcome. We here review the current literature, highlight these discrepancies, and explore alternatives. PMID:22890642
Wong, George Kwok Chu; Poon, Wai Sang
The discovery of tissue plasminogen activator to treat acute stroke is a success story of research on preventing brain injury following transient cerebral ischemia (TGI). That this discovery depended upon development of embolic animal model reiterates that proper stroke modeling is the key to develop new treatments. In contrast to TGI, despite extensive research, prevention or treatment of brain injury following aneurysmal subarachnoid hemorrhage (aSAH) has not been achieved. A lack of adequate aSAH disease model may have contributed to this failure. TGI is an important component of aSAH and shares mechanism of injury with it. We hypothesized that modifying aSAH model using experience acquired from TGI modeling may facilitate development of treatment for aSAH and its complications. This review focuses on similarities and dissimilarities between TGI and aSAH, discusses the existing TGI and aSAH animal models, and presents a modified aSAH model which effectively mimics the disease and has a potential of becoming a better resource for studying the brain injury mechanisms and developing a treatment.
Sehba, Fatima A.; Pluta, Ryszard M.
A 37-year-old man with C4-5 spinal cord injury (SCI) presented with abnormally high blood pressure after vesicocutaneous catheter exchange and was treated with antihypertensive agents. Two weeks later, he developed headache and visual disturbance, and presented with fluctuating blood pressure. Multiple subcortical hemorrhages in the left occipital and right frontal lobes occurred on the next day, and he died of increased intracranial pressure 3 weeks later. Based on the symptoms and computed tomography findings, the retrospective diagnosis was posterior reversible encephalopathy syndrome (PRES) due to autonomic dysreflexia (AD). AD occurs frequently in patients with quadriplegia and high paraplegia by distention of the bladder and bowel. PRES secondary to AD is very rare, but we must always be aware of this life-threatening complication in SCI patients. PMID:23006876
Yamashita, Tae; Hiramatsu, Hisaya; Sakai, Naoto; Namba, Hiroki
Cerebral vasospasm is the leading cause of mortality and morbidity in patients after aneurysmal subarachnoid hemorrhage (SAH). However, the mechanism and adequate treatment of vasospasm are still elusive. In the present study, we evaluate the effect and possible mechanism of progesterone on SAH-induced vasospasm in a two-hemorrhage rodent model of SAH. Progesterone (8?mg/kg) was subcutaneously injected in ovariectomized female Sprague-Dawley rats one hour after SAH induction. The degree of vasospasm was determined by averaging the cross-sectional areas of basilar artery 7 days after first SAH. Expressions of endothelial nitric oxide synthase (eNOS) and phosphorylated Akt (phospho-Akt) in basilar arteries were evaluated. Prior to perfusion fixation, there were no significant differences among the control and treated groups in physiological parameters recorded. Progesterone treatment significantly (P < 0.01) attenuated SAH-induced vasospasm. The SAH-induced suppression of eNOS protein and phospho-Akt were relieved by progesterone treatment. This result further confirmed that progesterone is effective in preventing SAH-induced vasospasm. The beneficial effect of progesterone might be in part related to upregulation of expression of eNOS via Akt signaling pathway after SAH. Progesterone holds therapeutic promise in the treatment of cerebral vasospasm following SAH.
Chang, Chia-Mao; Su, Yu-Feng; Chang, Chih-Zen; Tsai, Yee-Jean; Loh, Joon-Khim
Background: Whether unilateral moyamoya disease (MMD), confirmed by steno-occlusive lesion at the terminal portion of internal carotid artery with formation of moyamoya vessels unilaterally and normal or equivocal findings contralaterally, is an early form of definite (bilateral) MMD remains controversial. It is well-known that adult patients with MMD tend to suffer from cerebral hemorrhage, occasionally due to the rupture of aneurysm arising from moyamoya vessel. Case Description: A 61-year-old woman was diagnosed as unilateral MMD incidentally and followed by magnetic resonance imaging annually. Seven years after the diagnosis, cerebral aneurysm appeared on the moyamoya vessel. Before further examination, the aneurysm ruptured and resulted in massive cerebral hemorrhage. Conclusion: Even in the unilateral MMD, cerebral hemorrhage may occur due to the rupture of cerebral aneurysm. Careful follow-up is recommended and early treatment is required once cerebral aneurysm is detected.
Hayashi, Kentaro; Horie, Nobutaka; Nagata, Izumi
Only a very few cases of subarachnoid hemorrhage due to isolated anterior spinal artery aneurysms have been reported in the literature. We report a case of subarachnoid hemorrhage due to anterior spinal artery aneurysm rupture in a renal transplant patient at our institution. A 47-year-old male had abrupt onset of left lower extremity weakness with bowel and bladder disturbances which prompted emergent surgical evacuation of the clot and hence immediate diagnostic angiography was not performed. However, follow-up serial intracranial arterial ultrasound studies showed only vasospasm of the basilar artery. Repeat MRI of the thoracic spine showed persistence of subarachnoid blood products, but no larger foci compared to previous imaging. When spinal subarachnoid hemorrhage is present in the appropriate clinical setting, isolated anterior spinal artery aneurysm should be considered as a possible, treatable cause.
Seerangan, Geetha; Narayanan, Mohanram
Aneurysmal subarachnoid hemorrhage (SAH) has the highest morbidity and mortality rates of all types of stroke. Many aneurysmal SAH patients continue to suffer from significant neurological morbidity and mortality directly related to delayed cerebral ischemia. Pilot clinical studies of the use of Hydroxymethylglutaryl-CoA Reductase Inhibitors (statins) in aneurysmal SAH patients have reported a reduction in delayed cerebral ischemia and better clinical outcomes. We review the biochemical effects of statins on endothelium vascular function, glutamate-mediated neurotoxicity, inflammatory changes, and oxidative injuries, with reference to their possible neuroprotective effects in aneurysmal SAH.
Wong, George Kwok Chu; Poon, Wai Sang
Allograft recipients are often unwell with significant organ dysfunction by the time delayed or failed engraftment is diagnosed. We attempted to identify factors associated with graft failure, or death due to infection, hemorrhage or graft failure in 712 patients undergoing allogeneic BMT. Low leukocyte counts between days 12 and 22 were strongly associated with subsequent graft failure or death. In
J Mehta; R Powles; S Singhal; C Horton; G Middleton; T Eisen; S Meller; CR Pinkerton; J Treleaven
Background. Aneurysmal subarachnoid hemorrhage (aSAH) survivors commonly exhibit impairment on phonemic and semantic fluency tests; however, it is unclear which of the contributing cognitive processes are compromised in aSAH patients. One method of disentangling these processes is to compare initial word production, which is a rapid, semiautomatic, frontal-executive process, and late phase word production, which is dependent on more effortful retrieval and lexical size and requires a more distributed neural network. Methods. Seventy-two individuals with aSAH and twenty-five control subjects were tested on a cognitive battery including the phonemic and semantic fluency task. Demographic and clinical information was also collected. Results. Compared to control subjects, patients with aSAH were treated by clipping and those with multiple aneurysms were impaired across the duration of the phonemic test. Among patients treated by coiling, those with anterior communicating artery aneurysms or a neurological complication (intraventricular hemorrhage, vasospasm, and edema) showed worse output only in the last 45 seconds of the phonemic test. Patients performed comparably to control subjects on the semantic test. Conclusions. These results support a “diffuse damage” hypothesis of aSAH, indicated by late phase phonemic fluency impairment. Overall, the phonemic and semantic tests represent a viable, rapid clinical screening tool in the postoperative assessment of patients with aSAH.
Ladowski, Daniella; Qian, Winnie; Kapadia, Anish N.; Macdonald, R. Loch; Schweizer, Tom A.
Purpose To evaluate the results of intravitreal expansile gas injection, with or without recombinant tissue plasminogen activator (rtPA), followed by intravitreal bevacizumab injection for treatment of submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (AMD). Methods In this interventional case series, 5 eyes of 5 patients with SMH secondary to choroidal neovascularization (CNV) due to neovascular AMD were treated with 0.3 cc intravitreal SF6 (and 50 ?g of rtPA in two eyes), followed by face-down positioning; 24 hours later, 1.25 mg of bevacizumab was injected intravitreally. Main outcome measures included displacement of SMH and best corrected visual acuity (BCVA). Results Mean patient age was 75.6±9.2 (range, 60–83) years, mean duration of symptoms was 6.4±3.2 (range, 3–10) days, and mean number of bevacizumab injections was 1.8 (range, 1–3). Mean preoperative BCVA was 1.28±0.27 logMAR which improved significantly to 0.57±0.33 logMAR at 12 months (P=0.042). SMH displacement occurred in all eyes, and visual acuity improved and remained stable during the follow-up period of 12 months. Conclusion Intravitreal expansile gas injection, with or without rtPA, followed by intravitreal bevacizumab injection, seems to be an effective modality for SMH displacement and treatment of the underlying CNV in neovascular AMD.
Nourinia, Ramin; Bonyadi, Mohammad Hossein Jabbarpour; Ahmadieh, Hamid
Premacular retrohyaloid hemorrhage is a rare complication of acute severe anemia. The authors report two cases of premacular hemorrhage in which no treatment other than clinical and spectral-domain optical coherence tomography observation was performed. The natural history of this condition reveals that complete clinical resolution is not accompanied by full anatomical restoration. [Ophthalmic Surg Lasers Imaging Retina. 2014;45:E5-E7.]. PMID:24496165
Turco, Claudia Del; La Spina, Carlo; Mantovani, Elena; Gagliardi, Marco; Lattanzio, Rosangela; Pierro, Luisa
Background—The SA gene (SAH) has been isolated by differential screening from a genetically hypertensive rat strain as a candidate gene that may contribute to hypertension. Recently, the SA protein has been reported to be highly homologous to bovine xenobiotic-metabolizing medium-chain fatty acid:CoA ligase. Methods and Results—To clarify the pathophysiological significance of SAH, we searched for polymorphisms of human SAH and
Naoharu Iwai; Tomohiro Katsuya; Toshifumi Mannami; Jitsuo Higaki; Toshio Ogihara; Koichi Kokame; Jun Ogata; Shunroku Baba
Recent studies have revealed that oxidative stress has detrimental effects in several models of neurodegenerative diseases, including subarachnoid hemorrhage (SAH). However, how oxidative stress affects acute brain injury after SAH remains unknown. We have previously reported that overexpression of copper\\/zinc-superoxide dismutase (SOD1) reduces oxidative stress and subsequent neuronal injury after cerebral ischemia. In this study, we investigated the relationship between
Hidenori Endo; Chikako Nito; Hiroshi Kamada; Fengshan Yu; Pak H Chan
Aneurysmal subarachnoid hemorrhage (aSAH) is a common and often devastating condition that requires prompt neurosurgical evaluation and intervention. Modern management of aSAH involves a multidisciplinary team of subspecialists, including vascular neurosurgeons, neurocritical care specialists and, frequently, neurointerventional radiologists. This team is responsible for stabilizing the patient on presentation, diagnosing the offending ruptured aneurysm, securing the aneurysm, and managing the patient through a typically prolonged and complicated hospital course. Surgical intervention has remained a definitive treatment for ruptured cerebral aneurysms since the early 1900s. Over the subsequent decades, many innovations in microsurgical technique, adjuvant maneuvers, and intraoperative and perioperative medical therapies have advanced the care of patients with aSAH. This report focuses on the modern surgical management of patients with aSAH. Following a brief historical perspective on the origin of aneurysm surgery, the topics discussed include the timing of surgical intervention after aSAH, commonly used surgical approaches and craniotomies, fenestration of the lamina terminalis, intraoperative neurophysiological monitoring, intraoperative digital subtraction and fluorescent angiography, temporary clipping, deep hypothermic cardiopulmonary bypass, management of acute hydrocephalus, cerebral revascularization, and novel clip configurations and microsurgical techniques. Many of the topics highlighted in this report represent some of the more debated techniques in vascular neurosurgery. The popularity of such techniques is constantly evolving as new studies are performed and data about their utility become available. PMID:20380967
Colby, Geoffrey P; Coon, Alexander L; Tamargo, Rafael J
Background Patients with good-grade subarachnoid hemorrhage (SAH) are those without initial neurological deficit. However, they can die or present severe deficit due to secondary insult leading to brain ischemia. After SAH, in a known context of energy crisis, vasospasm, hydrocephalus and intracranial hypertension contribute to unfavorable outcome. Lumbar puncture (LP) is sometimes performed in an attempt to reduce intracranial pressure (ICP) and release headaches. We hypothesize that in good-grade SAH patients, a 20-ml LP releases headaches, reduces ICP and improves cerebral blood flow (CBF) as measured with O15 PET scan. Methods Six good-grade (WFNS grade 1or 2) SAH patients (mean age 48 years, 2 women, 4 men) were prospectively included. All aneurysms (4 anterior communicating artery and 2 right middle cerebral artery) were coiled at day 1. Patients were managed according to our local protocol. LP was performed for severe headache (VAS >7) despite maximal painkiller treatment. Patients were included when the LP was clinically needed. The 20-ml LP was done in the PET scan (mean delay between SAH and LP: 3.5 days). LP allows hydrostatic measurement of ICP. Arterial blood pressure (ABP) was noninvasively gauged with photoplethysmography. Every signal was monitored and analyzed off-line. Regional CBF (rCBF) was measured semiquantitatively with O15 PET before and after LP. Then we calculated the difference between baseline and post-LP condition for each area: positive value means augmentation of rCBF after the LP, negative value means reduction of rCBF. Individual descriptive analysis of CBF was first performed for each patient; then a statistical group analysis was done with SPM for all voxels using t statistics converted to Z scores (p < 0.01, Z score >3.2). Results A 20-ml LP yielded a reduction in pain (–4), a drop in ICP (24.3 ± 12.5 to 6.9 ± 4.7 mm Hg), but no change in ABP. Descriptive and statistical image analysis showed a heterogeneous and biphasic change in cerebral hemodynamics: rCBF was not kept constant and either augmented or decreased after the drop in ICP. Hence, cerebrovascular reactivity was spatially heterogeneous within the brain. rCBF seems to augment in the brain region roughly close to the bleed and to be reduced in the rest of the brain, with a rough plane of symmetry. Conclusions In good-grade SAH, LP releases headaches and lowers ICP. LP and the drop in ICP have a heterogeneous and biphasic effect on rCBF, suggesting that cerebrovascular reactivity is not spatially homogeneous within the brain.
Schmidt, Eric A.; Silva, Stein; Albucher, Jean Francois; Luzi, Aymeric; Loubinoux, Isabelle; Januel, Anne Christine; Cognard, Christophe; Payoux, Pierre; Chollet, Francois
Objective: TNF-? is an inflammatory cytokine that plays a central role in promoting the cascade of events leading to an inflammatory response. Recent studies have suggested that TNF-? may play a key role in the formation and rupture of cerebral aneurysms, and that the underlying cerebral inflammatory response is a major determinate of outcome following subrarachnoid hemorrhage (SAH). Methods: We studied 14 comatose SAH patients who underwent multimodality neuromonitoring with intracranial pressure (ICP) and cerebral microdialysis as part of their clinical care. Continuous physiological variables were time-locked every 8 hours and recorded at the same point that brain interstitial fluid TNF-? was measured in brain microdialysis samples. Significant associations were determined using generalized estimation equations. Results: Each patient had a mean of 9 brain tissue TNF-? measurements obtained over an average of 72 hours of monitoring. TNF-? levels rose progressively over time. Predictors of elevated brain interstitial TNF-? included higher brain interstitial fluid glucose levels (?=0.066, P<0.02), intraventricular hemorrhage (?=0.085, P<0.021), and aneurysm size >6 mm (?=0.14, p<0.001). There was no relationship between TNF-? levels and the burden of cisternal SAH; concurrent measurements of serum glucose, or lactate-pyruvate ratio. Interpretation: Brain interstitial TNF-? levels are elevated after SAH, and are associated with large aneurysm size, the burden of intraventricular blood, and elevation brain interstitial glucose levels.
Hanafy, Khalid A.; Grobelny, Bartosz; Fernandez, Luis; Kurtz, Pedro; Connolly, ES; Mayer, Stephan A.; Schindler, Christian; Badjatia, Neeraj
Background: This report provides a rare documentation of spontaneous thrombosis of a ruptured aneurysm followed by delayed recanalization and subsequent rerupture. Case Description: A 47-year-old female presented with spontaneous subarachnoid hemorrhage (SAH). Four aneurysms were identified on CT angiogram including a basilar apex aneurysm, considered source of bleeding. Cerebral angiogram on postbleed day (PBD) #1 showed spontaneous thrombosis of basilar apex aneurysm. The patient was discharged to a nursing home on PBD #18 after two subsequent studies showed no recanalization of the basilar aneurysm. The patient returned on PBD #26 with a second episode of spontaneous SAH. The previously thrombosed basilar aneurysm had recanalized and reruptured, which was now treated with coil embolization. Conclusion: We are not aware of a previous report of saccular cerebral aneurysm documenting spontaneous thrombosis after SAH and recanalization with second hemorrhage. This occurrence presents a dilemma regarding the timing and frequency of subsequent cerebrovascular imaging and treatment.
Chohan, Muhammad Omar; Westhout, Franklin D.; Taylor, Christopher L.
The Quality of Life after Brain Injury Overall Scale (QOLIBRI-OS) is a recently developed instrument that provides a brief summary measure of health-related quality of life (HRQoL) in domains typically affected by brain injury. This study examined the application of the six item QOLIBRI-OS in patients after aneurysmal subarachnoid hemorrhage (aSAH). Hong Kong Chinese aSAH patients were evaluated prospectively within the chronic phase of 1 year after aSAH in this multi-center observational study. Cronbach's ? was 0.88, and correlations were satisfactory for all six items. QOLIBRI-OS demonstrated good criterion validity with other 1 year outcome assessments. In conclusion, QOLIBRI-OS can be used as a brief index for disease-specific HRQoL assessment after aSAH. Further validation in another population of aSAH patients is recommended. PMID:24373816
Wong, George Kwok Chu; Lam, Sandy Wai; Ngai, Karine; Wong, Adrian; Mok, Vincent; Poon, Wai Sang
We report findings from an autopsy of a male in his 40s who died of a brain stem hemorrhage associated with cerebral amyloid angiopathy (CAA), senile plaques (SPs) and neurofibrillary tangles (NFTs), which are histopathological changes associated with Alzheimer's disease (AD). Our immunohistochemical study demonstrated amyloid ? (A?) deposition in the small cerebral arteries and SPs. Although hypertension (178/132 mmHg) was detected, the subject was not treated accordingly. CAA coupled with hypertension might have caused the intracerebral hemorrhage (ICH). PMID:24491518
Ohtani, Seiji; Shimizu, Keiko; Asari, Masaru; Maseda, Chikatoshi; Oka, Kumiko; Yamada, Hiromi; Hoshina, Chisato; Doi, Hiroki; Yajima, Daisuke; Shiono, Hiroshi; Ogawa, Katsuhiro
\\u000a \\u000a Objective: The incidence of subarachnoid hemorrhage (SAH) in the young is increasing recently. Among the young patients, some of them\\u000a do not have detectable aneurysms, so the cause of the disease may be non-aneurysmal. In this study, we analyzed some clinical\\u000a cases of subarachnoid hemorrhage in young adults and discussed the possible causes other than present aneurysm and arteriovenous\\u000a malformation
Tianzhu Wang; John H. Zhang; Xinyue Qin
Meningitis due to non-typhi salmonella is infrequent in HIV-positive adults.We report a case of a patient with >300 CD4+ cells/mm3 who presented with five episodes of recurrent meningitis, focal subarachnoid hemorrhage and cerebral vasculitis ultimately attributed to Salmonella choleraesuis infection. Even within the cART era invasive salmonellosis can occur in unusual ways in HIV-infected patients. PMID:21772932
Belloso, Waldo H; Romano, Marina; Greco, Graciela S; Davey, Richard T; Perelsztein, Ariel G; Sánchez, Marisa L; Ajzenszlos, Martín R; Otegui, Inés M
Magnesium offers theoretic vascular and neuroprotective benefits for patients with subarachnoid hemorrhage. An electronic\\u000a literature search was conducted to identify original research studies describing intravenous magnesium treatment in patients\\u000a with SAH published in English between January 1990 and October 2010. Seventeen articles were identified and reviewed, including\\u000a one phase III randomized-controlled clinical trial and six phase II randomized-controlled trials. Study
Jose I. Suarez; Daryl Gress; J. Claude Hemphill; Brian Hoh; Giuseppe Lanzino; David Menon; Alejandro Rabinstein; Lori Shutter; Nino Stocchetti; Mervyn Vergouwen; Paul Vespa; Gregory J. Zipfel
Autophagy is a self-degradative process and it plays a housekeeping role in removing misfolded or aggregated proteins, clearing\\u000a damaged organelles, and eliminating intracellular pathogens. Previous studies have demonstrated that autophagy pathway was\\u000a activated in brain after experimental subarachnoid hemorrhage (SAH); however, the role of autophagy in the pathogenesis of\\u000a early brain injury (EBI) following SAH remains unknown. Experiment 1 aimed to
Zhong Wang; Xiao-Yong Shi; Jia Yin; Gang Zuo; Jian Zhang; Gang Chen
Background: Cortical deafness is a rare symptom that is associated with bilateral lesions of the auditory cortex. To date, cortical deafness has been reported in only three cases of subarachnoid hemorrhage (SAH). Case Description: This 55-year-old female was admitted to our hospital with SAH caused by a ruptured left internal carotid artery (ICA) paraclinoid aneurysm. Computed tomography (CT) scans showed diffuse thick SAH with no other lesions such as an old infarction or hemorrhage. Emergent stent-assisted coil embolization was performed successfully and subsequent cisternal irrigation with urokinase almost completely washed out the thick SAH. During follow-up, she was alert and without any neurological deficits, however, she developed acute bilateral deafness on day 7 even though she had no history of hearing impairment. Because of the deafness, verbal communication was difficult. She became almost completely unable to hear and communication was confined to writing. Immediate diffusion-weighted (DW) image showed high intensities in bilateral superior temporal gyri due to severe vasospasm of bilateral middle cerebral arteries (MCAs). Immediate angiography showed severe vasospasm especially right MCA. A microcatheter was advanced to the right M1 and papaverine was administered. Soon after that, her hearing impairment dramatically improved. Our simple audiometry showed a hearing threshold average for both 1000 and 4000 Hz at 25 dB in both ears. She was discharged without any deficits in 2 weeks. Conclusions: To our knowledge, this is the first reported case of pure cortical deafness due to bilateral vasospasm, which was immediately resolved by intraarterial administration of papaverine.
Asakuno, Keizoh; Ishida, Atsushi
Introduction Outcome is poor in aneurysmal subarachnoid hemorrhage (SAH) patients with intracranial hypertension. As one treatment option\\u000a for increased intracranial pressure (ICP), decompressive craniectomy (DC) is discussed. Its impact on cerebral metabolism\\u000a and outcome in SAH patients is evaluated in this pilot study.\\u000a \\u000a \\u000a \\u000a Methods A prospectively collected database of cerebral metabolism in SAH patients was analyzed retrospectively for individuals developing\\u000a high ICP
Alexandra Nagel; Daniela Graetz; Peter Vajkoczy; Asita S. Sarrafzadeh
Introduction Predicting outcome in patients with poor-grade subarachnoid hemorrhage (SAH) may help guide therapy and assist in family discussions.\\u000a The objective of this study was to determine if continuous electroencephalogram (cEEG) monitoring results are predictive of\\u000a 3-month outcome in critically ill patients with SAH.\\u000a \\u000a \\u000a \\u000a Methods We prospectively studied 756 patients with SAH over a 7-year period. Functional outcome was assessed at 3
Jan Claassen; Lawrence J. Hirsch; Jennifer A. Frontera; Andres Fernandez; Michael Schmidt; Gregory Kapinos; John Wittman; E. Sander Connolly; Ronald G. Emerson; Stephan A. Mayer
Early brain injury (EBI) after subarachnoid hemorrhage (SAH) is characterized by a severe, cerebral perfusion pressure (CPP)-independent reduction in cerebral blood flow suggesting alterations on the level of cerebral microvessels. Therefore, we aimed to use in-vivo imaging to investigate the cerebral microcirculation after experimental SAH. Subarachnoid hemorrhage was induced in C57/BL6 mice by endovascular perforation. Pial arterioles and venules (10 to 80??m diameter) were examined using in-vivo fluorescence microscopy, 3, 6, and 72?hours after SAH. Venular diameter or flow was not affected by SAH, while >70% of arterioles constricted by 22% to 33% up to 3 days after hemorrhage (P<0.05 versus sham). The smaller the investigated arterioles, the more pronounced the constriction (r2=0.92, P<0.04). Approximately 30% of constricted arterioles were occluded by microthrombi and the frequency of arteriolar microthrombosis correlated with the degree of constriction (r2=0.93, P<0.03). The current study demonstrates that SAH induces microarterial constrictions and microthrombosis in vivo. These findings may explain the early CPP-independent decrease in cerebral blood flow after SAH and may therefore serve as novel targets for the treatment of early perfusion deficits after SAH.
Friedrich, Benjamin; Muller, Frank; Feiler, Sergej; Scholler, Karsten; Plesnila, Nikolaus
Objective: To assess long-term, cause-specific mortality rates and rate ratios of the patients alive at 1 year after subarachnoid hemorrhage (SAH). Methods: The population-based, prospective, cohort study with a nested case-control design consisted of 64,349 persons (aged 25–74 years at enrollment) who participated in the National FINRISK Study between 1972 and 2007. Four hundred thirty-seven SAH cases, 233 one-year SAH survivors, and their matched intrinsic controls were identified and followed up until the end of 2009 through the nationwide Finnish Causes of Death Register. All-cause mortality rates and rate ratios of the 1-year SAH survivors and controls were the main outcome measures. Results: Eighty-eight (37.8%) of 233 one-year SAH survivors died during the total follow-up time of 2,487 person-years (median 8.6 years, range 0.1–35.8 years). The 1-year SAH survivors had a hazard ratio of 1.96 (95% confidence interval 1.57–2.47) for death compared with the matched general population with 10 controls for each SAH survivor. One-year SAH survivors had up to 31 additional deaths per 1,000 person-years compared with controls with minimal cerebrovascular risk factors. The higher long-term risk of death among SAH survivors was attributed solely to cerebrovascular diseases, and most important modifiable risk factors for death were smoking, high systolic blood pressure (?159 mm Hg), and high cholesterol levels (?7.07 mmol/L). Conclusion: One-year SAH survivors have excess mortality, which is attributed to an exceptional risk of deadly cerebrovascular events. Aggressive post-SAH cerebrovascular risk factor intervention strategies are highly warranted.
Silventoinen, Karri; Laatikainen, Tiina; Jousilahti, Pekka; Salomaa, Veikko; Kaprio, Jaakko
Background and Purpose Subarachnoid hemorrhage (SAH) can leave patients with memory impairments that may not recover fully. Molecular mechanisms are poorly understood, and no treatment is available. The sulfonylurea receptor 1–transient receptor potential melastatin 4 (Sur1-Trpm4) channel plays an important role in acute central nervous system injury. We evaluated upregulation of Sur1-Trpm4 in humans with SAH and, in rat models of SAH, we examined Sur1- Trpm4 upregulation, its role in barrier dysfunction and neuroinflammation, and its consequences on spatial learning. Methods We used Förster resonance energy transfer to detect coassociated Sur1 and Trpm4 in human autopsy brains with SAH. We studied rat models of SAH involving filament puncture of the internal carotid artery or injection of blood into the subarachnoid space of the entorhinal cortex. In rats, we used Förster resonance energy transfer and coimmunoprecipitation to detect coassociated Sur1 and Trpm4, we measured immunoglobulin G extravasation and tumor necrosis ? overexpression as measures of barrier dysfunction and neuroinflammation, and we assessed spatial learning and memory on days 7 to 19. Results Sur1-Trpm4 channels were upregulated in humans and rats with SAH. In rats, inhibiting Sur1 using antisense or the selective Sur1 inhibitor glibenclamide reduced SAH-induced immunoglobulin G extravasation and tumor necrosis ? overexpression. In models with entorhinal SAH, rats treated with glibenclamide for 7 days after SAH exhibited better platform search strategies and better performance on incremental and rapid spatial learning than vehicle-treated controls. Conclusions Sur1-Trpm4 channels are upregulated in humans and rats with SAH. Channel inhibition with glibenclamide may reduce neuroinflammation and the severity of cognitive deficits after SAH.
Tosun, Cigdem; Kurland, David B.; Mehta, Rupal; Castellani, Rudy J.; deJong, Joyce L.; Kwon, Min Seong; Woo, Seung Kyoon; Gerzanich, Volodymyr; Simard, J. Marc
Background and Purpose. The vasoconstrictor endothelin-1 (ET-1) has been implicated in the pathogenesis of cerebral vasospasm following subarachnoid hemorrhage (SAH). Previous results showed that CGS 26303, an endothelin converting enzyme (ECE) inhibitor, effectively prevented and reversed arterial narrowing in animal models of SAH. In the present study, we assessed the effect of CGS 26303 on neurological deficits in SAH rats. The involvement of vasoactive pathways downstream of ET-1 signaling in SAH was also investigated. Methods. Sprague-Dawley rats were divided into five groups (n = 6/group): (1) normal control, (2) SAH, (3) SAH+vehicle, (4) SAH+CGS 26303 (prevention), and (5) SAH+CGS 26303 (reversal). SAH was induced by injecting autologous blood into cisterna magna. CGS 26303 (10?mg/kg) was injected intravenously at 1 and 24?hr after the initiation of SAH in the prevention and reversal protocols, respectively. Behavioral changes were assessed at 48?hr after SAH. Protein expression was analyzed by Western blots. Results. Deficits in motor function were obvious in the SAH rats, and CGS 26303 significantly improved the rate of paraplegia. Expressions of rho-kinase-II and membrane-bound protein kinase C-? and rhoA were significantly increased, while those of soluble guanylyl cyclase ?1 and ?1 as well as protein kinase G were significantly decreased in the basilar artery of SAH rats. Treatment with CGS 26303 nearly normalized these effects. Conclusions. These results demonstrate that the rhoA/rho-kinase and sGC/cGMP/PKG pathways play pivotal roles in cerebral vasospasm after SAH. It also shows that ECE inhibition is an effective strategy for the treatment of this disease.
Wang, Chih-Jen; Lee, Pei-Yu; Wu, Bin-Nan; Wu, Shu-Chuan; Loh, Joon-Khim; Tsai, Hung-Pei; Kassell, Neal F.; Kwan, Aij-Lie
Tert-butylhydroquinone (tBHQ), an Nrf2 activator, has demonstrated neuroprotection against brain trauma and ischemic stroke in vivo. However, little work has been done with respect to its effect on early brain injury (EBI) after subarachnoid hemorrhage (SAH). At the same time, as an oral medication, it may have extensive clinical applications for the treatment of SAH-induced cognitive dysfunction. This study was undertaken to evaluate the influence of tBHQ on EBI, secondary deficits of learning and memory, and the Keap1/Nrf2/ARE pathway in a rat SAH model. SD rats were divided into four groups: (1) Control group (n?=?40); (2) SAH group (n?=?40); (3) SAH+vehicle group (n?=?40); and (4) SAH+tBHQ group (n?=?40). All SAH animals were subjected to injection of autologous blood into the prechiasmatic cistern once in 20 s. In SAH+tBHQ group, tBHQ was administered via oral gavage at a dose of 12.5 mg/kg at 2 h, 12 h, 24 h, and 36 h after SAH. In the first set of experiments, brain samples were extracted and evaluated 48 h after SAH. In the second set of experiments, changes in cognition and memory were investigated in a Morris water maze. Results shows that administration of tBHQ after SAH significantly ameliorated EBI-related problems, such as brain edema, blood-brain barrier (BBB) impairment, clinical behavior deficits, cortical apoptosis, and neurodegeneration. Learning deficits induced by SAH was markedly alleviated after tBHQ therapy. Treatment with tBHQ markedly up-regulated the expression of Keap1, Nrf2, HO-1, NQO1, and GST?1 after SAH. In conclusion, the administration of tBHQ abated the development of EBI and cognitive dysfunction in this SAH model. Its action was probably mediated by activation of the Keap1/Nrf2/ARE pathway.
Wu, Lingyun; Qiu, Jiaoxue; Li, Qi; Shao, Zhong; Chen, Gang
Tert-butylhydroquinone (tBHQ), an Nrf2 activator, has demonstrated neuroprotection against brain trauma and ischemic stroke in vivo. However, little work has been done with respect to its effect on early brain injury (EBI) after subarachnoid hemorrhage (SAH). At the same time, as an oral medication, it may have extensive clinical applications for the treatment of SAH-induced cognitive dysfunction. This study was undertaken to evaluate the influence of tBHQ on EBI, secondary deficits of learning and memory, and the Keap1/Nrf2/ARE pathway in a rat SAH model. SD rats were divided into four groups: (1) Control group (n?=?40); (2) SAH group (n?=?40); (3) SAH+vehicle group (n?=?40); and (4) SAH+tBHQ group (n?=?40). All SAH animals were subjected to injection of autologous blood into the prechiasmatic cistern once in 20 s. In SAH+tBHQ group, tBHQ was administered via oral gavage at a dose of 12.5 mg/kg at 2 h, 12 h, 24 h, and 36 h after SAH. In the first set of experiments, brain samples were extracted and evaluated 48 h after SAH. In the second set of experiments, changes in cognition and memory were investigated in a Morris water maze. Results shows that administration of tBHQ after SAH significantly ameliorated EBI-related problems, such as brain edema, blood-brain barrier (BBB) impairment, clinical behavior deficits, cortical apoptosis, and neurodegeneration. Learning deficits induced by SAH was markedly alleviated after tBHQ therapy. Treatment with tBHQ markedly up-regulated the expression of Keap1, Nrf2, HO-1, NQO1, and GST?1 after SAH. In conclusion, the administration of tBHQ abated the development of EBI and cognitive dysfunction in this SAH model. Its action was probably mediated by activation of the Keap1/Nrf2/ARE pathway. PMID:24848277
Wang, Zhong; Ji, Chengyuan; Wu, Lingyun; Qiu, Jiaoxue; Li, Qi; Shao, Zhong; Chen, Gang
Gap junction inhibition has been demonstrated to reverse the vascular contraction that follows experimental subarachnoid hemorrhage. This study hypothesizes that the use of established gap junction inhibitors: octonal and carbenoxolone, to interrupt cell to cell communication will provide neuroprotection against early brain injury after SAH. The filament perforation model of SAH was performed in male Sprague–Dawley rats weighing between 300 and 380g. Octanol (260.46mg or 781.38 mg/kg), carbenoxolone (100 mg/kg), or vehicles were given via intraperitoneal injection 1 hour after SAH. Neurologic deficits and cerebral apoptosis were assessed 24 and 72 hours after SAH. In addition, Western blot analysis was performed to confirm the in vivo inhibition of CNS gap junctions. The administration of octanol and carbenoxolone both failed to attenuate the neurological deficits induced by SAH, and they did not reduce neuronal apoptosis. Additionally, carbenoloxone increased post SAH mortality and exacerbated SAH induced apoptosis. Despites previous studies that show gap junction inhibitors reverse vasospasm following experimental SAH, they failed to improve clinical outcomes or provide neuroprotection in this study.
Ayer, Robert; Chen, Wanqiu; Sugawara, Takashi; Suzuki, Hidenori; Zhang, John H.
Working memory impairments are prevalent among survivors of aneurysmal subarachnoid hemorrhage (SAH), but few studies have examined specifically these impairments. Such an examination is important because working memory processes are vital for daily cognitive functioning. In the current study, patients with SAH and healthy control participants were administered the word-span and alpha-span test - experimental tests of working memory. In the word-span test, participants recalled increasingly longer word-lists, requiring the maintenance of information in mind. In the alpha-span test, participants recalled the word-lists in alphabetical order, requiring both the maintenance and manipulation of information. Patients with SAH were no different from healthy controls on a battery of standard neuropsychological measures or on the word-span test. They were, however, significantly impaired on the alpha-span test, suggesting a deficit in the manipulation components of working memory. That is, impairment resulting from SAH is present when a working memory task requires additional executive processing demands. This deficit in patients with SAH does not appear to be influenced by aneurysm location, suggesting that some of the effects of SAH on cognition are from diffuse rather than focal pathology; however, a larger sample size is needed to reinforce this claim. PMID:23871092
Sheldon, Signy; Macdonald, R Loch; Cusimano, Michael; Spears, Julian; Schweizer, Tom A
Abstract Recent studies have shown that isolated traumatic subarachnoid hemorrhage (tSAH) in the setting of a high Glasgow Coma Scale (GCS) score (13-15) is a relatively less severe finding not likely to require operative neurosurgical intervention. This study sought to provide a more comprehensive assessment of isolated tSAH among patients with any GCS score, and to expand the analysis to examine the potential need for aggressive medical, endovascular, or open surgical interventions in these patients. By undertaking a retrospective review of all patients admitted to our trauma center from 2003-2012, we identified 661 patients with isolated tSAH. Only four patients (0.61%) underwent any sort of aggressive neurosurgical, medical, or endovascular intervention, regardless of GCS score. Most tSAH patients without additional systemic injury were discharged home (68%), including 53% of patients with a GCS score of 3-8. However, older patients were more likely to be discharged to a rehabilitation facility (p<0.01). There were six (1.7%) in-hospital deaths, and five patients of these patients were older than 80 years old. We conclude that isolated tSAH, regardless of admission GCS score, is a less severe intracranial injury that is highly unlikely to require aggressive operative, medical, or endovascular intervention, and is unlikely to be associated with major neurologic morbidity or mortality, except perhaps in elderly patients. Based upon our findings, we argue that impaired consciousness in the setting of isolated tSAH should strongly compel a consideration of non-traumatic factors in the etiology of the altered neurological status. PMID:24224706
Lee, Jonathan J; Segar, David J; Asaad, Wael F
Neuroglobin (Ngb) is a member of the globin superfamily expressed mainly in the nervous system and retina of vertebrates. Accumulated evidence has clearly demonstrated that Ngb has a neuro-protective role enhancing cell viability under hypoxia and other types of oxidative stress. It was suggested that oxidant stress could play an important role in neuronal injury after subarachnoid hemorrhage (SAH). The present study aims to examine the expression of Ngb in the temporal cortex and its cellular localization after SAH. We used a prechiasmatic cistern model of SAH. Ngb expression was examined at 3, 6, 12, 24, 48, and 72 h after SAH by western blot analysis and real-time polymerase chain reaction (PCR). Immunohistochemistry and immunofluorescence were performed to detect the localization of Ngb. Real-time PCR demonstrated that Ngb mRNA levels increased from 3 h after SAH, peaked at 6 h. Western blot showed Ngb protein levels were significantly increased in SAH groups in the temporal cortex and reached the peak at 24 h after SAH. The immunohistochemical staining demonstrated that Ngb was weakly expressed in the cortex in the control group while the enhanced expression of Ngb could be detected in the SAH groups. In addition, immunofluorescence results revealed that the over-expressed Ngb was located in the neuronal and microglia cell cytoplasm. These findings indicated that Ngb might play an important neuro-protective effect after SAH. PMID:24281943
Li, Wei-De; Sun, Qing; Zhang, Xiang-Sheng; Wang, Chun-Xi; Li, Song; Li, Wei; Hang, Chun-Hua
Platelet aggregates are present in parenchymal vessels as early as 10 minutes after experimental subarachnoid hemorrhage (SAH). Structural injury to parenchymal vessel walls and depletion of collagen-IV (the major protein of basal lamina) occur in a similar time frame. Since platelets upon activation release enzymes which can digest collagen-IV, we investigated the topographical relationship between platelet aggregates, endothelium, and basal lamina after SAH produced by endovascular perforation, using triple immunofluorescence and confocal microscopy with deconvolution. The location of platelet aggregates in relation to zymography-detected active collagenase was also examined. As reported previously, most cerebral vessels profiles contained platelets aggregates at 10 minutes after SAH. High-resolution three-dimensional image analysis placed many platelets at the ab-luminal (basal) side of endothelium at 10 minutes, and others either within the vascular basal lamina or in nearby parenchyma. By 24 hours post-hemorrhage, large numbers of platelets had entered the brain parenchyma. The vascular sites of platelet movement were devoid of endothelium and collagen IV. Collagenase activity colocalized with vascular platelet aggregates. Our data demonstrate that parenchymal entry of platelets into brain parenchyma begins within minutes after hemorrhage. Three-dimensional analysis suggests that platelet aggregates initiate or stimulate local disruption of endothelium and destruction of adjacent basal lamina after SAH.
Friedrich, Victor; Flores, Rowena; Muller, Artur; Sehba, Fatima A.
Background Percutaneous endoscopic gastrostomy (PEG) is often performed for alimentation and to prevent weight loss in patients with feeding problems due to central neurologic diseases such as cerebral infarction or intracranial hemorrhage. Although infection at the skin site after PEG placement is a typical late complication of PEG, a ruptured infectious pseudoaneurysm caused massive bleeding adjacent to the tract is rare. Prompt treatment is required to avoid the hemorrhage shock, however surgical ligation is difficult to obtain the arrest of bleeding in damaged skin due to the infection. Case presentation A 70-year-old male was bedridden due a cerebral infarction suffered 1 year previously. APEG was placed because of feeding problems, and a push-type, 20-Fr gastrostomy tube was inserted through the anterior abdominal wall. On day 16 after PEG placement, the patient had massive bleeding from the PEG site due to the rupture of infectious pseudoaneurysm and developed a decreased level of consciousness and hypotension. Treatment by percutaneous direct injection of a mixture of n-butyl-cyanoacrylate (NBCA)-lipiodol was performed and achieved good hemostasis is obtained. Conclusions A rare case of an infectious pseudoaneurysm that developed in the abdominal wall and caused massive bleeding at a PEG placement site was described. Percutaneous injection of a mixture of n-butyl-cyanoacrylate (NBCA)-lipiodol under ultrasound guidance is an effective treatment in this case.
Coxsackievirus A24 variant is, together with enterovirus 70 and adenoviruses, the major etiological agent involved in acute hemorrhagic conjunctivitis outbreaks worldwide. However, the standard virus isolation method followed by serotyping or VP1 region sequencing is time-consuming. A rapid method for the detection of coxsackievirus A24 variant from conjunctival swab specimens would be useful in the context of explosive and extensive outbreaks. A one-step real-time RT-PCR assay based on TaqMan technology was thus developed and assessed on 36 conjunctival swabs from outbreaks of conjunctivitis in Morocco in 2004 due to a coxsackievirus A24 variant and in Corsica in 2006 due to adenovirus type 3, and 83 virus strains including 41 coxsackievirus A24 variant collected in French Guiana and Guadeloupe in 2003, in the Democratic Republic of the Congo in 2003, in Morocco in 2004 and 42 other virus species genetically close or known to be responsible for conjunctivitis. All the conjunctival swabs from coxsackievirus A24 variant related outbreak and the 41 coxsackievirus A24 variant strains were tested positive by the RT-PCR assay within 4h. This novel single-tube real-time RT-PCR assay is sensitive and specific, and consists in a reliable and faster alternative to the viral culture for recent and future acute hemorrhagic conjunctivitis outbreaks caused by coxsackievirus A24 variant. PMID:17328967
Lévêque, Nicolas; Lahlou Amine, Idriss; Tcheng, Remy; Falcon, Delphine; Rivat, Nathalie; Dussart, Philippe; Muyembe, Jean-Jacques; Chomel, Jean-Jacques; Norder, Helene; Eugene, Maxime; Lina, Bruno
A 65-year-old male, who had been diagnosed with melanoma of stage IIB and treated by chemotherapy since 2003 at the Dermatology Department, was referred to our department for liver metastasis of melanoma that had become resistant to chemotherapeutic agents. In 2006, he started receiving hepatic arterial infusion of CDDP. He was admitted to the hospital on an emergency basis for general fatigue the next May. Blood tests revealed anemia and thrombocytopenia. Contrast CT showed aggravation of liver metastasis. Contrast ultrasonography revealed nodular contrast enhancement at the margin of the tumor. On the basis of image findings and blood test results, DIC due to intratumoral hemorrhage was diagnosed. CDDP arterial infusion with DSM resulted in improved DIC, and he was able to be discharged. Taken together, attention has to be paid to the potential for emergency complications of DIC due to liver metastasis of melanoma with intratumoral hemorrhage. Moreover, it was shown that arterial infusion with DSM was effective for liver metastasis of melanoma. PMID:18931594
Takada, Kohichi; Kato, Junji; Kawano, Yutaka; Takahashi, Sho; Hayashi, Tsuyoshi; Ishiwatari, Hirotoshi; Miyanishi, Koji; Takimoto, Rishu; Kobune, Masayoshi; Sagawa, Tamotsu; Sato, Tsutomu; Sato, Yasushi; Yamashita, Toshiharu; Natori, Hiroshi; Niitsu, Yoshiro
Cerebral aneurysm re-rupture following subarachnoid hemorrhage(SAH)is a serious problem that is related with poor outcome. It is generally said that re-rupture occurs within 6 hours of the initial SAH;in the acute stage, strict management is needed even in the period before hospitalization. The aim of this study was to confirm whether patients on isolated islands should be transferred by helicopter > 6 hours after the initial SAH. Here we reviewed 125 cases of SAH in the isolated islands of Nagasaki prefecture between January 2007 and December 2012 who were transferred to Nagasaki Medical Center by helicopter as a result of consultation via TeleStroke(41 men, 84 women;mean age, 65.76 years). Re-rupture was observed in seven patients(5.6%), five of whom were diagnosed with re-rupture in a prior hospital on the isolated island. No patients demonstrated clinical deterioration during transport. Early helicopter transportation under adequate sedation and control of blood pressure within 6 hours is safe, and patients should be transferred as quickly as possible during the day. On the other hand, at night, flight safety must first be considered. Patients in stable clinical condition may be transferred the next day. We should pay special attention to patients with SAH and intracerebral hemorrhage, severe SAH, or vertebral artery dissecting aneurysm because their condition may gradually become more serious even if initially stable. PMID:24920741
Kawahara, Ichiro; Matsunaga, Yuki; Tsutsumi, Keisuke; Takahata, Hideaki; Ono, Tomonori; Toda, Keisuke; Baba, Hiroshi
Despite the many studies about timing for surgery in subarachnoid hemorrhage (SAH), the optimum time is still unclear. The aim of this study was to determine the results of early and late surgery for aneurysmal subarachnoid hemorrhage. In this cross-sectional study we evaluated the results of 70 consecutive surgery for aneurysmal subarachnoid hemorrhage in in Firuzgar hospital from 2005 to 2008. Surgery was performed in 50 cases (71.4%) in early period after SAH (first 4 days) and in 20 cases (28.6%) in at least 7 days after SAH. Statitical analysis was done by SPSS software, using Chi-square and t-test. Mean age of patients was 48.54 ± 13.4 years. 41.4% of patients were male and 58.6% were female. Most (77.2%) of patients had clinical grade I or II. 92.9% of aneurysms were single. Hypertension was the most common associated disease (34.3%). The most common site of aneurysms was anterior communicating artery (41.4%), followed by middle cerebral artery (35.7%). The outcome of surgery was favorable in 70% and unfavorable in 30%. Mortality rate was 24.3%. Outcome was favorable in 66% of early surgeries and 80% of late surgeries. There was no statistically significant difference between early and late surgery in terms of complications and outcome. Mean hospital stay of patients in the early surgery group was significantly lower than late group (16.46 ± 9.36 vs. 22.5 ± 7.97 days; P=0.01). The results of early and late surgery for aneurysmal subarachnoid hemorrhage is similar and decision making for timing of surgery should be based on each patient individual clinical conditions, age, size and site of aneurysm. PMID:21960072
Hashemi, Seyed Mahmoud Ramak; Golchin, Navid; Nejad, Enayatollah Abbas; Noormohamadi, Shabnam
Early brain injury (EBI), following subarachnoid hemorrhage (SAH), comprises blood-brain barrier (BBB) disruption and consequent edema formation. Peripheral leukocytes can infiltrate the injured brain, thereby aggravating BBB leakage and neuroinflammation. Thus, anti-inflammatory pharmacotherapies may ameliorate EBI and provide neuroprotection after SAH. Cannabinoid type 2 receptor (CB2R) agonism has been shown to reduce neuroinflammation; however, the precise protective mechanisms remain to be elucidated. This study aimed to evaluate whether the selective CB2R agonist, JWH133 can ameliorate EBI by reducing brain-infiltrated leukocytes after SAH. Adult male Sprague-Dawley rats were randomly assigned to the following groups: sham-operated, SAH with vehicle, SAH with JWH133 (1.0mg/kg), or SAH with a co-administration of JWH133 and selective CB2R antagonist SR144528 (3.0mg/kg). SAH was induced by endovascular perforation, and JWH133 was administered 1h after surgery. Neurological deficits, brain water content, Evans blue dye extravasation, and Western blot assays were evaluated at 24h after surgery. JWH133 improved neurological scores and reduced brain water content; however, SR144528 reversed these treatment effects. JWH133 reduced Evans blue dye extravasation after SAH. Furthermore, JWH133 treatment significantly increased TGF-?1 expression and prevented an SAH-induced increase in E-selectin and myeloperoxidase. Lastly, SAH resulted in a decreased expression of the tight junction protein zonula occludens-1 (ZO-1); however, JWH133 treatment increased the ZO-1 expression. We suggest that CB2R stimulation attenuates neurological outcome and brain edema, by suppressing leukocyte infiltration into the brain through TGF-?1 up-regulation and E-selectin reduction, resulting in protection of the BBB after SAH. PMID:24819918
Fujii, Mutsumi; Sherchan, Prativa; Krafft, Paul R; Rolland, William B; Soejima, Yoshiteru; Zhang, John H
Subarachnoid hemorrhage (SAH) causes widespread disruption in the cerebral architecture.The process of SAH is complicated and many people lose their lives or become disabled after injury. Mesenchymal stem cells (MSCs) are considered as good candidate for repair of cerebral damage. The aim was to assess the ultrastructural changes in the rat cerebral tissue after intravenous transplantation of MSCs. Female Wistar rats (8 per group) weighing 275~300 g were assigned to control (SAH+PBS) and experimental groups (SAH+MSCs).The samples from middle cerebral arterial wall and parietal cerebral tissue were prepared for transmission electron microscopy (TEM) according to standard protocol. Fine architectures of the vessel wall, including the contraction of the inner layer, smooth muscle layer,as well as neural cells were observed after SAH. Cerebral arterial wall and cortex, including neuronal and glial cells were injured post SAH. But, administration of MSCs improved the structural integrity of cerebral tissues. Changes were much more balanced with their relative improvement in some areas. The role of MSCs for repairing the injured cerebral tissues post experimental SAH was approved by electron microscopy. PMID:24737942
Khalili, Mohammad Ali; Sadeghian-Nodoushan, Fatemeh; Fesahat, Farzaneh; Mir-Esmaeili, Seyed Mohsen; Anvari, Morteza; Hekmati-Moghadam, Seyed Hossain
The role of tenascin-C (TNC), a matricellular protein, in brain injury is unknown. The aim of this study was to examine if TNC causes neuronal apoptosis after subarachnoid hemorrhage (SAH), a deadly cerebrovascular disorder, using imatinib mesylate (a selective inhibitor of platelet-derived growth factor receptor [PDGFR] that is reported to suppress TNC induction) and recombinant TNC. SAH by endovascular perforation caused caspase-dependent neuronal apoptosis in the cerebral cortex irrespective of cerebral vasospasm development at 24 and 72 h post-SAH, associated with PDGFR activation, mitogen-activated protein kinases (MAPKs) activation, and TNC induction in rats. PDGFR inactivation by an intraperitoneal injection of imatinib mesylate prevented neuronal apoptosis, as well as MAPKs activation and TNC induction in the cerebral cortex at 24 h. A cisternal injection of recombinant TNC reactivated MAPKs and abolished anti-apoptotic effects of imatinib mesylate. The TNC injection also induced TNC itself in SAH brain, which may internally augment neuronal apoptosis after SAH. These findings suggest that TNC upregulation by PDGFR activation causes neuronal apoptosis via MAPK activation, and that the positive feedback mechanisms may exist to augment neuronal apoptosis after SAH. TNC-induced neuronal apoptosis would be a new target to improve outcome after SAH. PMID:24481545
Shiba, Masato; Fujimoto, Masashi; Imanaka-Yoshida, Kyoko; Yoshida, Toshimichi; Taki, Waro; Suzuki, Hidenori
Nuclear factor erythroid 2-related factor 2 (Nrf2) is a key endogenous protective regulator in the body. This study aimed to explore the role of Nrf2 in subarachnoid hemorrhage (SAH)-induced secondary complications. Wild type (WT) and Nrf2 knockout (KO) mice were subjected to experimental SAH by injecting fresh autologous blood into pre-chiasmatic cistern. The absence of Nrf2 function in mice resulted in exacerbated brain injury with increased brain edema, blood-brain barrier (BBB) disruption, neural apoptosis, and severe neurological deficits at 24h after SAH. Moreover, cerebral vasospasm was severe at 24h after SAH, but not significantly different between WT and Nrf2 KO mice after SAH. Meanwhile, Molondialdehyde (MDA) was increased and GSH/GSSG ratio was decreased in Nrf2 KO mice after SAH. Furthermore, higher expression of TNF-? and IL-1? was also found after SAH in Nrf2 KO mice. In conclusion, our results revealed that Nrf2 plays an important role in attenuating SAH-induced secondary complications by regulating excessive oxidative stress and inflammatory response. PMID:24576487
Li, Tao; Wang, Handong; Ding, Yu; Zhou, Mengliang; Zhou, Xiaoming; Zhang, Xiangshen; Ding, Ke; He, Jin; Lu, Xinyu; Xu, Jianguo; Wei, Wuting
Background and Purpose To prospectively evaluate the diagnostic accuracy of CT perfusion (CTP) and determine a quantitative threshold for delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (SAH). Methods SAH patients were prospectively enrolled in an IRB approved protocol. CTP was performed during the typical time-period for DCI, between days 6–8 following SAH. Quantitative cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) values were obtained using standard region-of-interest placement sampling gray matter. The reference standard for DCI is controversial and consisted of clinical and imaging criteria in this study. In a subanalysis of vasospasm, digital subtraction angiography was used as the reference standard. Receiver operating characteristic curves determined diagnostic accuracy using area under the curve. Optimal threshold values were calculated using patient population utility method. Results Ninety-seven patients were included; 41% (40/97) had DCI. Overall diagnostic accuracy was 93% CBF, 88% MTT and 72% CBV. Optimal threshold values were 35mL/100gm/min (90% sensitivity,68% specificity) for CBF and 5.5sec (73% sensitivity,79% specificity) for MTT. In the subanalysis (n=57), 63% (36/57) had vasospasm. Overall diagnostic accuracy was 94% CBF, 85% MTT and 72% CBV. Optimal threshold values were 36.5 mL/100gm/min (95% sensitivity,70% specificity) for CBF and 5.4 sec (78% sensitivity,70% specificity) for MTT. Conclusion CBF and MTT have the highest overall diagnostic accuracy. Threshold values of 35mL/100gm/min CBF and 5.5sec MTT are suggested for DCI based on patient population utility method. Absolute threshold values may not be generalizable due to differences in scanner equipment and post-processing methods.
Sanelli, Pina C.; Ugorec, Igor; Johnson, Carl E.; Tan, Jessica; Segal, Alan Z.; Fink, Matthew; Heier, Linda A.; Tsiouris, Apostolos J.; Comunale, Joseph P.; John, Majnu; Stieg, Philip E.; Zimmerman, Robert D.; Mushlin, Alvin I.
This paper describes the angiographic findings of spontaneous aneurysmal subarachnoid hemorrhage (SAH) patients, including frequency, anatomic location and multiplicity of cerebral aneurysms. We retrospectively reviewed the records of 796 SAH patients at our university affiliated hospital. After confirming SAH by lumbar puncture or CT scan, all patients underwent digital subtraction angiography to find the definite anatomic location. The male to Female ratio in SAH patients was 9:10. The mean (SD) age of all patients with SAH was 47.9±14.7 years. The mean (SD) age of men with SAH was 46.6 ±15.6 years and women with SAH was 49.3±13.5 years (P=0.015). 357 (44.8%) patients had aneurysms. The mean (SD) age of aneurysmal patients was 49.8±14.3 years. The mean (SD) age of men with aneurysm was 47.8 ±15.9 years and women with aneurysm was 51.3±12.9 years (P= 0.03). The male to female ratio in aneurysms was 0.72:1. The most common aneurysm location was in the anterior communicating artery (N=166, 39%). The second most common anatomic location was the middle cerebral artery bifurcation (66 left, 60 right). The total number of patients with single aneurysms was 303 (84.9%) while 54 (15.1%) patients had multiple aneurysms. Among these patients, 49 had two aneurysms, three had three aneurysms and two had four aneurysms. In all, 418 aneurysms were detected. Of 357 patients with aneurysms 150 (42%) had vasospasm during angiography. In conclusion, the most common aneurysm location was the anterior communicating artery and the rate of multiplicity was also higher in our patients. PMID:24148598
Firouznia, K; Ghanaati, H; Rahmat Sadeghi, S; Shakiba, M; Jalali, A H
Diagnosis of sleep apnea hypopnoea syndrome (SAHS) depends on the apnea-hypopnea index determined by the standard in-laboratory overnight polysomnography (PSG). PSG is a costly, labor intensive and, at times, inaccessible approach. Because of the high demand, the need for timely diagnosis and the associated costs, novel methods for SAHS detection are required. In this study, a novel multivariate system is proposed for SAHS detection from the analysis of overnight blood oxygen saturation (SpO2). 115 subjects with SAHS suspicion were studied. A starting set of 17 time domain, stochastic, frequency-domain and nonlinear features were initially computed from SpO2 recordings. Sequential forward feature selection and a probabilistic neural network with leave-one-out cross-validation were applied. Oxygen desaturations below a 4 % threshold within 30 s (ODI430), restorations of 4 % within 10 s (RES4), median value (Sat50), SD1 Poincaré descriptor and the relative power in the 0.013-0.067 Hz frequency band (PSD15/75) formed the optimum features subset. 92.4 % sensitivity and 95.9 % specificity were achieved. Results significantly outperformed the univariate and multivariate approaches reported in literature. The outcome is a simple cost-effective tool that could be used as an alternative or supplementary method in a domiciliary approach to early diagnosis of SAHS. PMID:23160897
Morillo, Daniel Sánchez; Gross, Nicole
Aneurysmal subarachnoid hemorrhage (SAH) is a neurologic emergency caused by a brain aneurysm burst, resulting in a bleeding into the subarachnoid space. Its incidence is estimated between 4 and 28/10,000 inhabitants and it is the main cause of sudden death from stroke. The prognosis of patients with SAH is directly related to neurological status on admission, to the magnitude of the initial bleeding, as well as to the development of cerebral vasospasm (CVS). Numerous researchers have studied the role of different biomarkers in CVS development. These biomarkers form part of the metabolic cascade that is triggered as a result of the SAH. Hence, among these metabolites we found biomarkers of oxidative stress, inflammation biomarkers, indicators of brain damage, and markers of vascular pathology. However, to the author knowledge, none of these biomarkers has been demonstrated as a useful tool for predicting neither CVS development nor outcome after SAH. In order to reach success on future researches, firstly it should be stated which pathophysiological process is mainly responsible for CVS development. Once this process has been determined, the temporal course of this pathophysiologic cascade should be characterized, and then, perform further studies on biomarkers already analyzed, as well as on new biomarkers not yet studied in the SAH pathology, focusing attention on the temporal course of the diverse metabolites and the sampling time for its quantification. PMID:24811975
Rodríguez-Rodríguez, Ana; Egea-Guerrero, Juan José; Ruiz de Azúa-López, Zaida; Murillo-Cabezas, Francisco
Aneurysmal subarachnoid hemorrhage (SAH) has devastating consequences on brain function including profound effects on communication between neurons and the vasculature leading to cerebral ischemia. Physiologically, neurovascular coupling represents a focal increase in cerebral blood flow to meet increased metabolic demand of neurons within active regions of the brain. Neurovascular coupling is an ongoing process involving coordinated activity of the neurovascular unit—neurons, astrocytes, and parenchymal arterioles. Neuronal activity can also influence cerebral blood flow on a larger scale. Spreading depolarizations (SD) are self-propagating waves of neuronal depolarization and are observed during migraine, traumatic brain injury, and stroke. Typically, SD is associated with increased cerebral blood flow. Emerging evidence indicates that SAH causes inversion of neurovascular communication on both the local and global level. In contrast to other events causing SD, SAH-induced SD decreases rather than increases cerebral blood flow. Further, at the level of the neurovascular unit, SAH causes an inversion of neurovascular coupling from vasodilation to vasoconstriction. Global ischemia can also adversely affect the neurovascular response. Here, we summarize current knowledge regarding the impact of SAH and global ischemia on neurovascular communication. A mechanistic understanding of these events should provide novel strategies to treat these neurovascular disorders.
Koide, Masayo; Sukhotinsky, Inna; Ayata, Cenk; Wellman, George C.
Introduction Vasospastic brain infarction is a devastating complication of aneurysmal subarachnoid hemorrhage (SAH). Using a probe for invasive monitoring of brain tissue oxygenation or blood flow is highly focal and may miss the site of cerebral vasospasm (CVS). Probe placement is based on the assumption that the spasm will occur either at the dependent vessel territory of the parent artery of the ruptured aneurysm or at the artery exposed to the focal thick blood clot. We investigated the likelihood of a focal monitoring sensor being placed in vasospasm or infarction territory on a hypothetical basis. Methods From our database we retrospectively selected consecutive SAH patients with angiographically proven (day 7–14) severe CVS (narrowing of vessel lumen >50%). Depending on the aneurysm location we applied a standard protocol of probe placement to detect the most probable site of severe CVS or infarction. We analyzed whether the placement was congruent with existing CVS/infarction. Results We analyzed 100 patients after SAH caused by aneurysms located in the following locations: MCA (n?=?14), ICA (n?=?30), A1CA (n?=?4), AcoA or A2CA (n?=?33), and VBA (n?=?19). Sensor location corresponded with CVS territory in 93% of MCA, 87% of ICA, 76% of AcoA or A2CA, but only 50% of A1CA and 42% of VBA aneurysms. The focal probe was located inside the infarction territory in 95% of ICA, 89% of MCA, 78% of ACoA or A2CA, 50% of A1CA and 23% of VBA aneurysms. Conclusion The probability that a single focal probe will be situated in the territory of severe CVS and infarction varies. It seems to be reasonably accurate for MCA and ICA aneurysms, but not for ACA or VBA aneurysms.
Ulrich, Christian T.; Fung, Christian; Vatter, Hartmut; Setzer, Matthias; Gueresir, Erdem; Seifert, Volker; Beck, Juergen; Raabe, Andreas
Apolipoprotein E (apoE), the major apolipoprotein in the central nervous system, has been shown to influence neurologic disease progression and response to neurologic injury in a gene-specific manner. Presence of the APOE4 allele is associated with poorer response to traumatic brain injury and ischemic stroke, but the association between APOE genotype and outcome following aneurysmal subarachnoid hemorrhage (SAH) remains unclear. The purpose of this project was to investigate the association between APOE genotype and outcome after SAH. We also explored the association of APOE4 genotype and cerebral vasospasm (CV) presence in a subsample of our population with available angiographic data. A sample of 206 aneurysmal SAH participants had APOE genotyping performed, Glasgow outcome scores (GOS) and modified Rankin scores (MRS) collected at 3 and 6 months after aneurysm rupture. No significant association was found between the presence of the APOE4 genotype and functional outcomes controlling for age, race, size of hemorrhage (Fisher grade), and severity of injury (Hunt & Hess grade). However when controlling for CV and the covariates listed above, individuals with the APOE4 allele had worse functional outcomes at both time points. The presence of the APOE2 allele was not associated with functional outcomes even when considering presence of CV. There was no difference in mortality associated with APOE4 presence, APOE2 presence, or presence of CV. These findings suggest APOE4 allele is associated with poor outcome after aneurysmal SAH. PMID:19017669
Gallek, Matthew J; Conley, Yvette P; Sherwood, Paula R; Horowitz, Michael B; Kassam, Amin; Alexander, Sheila A
Elevated cerebrospinal fluid (CSF) concentrations of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, have been found in patients with subarachnoid hemorrhage (SAH). In addition, CSF levels of ADMA are associated with the severity of vasospasm. However, the relation between CSF ADMA levels and the clinical outcome of SAH patients is still unclear. We hypothesized that elevated ADMA levels in CSF might be related to the clinical outcome of SAH patients. CSF ADMA levels were measured in 20 SAH patients at days 3-5, days 7-9 and days 12-14 after SAH onset using high-performance liquid chromatography. Cerebral vasospasm was assessed by transcranial Doppler ultra sonography. Clinical outcome at 2year follow-up was evaluated using the Karnofsky Performance Status scale (KPS). CSF ADMA concentrations in all SAH patients were significantly increased at days 3-5 (p=0.002) after SAH, peaked on days 7-9 (p<0.001) and remained elevated until days 12-14 (p<0.001). In subgroup analysis, significant increases of CSF ADMA levels were found in patients both with and without vasospasm. The KPS scores significantly correlated with CSF levels of ADMA at days 7-9 (correlation coefficient=-0.55, p=0.012; 95% confidence interval -0.80 to -0.14). Binary logistic regression analysis indicated that higher ADMA level at days 7-9 predicted a poor clinical outcome at 2year follow-up after SAH (odds ratio=1.722, p=0.039, 95% confidence interval 1.029 to 2.882). ADMA may be directly involved in the pathological process and future adverse prognosis of SAH. PMID:24814854
Li, Hua; Wu, Wei; Liu, Ming; Zhang, Xin; Zhang, Qing-Rong; Ni, Li; Hang, Chun-Hua
Background: Adrenomedullin (AM), a vasorelaxant peptide, is secreted into the cerebrospinal fluid (CSF) from the choroid plexus and can exert natriuretic effects in the kidney. CSF AM concentration is elevated 7–10 days after the onset of aneurysmal subarachnoid hemorrhage (SAH). The aim of the present study was to determine whether CSF AM concentrations correlate with hyponatremia and delayed ischemic neurological
Yoshitaka Kubo; Kuniaki Ogasawara; Shunsuke Kakino; Hiroshi Kashimura; Kenji Yoshida; Akira Ogawa
Background: Outcome prediction for subarachnoid hemorrhage (SAH) helps guide care and compare global management strategies. Logistic regression models for outcome prediction may be cumbersome to apply in clinical practice. Objective: To use machine learning techniques to build a model of outcome prediction that makes the knowledge discovered from the data explicit and communicable to domain experts. Material and methods: A
Paula de Toledo; Pablo M. Rios; Agapito Ledezma; Araceli Sanchís; Jose F. Alen; Alfonso Lagares
Background and Purpose—To determine the frequency and severity of disorders of sleep and wake and their relation to the quality of life (QoL) in patients who have survived an episode of subarachnoid hemorrhage (SAH). Methods—In a prospectively collected, consecutive series of 89 patients, 83 patients completed validated and frequently used questionnaires for the assessment of disorders of sleep and wake
Wouter J. Schuiling; Gabriel J. E. Rinkel; Rob Walchenbach; Al W. de Weerd
Convincing evidence indicates that inflammation contributes to the adverse prognosis of subarachnoid hemorrhage (SAH). Some pro-inflammatory molecules such as high mobility group protein 1, S100 family of proteins, ?-amyloid peptide, and macrophage antigen complex 1 have been involved in the damaging inflammation process following SAH. The receptor for advanced glycation end-products (RAGE) is a transmembrane receptor that senses these molecules and plays central role in inflammatory processes. This study aimed to determine the expression and cell distribution of RAGE in the brain cortex after SAH. Male Sprague-Dawley rats were randomly divided into sham group and SAH groups at 6 h, 12 h and on day 1, day 2 and day 3 (n=6 for each subgroup). SAH groups suffered experimental SAH by injection of 0.3 ml autologous blood into the prechiasmatic cistern. RAGE expression was measured by Western blot, real-time PCR, immunohistochemistry and immunofluorescence. Nuclear expression of p65 protein, the major subunit of nuclear factor kappa B, was also detected. Our data demonstrated that the expression levels of RAGE and nuclear p65 protein were both markedly increased after SAH. Moreover, there was a significant positive correlation between the expression of RAGE and that of p65 protein. Double immunofluorescence staining showed that RAGE was expressed by neuron and microglia rather than astrocyte after SAH. These results suggest that RAGE may be directly involved in the inflammatory response after SAH, and there might be important implications for further studies using specific RAGE antagonists to decrease inflammation-mediated brain injury following SAH. PMID:24291745
Li, Hua; Wu, Wei; Sun, Qing; Liu, Ming; Li, Wei; Zhang, Xiang-sheng; Zhou, Meng-liang; Hang, Chun-hua
This study was undertaken to investigate the preventive or therapeutic effect of hyperbaric oxygen therapy (HBOT) on cerebral vasospasm following experimental subarachnoid hemorrhage (SAH). Twenty rabbits were assigned randomly to one of four groups. Animals in Group I were not subjected to SAH or sham operation (control group, n = 5). Animals in Group II were subjected to sham operation and received no treatment after the procedure (sham group, n = 5). Animals in Group III were subjected to SAH and received no treatment after SAH induction (SAH group, n = 5). Animals in Group IV were subjected to SAH and received five sessions of HBOT at 2.4 atmospheres absolute (ATA) for 2 h (treatment group, n = 5). Animals were euthanized by perfusion and fixation 72 h after procedures. Basilar artery vasospasm indices, arterial wall thicknesses, and cross-sectional luminal areas were evaluated. Statistical comparisons were performed using Kruskal-Wallis and Mann-Whitney U tests. Mean basilar artery vasospasm index in the treatment group was significantly smaller than in the SAH group. Mean basilar artery wall thickness in the treatment group was significantly smaller than in the SAH group. Mean basilar artery cross-sectional luminal area in the treatment group showed an increase relative to the SAH group, but this difference remained statistically insignificant. Our results demonstrated that repeated application of HBOT at 2.4 ATA for 2 h attenuated vasospastic changes such as increased vasospasm index and arterial wall thickness. HBOT is thus a promising candidate for SAH-induced vasospasm. Further studies are needed to evaluate maximal effect and optimal application regimen. PMID:24228831
Celik, Ozgür; Bay, Hüsniye Hac?o?lu; Arslanhan, Ayça; Oro?lu, Bengüsu; Bozkurt, Süheyla Uyar; Sehirli, Umit Süleyman; Ziyal, Mustafa ?brahim
Paroxysmal sympathetic storming (PSS) is a rare disorder characterized by acute onset of nonstimulated tachycardia, hypertension, tachypnea, hyperthermia, external posturing, and diaphoresis. It is most frequently associated with severe traumatic brain injuries and has been reported in intracranial tumors, hydrocephalous, severe hypoxic brain injury, and intracerebral hemorrhage. Although excessive release of catecholamine and therefore increased sympathetic activities have been reported in subarachnoid hemorrhage (SAH), there is no descriptive report of PSS primarily caused by spontaneous SAH up to date. Here, we report a case of prolonged PSS in a patient with spontaneous subarachnoid hemorrhage and consequent vasospasm. The sympathetic storming started shortly after patient was rewarmed from hypothermia protocol and symptoms responded to Labetalol, but intermittent recurrence did not resolve until 3 weeks later with treatment involving Midazolam, Fentanyl, Dexmedetomidine, Propofol, Bromocriptine, and minimizing frequency of neurological and vital checks. In conclusion, prolonged sympathetic storming can also be caused by spontaneous SAH. In this case, vasospasm might be a precipitating factor. Paralytics and hypothermia could mask the manifestations of PSS. The treatment of the refractory case will need both timely adjustment of medications and minimization of exogenous stressors or stimuli. PMID:23476663
Liu, Yan; Jolly, Suneil; Pokala, Krishna
Background Crimean-Congo Hemorrhagic Fever (CCHF) is a fatal infection, but no clinical case due to AP92 strain was reported. We described the first clinical case due to AP92 like CCHFV. Methods A case infected by a AP92 like CCHFV was detected in Balkanian part of Turkey. Diagnosis was confirmed by RT-PCR and sequencing. A human serologic and tick survey studies were performed in the region, where the case detected. Results Thirty eight individuals out of 741 were found to be anti CCHFV IgM positive. The attack rate for overall CCHFV was calculated as 5.2%. In univariate analyses, CCHFV IgM positivity was found to be associated with the age (p < 0.001), male gender (p = 0.001), agricultural activity (p = 0.036), and history of tick bite (p = 0.014). In multivariate analysis, older age (OR: 1.03, CI:1.01–1.05, p < 0.001), male gender were found to be the risk factors (OR: 2.5, CI:1.15–5.63, p = 0.020) for CCHFV infection. Conclusion This is the first human case with AP92 like CCHFV infection. Furthermore, this is the first report of AP92 like strain in Turkey. In the region, elderly males carry the highest risk for CCHFV infection.
We studied the risk factors associated with cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH). The subjects were 370 patients with ruptured aneurysms who fulfilled all of the following criteria: admission by day 2 after onset, operation performed by day 3 by the same surgeon (T.I.), Hunt-Hess grade I-IV, availability of bilateral carotid angiograms acquired by day 2 and repeated between days 7 and 9. The demographic, clinical, radiographic, surgical, laboratory, and electrocardiographic data were analyzed for angiographic vasospasm (AV), symptomatic vasospasm (SV), and cerebral infarction on computed tomography (CT) scan. Both CT-evident SAH and AV were graded as 0-IV. Among the 370 patients, AV grade III-IV, SV, and cerebral infarction occurred in 26%, 24%, and 20%, respectively. Univariate analysis showed that Hunt-Hess grade III-IV, SAH grade III-IV, intracerebral or/and intraventricular hemorrhage, rebleeding, cigarette smoking, hypertension, alcohol intake, leukocytosis, hyperglycemia, and electrocardiographic QTc prolongation, left ventricular hypertrophy (LVH), and ST depression were significantly related to at least one of AV grade III-IV, SV, or cerebral infarction. Multivariate analysis showed that SAH grade III-IV was the most important risk factor for vasospasm followed by LVH on electrocardiogram, cigarette smoking, and hypertension. AV grade III-IV, SV, and cerebral infarction occurred in 57%, 54%, and 39% of the 46 smokers with LVH, and in 43%, 49%, and 35% of the 68 patients who had both LVH and hypertension, respectively. CT-evident SAH, LVH, cigarette smoking, and hypertension are associated with vasospasm. In smokers or hypertensive patients, premorbid LVH appears to predict much more severe vasospasm. PMID:24670311
Inagawa, Tetsuji; Yahara, Kaita; Ohbayashi, Naohiko
Objective To determine the diagnostic value of a ghrelin test in the diagnosis of GH deficiency (GHD) shortly after aneurysmal subarachnoid hemorrhage (SAH). Design Prospective single-center observational cohort study. Methods A ghrelin test was assessed after the acute phase of SAH and a GH-releasing hormone (GHRH)–arginine test 6 months post SAH. Primary outcome was the diagnostic value of a ghrelin test compared with the GHRH–arginine test in the diagnosis of GHD. The secondary outcome was to assess the safety of the ghrelin test, including patients' comfort, adverse events, and idiosyncratic reactions. Results Forty-three survivors of SAH were included (15 males, 35%, mean age 56.6±11.7). Six out of 43 (14%) SAH survivors were diagnosed with GHD by GHRH–arginine test. In GHD subjects, median GH peak during ghrelin test was significantly lower than that of non-GHD subjects (5.4 vs 16.6, P=0.002). Receiver operating characteristics analysis showed an area under the curve of 0.869. A cutoff limit of a GH peak of 15??g/l corresponded with a sensitivity of 100% and a false-positive rate of 40%. No adverse events or idiosyncratic reactions were observed in subjects undergoing a ghrelin test, except for one subject who reported flushing shortly after ghrelin infusion. Conclusion Owing to its convenience, validity, and safety, the ghrelin test might be a valuable GH provocative test, especially in the early phase of SAH.
Blijdorp, K; Khajeh, L; Ribbers, G M; Sneekes, E M; Heijenbrok-Kal, M H; van den Berg-Emons, H J G; van der Lely, A J; van Kooten, F; Neggers, S J C M M
Object. The strategy to treat asymptomatic angiographic vasospasm following subarachnoid hemorrhage (SAH) is controversial. In this study we review our consecutive vasospasm series and discuss an adequate treatment strategy for asymptomatic vasospasm. Methods. From January 2007 to December 2012 we treated 281 aneurysmal SAH cases, with postoperative angiography performed 9?±?2 days after the onset of SAH. Four asymptomatic cases received intra-arterial (IA) injection of vasodilator due to angiographic vasospasm. All cases improved vasospasm immediately following intervention. But all cases turned symptomatic within 48 hours. We retrospectively analyzed the time-density angiography curve and calculated the time to peak (TTP), mean transit time (MTT), and relative blood flow (rBF). Relative blood flow was calculated as follows. The integration of the value of the time-density curve for the artery was divided by the same value for the internal carotid artery multiplied by the MTT. Results. The decrease in TTP and MTT for the etiologic artery was similar to that of the nonetiologic artery. But the improvement in rBF for the etiologic artery and nonetiologic artery was 10% and 17%, respectively. Blood supply to the spastic artery decreased due to iatrogenic steal. Conclusion. Prophylactic IA injection of vasodilator in cases of asymptomatic vasospasm can produce symptomatic vasospasm.
Matsuda, Naoya; Kakuta, Kiyohide; Ohkuma, Hiroki
Three-dimensional volume rendering digital subtraction angiography in comparison with two-dimensional digital subtraction angiography and rotational angiography for detecting aneurysms and their morphological properties in patients with subarachnoid hemorrhage
ObjectiveSubarachnoid hemorrhage (SAH), which can cause mortality and severe morbidity, is a serious condition whose underlying cause must be determined. We aimed to compare 2D digital subtraction angiography (2DDSA), rotational angiography (RA) and 3D volume rendering digital subtraction angiography (3DVRDSA) for detecting aneurysms and their morphological properties in patients with subarachnoid hemorrhage.
Fahrettin Kucukay; R. Sarper Okten; Ayhan Tekiner; Mustafa Dagli; Cevdet Gocek; Mehmet Akif Bayar; Turhan Cumhur
Previous Presentation Portions of this study were presented at the Annual Congress of Société Française d’Anesthésie et de Réanimation in Paris, September 2012. Background Toll-like receptor (TLR) agonists are promising therapy for the prevention of nosocomial infections in critical ill patients. We aimed to analyze the TLR-reactivity of circulating dendritic cells (DC) as assessed by cytokine production after an ex vivo challenge with TLR agonists in aneurysmal subarachnoid hemorrhage (SAH) patients. Methods and Findings A single-center prospective observational study took place in one intensive care unit of a teaching hospital. Blood samples were harvested on days 2, 5 and 10 in 21 severe SAH patients requiring mechanical ventilation and 17 healthy controls. DC production of cytokines (Tumour Necrosis Factor, TNF-?; Interleukin, IL-12; and Interferon, IFN-?) was assessed by intracellular immunostaining on TLR-3, 4, 7/8 and 9 stimulations. SAH patients had decreased numbers of blood myeloid (mDCs) and plasmacytoid DCs (pDCs) on days 2, 5 and 10. Compared with the healthy controls, the frequency of mDCs producing TNF-? after TLR-3 stimulation was decreased in the SAH patients. The frequency of myeloid DCs producing IL-12 after TLR-3 and 4 stimulations was also decreased in the SAH patients. In contrast, the mDCs response to TLR-7/8 was not impaired in the SAH patients. The frequency of pDCs producing TNF-?+ and IFN-?+ on TLR-7/8 stimulation were reduced at all of the tested times in the SAH patients, whereas reactivity to TLR-9 was preserved. On day 2, the pDCs from non-survivor patients (n?=?8) had a decreased ability to produce IFN-? on TLR-9 stimulation compared with the survivors. Conclusions These data suggest functional abnormalities of circulating pDCs and mDCs that could be important for immunomodulation after SAH.
Cinotti, Raphael; Dumonte, Erwan; Motreul, Remi; Josien, Regis; Asehnoune, Karim
The hypothesis that alterations in hormone levels can impact on subarachnoid hemorrhage (SAH) is rapidly gaining momentum. Specifically, the concept that post-menopausal women are more susceptible to the condition has convinced many of the protective roles of estrogen and progesterone. Here we review the mechanisms of their actions and the potential for estrogen and progesterone replacement therapy in subarachnoid hemorrhage. Searches were performed using PubMed with the search terms "subarachnoid hemorrhage", "estrogen", "progesterone "treatment", "management", "cerebral aneurysm", and "vasospasm" from 1970 to February, 2012. Articles were also identified through searches of the Cochrane library and searches of the authors' own files. Only papers published in English were reviewed. In conclusion, there is significant theoretical evidence for the potential role of estrogen and progesterone use in altering the pathogenesis of SAH. Nevertheless, this has received mixed reviews in both case controlled studies and cohort analysis within the literature. PMID:22950381
Young, Adam M H; Karri, Surya K; Ogilvy, Christopher S
Objective Although prophylactic antiepileptic drug (AED) use in patients with aneurysmal subarachnoid hemorrhage (SAH) is a common practice, lack of uniform definitions and guidelines for seizures and AEDs rendered this prescription more habitual instead of evidence-based manner. We herein evaluated the incidence and predictive factors of seizure and complications about AED use. Methods From July 1999 to June 2007, data of a total of 547 patients with aneurysmal SAH who underwent operative treatments were reviewed. For these, the incidence and risk factors of seizures and epilepsy were assessed, in addition to complications of AEDs. Results Eighty-three patients (15.2%) had at least one seizure following SAH. Forty-three patients (7.9%) had onset seizures, 34 (6.2%) had perioperative seizures, and 17 (3.1%) had late epilepsy. Younger age (< 40 years), poor clinical grade, thick hemorrhage, acute hydrocephalus, and rebleeding were related to the occurrence of onset seizures. Cortical infarction and thick hemorrhage were independent risk factors for the occurrence of late epilepsy. Onset seizures were not predictive of late epilepsy. Moreover, adverse drug effects were identified in 128 patients (23.4%) with AEDs. Conclusion Perioperative seizures are not significant predictors for late epilepsy. Instead, initial amount of SAH and surgery-induced cortical damage should be seriously considered as risk factors for late epilepsy. Because AEDs can not prevent early postoperative seizures (< 1 week) and potentially cause unexpected side effects, long-term use should be readjusted in high-risk patients.
Choi, Kyu-Sun; Chun, Hyoung-Joon; Ko, Yong; Kim, Young-Soo; Kim, Jae-Min
To elucidate the putative neuroprotective effects of ghrelin in subarachnoid hemorrhage (SAH)-induced brain injury, Wistar albino rats (n = 54) were divided into sham-operated control, saline-treated SAH, and ghrelin-treated (10 microg/kg/d IP) SAH groups. The rats were injected with blood (0.3 mL) into the cisterna magna to induce SAH, and were sacrificed 48 h after the neurological examination scores were recorded. In plasma samples, neuron-specific enolase (NSE), S-100beta protein, TNF-alpha, and IL-1beta levels were evaluated, while forebrain tissue samples were taken for the measurement of malondialdehyde (MDA), glutathione (GSH), reactive oxygen species levels, myeloperoxidase (MPO), Na(+)-K(+)-ATPase activity, and DNA fragmentation ratio. Brain tissue samples containing the basilar arteries were obtained for histological examination, while cerebrum and cerebellum were removed for the measurement of blood-brain barrier (BBB) permeability and brain water content. The neurological scores were impaired at 48 h after SAH induction, and SAH caused significant decreases in brain GSH content and Na(+)-K(+)-ATPase activity, and increases in chemiluminescence, MDA levels, and MPO activity. Compared with the control group, the protein levels of NSE, S-100beta, TNF-alpha, and IL-1beta in plasma were also increased, while ghrelin treatment prevented all SAH-induced alterations observed both biochemically and histopathologically. The results demonstrate that ghrelin alleviates SAH-induced oxidative brain damage, and exerts neuroprotection by maintaining a balance in oxidant-antioxidant status, by inhibiting proinflammatory mediators, and preventing the depletion of endogenous antioxidants evoked by SAH. PMID:20205513
Er?ahin, Mehmet; Toklu, Hale Z; Erzik, Can; Cetinel, Sule; Akakin, Dilek; Velio?lu-O?ünç, Ayliz; Tetik, Sermin; Ozdemir, Zarife N; Sener, Göksel; Ye?en, Berrak C
Patients with aneurysmal subarachnoid hemorrhage (SAH) are frequently complicated by acute cardiac dysfunctions, including cardiac wall motion abnormality (WMA). Massive release of catecholamine into the systemic circulation after aneurysmal rupture is believed to result in WMA, and poor-grade SAH seems to be the most important risk factor. However, plasma catecholamine levels have rarely been measured in SAH patients with WMA, and previous studies indicated that the elevated levels might not necessarily predict WMA. The objective of this study is (1) to evaluate relationship between WMA and plasma catecholamine levels in poor-grade SAH patients in the acute phase and (2) to clarify clinical characteristics of SAH patients with WMA. Among 142 poor-grade (World Federation of Neurosurgical Societies grades IV and V) SAH patients, 48 underwent both transthoracic ultrasound and measurement of plasma catecholamine levels within 24 h of SAH onset. They were divided into WMA+ (n?=?23) and WMA- (n?=?25) groups, and intergroup comparison was made on demographics, plasma catecholamine levels, and outcomes. Plasma norepinephrine levels were significantly higher in WMA+ group than in WMA- group (2,098.4?±?1,773.4 vs. 962.9?±?838.9 pg/mL, p?=?0.02), and the former showed significantly worse outcomes 90 days after admission. There were no intergroup differences in the plasma levels of epinephrine. Plasma norepinephrine levels were inversely correlated with left ventricular ejection fraction. Multivariate logistic regression analysis revealed that increased plasma norepinephrine levels were predictive of WMA, although age, female sex, and grade V SAH were not. This retrospective study highlights the role of norepinephrine in pathogenesis of SAH-induced WMA. PMID:22936520
Sugimoto, Keiko; Inamasu, Joji; Kato, Yoko; Yamada, Yasuhiro; Ganaha, Tsukasa; Oheda, Motoki; Hattori, Natsuki; Watanabe, Eiichi; Ozaki, Yukio; Hirose, Yuichi
Subarachnoid hemorrhage (SAH) is most often followed by a delayed phase of cerebral ischemia which is associated with high morbidity and mortality rates. The causes underlying this delayed phase are still unsettled, but are believed to include cerebral vasospasm, cortical spreading depression, inflammatory reactions, and microthrombosis. Additionally, a large body of evidence indicates that vascular plasticity plays an important role in SAH pathophysiology, and this review aims to summarize our current knowledge on the phenotypic changes of vascular smooth muscle cells of the cerebral vasculature following SAH. In light of the emerging view that the whole cerebral vasculature and the cells of the brain parenchyma should be viewed as one integrated neurovascular network, phenotypical changes are discussed both for the cerebral arteries and the microvasculature. Furthermore, the intracellular signaling involved in the vascular plasticity is discussed with a focus on the Raf-MEK1/2-ERK1/2 pathway which seems to play a crucial role in SAH pathology. PMID:24449486
Edvinsson, Lars; Larsen, Stine Schmidt; Maddahi, Aida; Nielsen, Janne
Patients with aneurysmal subarachnoid hemorrhage (SAH) frequently have deficits in learning and memory that may or may not be associated with detectable brain lesions. We examined mediators of long-term potentiation after SAH in rats to determine what processes might be involved. There was a reduction in synapses in the dendritic layer of the CA1 region on transmission electron microscopy as well as reduced colocalization of microtubule-associated protein 2 (MAP2) and synaptophysin. Immunohistochemistry showed reduced staining for GluR1 and calmodulin kinase 2 and increased staining for GluR2. Myelin basic protein staining was decreased as well. There was no detectable neuronal injury by Fluoro-Jade B, TUNEL, or activated caspase-3 staining. Vasospasm of the large arteries of the circle of Willis was mild to moderate in severity. Nitric oxide was increased and superoxide anion radical was decreased in hippocampal tissue. Cerebral blood flow, measured by magnetic resonance imaging, and cerebral glucose metabolism, measured by positron emission tomography, were no different in SAH compared with control groups. The results suggest that the etiology of loss of LTP after SAH is not cerebral ischemia but may be mediated by effects of subarachnoid blood such as oxidative stress and inflammation. PMID:24064494
Han, Sang Myung; Wan, Hoyee; Kudo, Gen; Foltz, Warren D; Vines, Douglass C; Green, David E; Zoerle, Tommaso; Tariq, Asma; Brathwaite, Shakira; D'Abbondanza, Josephine; Ai, Jinglu; Macdonald, R Loch
KD-Tree is an important accelerating structure for ray-tracing based realistic rendering. How to construct kd-tree efficiently is very crucial for ray tracing performance. In this paper, we present a fast construction algorithm. It is based on SAH cost estimation function and adopts a clever way to keep sorting order without sorting every time. Thus we reduce the complexity to O(NlogN),
Liuzhou Wu; Zelin Chen
Hemorrhagic cystitis (HC) is a common urological disorder, presenting in 6.5% of patients following pelvic radiation therapy\\u000a and up to 25% of patients receiving alkylating chemotherapeutic agents. HC can be devastating, with high morbidity and mortality\\u000a despite aggressive interventions (1). Massive urothelial hemorrhage may involve both upper and lower urinary tracts (2), leading to acute renal failure that requires emergent
Kian Tai Chong; John M. Corman
Hemorrhage control is a high priority task in advanced trauma care, because hemorrhagic shock can result in less than a minute in cases of severe injuries. Hemorrhage was found to be solely responsible for 40-50% of traumatic civilian and battlefield deaths in recent years. The majority of these deaths were due to abdominal and pelvic injuries with hidden and inaccessible
Shahram Vaezy; Vesna Zderic
Background Subarachnoid hemorrhage (SAH) is mainly caused by ruptured cerebral aneurysms but in up to 15% of patients with SAH no bleeding source could be identified. Our objective was to analyze patient characteristics, clinical outcome and prognostic factors in patients suffering from non-aneurysmal SAH. Methods From 1999 to 2009, data of 125 patients with non-aneurysmal SAH were prospectively entered into a database. All patients underwent repetitive cerebral angiography. Outcome was assessed according to the modified Rankin Scale (mRS) (mRS 0–2 favorable vs. 3–6 unfavorable). Also, patients were divided in two groups according to the distribution of blood in the CT scan (perimesencephalic and non-perimesencephalic SAH). Results 106 of the 125 patients were in good WFNS grade (I-III) at admission (85%). Overall, favorable outcome was achieved in 104 of 125 patients (83%). Favorable outcome was associated with younger age (P?0.001), good admission status (P?0.0001), and absence of hydrocephalus (P?=?0.001). 73 of the 125 patients suffered from perimesencephalic SAH, most patients (90%) were in good grade at admission, and 64 achieved favorable outcome. 52 of the 125 patients suffered from non-perimesencephalic SAH and 40 were in good grade at admission. Also 40 patients achieved favorable outcome. Conclusions Patients suffering from non-aneurysmal SAH have better prognosis compared to aneurysm related SAH and poor admission status was the only independent predictor of unfavorable outcome in the multivariate analysis. Patients with a non-perimesencephalic SAH have an increased risk of a worse neurological outcome. These patients should be monitored attentively.
Electrocardiographic (ECG) abnormalities and cardiac troponin I elevation are seen in addition to the classic clinical symptoms and signs of subarachnoid hemorrhage (SAH). We aimed to show that, in patients with ST elevation, troponin elevation, and altered consciousness, the reason may be SAH. A 36-year-old man presented to emergency service with ECG abnormalities, high level of cardiac troponin I, and neurologic symptoms. In the patient's initial ECG, there were sinus arrhythmia, bradycardia, T-wave inversions inferiorly, and concave ST elevations in V1 to V4. Three hours later, his ECG showed increased ST-segment elevations with normal heart rate. The patient's troponin I value was 10 mg/L. Ejection fraction was 60%, and there were no wall motion abnormalities on echocardiography. Computed tomographic scan of the brain demonstrated SAH with falx sign and midline cerebellar hematoma (3 × 4 cm in size) in the occipital region. The patient died on the 10th day of follow-up because of severe metabolic acidosis, multiorgan failure, and bradycardia. Cardiac evaluation is recommended in patients with intracranial hemorrhage in many studies. In our opinion, if there are neurologic symptoms or signs in patients diagnosed as acute myocardial infarction with ECG changes and troponin elevation, requesting threshold of brain computed tomography should be low before the thrombolytic therapy. PMID:22809772
Saritemur, Murat; Akoz, Ayhan; Kalkan, Kamuran; Emet, Mucahit
Molecular mechanisms behind increased cerebral vasospasm and local inflammation in late cerebral ischemia after subarachnoid hemorrhage (SAH) are poorly elucidated. Using system biology tools and experimental SAH models, we have identified signal transducer and activator of transcription 3 (STAT3) transcription factor as a possible major regulatory molecule. On the basis of the presence of transcription factor binding sequence in the promoters of differentially regulated genes (significant enrichment PE: 6 × 10(5)) and the consistent expression of STAT3 (mRNA, P=0.0159 and Protein, P=0.0467), we hypothesize that unphosphorylated STAT3 may directly DNA bind and probably affect the genes that are involved in inflammation and late cerebral ischemia to influence the pathologic progression of SAH. PMID:24517975
Samraj, Ajoy K; Müller, Anne H; Grell, Anne-Sofie; Edvinsson, Lars
Cerebral vasospasm and delayed cerebral ischemia remain an unsolved problem in patients with aneurysmal subarachnoid hemorrhage (SAH). In theory, high-dose magnesium sulfate (MgSO(4)) therapy offers vascular and neuroprotective benefits and is therefore currently under evaluation. The intensity of the inflammatory response after SAH is associated with the outcome. The aim of the current study was to evaluate a possible link between the inflammatory response and MgSO(4) therapy, since magnesium (Mg(2+)) has anti-inflammatory properties. In 15 patients with SAH, inflammatory cytokine levels in the cerebrospinal fluid (CSF) and peripheral blood were determined daily using an enzyme-linked immunosorbent assay between day 4 and day 12. Eight patients were treated with standard therapy alone (group 1) and seven patients were treated with an additional, high-dose of MgSO(4) (group 2). Serum Mg(2+) levels in group 2 were significantly higher compared to group 1: 1.48 ± 0.04 mmol/L versus 0.90 ± 0.01 mmol/L, ?<0.001. Interleukin-6 (IL-6) in the CSF was significantly lower in group 2 compared to group 1: 6680 ± 989 vs.11079 ± 1277 pg/mL, ? = 0.021. A trend towards lower systemic IL-6 levels was found in group 2: 58 ± 7 versus 104 ± 21 pg/mL, ? = 0.052. Systemic IL-1? levels were significantly lower in group 2: 0.66 ± 0.11 and 0.15 ± 0.01 pg/mL (?<0.001), while the CSF levels did not differ. Tumor necrosis factor-? levels did not differ between the two groups. Although there were more patients with favorable outcome in group 2, the difference was not statistically significant. This was probably due to the small sample size. The results indicate a suppression of inflammatory cytokine release, in particular IL-6, in patients treated with high-dose MgSO(4). These results call for further studies of the effect of Mg(2+) on the inflammatory signaling pathway with regard to delayed cerebral ischemia following SAH. PMID:22966500
Muroi, Carl; Burkhardt, Jan-Karl; Hugelshofer, Michael; Seule, Martin; Mishima, Kenichi; Keller, Emanuela
Early brain injury (EBI) after subarachnoid hemorrhage (SAH) is characterized by a reduction in excitatory amino acid transporter 2 (EAAT2) expression and severe amino acid excitotoxicity. The aim of this study was to explore the neuroprotective effect of ceftriaxone (CEF), a potent compound that up-regulates EAAT2, against EBI and the potential mechanisms using in vitro experiments and a rat model of SAH. Intracisternal treatment with CEF significantly improved neurological outcomes and alleviated extracellular glutamate accumulation after SAH. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling assay (TUNEL) staining and Western blot analysis of cleaved caspase 3 showed that CEF decreased hippocampal neuronal apoptosis following SAH. Immunofluorescent staining and Western blotting revealed that CEF significantly reversed the down-regulation of EAAT2 expression following SAH. In Morris water maze (MWM) tests, CEF remarkably ameliorated the SAH-induced cognitive dysfunction in spatial learning memory and reference memory. CEF promoted the nuclear translocation of p65 as well as the activation of Akt in hippocampal astrocytes in vitro and in vivo. These findings suggest that CEF may exert significant protective effects against EBI following SAH by modulating the PI3K/Akt/NF-?B signaling pathway. PMID:24631672
Feng, D; Wang, W; Dong, Y; Wu, L; Huang, J; Ma, Y; Zhang, Z; Wu, S; Gao, G; Qin, H
Objective. The novel clinical prediction approach of Bayesian neural networks with fuzzy logic inferences is created and applied to derive prognostic decision rules in cerebral aneurysmal subarachnoid hemorrhage (aSAH). Methods. The approach of Bayesian neural networks with fuzzy logic inferences was applied to data from five trials of Tirilazad for aneurysmal subarachnoid hemorrhage (3551 patients). Results. Bayesian meta-analyses of observational studies on aSAH prognostic factors gave generalizable posterior distributions of population mean log odd ratios (ORs). Similar trends were noted in Bayesian and linear regression ORs. Significant outcome predictors include normal motor response, cerebral infarction, history of myocardial infarction, cerebral edema, history of diabetes mellitus, fever on day 8, prior subarachnoid hemorrhage, admission angiographic vasospasm, neurological grade, intraventricular hemorrhage, ruptured aneurysm size, history of hypertension, vasospasm day, age and mean arterial pressure. Heteroscedasticity was present in the nontransformed dataset. Artificial neural networks found nonlinear relationships with 11 hidden variables in 1 layer, using the multilayer perceptron model. Fuzzy logic decision rules (centroid defuzzification technique) denoted cut-off points for poor prognosis at greater than 2.5 clusters. Discussion. This aSAH prognostic system makes use of existing knowledge, recognizes unknown areas, incorporates one's clinical reasoning, and compensates for uncertainty in prognostication.
Lo, Benjamin W. Y.; Macdonald, R. Loch; Baker, Andrew; Levine, Mitchell A. H.
Background: Hyponatremia is the most common electrolyte abnormality seen in patients with aneurysmal SAH. Clinically significant hyponatremia (Serum Sodium <131 mEq/L) which needs treatment, has been redefined recently and there is a paucity of outcome studies based on this. This study aims to identify the mean Serum Sodium (S.Na+) level and its duration among inpatients with SAH and to identify the relationship between hyponatremia and the outcome status of patients undergoing surgery for SAH. Materials and Methods: This outcome study is undertaken in the department of neurosurgery, The Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala. Medical records of all patients with SAH from 1st January to 31st July 2010 were reviewed. Preoperative status was assessed using World Federation of Neurosurgical Societies (WFNS) grading system. Discharge status was calculated using the Glasgow outcome score scale. Results: Fifty nine patients were included in the study and 53 (89.8%) of them have undergone surgical treatment. Hyponatremia was observed in 22 of 59 patients (37%). The mean Sodium level of hyponatremic patients was 126.97 mEq/L for a median duration of two days. Glasgow outcome score was good in 89.8% of patients. We lost two patients, one of whom had hyponatremia and vasospasm. Conclusion: Hyponatremia is significantly associated with poor outcome in patients with SAH. Anticipate hyponatremia in patients with aneurysmal subarachnoid hemorrhage, timely detect and appropriately treat it to improve outcome. It is more common in patients who are more than 50 years old and whose aneurysm is in the anterior communicating artery. Our comprehensive monitoring ensured early detection and efficient surgical and nursing management reduced morbidity and mortality.
Saramma, PP; Menon, R Girish; Srivastava, Adesh; Sarma, P Sankara
Background Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with very high mortality and morbidity. Our limited knowledge on predictors of long-term outcome in poor-grade patients with aSAH definitively managed comes from retrospective and prospective studies of small case series of patients in single center. The purpose of the AMPAS is to determine the long-term outcomes in poor-grade patients with different managements within different time after aSAH, and identify the independent predictors of the outcome that help guide the decision on definitive management. Methods/design The AMPAS study is a prospective, multicenter, observational registry of consecutive hospitalized patients with poor grade aSAH (WFNS grade IV and V). The aim is to enroll at least 226 poor-grade patients in 11 high-volume medical centers (eg, >150 aSAH cases per year) affiliated to different universities in China. This study will describe poor grade patients and aneurysm characteristics, treatment strategies (modality and time of definitive management), hospitalization complications and outcomes evolve over time. The definitive management is ruptured aneurysm treatment. Outcomes at 3, 6, 12 months after the management were measured using the Glasgow Outcome Scale and the Modified Rankin Scale. Discussion The AMPAS is the first prospective, multicenter, observational registry of poor grade aSAH with any management. This study will contribute to a better understanding of significant predictors of outcome in poor grade patients and help guide future treatment of the worst patients after aSAH. Trial registration Chinese Clinical Trial Registry: ChiCTR-TNRC-10001041.
Background and Purpose Plasma thrombin concentration is increased following subarachnoid hemorrhage (SAH). However, the role of thrombin receptor (protease activated recptor-1, PAR-1) in endothelial barrier disruption has not been studied. The aims of this study were to investigate the role of PAR-1 in orchestrating vascular permeability and assess the potential therapeutics of a PAR-1 antagonist, SCH79797, through maintaining vascular integrity. Methods SCH79797 was injected intraperitoneally into male Sprauge-Dawley rats undergoing SAH by endovascular perforation. Assessment was conducted at 24 hours after SAH for brain water content, Evans blue content, and neurobehavioral testing. To explore the role of PAR-1 activation and the specific mechanism of SCH79797’s effect after SAH, Western blot, immunoprecipitation, and immunofluorescence of hippocampus tissue were performed. A p21-activated kinase1 (PAK1) inhibitor, IPA-3, was used to explore the underlying protective mechanism of SCH79797. Results At 24 hours after SAH, animals treated with SCH79797 demonstrated a reduction in brain water content, Evans blue content, and neurobehavioral deficits. SCH79797 also attenuated PAR-1 expression and maintained the level of VE-cadherin, an important component of adherens junctions. Downstream to PAR-1, c-Src dependent activation of PAK1 led to an increased serine/threonine phosphorylation of VE-cadherin; immunoprecipitation results revealed an enhanced binding of phosphorylated VE-cadherin with endocytosis orchestrator ?-arrestin2. These pathological states were suppressed following SCH79797 treatment. Conclusions PAR-1 activation following SAH increases microvascular permeability, at least, partly through a PAR-1-c-Src-PAK1-VE-cadherin phosphorylation pathway. Through suppressing PAR-1 activity, SCH79797 plays a protective role in maintaining microvascular integrity after SAH.
Yan, Junhao; Manaenko, Anatol; Chen, Sheng; Klebe, Damon; Ma, Qingyi; Caner, Basak; Fujii, Mutsumi; Zhou, Changman; Zhang, John H.
Outcome of patients with aneurysmal subarachnoid hemorrhage (SAH) has improved over the last decades. Yet, case fatality remains nearly 40% and survivors often have permanent neurological, cognitive and/or behavioural sequelae. Other than nimodipine drug or clinical trials have not consistently improved outcome. We formed a collaboration of SAH investigators to create a resource for prognostic analysis and for studies aimed at optimizing the design and analysis of phase 3 trials in aneurysmal SAH. We identified investigators with data from randomized, clinical trials of patients with aneurysmal SAH or prospectively collected single- or multicentre databases of aneurysmal SAH patients. Data are being collected and proposals to use the data and to design future phase 3 clinical trials are being discussed. This paper reviews some issues discussed at the first meeting of the SAH international trialists (SAHIT) repository meeting. Investigators contributed or have agreed to contribute data from several phase 3 trials including the tirilazad trials, intraoperative hypothermia for aneurysmal SAH trial, nicardipine clinical trials, international subarachnoid aneurysm trial, intravenous magnesium sulphate for aneurysmal SAH, magnesium for aneurysmal SAH and from prospectively-collected data from four institutions. The number of patients should reach 15,000. Some industry investigators refused to provide data and others reported that their institutional research ethics boards would not permit even deidentified or anonymized data to be included. Others reported conflict of interest that prevented them from submitting data. The problems with merging data were related to lack of common definitions and coding of variables, differences in outcome scales used, and times of assessment. Some questions for investigation that arose are discussed. SAHIT demonstrates the possibility of SAH investigators to contribute data for collaborative research. The problems are similar to those already documented in other similar collaborative efforts such as in head injury research. We encourage clinical trial and registry investigators to contact us and participate in SAHIT. Key issues moving forward will be to use common definitions (common data elements), outcomes analysis, and to prioritize research questions, among others. PMID:24323299
Macdonald, R Loch; Jaja, Blessing; Cusimano, Michael D; Etminan, Nima; Hanggi, Daniel; Hasan, David; Ilodigwe, Don; Lantigua, Hector; Le Roux, Peter; Lo, Benjamin; Louffat-Olivares, Ada; Mayer, Stephan; Molyneux, Andrew; Quinn, Audrey; Schweizer, Tom A; Schenk, Thomas; Spears, Julian; Todd, Michael; Torner, James; Vergouwen, Mervyn D I; Wong, George K C; Singh, Jeff
Cerebral vasospasm (CV) remains the leading cause of delayed morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). However, increasing evidence supports etiologies of delayed cerebral ischemia (DCI) other than CV. Estrogen, specifically 17?-estradiol (E2), has potential therapeutic implications for ameliorating the delayed neurological deterioration which follows aneurysmal SAH. We review the causes of CV and DCI and examine the evidence for E2-mediated vasodilation and neuroprotection. E2 potentiates vasodilation by activating endothelial nitric oxide synthase (eNOS), preventing increased inducible NOS (iNOS) activity caused by SAH, and decreasing endothelin-1 production. E2 provides neuroprotection by increasing thioredoxin expression, decreasing c-Jun N-terminal kinase activity, increasing neuroglobin levels, preventing SAH-induced suppression of the Akt signaling pathway, and upregulating the expression of adenosine A2a receptor. The net effect of E2 modulation of these various effectors is the promotion of neuronal survival, inhibition of apoptosis, and decreased oxidative damage and inflammation. E2 is a potentially potent therapeutic tool for improving outcomes related to post-SAH CV and DCI. However, clinical evidence supporting its benefits remains lacking. Given the promising preclinical data available, further studies utilizing E2 for the treatment of patients with ruptured intracranial aneurysms appear warranted.
Starke, Robert M.; Dumont, Aaron S.; Owens, Gary K.; Hasan, David M.
The mortality after aneurysmal subarachnoid hemorrhage (SAH) is 50%, and most survivors suffer severe functional and cognitive deficits. Half of SAH patients deteriorate 5 to 14 days after the initial bleeding, so-called delayed cerebral ischemia (DCI). Although often attributed to vasospasms, DCI may develop in the absence of angiographic vasospasms, and therapeutic reversal of angiographic vasospasms fails to improve patient outcome. The etiology of chronic neurodegenerative changes after SAH remains poorly understood. Brain oxygenation depends on both cerebral blood flow (CBF) and its microscopic distribution, the so-called capillary transit time heterogeneity (CTH). In theory, increased CTH can therefore lead to tissue hypoxia in the absence of severe CBF reductions, whereas reductions in CBF, paradoxically, improve brain oxygenation if CTH is critically elevated. We review potential sources of elevated CTH after SAH. Pericyte constrictions in relation to the initial ischemic episode and subsequent oxidative stress, nitric oxide depletion during the pericapillary clearance of oxyhemoglobin, vasogenic edema, leukocytosis, and astrocytic endfeet swelling are identified as potential sources of elevated CTH, and hence of metabolic derangement, after SAH. Irreversible changes in capillary morphology and function are predicted to contribute to long-term relative tissue hypoxia, inflammation, and neurodegeneration. We discuss diagnostic and therapeutic implications of these predictions. PMID:24064495
Østergaard, Leif; Aamand, Rasmus; Karabegovic, Sanja; Tietze, Anna; Blicher, Jakob Udby; Mikkelsen, Irene Klaerke; Iversen, Nina Kerting; Secher, Niels; Engedal, Thorbjørn Søndergaard; Anzabi, Mariam; Jimenez, Eugenio Gutierrez; Cai, Changsi; Koch, Klaus Ulrik; Naess-Schmidt, Erhard Trillingsgaard; Obel, Annette; Juul, Niels; Rasmussen, Mads; Sørensen, Jens Christian Hedemann
Background and Purpose Patients suspected of having aneurysmal subarachnoid hemorrhage (SAH) are initially evaluated with noncontrast head computed tomography (CT). If the CT is negative, but clinical concern for SAH is high, a lumbar puncture (LP) with cerebrospinal fluid (CSF) analysis is typically performed. The purpose of this study was to evaluate the accuracy of CSF xanthochromia and erythrocytosis for aneurysmal SAH. Methods Medical records of all patients who underwent catheter angiography at Barnes Jewish Hospital between July 2002 and April 2012 for clinical suspicion of a ruptured brain aneurysm after a negative CT scan and an LP suspicious for SAH were reviewed. The CSF analysis results, angiographic findings and outcomes of each case were recorded. Results Fifty nine patients were identified. Two angiographic lesions were identified in patients with xanthochromia was 8.3% (2/24), both of which were confirmed to have ruptured. The diagnostic yield in patients with non-clearing erythrocytosis and no xanthrochromia was 6.3% (1/16), though this lesion was not considered the source of SAH. Conclusion Catheter angiography should be performed in patients with CT negative but suspicious LP, particularly in the presence of xanthrochromia. The benefit of angiography in patients with erythrocytosis only is unclear and deserves future study.
Dines, Jeffrey N; Zipfel, Gregory J; Derdeyn, Colin P
Blood glutamate scavengers have been shown to effectively reduce blood glutamate concentrations and improve neurological outcome after traumatic brain injury and stroke in rats. This study investigates the efficacy of blood glutamate scavengers oxaloacetate and pyruvate in the treatment of subarachnoid hemorrhage (SAH) in rats. Isotonic saline, 250 mg/kg oxaloacetate, or 125 mg/kg pyruvate was injected intravenously in 60 rats, 60 minutes after induction of SAH at a rate of 0.1 ml/100 g/min for 30 minutes. There were 20 additional rats that were used as a sham-operated group. Blood samples were collected at baseline and 90 minutes after SAH. Neurological performance was assessed at 24 h after SAH. In half of the rats, glutamate concentrations in the cerebrospinal fluid were measured 24 h after SAH. For the remaining half, the blood brain barrier permeability in the frontal and parieto-occipital lobes was measured 48 h after SAH. Blood glutamate levels were reduced in rats treated with oxaloacetate or pyruvate at 90 minutes after SAH (p?0.001). Cerebrospinal fluid glutamate was reduced in rats treated with pyruvate (p?0.05). Neurological performance was significantly improved in rats treated with oxaloacetate (p?0.05) or pyruvate (p?0.01). The breakdown of the blood brain barrier was reduced in the frontal lobe in rats treated with pyruvate (p?0.05) and in the parieto-occipital lobes in rats treated with either pyruvate (p?0.01) or oxaloacetate (p?0.01). This study demonstrates the effectiveness of blood glutamate scavengers oxaloacetate and pyruvate as a therapeutic neuroprotective strategy in a rat model of SAH. PMID:22711471
Boyko, Matthew; Melamed, Israel; Gruenbaum, Benjamin Fredrick; Gruenbaum, Shaun Evan; Ohayon, Sharon; Leibowitz, Akiva; Brotfain, Evgeny; Shapira, Yoram; Zlotnik, Alexander
Abstract Subarachnoid hemorrhage (SAH) results in significant long-lasting cognitive dysfunction. Therefore, evaluating acute and long-term outcomes after therapeutic intervention is important for clinical translation. The aim of this study was to use minocycline, a known neuroprotectant agent, to evaluate the long-term benefits in terms of neurobehavior and neuropathology after experimental SAH in rats, and to determine which neurobehavioral test would be effective for long-term evaluation. SAH was induced by endovascular perforation in adult male Sprague-Dawley rats (n=118). The animals were treated with intraperitoneal injection of minocycline (45?mg/kg or 135?mg/kg) or vehicle 1?h after SAH induction. In the short-term, animals were euthanized at 24 and 72?h for evaluation of neurobehavior, brain water content, and matrix metalloproteinase (MMP) activity. In the long-term, neurobehavior was evaluated at days 21–28 post-SAH, and histopathological analysis was done at day 28. High-dose but not low-dose minocycline reduced brain water content at 24?h, and therefore only the high-dose regimen was used for further evaluation, which reduced MMP-9 activity at 24?h. Further, high-dose minocycline improved spatial memory and attenuated neuronal loss in the hippocampus and cortex. The rotarod, T-maze, and water maze tests, but not the inclined plane test, detected neurobehavioral deficits in SAH rats at days 21–28. This study demonstrates that minocycline attenuates long-term functional and morphological outcomes after endovascular perforation-induced SAH. Long-term neurobehavioral assessments using the rotarod, T-maze, and water maze tests could be useful to evaluate the efficacy of therapeutic intervention after experimental SAH.
Sherchan, Prativa; Lekic, Tim; Suzuki, Hidenori; Hasegawa, Yu; Rolland, William; Duris, Kamil; Zhan, Yan; Tang, Jiping
Purpose: Clevidipine is a novel, ultra-short acting dihydropyridine. We hypothesized that clevidipine would rapidly control elevated blood pressure (BP) in patients with aneurysmal subarachnoid hemorrhage (SAH). Materials and Methods: This prospective open-label pilot study evaluated the efficacy and safety of clevidipine in reducing blood pressure (BP) to a pre-specified range and within 30 min before or after clipping or coiling of the aneurysm. Results: We enrolled five patients who received eight clevidipine infusions, including 1587 systolic or diastolic BP data points. The mean SBP upper and lower goals were set at 154 and 122 mmHg. The primary end point of achieving SBP control within <30 min was reached in all patients within 14.2 ± 6.4 min at an infusion rate of 10.8 ± 9.1 mg/h. The mean pre-infusion, during infusion and post-infusion SBP measurements were 165.5 ± 2.55, 146.4 ± 2.48 and 159.3 ± 11.5 mmHg (?p < 0.05 for pre- vs infusion comparison), respectively. After reaching the primary end point and during the clevidipine infusion, 17.5% and 11.8% of SBP readings were above the upper and below the lower goals, respectively. No patients re-bled. In one patient, the infusion had to be stopped temporarily three times due to SBP decrease below the lower goal. Conclusion: Clevidipine controlled SBP in all patients with aneurysmal SAH in <22 min and kept it within the elective range 70% of the time without major complications. PMID:24007334
Varelas, Panayiotis N; Abdelhak, Tamer; Corry, Jesse J; James, Elysia; Rehman, Mohammed F; Schultz, Lonni; Mays-Wilson, Kathleen; Mitsias, Panayiotis
Introduction Recent clinical observations demonstrate that the APOE4 genotype increases the development of delayed ischemic deficit and\\u000a worsens prognosis following aneurysmal subarachnoid hemorrhage (SAH). In the current study, we use targeted replacement mice\\u000a expressing only human apoE3 or apoE4 to model the isoform-specific effects of apoE following SAH. We then test the hypothesis\\u000a that an apoE-derived therapeutic peptide reduces vasospasm and
Junling Gao; Haichen Wang; Huaxin Sheng; John R. Lynch; David S. Warner; Lori Durham; Michael P. Vitek; Daniel T. Laskowitz
We investigate how to efficiently build bounding volume hierarchies (BVHs) with surface area heuristic (SAH) on the Intel Many Integrated Core (MIC) Architecture. To achieve maximum performance, we use four key concepts: progressive 10-bit quantization to reduce cache footprint with negligible loss in BVH quality; an AoSoA data layout that allows efficient streaming and SIMD processing; high-performance SIMD kernels for binning and partitioning; and a parallelization framework with several build-specific optimizations. The resulting system is more than an order of magnitude faster than today's high-end GPU builders for comparable BVHs; it is usually faster even than spatial median builders; it can build SAH BVHs almost as fast as existing GPUs and CPUs- and CPU-based approaches can build regular grids; and in aggregate ``build+render'' performance is significantly faster than the best published numbers for either of these systems, be it CPU or GPU, BVH, kd-tree, or grid. PMID:21149890
It has been reported that inflammation is involved in brain injury after subarachnoid hemorrhage (SAH). Nuclear factor-?B (NF-?B) is a key transcriptional regulator of inflammatory genes. Here, we used pyrrolidine dithiocarbamate(PDTC), an inhibitor of NF-?B, through intracisternal injection to study the role of NF-?B in delayed brain injury after SAH. A total of 55 rabbits were randomly divided into five groups: the control group; the SAH groups including Day-3, 5, and 7 SAH groups (the rabbits in these groups were sacrificed at 3, 5, 7 days after SAH, respectively); and the PDTC group (n?=?11 for each group). Electrophoretic mobility shift assay (EMSA) was performed to detect NF-?B DNA-binding activity. The mRNA levels of tumor necrosis factor (TNF)-?, interleukin (IL)-1?, and intercellular adhesion molecule (ICAM)-1 were evaluated by RT-PCR analysis. Deoxyribonucleic acid fragmentation was detected by TUNEL and p65 immunoactivity was assessed by immunohistochemistry. Our results showed the activation of NF-?B after SAH, especially at day 3 and 5. The activated p65 was detected in neurons. NF-?B DNA-binding activity was suppressed by intracisternal administration of PDTC. Increased levels of the TNF-?, IL-1?, and ICAM-1 mRNA were found in the brain at day 5 after SAH, and which were suppressed in the PDTC group. The number of TUNEL-positive cells also decreased significantly in the PDTC group compared with that in the Day-5 SAH group. These results demonstrated that the activated NF-?B in neurons after SAH plays an important role in regulating the expressions of inflammatory genes in the brain, and ultimately contributes to delayed brain injury.
You, Wan-Chun; Wang, Chun-xi; Pan, Yun-xi; Zhang, Xin; Zhou, Xiao-ming; Zhang, Xiang-sheng; Shi, Ji-xin; Zhou, Meng-liang
Diffuse alveolar hemorrhage (DAH) is defined by the presence of red blood cells originating from the lung capillaries or venules within the alveoli. The diagnosis is established on clinical features, radiological pattern, and especially bronchoalveolar lavage. Diffuse alveolar hemorrhage may have many immune or non-immune causes. Immune causes of DAH include vasculitides, connective tissue diseases, especially systemic lupus erythematosus, and antiglomerular basement membrane antibody disease (Goodpasture's syndrome). Treatment is both supportive and causal, often based on high dose corticosteroids and immunosuppressive therapy (especially intravenous cyclophosphamide). Plasma exchanges are performed in antiglomerular basement membrane antibody disease and systemic lupus erythematosus, and are considered in systemic vasculitis. Non-immune causes of DAH mainly include heart diseases, coagulation disorders, infections, drug toxicities and idiopathic DAH. Treatment of non-immune DAH is that of its cause. Whatever the cause, DAH is an emergency requiring prompt assessment and early treatment. PMID:22963805
Traclet, J; Lazor, R; Cordier, J-F; Cottin, V
In patients with aneurysmal subarachnoid hemorrhage (SAH), secondary complications are an important cause of morbidity and\\u000a case fatality. Delayed cerebral ischemia and hydrocephalus are important intracranial secondary complications. Potentially\\u000a treatable extracranial complications are also frequently observed, and some are related to the occurrence of delayed cerebral\\u000a ischemia and outcome. In addition to the occurrence of an inflammatory response and metabolic
Wouter J. Schuiling; Paul J. W. Dennesen; Gabriël J. E. Rinkel
Background and Purpose—Inflammatory cytokines are involved in the pathogenesis of cerebral vasospasm after subarachnoid hemorrhage (SAH). This study was conducted to examine the role of p38 mitogen-activated protein kinase (MAPK) in the development of vasospasm and cytokine production. Methods—We measured the expression levels of genes and proteins related to inflammation in human vascular smooth muscle cells (hVSMCs) treated with hemolysate
Toshiyuki Sasaki; Hidetoshi Kasuya; Hideaki Onda; Atsushi Sasahara; Shin Goto; Tomokatsu Hori; Ituro Inoue
The pathogenesis of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) remains unknown. Besides vasospasm, microthrombosis might have an important function. As in patients with thrombotic thrombocytopenic purpura an A Disintegrin And Metalloprotease with ThromboSpondin repeats-13 (ADAMTS13) deficiency leads to higher concentrations of large von Willebrand factor (vWF) multimers resulting in microthrombosis, our purpose was to compare ADAMTS13 and
Mervyn DI Vergouwen; Kamran Bakhtiari; Nan van Geloven; Marinus Vermeulen; Yvo BWEM Roos; Joost CM Meijers; MDI Vergouwen
Delayed vasospasm that develops 3–7 days after aneurysmal subarachnoid hemorrhage (SAH) has traditionally been considered\\u000a the most important determinant of delayed ischemic injury and poor outcome. Consequently, most therapies against delayed ischemic\\u000a injury are directed towards reducing the incidence of vasospasm. The clinical trials based on this strategy, however, have\\u000a so far claimed limited success; the incidence of vasospasm is reduced
Fatima A. Sehba; Ryszard M. Pluta; John H. Zhang
Introduction: Recent evidence suggests that magnesium may be neuroprotective in the setting of cerebral ischemia, and therapeutic magnesium\\u000a infusion has been proposed for prophylaxis and treatment of delayed ischemic neurological deficit (DIND) resulting from vasospasm\\u000a in patients with aneurysmal subarachnoid hemorrhage (SAH). We studied the association between serum magnesium levels, the\\u000a development of DIND, and the outcomes of patients with
Frederic P. Collignon; Jonathan A. Friedman; David G. Piepgras; Mark A. Pichelmann; Jon I. McIver; L. Gerard Toussaint III; Robyn L. McClelland
BACKGROUND AND PURPOSE:Fluid-attenuated inversion-recovery (FLAIR) MR imaging may show subarachnoid hemorrhage (SAH) with high sensitivity. We hypothesized that the FLAIR technique is effective and reliable in the diagnosis of cerebral intraventricular hem- orrhage (IVH). METHODS: Two observers evaluated the 1.5-T MR fast spin-echo FLAIR images, T1- and T2-weighted MR images, and CT scans of 13 patients with IVH and the
Rohit Bakshi; Sadaat Kamran; Peter R. Kinkel; Vernice E. Bates; Laszlo L. Mechtler; Vallabh Janardhan; Shaleen L. Belani; William R. Kinkel
Spontaneous rapture with consequent retroperitoneal hemorrhage (Wunderlich's syndrome) is the complication mostly feared from large renal angiomyolipomas (RAMLs). In hemodynamic stable patients, minimal invasive therapies have superseded open surgery as the mainstay of treatment, with contemporary cases mostly treated by selective arterial embolization. Robotic-assisted laparoscopic partial nephrectomy (RALPN) is an established minimal access treatment that has been used in the past for benign and malignant lesions of the kidney in the elective setting, but rarely in urgent situations as primary treatment. We present a case of a ruptured RAML in a young female treated effectively by RALPN.
Ploumidis, Achilles; Katafigiotis, Ioannis; Thanou, Maria; Bodozoglou, Nikos; Athanasiou, Labros; Ploumidis, Antonios
Computerized tomography, carotid angiograms, and arteriography were used to diagnose several cases of cerebral hemorrhage following the use of phenylpropanolamine. The angiographic picture in one of the three cases was similar to that previously described in association with amphetamine abuse and pseudoephedrine overdose, both substances being chemically and pharmacologically similar to phenylpropanolamine. The study suggests that the arterial change responsible for symptoms may be due to spasm rather than arteriopathy. 14 references, 5 figures.
McDowell, J.R.; LeBlanc, H.J.
Objective The objective of this study was to compare the incidence of ventricular shunt placement for shunt-dependent hydrocephalus (SDHC) after clipping versus coiling of ruptured aneurysms. Materials and Methods A retrospective review was conducted in 215 patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent surgical clipping or endovascular coiling during the period from May 2008 to December 2011. Relevant clinical and radiographic data were analyzed with regard to the incidence of hydrocephalus and ventriculo-peritoneal shunt (VPS). Patients treated with clipping were assigned to Group A, while those treated with coiling were assigned to Group B. Results Of 215 patients (157 clipping, 58 coiling), no significant difference in the incidence of final VPS was observed between treatment modalities (15.3% vs. 10.3%) (p = 0.35). Independent risk factors for VPS for treatment of chronic hydrocephalus were as follows: (1) older than 65 years, (2) poorer Hunt-Hess grade IV and V, (3) Fisher grade III and IV, and (4) particularly initial presence of an intraventricular hemorrhage. Conclusion In this study comparing two modalities for treatment of aneurysm, there was no difference in the incidence of chronic hydrocephalus requiring VPS. A significantly higher rate of shunt dependency was observed for age older than 65 years, poor initial neurological status, and thick SAH with presence of initial intraventricular hemorrhage. By understanding these factors related to development of SDHC and results, it is expected that management of aneurysmal SAH will result in a better prognosis.
Bae, In-Seok; Choi, Kyu-Sun; Chun, Hyoung-Joon
Background Matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) are involved in vascular remodeling, (neuro)inflammation, blood-brain barrier breakdown and neuronal apoptosis. Proinflammatory mechanisms are suggested to play an important role during early brain injury and cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). This study aimed to analyze MMP-3, MMP-9, TIMP-1 and TIMP-3 in patients with SAH and their respective association with cerebral vasospasm (CVS). Methods Blood samples were collected in 20 SAH patients on days 1 to 7, 9, 11, 13 and 15 and 20 healthy age and gender matched volunteers. Serum MMPs and TIMPs were analyzed using enzyme-linked immunosorbent assay. Doppler sonographic CVS was defined as a mean blood flow velocity above 120 cm/sec in the middle cerebral artery. When discharged from hospital and at 6 month follow-up neurological outcome was evaluated using the Glasgow Outcome Score and the modified Rankin Scale. Results MMP-9 was higher in SAH patients compared to healthy controls (p<0.001). Patients with CVS (n?=?11) had elevated MMP-9 serum levels compared to patients without CVS (n?=?9, p<0.05). Higher MMP-9 was observed in the presence of cerebral ischemia associated with cerebral vasospasm (p<0.05). TIMP-1 was increased in patients with SAH on day 4 (p<0.05). There was an imbalance of the MMP-9/TIMP-1 ratio in favor of MMP-9 in SAH patients, in particular those with CVS (p<0.001). MMP-3 and TIMP-3 were significantly lower in SAH patients throughout day 4 and day 7, respectively (p<0.05). We did not find an association between MMP-, TIMP levels and neurological outcome after 6 months. Conclusions MMP-3 and -9 are differentially regulated in SAH patients with both enzymes showing peak levels correlating with the development of CVS. The inhibitors TIMP-1 and -3 were low during the acute phase after SAH and increased later on which might suggest a preponderance of pro-inflammatory mechanisms.
Fischer, Marlene; Dietmann, Anelia; Beer, Ronny; Broessner, Gregor; Helbok, Raimund; Pfausler, Bettina; Schmutzhard, Erich; Lackner, Peter
Syringomyelia resulting from arachnoiditis secondary to aneurysmal subarachnoid hemorrhage (SAH) is an extremely rare clinical entity with few cases reported in the literature. The presentation, management, and pathogenesis of syringomyelia in this setting is poorly understood. We describe the presentation, radiology, management, and outcomes in two patients with syringomyelia resulting from arachnoiditis secondary to aneurysmal SAH and review the literature on this rare condition. Case number 1 was treated successfully with syrinx-subarachnoid shunt after extensive lysis of adhesions. Case number 2 was treated with syringoperitoneal shunt. Both patients had radiographic decreased syrinx size postoperatively. These patients add to the small literature on syringomyelia occurring secondary to SAH-associated arachnoiditis. The radiographic outcomes demonstrate that in the appropriately selected patient, syrinx-subarachnoid or syringoperitoneal shunting are viable options.
Abel, Taylor J.; Howard, Matthew A.; Menezes, Arnold
TBI and hemorrhagic shock, the most common causes of trauma deaths, often occur concomitantly due to multiple injuries. Hemorrhagic shock markedly exacerbates secondary damage in the traumatically injured brain and doubles TBI mortality. Therefore, a ther...
Background Upregulation of vasoconstrictor receptors in cerebral arteries, including endothelin B (ETB) and 5-hydroxytryptamine 1B (5-HT1B) receptors, has been suggested to contribute to delayed cerebral ischemia, a feared complication after subarachnoid hemorrhage (SAH). This receptor upregulation has been shown to be mediated by intracellular signalling via the mitogen activated protein kinase kinase (MEK1/2) - extracellular regulated kinase 1/2 (ERK1/2) pathway. However, it is not known what event(s) that trigger MEK-ERK1/2 activation and vasoconstrictor receptor upregulation after SAH. We hypothesise that the drop in cerebral blood flow (CBF) and wall tension experienced by cerebral arteries in acute SAH is a key triggering event. We here investigate the importance of the duration of this acute CBF drop in a rat SAH model in which a fixed amount of blood is injected into the prechiasmatic cistern either at a high rate resulting in a short acute CBF drop or at a slower rate resulting in a prolonged acute CBF drop. Results We demonstrate that the duration of the acute CBF drop is determining for a) degree of early ERK1/2 activation in cerebral arteries, b) delayed upregulation of vasoconstrictor receptors in cerebral arteries and c) delayed CBF reduction, neurological deficits and mortality. Moreover, treatment with an inhibitor of MEK-ERK1/2 signalling during an early time window from 6 to 24 h after SAH was sufficient to completely prevent delayed vasoconstrictor receptor upregulation and improve neurological outcome several days after the SAH. Conclusions Our findings suggest a series of events where 1) the acute CBF drop triggers early MEK-ERK1/2 activation, which 2) triggers the transcriptional upregulation of vasoconstrictor receptors in cerebral arteries during the following days, where 3) the resulting enhanced cerebrovascular contractility contribute to delayed cerebral ischemia.
Background Cardiac complications are often developed after subarachnoid hemorrhage (SAH) and may cause sudden death of the patient. There are reports in the literature addressing ischemia modified albumin (IMA) as an early and useful marker in the diagnosis of ischemic heart events. The aim of this study is to evaluate serum IMA by using the albumin cobalt binding (ACB) test in the first, second, and seventh days of experimental SAH in rats. Twenty-eight Wistar albino rats were divided into four groups each consisting of seven animals. These were classified as control group, 1st, 2nd and 7th day SAH groups. SAH was done by transclival basilar artery puncture. Blood samples were collected under anesthesia from the left ventricles of the heart using the cardiac puncture method for IMA measurement. Histopathological examinations were performed on the heart and lung tissues. Albumin with by colorimetric, creatine kinase (CK), aspartate aminotransferase (AST), lactate dehydrogenase (LDH) were determined on an automatic analyser using the enzymatic method. IMA using by ACB test was detected with spectrophotometer. Results Serum IMA (p?=?0.044) in seventh day of SAH were higher compared to the control group. Total injury scores of heart and lung tissue, also myocytolysis at day 7 were significantly higher than control group (p?=?0.001, p?=?0.001, p?=?0.001), day 1 (p?=?0.001, p?=?0.001, p?=?0.001) and day 2 (p?=?0.001, p?=?0.007, p?=?0.001). A positive correlation between IMA - myocytolysis (r?=?0.48, p?=?0.008), and between IMA – heart tissue total injury score (r?=?0.41, p?=?0.029) was found. Conclusion The results revealed that increased serum IMA may be related to myocardial stress after SAH.
A 45-year-old man presented with hemorrhagic cystitis and was found to have herpes simplex infection of the bladder by biopsy, immunohistochemistry and in situ hybridization. The patient had no clinical evidence of immunosuppression or disseminated infection. Although viral etiologies of hemorrhagic cystitis are recognized, to our knowledge only 4 cases of hemorrhagic cystitis due to herpes simplex virus have been reported. PMID:8254799
McClanahan, C; Grimes, M M; Callaghan, E; Stewart, J
Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a type of stroke that affects women and men with a mean age of 50 years. Return to work (RTW) has been cited as a strategic goal of patients after injury; however, success rates are low in multiple studies. Therefore, the purpose of this study was to investigate factors influencing RTW after aSAH. The study design was a cross-sectional design at 1-2 years after injury to assess work status in 134 patients who were treated for aSAH. Participants were recruited at one hospital setting via mailed invitations. They were interviewed over the telephone after consent was obtained for chart review and to participate in the study. Eligible participants were asked to complete the Brief Illness Perception Questionnaire and the Functional Status Questionnaire. Data analysis was performed using univariate analysis and logistic regression with Statistical Package for the Social Sciences software. Results: There was a moderate negative correlation between illness perception and RTW. Illness perception was found to significantly predict failure to RTW, whereas marital status improved the prediction model to significantly predict successful RTW. Conclusions: This study addressed a gap in the literature regarding work status after aSAH and has provided direction for further investigation. Addressing issues surrounding patients' perception of illness may serve as an important conduit to remove barriers to RTW. Recognition of these barriers to RTW in assessing a person's illness perception may be the key to the development of interventions in the recovery process. PMID:24992146
Aneurysmal subarachnoid hemorrhage (aSAH)-induced cerebral vasospasm and delayed ischemic neurological deficit (DIND) are the major causes of morbidity and mortality in patients with aSAH. The effects of statins-use for patients with aSAH remain controversial. Here,a total of 249 patients from six randomized controlled trials(RCTs) were subjected to meta-analysis. No significant decrease was found in the incidence of vasospasm(RR, 0.80; 95% CI, 0.54-1.17), with substantial heterogeneity (I(2) = 49%, P = 0.08), which was verified by the further sensitivity analysis and subgroup meta-analysis. Furthermore, no significant difference was presented in the incidence of poor neurological outcome(RR, 0.94; 95% CI, 0.77-1.16), and potential side effects(RR, 2.49; 95% CI, 0.75-8.33). Nevertheless, significant difference was reported in the occurrence of DIND(RR, 0.58; 95% CI, 0.37-0.92) and mortality(RR, 0.30; 95% CI, 0.14-0.64). At present, although statins-use in the patients with aSAH should not be considered standard care at present, statins-use may have the potential effects in the prevention of mortality in patients with aSAH. PMID:24763190
Su, Shao-Hua; Xu, Wei; Hai, Jian; Wu, Yi-Fang; Yu, Fei
Synapses, the junctions between nerve cells through which they communicate, are formed by the coordinated assembly and tight attachment of pre- and postsynaptic specializations. Synaptic cell adhesion molecule 1 (SynCAM 1) has been proved to be an important factor for synapse function and behavior cognition. The current research aimed to investigate the expression of the SynCAM 1 in the brain after experimental subarachnoid hemorrhage (SAH) in rats. A total of 42 rats were randomly divided into seven groups: control group, sham group, day 1, day 3, day 5, day 7, and day 14 groups. Day 1, day 3, day 5, day 7, and day 14 groups were all SAH groups in which the rats were killed on days 1, 3, 5, 7, and 14, respectively. The rat SAH model was induced by injection of 0.3 ml fresh arterial, non-heparinized blood into the prechiasmatic cistern in 20 s. Immunostaining and immunoblotting experiments were performed to detect the expression of SynCAM 1 protein. The clinical behavior scale was measured on day 14 after SAH. The expression of SynCAM 1 protein was decreased remarkably in SAH groups compared with the sham group. The down-regulated expression of SynCAM 1 was detected after SAH and the low ebb was on days 1-3. The immunohistochemical staining demonstrated expression of SynCAM 1 was present mainly in the neurons in all of the three different regions such as cortex, hippocampus, and cerebellum. The clinical behavior scale was significantly decreased compared with sham rats. Our results indicate that SynCAM 1 expression is down-regulated in the brain after experimental SAH. These finding suggests that decreased SynCAM 1 expression may facilitate the development of cognitive dysfunction after SAH. PMID:23179183
Wang, Zhong; Hu, Tong; Feng, Dongxia; Chen, Gang
The term mitophagy is coined to describe the selective removal of mitochondria by autophagy but the process itself is still contentious, especially in the early period following subarachnoid hemorrhage (SAH). In the present study, we investigated the role of mitophagy following 48h after SAH injury in rats. Specifically evaluating whether mitophagy, through voltage dependant anion channels (VDACs) interacting with microtubule-associated protein 1 light chain 3, could orchestrate the induction of apoptotic and necrotic cell death in neurons, a VDAC1siRNA and an activitor Rapamycian (RAPA), were engaged. One hundred and twelve male Sprague-Dawley rats were randomly divided into 4 groups: Sham, SAH, SAH+VDAC1siRNA, and SAH+RAPA. Outcomes measured included mortality rate, brain edema, BBB disruption, and neurobehavioral testing. We also used western blotting techniques to analyze the expressions of key mitophagic/autophagic proteins and pro-apoptotic protein such as ROS, VDAC1, LC-3II and Caspase-3. Rapamycin treatment significantly improved the mortality rate, cerebral edema, and neurobehavioral deficits; apoptotic and necrotic cell death in neurons were reduced by Rapamycin following SAH injury. However, VDAC1siRNA worsened the brain injury following SAH. Immunohistochemical staining and western blot analysis demonstrated a decreased expression of VDAC1, LC3II, and an increase of ROS and Caspase-3 followed by VDAC1siRNA administration. In conclusion, mitophagy induced by VDAC1 following SAH injury may in fact play a significant role in neuroprotection, the mechanism which may be through the attenuation of the apoptosic and necrosic molecular pathways. This translates a preservation of functional integrity and an improvement in mortality. PMID:24880016
Li, Jian; Lu, Jianfei; Mi, Yongjie; Shi, Zhao; Chen, Chunhua; Riley, John; Zhou, Changman
In North America, approximately 30,000 people annually suffer an aneurismal subarachnoid hemorrhage (SAH). Using computerized tomography (CT), the blood is generally not visible after 12 hours. Currently lumbar puncture (LP) results are equivocal for diagnosing SAH largely because of technical limitations in performing a quick and objective evaluation. Having ruptured once, an aneurysm is statistically more likely to rupture again. Therefore, for those individuals with a sentinel (or warning) hemorrhage, detection within the first 12 hours is paramount. We present a diagnostic technology based on visible spectroscopy to quickly and objectively assess low-blood volume SAH from a diagnostic spinal tap. This technology provides clinicians, with the resources necessary for assessing patients with suspected aneurismal SAH beyond the current 12-hour limitation imposed by CT scans. This aids in the improvement of patient care and results in rapid and appropriate treatment of the patient. To perform this diagnosis, we quantify bilirubin and hemoglobin in human CSF over a range of concentrations. Because the bilirubin and hemoglobin spectra overlap quantification is problematic. To solve this problem, two algorithmic approaches are presented: a statistical or a random stochastic component known as Partial Least Square (PLS) and a control theory based mathematical model. These algorithms account for the noise and distortion from blood in CSF leading to the quantification of bilirubin and methemoglobin spectroscopically. The configurations for a hardware platform is introduced, that is portable and user-friendly composed of specific components designed to have the sensitivity and specificity required. This aids in measuring bilirubin in CSF, hemorrhagic-CSF and CSF-like solutions. The prototype uses purpose built algorithms contained within the platform, such that physicians can use it in the hospital and lab as a point of care diagnostic test.
Salgaonkar, Vasant A.; Bhadri, Prashant R.; Huang, Jian; Kumar, Alla S.; Pyne, Gail J.; Caffery, James, Jr.; Clark, Joseph F.; Shukla, Rakesh; Beyette, Fred R., Jr.
We present a case of hemorrhagic bullous dermatosis occurring in areas distant from the site of injection of enoxaparin. A 88 year old woman was admitted for inter trochantric fracture. She was put enoxaparin 60mg subcutaneous 12 hrly for deep vein thrombosis. After 5 days she developed huge hemorrhagic bulla on left leg and multiple hemorrhagic bullae at other sites distant from injected site. A diagnosis of Bullous hemorrhagic dermatoses due to enoxaparin was made. Enoxaparin was stopped and started on oral heparin. Lesions started to regress. Only 9 similar cases have been reported throughout world and none from India.
Naveen, Kikkeri Narayanasetty; Rai, Vijetha
Intracerebral hemorrhage and subarachnoid hemorrhage account for almost 20% of all stroke cases. Both forms of stroke are associated with a high morbidity and mortality rate. The incidence of intracerebral hemorrhage increases with the age and certain ethnical groups are more affected. Subarachnoid hemorrhage tends to occur in a much younger population than other types of strokes. Outcome predictors for intracerebral and subarachnoid hemorrhage have been extensively discussed in the literature. Based on the current literature, we review the morbidity and mortality rates and predictors of outcome for these two life-threatening diseases. Initial Glasgow Coma Scale (GCS) score, hematoma volume, and presence of ventricular blood are the most prominent predictors of outcome following intracerebral hemorrhage. Age and initial severity of neurologic deficits on presentation, measured by GCS, Hunt and Hess Scale or the World Federation of Neurological Surgeons Scale, are the most important predictors of outcome following subarachnoid hemorrhage. PMID:12074438
Hanel, Ricardo A; Xavier, Andrew R; Mohammad, Yousef; Kirmani, Jawad F; Yahia, Abutaher M; Qureshi, Adnan I
Cerebral vasospasm (CVS) is the most treatable component of subarachnoid hemorrhage (SAH), which can be reduced by endothelin receptor antagonists. Endothelin-evoked vasospasm is considered to be mediated by Ca(2+) influx in the smooth muscle through voltage-dependent Ca(2+) channel (VDCC) and nonselective cation channels (NSCC). Because VDCC antagonists such as nimodipine have been shown to be relatively less effective than the endothelin receptor antagonists, it is assumed that NSCC maybe a more important component in mediating Ca(2+) influx during CVS. In this study, we used the basilar arteries from a "two-hemorrhage" rat model of SAH to investigate expressions of transient receptor potential channel 1 (TRPC1), transient receptor potential channel 3 (TRPC3) and stromal interaction molecule 1 (STIM1), which are considered as the promising candidates constituting NSCC. To investigate the possible role of NSCC in phenotypic switching, we performed immunohistochemical staining to examine expressions of SM?-actin and PCNA, markers of smooth muscle phenotypic switching. We found that the basilar arteries exhibited vasospasm after SAH and that vasospasm became more severe on days 5 and 7 after SAH. Elevated mRNA and protein expressions of TRPC1 and STIM1 were detected after SAH and peaked on days 5 and 7, which was in a parallel time course to the development of cerebral vasospasm. The mRNA and protein expressions of TRPC3 were not changed in the SAH group when compared with those in the control. Results of immunohistochemical staining with anti-PCNA and anti-SM?-actin antibodies also showed enhanced expression of PCNA and disappearance of SM?-actin from day 1 to day 7. Taken together, the above results supported a novel mechanism that the components of store-operated calcium channels, TRPC1 and STIM1 mediated the Ca(2+) influx and phenotypic switching in smooth muscle cells, which promoted the development of vasospasm after SAH. TRPC3, which is a component of receptor-operated calcium channels, was not involved in the above-mentioned mechanism. PMID:23542055
Song, Jin-Ning; Yan, Wen-Tao; An, Ji-Yang; Hao, Guang-Shan; Guo, Xiao-Ye; Zhang, Ming; Li, Yu; Li, Dan-Dong; Sun, Peng
Background and Purpose—Small asymptomatic cerebral hemorrhages detectable by gradient-echo MRI are common in patients with intracerebral hemorrhage (ICH), particularly lobar ICH related to cerebral amyloid angiopathy (CAA). We sought to determine whether hemorrhages detected at the time of lobar ICH predict the major clinical complications of CAA: recurrent ICH or decline in cognition and function. Methods—Ninety-four consecutive survivors of primary
Steven M. Greenberg; Jessica A. Eng; MingMing Ning; Eric E. Smith; Jonathan Rosand
Opinion Statement Aneurysmal subarachnoid hemorrhage induces a potent inflammatory cascade that contributes to endothelial dysfunction, imbalance of vasoactive substances (excess endothelin, depletion of nitric oxide) and arterial vasospasm. This process results in delayed cerebral ischemia, a major cause of neurological disability in those surviving the initial hemorrhage. The only therapy shown to be effective in improving neurologic outcomes after SAH is the calcium-channel antagonist, nimodipine (although it achieved this without reducing vasospasm). A number of novel therapies have been explored to inhibit the development of vasospasm and reduce the burden of ischemia and cerebral infarction. Statins are promising candidates, as they block multiple aspects of the inflammatory pathway that contributes to ischemic brain injury. Early clinical trials, however, have produced conflicting results and adoption of their use in clinical practice should await the results of larger more definitive studies. While endothelin-receptor antagonists showed promise in significantly reducing vasospasm in preliminary trials, their failure to improve clinical outcomes in phase III studies has been disappointing, highlighting the complex link between vasospasm and ischemia. Future directions in the quest to improve outcomes of patients with SAH may need to approach ischemia as a multifactorial process with inflammatory, vasoactive, and ionic/metabolic components.
Dhar, Rajat; Diringer, Michael
One-half of deaths among trauma victims occur within 1 hour of injury and are due to rapid hemorrhage or CNS trauma. We developed a rapid hemorrhage model in unanesthetized swine to simulate human exsanguination. We compared the ability of four crystalloi...
L. W. Traverso W. P. Lee M. J. Langford L. D. Witcher
Recovery from aneurysmal subarachnoid hemorrhage (SAH) is often incomplete and accompanied by subtle but persistent cognitive deficits. Previous neuropsychological reports indicate these deficits include most prominently memory impairment, with working memory particularly affected. The neural basis of these memory deficits remains unknown and unexplored by functional magnetic resonance imaging (fMRI). In the present study, patients who experienced (SAH) underwent fMRI during the performance of a verbal working memory paradigm. Behavioral results indicated a subtle but statistically significant impairment relative to healthy subjects in working memory performance accuracy, which was accompanied by relatively increased blood-oxygen level dependent signal in widespread left and right hemisphere cortical areas during periods of encoding, maintenance, and retrieval. Activity increases remained after factoring out inter-individual differences in age and task performance, and included most notably left hemisphere regions associated with phonological loop processing, bilateral sensorimotor regions, and right hemisphere dorsolateral prefrontal cortex. We conclude that deficits in verbal working memory following recovery from (SAH) are accompanied by widespread differences in hemodynamic correlates of neural activity. These differences are discussed with respect to the immediate and delayed focal and global brain damage that can occur following (SAH), and the possibility that this damage induces subcortical disconnection and subsequent decreased efficiency in neural processing.
Ellmore, Timothy M.; Rohlffs, Fiona; Khursheed, Faraz
Background Rebleeding is a serious complication of aneurysmal subarachnoid hemorrhaging. To date, there are conflicting data regarding the factors contributing to rebleeding and their significance. Methods A systematic review of PubMed and Embase databases was conducted for studies pertaining to aneurysmal subarachnoid hemorrhage (aSAH) and rebleeding in order to assess the associated risk factors. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were estimated from fourteen studies comprised of a total of 5693 patients that met the inclusion criteria. Results Higher rebleeding rates were observed < 6 h after the initial aSAH (OR ?=?3.22, 95% CI ?=?1.46–7.12), and were associated with high systolic blood pressure (OR ?=?1.93, 95% CI ?=?1.31–2.83), poor Hunt-Hess grade (III–IV) (OR ?=?3.43, 95% CI ?=?2.33–5.05), intracerebral or intraventricular hematomas (OR ?=?1.65, 95% CI ?=?1.33–2.05), posterior circulation aneurysms (OR ?=?2.15, 95% CI ?=?1.32–3.49), and aneurysms >10 mm in size (OR ?=?1.70, 95% CI ?=?1.35–2.14). Conclusions Aneurysmal rebleeding occurs more frequently within the first 6 hours after the initial aSAH. Risk factors associated with rebleeding include high systolic pressure, the presence of an intracerebral or intraventricular hematoma, poor Hunt-Hess grade (III-IV), aneurysms in the posterior circulation, and an aneurysm >10 mm in size.
Tang, Chao; Zhang, Tian-Song; Zhou, Liang-Fu
Despite extensive effort to elucidate the cellular and molecular bases for delayed cerebral injury after aneurysmal subarachnoid hemorrhage (aSAH), the pathophysiology of these events remains poorly understood. Recently, much work has focused on evaluating the genetic underpinnings of various diseases in an effort to delineate the contribution of specific molecular pathways as well as to uncover novel mechanisms. The majority of subarachnoid hemorrhage genetic research has focused on gene expression and linkage studies of these markers as they relate to the development of intracranial aneurysms and their subsequent rupture. Far less work has centered on the genetic determinants of cerebral vasospasm, the predisposition to delayed cerebral injury, and the determinants of ensuing functional outcome after aSAH. The suspected genes are diverse and encompass multiple functional systems including fibrinolysis, inflammation, vascular reactivity, and neuronal repair. To this end, we present a systematic review of 21 studies suggesting a genetic basis for clinical outcome after aSAH, with a special emphasis on the pathogenesis of cerebral vasospasm and delayed cerebral ischemia. In addition, we highlight potential pitfalls in the interpretation of genetic association studies, and call for uniformity of design of larger multicenter studies in the future.
Ducruet, Andrew F; Gigante, Paul R; Hickman, Zachary L; Zacharia, Brad E; Arias, Eric J; Grobelny, Bartosz T; Gorski, Justin W; Mayer, Stephan A; Connolly, E Sander
Vascular endothelial growth factor (VEGF) stimulating angiogenesis was shown to be a potential novel therapeutic approach for the treatment of ischemic vascular diseases. The goal of the present study was to examine whether transfection of VEGF before occurrence of major stroke (part I) and cerebral vasospasm after experimental subarachnoid hemorrhage (SAH; part II) develops neuroprotective qualities. A total of 25 (part I) and 26 (part II) brains were analyzed, respectively. In part one, a significant reduction of infarct volume in the VEGF-treated stroke animals (43% reduction, P < 0.05) could be detected. In part two, significant vasospasm was induced in all hemorrhage groups (P < 0.02). Analyzing microperfusion, a significant higher amount of perfused vessels could be detected (P < 0.01), whereas no significant effect could be detected towards macroperfusion. Histologically, no infarctions were observed in the VEGF-treated SAH group and the sham-operated group. Minor infarction in terms of vasospasm-induced small lesions could be detected in the control vector transduced group (P = 0.05) and saline-treated group (P = 0.09). The present study demonstrates the preconditioning impact of systemic intramuscular VEGF injection in animals after major stroke and induced severe vasospasm after SAH.
Eicker, Sven Oliver; Hoppe, Moritz; Etminan, Nima; Macht, Stephan; Perrin, Jason; Steiger, Hans-Jakob; Hanggi, Daniel
Vascular endothelial growth factor (VEGF) stimulating angiogenesis was shown to be a potential novel therapeutic approach for the treatment of ischemic vascular diseases. The goal of the present study was to examine whether transfection of VEGF before occurrence of major stroke (part I) and cerebral vasospasm after experimental subarachnoid hemorrhage (SAH; part II) develops neuroprotective qualities. A total of 25 (part I) and 26 (part II) brains were analyzed, respectively. In part one, a significant reduction of infarct volume in the VEGF-treated stroke animals (43% reduction, P < 0.05) could be detected. In part two, significant vasospasm was induced in all hemorrhage groups (P < 0.02). Analyzing microperfusion, a significant higher amount of perfused vessels could be detected (P < 0.01), whereas no significant effect could be detected towards macroperfusion. Histologically, no infarctions were observed in the VEGF-treated SAH group and the sham-operated group. Minor infarction in terms of vasospasm-induced small lesions could be detected in the control vector transduced group (P = 0.05) and saline-treated group (P = 0.09). The present study demonstrates the preconditioning impact of systemic intramuscular VEGF injection in animals after major stroke and induced severe vasospasm after SAH. PMID:23634319
Eicker, Sven Oliver; Hoppe, Moritz; Etminan, Nima; Macht, Stephan; Perrin, Jason; Steiger, Hans-Jakob; Hänggi, Daniel
Nontraumatic orbital hemorrhage (NTOH) is uncommon. I summarize the published reports of NTOH and offer a classification based on anatomic and etiologic factors. Anatomic patterns of NTOH include diffuse intraorbital hemorrhage, "encysted" hemorrhage (hematic cyst), subperiosteal hemorrhage, hemorrhage in relation to extraocular muscles, and hemorrhage in relation to orbital floor implants. Etiologic factors include vascular malformations and lesions, increased venous pressure, bleeding disorders, infection and inflammation, and neoplastic and nonneoplastic orbital lesions. The majority of NTOH patients can be managed conservatively, but some will have visual compromise and may require operative intervention. Some will suffer permanent visual loss, but a large majority have a good visual outcome. PMID:24359805
McNab, Alan A
Backgrounds Early brain injury (EBI) plays a key role in the pathogenesis of subarachnoid hemorrhage (SAH). Neuronal apoptosis is involved in the pathological process of EBI. Hydrogen can inhibit neuronal apoptosis and attenuate EBI following SAH. However, the molecular mechanism underlying hydrogen-mediated anti-apoptotic effects in SAH has not been elucidated. In the present study, we aimed to evaluate whether hydrogen alleviates EBI after SAH, specifically neuronal apoptosis, partially via the Akt/GSK3? signaling pathway. Methods Sprague-Dawley rats (n?=?85) were randomly divided into the following groups: sham group (n?=?17), SAH group (n?=?17), SAH + saline group (n?=?17), SAH + hydrogen-rich saline (HS) group (n?=?17) and SAH + HS + Ly294002 (n?=?17) group. HS or an equal volume of physiological saline was administered immediately after surgery and repeated 8 hours later. The PI3K inhibitor, Ly294002, was applied to manipulate the proposed pathway. Neurological score and SAH grade were assessed at 24 hours after SAH. Western blot was used for the quantification of Akt, pAkt, GSK3?, pGSK3?, Bcl-2, Bax and cleaved caspase-3 proteins. Neuronal apoptosis was identified by double staining of terminal deoxynucleotidyl transferase mediated nick end labeling (TUNEL) staining and NeuN, and quantified by apoptosis index. Immunohistochemistry and immunofluorescent double-labeling staining was performed to clarify the relationships between neuronal apoptosis and pAkt or pGSK3?. Results HS significantly reduced neuronal apoptosis and improved neurological function at 24 hours after SAH. The levels of pAkt and pGSK3?, mainly expressed in neurons, were markedly up-regulated. Additionally, Bcl-2 was significantly increased while Bax and cleaved caspase-3 was decreased by HS treatment. Double staining of pAkt and TUNEL showed few colocalization of pAkt-positive cells and TUNEL-positive cells. The inhibitor of PI3K, Ly294002, suppressed the beneficial effects of HS. Conclusions HS could attenuate neuronal apoptosis in EBI and improve the neurofunctional outcome after SAH, partially via the Akt/GSK3? pathway.
Wang, Jianfeng; Chen, Sheng; Wu, HaiJian; McBride, Devin W.; Wu, Qun; Sun, XueJun; Zhang, JianMin
Cerebral microdialysis (CMD) is a laboratory tool that provides on-line analysis of brain biochemistry via a thin, fenestrated, double-lumen dialysis catheter that is inserted into the interstitium of the brain. A solute is slowly infused into the catheter at a constant velocity. The fenestrated membranes at the tip of the catheter permit free diffusion of molecules between the brain interstitium and the perfusate, which is subsequently collected for laboratory analysis. The major molecules studied using this method are glucose, lactate, pyruvate, glutamate, and glycerol. The collected substances provide insight into the neurochemical features of secondary injury following traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) and valuable information about changes in brain metabolism within a short time frame. In this review, the authors detail the CMD technique and its associated markers and then describe pertinent findings from the literature about the clinical application of CMD in TBI and SAH. PMID:24072457
de Lima Oliveira, Marcelo; Kairalla, Ana Carolina; Fonoff, Erich Talamoni; Martinez, Raquel Chacon Ruiz; Teixeira, Manoel Jacobsen; Bor-Seng-Shu, Edson
A prospective study was made of 30 patients, admitted to the neurology ward with subarachnoidal hemorrhage (SAH), at its onset. The diagnosis was established on the basis of anamnesis, clinical examination, spinal puncture, anatomopathological examination. The patients with other cerebrovascular affections or with antecedents of ischaemic cardiac affections were excluded. ECG tracings, serum ionogram, AT and VA at the onset and in evolution, and their modifications were followed and assessed in all the patients. The conclusion is reached that SAH in acute phase is associated with transitory ECG and pressure anomalies which become elements of unfavourable prognosis when persistent and deeply altered. They are valuable, at hand, elements in the differential diagnosis, and in the opportune therapeutical intervention. PMID:2575277
Popescu, M; Nu??, G; Toma, D
Gases such as nitric oxide (NO) and carbon monoxide (CO) play important roles both in normal physiology and in disease. Recent studies have shown that hydrogen sulfide (H2S) protects neurons against oxidative stress and ischemia-reperfusion injury and attenuates lipopolysaccharides (LPS) induced neuroinflammation in microglia, exhibiting anti-inflammatory and antiapoptotic activities. The gas H2S is emerging as a novel regulator of important physiologic functions such as arterial diameter, blood flow, and leukocyte adhesion. It has been known that multiple factors, including oxidative stress, free radicals, and neuronal nitric oxide synthesis as well as abnormal inflammatory responses, are involved in the mechanism underlying the brain injury after subarachnoid hemorrhage (SAH). Based on the multiple physiologic functions of H2S, we speculate that it might be a promising, effective, and specific therapy for brain injury after SAH.
Yu, Yong-Peng; Chi, Xiang-Lin; Liu, Li-Jun
Subarachnoid hemorrhage (SAH) is a frequent occurrence in cerebrovascular accidents, and inflammation occurs in the subarachnoid space after SAH. Arachnoid cells have the capability to present antigens and active T-lymphocytes after stimulation by cerebrospinal fluid (CSF). However, the effect of CSF on T-lymphocytes and arachnoid cell adhesion was not clearly understood. In this study, we used ELISA to detected tumor necrosis factor-? (TNF-?) content in CSF of SAH patients. CSF or recombinant TNF-? were applied on arachnoid cells and T-lymphoctes, and RT-PCR and western blotting were performed to determine the expression of intercellular adhesion molecule-1 (ICAM-1) in arachnoid cells and Lymphocyte Function-Associated Antigen-1 (LFA-1) in T-lymphocytes, respectively. Meanwhile, the Matrix Metal Proteinase-9 (MMP-9) expression in these cells was also determined. We found that the content of TNF-? in the CSF was significantly increased in the CSF of SAH patients (from 22 ± 8 pg/mL of healthy people to 436-450 pg/mL of SAH patients). Treatement with CSF could increase the expression of ICAM-1 in arachnoid cells and that of LFA-1 in T-lymphocytes, mainly through the increased levels of TNF-?. We also found that the co-culture of arachnoid cells and T-lymphocytes increased the expression of MMP-9 in both cells through the interaction of ICAM-1 of and LFA-1. All of these results suggested that arachnoid cells are involved in the T-lymphocytes invasion in the subarachnoid space after SAH. PMID:23548604
Xie, Xin; Wu, Xiaokang; Cui, Jihong; Li, Hongmin; Yan, Xingrong
Background Care of individuals in the intensive care unit (ICU) with brain injury traditionally focuses on maintaining ABP and ICP within prescribed ranges. However research suggests that the dynamic variability of these pressure signals provides additional information about physiologic functioning and may reflect adaptive capacity. Objectives The purpose of this study was to examine the ability to predict long-term outcome from arterial blood pressure (ABP) and intracranial pressure (ICP) variability in patients with aneurysmal subarachnoid hemorrhage (SAH). Methods ABP and ICP were monitored continuously for four days in 90 patients (74% female; mean age 53 years) in an ICU following SAH. Variability of ABP and ICP signals was calculated at four time scales (24-hour, hourly, 5-minute, and difference of sequential 5second averages). Long-term functional outcome was assessed 6 months post-SAH using the Extended Glasgow Outcome Scale. Results Pressure (ABP, ICP) variability indices were better predictors of 6-month functional outcome than mean pressure levels. Indices reflecting faster variability (particularly 5-second) were positively associated with better long-term outcome (typical p<0.001), while greater 24-hour variability was related to poorer outcomes (typical p <0.001), controlling for initial neurologic condition. Conclusions Beyond the measurement of ABP and ICP levels in acutely ill patients with SAH, simple measures of variability of these signals provide prognostic information regarding long-term functional outcome. The relationship between outcome and ICP and ABP variability in SAH 2 variability was dependent on the time scale at which the variability was measured. Given its positive association with better outcome, greater faster variability may reflect better physiologic adaptive capacity.
Kirkness, Catherine J.; Burr, Robert L.; Mitchell, Pamela H.
Background Angiopoietin-1 (Ang-1) and -2 (Ang-2) are keyplayers in the regulation of endothelial homeostasis and vascular proliferation. Angiopoietins may play an important role in the pathophysiology of cerebral vasospasm (CVS). Ang-1 and Ang-2 have not been investigated in this regard so far. Methods 20 patients with subarachnoid hemorrhage (SAH) and 20 healthy controls (HC) were included in this prospective study. Blood samples were collected from days 1 to 7 and every other day thereafter. Ang-1 and Ang-2 were measured in serum samples using commercially available enzyme-linked immunosorbent assay. Transcranial Doppler sonography was performed to monitor the occurrence of cerebral vasospasm. Results SAH patients showed a significant drop of Ang-1 levels on day 2 and 3 post SAH compared to baseline and HC. Patients, who developed Doppler sonographic CVS, showed significantly lower levels of Ang-1 with a sustained decrease in contrast to patients without Doppler sonographic CVS, whose Ang-1 levels recovered in the later course of the disease. In patients developing cerebral ischemia attributable to vasospasm significantly lower Ang-1 levels have already been observed on the day of admission. Differences of Ang-2 between SAH patients and HC or patients with and without Doppler sonographic CVS were not statistically significant. Conclusions Ang-1, but not Ang-2, is significantly altered in patients suffering from SAH and especially in those experiencing CVS and cerebral ischemia. The loss of vascular integrity, regulated by Ang-1, might be in part responsible for the development of cerebral vasospasm and subsequent cerebral ischemia.
Subarachnoid hemorrhage (SAH), one of the serious types of stroke incurred by bleeding into the space surrounding the brain, occurs when brains are deprived of oxygen by various factors, particularly an interruption to the blood supply or a ruptured aneurysm. Cerebral vasospasm (CVS) is one of the most common complications of SAH. It has been proposed that platelet?derived growth factor (PDGF) is involved in CVS. The aim of the present study was to analyze expression of PDGF in rabbit models of CVS. Post-SAH CVS rabbit models were created using endovascular puncture and employed to analyze the expression patterns of PDGF by enzyme-linked immunosorbent assay and immunohistochemistry. The results indicated that the creation of the rabbit model of CVS induced using endovascular puncture was successful and demonstrated the double phase changes observed in human CVS. The acute stage started at 12 h post-SAH with narrowing of the vascular lumen diameter. This narrowing appeared again on the seventh day in delayed CVS alongside increased thickness of vessel walls. PDGF-? expression was observed in vascular smooth muscle cells of the rabbit models. PDGF-? was expressed as early as 3 h post-SAH, it was evident after 1 day and reached a peak in 7 days, suggesting that PDGF-? is involved in the early stages of CVS. In the current study, it was confirmed that PDGF-? expression was present in the rabbit models of CVS, which may aid the elucidation of the pathogenesis of CVS, and also provide useful information for diagnosis and treatment of CVS. PMID:24969827
Cui, Hong-Kai; Yan, Rui-Fang; Ding, Xiao-Li; Zhao, Peng; Wu, Qing-Wu; Wang, Hong-Po; Qin, Hai-Xia; Tu, Jian-Fei; Yang, Rui-Min
Objective Cerebral vasospasm is a common and potentially devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). Inflammatory processes seem to play a major role in the pathogenesis of vasospasm. C-reactive protein (CRP) constitutes a highly sensitive inflammatory marker. Elevation of serum CRP levels has been demonstrated in patients with aSAH. The purpose of the current study was to evaluate the possible relationship between CRP levels in the serum and transcranial Doppler (TCD) and the development of vasospasm in patients with aSAH. Methods A total of 61 adult patients in whom aSAH was diagnosed were included in the study from November 2008 to May 2011. The patients' demographics, Hunt and Hess grade, Fisher grade, CT scans, digital subtraction angiography studies, and daily neurological examinations were recorded. Serial serum CRP measurements were obtained on days 1, 3, 5, 7, 9, 11 and 13 and TCD was measured on days 3, 5, 7, 9, 11 and 13. All patients underwent either surgical or endovascular treatment within 24 hours of their hemorrhagic attacks. Results Serum CRP levels peaked on the 3rd postoperative day. There were significant differences between the vasospasm group and the non-vasospasm group on the 1st, 3rd and 5th day. There were significant differences between the vasospasm group and the non-vasospasm group on the 3rd day in the mean middle cerebral artery velocities on TCD. Conclusion Patients with high levels of CRP on the 1st postoperative day and high velocity of mean TCD on the 3rd postoperative day may require closer observation to monitor for the development of vasospasm.
Hwang, Sung-Hwan; Kwon, Jeong-Taik; Nam, Taek-Kyun; Hwang, Sung-Nam; Kang, Hyun
Introduction: Subarachnoid hemorrhage (SAH) can trigger immune activation sufficient to induce the systemic inflammatory response syndrome (SIRS). This may promote both extra-cerebral organ dysfunction and delayed cerebral ischemia, contributing to worse outcome. We ascertained the frequency and predictors of SIRS after spontaneous SAH, and determined whether degree of early systemic inflammation predicted the occurrence of vasospasm and clinical outcome. Methods: Retrospective analysis of prospectively collected data on 276 consecutive patients admitted to a neurosciences intensive care unit with acute, non-traumatic SAH between 2002 and 2005. A daily SIRS score was derived by summing the number of variables meeting standard criteria (HR >90, RR >20, Temperature >38°C or <36°C, WBC count <4,000 or >12,000). SIRS was considered present if two or more criteria were met, while SIRS burden over the first four days was calculated by averaging daily scores. Regression modeling was used to determine the relationship between SIRS burden (after controlling for confounders including infection, surgery, and corticosteroid use), symptomatic vasospasm, and outcome, determined by hospital disposition. Results: SIRS was present in over half the patients on admission and developed in 85% within the first four days. Factors associated with SIRS included poor clinical grade, thick cisternal blood, larger aneurysm size, higher admission blood pressure, and surgery for aneurysm clipping. Higher SIRS burden was independently associated with death or discharge to nursing home (OR 2.20/point, 95% CI 1.27-3.81). All of those developing clinical vasospasm had evidence of SIRS, with greater SIRS burden predicting increased risk for delayed ischemic neurological deficits (OR 1.77/point, 95% CI 1.12-2.80). Conclusions: Systemic inflammatory activation is common after SAH even in the absence of infection; it is more frequent in those with more severe hemorrhage and in those who undergo surgical clipping. Higher burden of SIRS in the initial four days independently predicts symptomatic vasospasm and is associated with worse outcome.
Dhar, Rajat; Diringer, Michael N.
Objective Tonic-clonic activity (TCA) at onset complicates 3% to 21% of cases of subarachnoid hemorrhage (SAH). The impact of onset TCA on in-hospital complications, including seizures, remains unclear. One study associated onset TCA with poor clinical outcome at 6 weeks after SAH, but to our knowledge no other studies have confirmed this relationship. This study aims to assess the impact of onset TCA on in-hospital complications, poor functional outcome, mortality, and epilepsy at 3 months. Methods Analysis of a prospective study cohort of 1479 SAH patients admitted to Columbia University Medical Center between 1996 and 2012. TCA within 6 hours of hemorrhage onset was identified based on accounts of emergency care providers or family witnesses. Results TCA at onset was described in 170 patients (11%). Patients with onset TCA were younger (P?=?0.002), presented more often with poor clinical grade (55% vs. 26%, P<0.001) and had larger amounts of cisternal, intraventricular, and intracerebral blood than those without onset TCA (all, P<0.001). After adjusting for known confounders, onset TCA was significantly associated with in-hospital seizures (OR 3.80, 95%-CI: 2.43–5.96, P<0.001), in-hospital pneumonia (OR 1.56, 95%-CI: 1.06–2.31, p?=?0.02), and delayed cerebral ischemia (OR 1.77, 95%-CI: 1.21–2.58, P?=?0.003). At 3 months, however, onset TCA was not associated with poor functional outcome, mortality, and epilepsy after adjusting for age, admission clinical grade, and cisternal blood volume. Conclusions Onset TCA is not a rare event as it complicates 11% of cases of SAH. New and clinically relevant findings are the association of onset TCA with in-hospital seizures, pneumonia and delayed cerebral ischemia. Despite the increased risk of in-hospital complications, onset TCA is not associated with disability, mortality, and epilepsy at 3 months.
De Marchis, Gian Marco; Pugin, Deborah; Lantigua, Hector; Zammit, Christopher; Tadi, Prasanna; Schmidt, J. Michael; Falo, M. Cristina; Agarwal, Sachin; Mayer, Stephan A.; Claassen, Jan
Background Aneurysmal subarachnoid hemorrhage (SAH) may produce cerebral ischemia and systemic responses including stress. To study immediate cerebral and systemic changes in response to aneurysm rupture, animal models are needed. Objective To study early cerebral energy changes in an animal model. Methods Experimental SAH was induced in 11 pigs by autologous blood injection to the anterior skull base, with simultaneous control of intracranial and cerebral perfusion pressures. Intracerebral microdialysis was used to monitor concentrations of glucose, pyruvate and lactate. Results In nine of the pigs, a pattern of transient ischemia was produced, with a dramatic reduction of cerebral perfusion pressure soon after blood injection, associated with a quick glucose and pyruvate decrease. This was followed by a lactate increase and a delayed pyruvate increase, producing a marked but short elevation of the lactate/pyruvate ratio. Glucose, pyruvate, lactate and lactate/pyruvate ratio thereafter returned toward baseline. The two remaining pigs had a more severe metabolic reaction with glucose and pyruvate rapidly decreasing to undetectable levels while lactate increased and remained elevated, suggesting persisting ischemia. Conclusion The animal model simulates the conditions of SAH not only by deposition of blood in the basal cisterns, but also creating the transient global ischemic impact of aneurysmal SAH. The metabolic cerebral changes suggest immediate transient substrate failure followed by hypermetabolism of glucose upon reperfusion. The model has features that resemble spontaneous bleeding, and is suitable for future research of the early cerebral and systemic responses to SAH that are difficult to study in humans.
Nyberg, Christoffer; Karlsson, Torbjorn; Hillered, Lars; Engstrom, Elisabeth Ronne
We have shown recently that estrogen receptor (ER) ligands share a diphenyl ethane pharmacophore with Sah 58-035 [3-[decyldimethylsilyl]-N-[2-(4-methylphenyl)-1-phenylethyl]-propanamide], a prototypical inhibitor of the acyl-cholesterolacyl-transferase (ACAT), which enabled us to establish that ER ligands were potent inhibitors of ACAT and blocked the formation of foam cells. In the present study, we have tested whether this structural similarity means that Sah 58-035 is an ER modulator. We report that Sah 58-035 bound to ERalpha and ERbeta with an IC(50) of 2.9 and 3.1 microM, respectively. Docking studies using molecular modeling of Sah 58-035 with the X-ray structure of the ER showed that Sah 58-035 fits well into the ligand binding site known for 4-hydroxy-tamoxifen. Despite having high three-dimensional structural similarities with the pure antiestrogen ICI 164,384 [(N-n-butyl-N-methyl-11-[3,17beta-di-hydroxyestra-1,3, 5(10)-trien-7alpha-yl]-undecanamide], we showed that Sah 58-035 is an agonist of ER for transcription and cellular proliferation. These data showed that Sah 58-035 was an estrogen receptor agonist and that the size and the chemical nature of the side chain were critical for agonist versus antagonist activity on ER. This new molecular mechanism of action for Sah 58-035 has to be taken into account in understanding better its pharmacological activities. Moreover, these data give new structural insights into the understanding of agonist versus antagonist activities of ER ligands and also for the conception of new drugs with a dual ACAT inhibition and ER modulation potential and their evaluation in different pathologies where both targets are involved, such as atherosclerosis, Alzheimer's disease, and cancer. PMID:16835370
de Medina, Philippe; Boubekeur, Nadia; Balaguer, Patrick; Favre, Gilles; Silvente-Poirot, Sandrine; Poirot, Marc
Retinal hemorrhages in children in the absence of risk factors are regarded to be pathognomonic of shaken baby syndrome or other nonaccidental injuries. The physician must decide whether the retinal hemorrhages in children without risk factors are due to abuse or cardiopulmonary resuscitation with chest compression (CPR-CC). The objective of this study was to determine if CPR-CC can lead to retinal hemorrhages in children. Twenty-two patients who received in-hospital CPR-CC between February 15, 1990, and June 15, 1990, were enrolled. Pediatric ophthalmology fellows carried a code beeper and responded to calls for cardiopulmonary arrest situations. At the scene of CPR-CC, an indirect funduscopic examination was conducted for presence of retinal hemorrhages in the posterior pole. Follow-up examinations were performed at 24 and 72 hours. Of the 22 patients, 6 (27%) had retinal hemorrhages at the time of CPR-CC. Of these 6 patients, 5 had risk factors for retinal hemorrhages. The sixth patient had no risk factors and may have represented the only true case of retinal hemorrhages due to CPR-CC. Retinal hemorrhages are uncommon findings after CPR-CC. Retinal hemorrhages that are found after CPR-CC usually occur in the presence of other risk factors for hemorrhage with a mild hemorrhagic retinopathy in the posterior pole. PMID:23629401
Pham, Hang; Enzenauer, Robert W; Elder, James E; Levin, Alex V
A case of a dissecting vertebral aneurysm concurrent with contralateral cerebellar hemorrhage is reported. A 69-year-old man was referred to our hospital for treatment of subarachnoid hemorrhage (SAH). On admission, CT scanning showed SAH and left cerebellar hematoma. Angiography was performed and it revealed a dissecting aneurysm of the right vertebral artery. Proximal clipping of the right vertebral dissecting artery was performed through right suboccipital craniotomy. During the operation, the cerebellar hemisphere gradually became firm, but the operation was finished without any complications. After the operation, the patient's consciousness level decreased from somnolence to semicomatose for a period of 2 hours 30 min. CT scanning showed the left cerebellar hematoma expanding. The cerebellar hematoma was evacuated immediately by midline suboccipital craniectomy, and the patient's consciousness level improved. In such a case, care must be taken to discover the cause of the expansion and to prevent concurrent hematoma during the operation. Through this case, discussion was held concerning the pitfalls of treatment of aneurysmal subarachnoid hemorrhage concurrent with intracerebral hematoma in the remote region. PMID:11260895
Ochiai, H; Yamakawa, Y; Kawasoe, T
Background Anticoagulation therapy is a routine treatment in patients with hemorrhagic cerebral venous thrombosis (CVT). However, fear of hemorrhagic complications and deterioration course following anticoagulation often disturbs the responsible physician. Methods This was a Prospective observational study on consecutive CVT patients with hemorrhagic venous infarction or subarachnoid hemorrhage (SAH) admitted in Ghaem Hospital, Mashhad, Iran, during 2006-2012. The diagnosis of CVT in suspected cases was confirmed by magnetic resonance imaging/magnetic resonance venography (MRI/MRV), and computerized tomography (CT) angiography following established diagnostic criteria. Demographic data, clinical manifestations from onset to end of the observation period, location of thrombus, location and size of infarction and hemorrhage, and clinical course during treatment were recorded. Choice of the treatment was left to the opinion of the treating physician. Clinical course during 1 week of treatment was assessed based on the baseline modified National Institute of Health Stroke Scale (NIHSS) score. Three or more points decrease or increase of modified NIHSS after 1 week of treatment was considered as improvement or deterioration courses, respectively. Other clinical courses were categorized as stabilization course. Results 102 hemorrhagic CVT patients (80 females, 22 males) with mean age of 38.6 ± 8 years were prospectively investigated. Of the 102 hemorrhagic CVT patients in the acute phase, 52 patients (50.9%) were anticoagulated with adjusted dose intravenous heparin infusion and 50 cases (49.1%) received subcutaneous enoxaparin 1mg/Kg twice daily. Decreased consciousness had a significant effect on the clinical course of the patients (X2 = 9.493, df = 2, P = 0.009). Presence of SAH had no significant effect on the clinical course of our anticoagulated hemorrhagic CVT cases (X2 = 0.304, df = 2, P = 0.914). Extension of Infarction in more than two thirds of a hemisphere had a significant influence on the distribution of clinical courses (X2 = 5.867, df = 2, P = 0.044). Difference in distribution of clinical course among the two groups of our hemorrhagic CVT patients was not significant (X2 = 8.14, df = 1, P = 0.87). Conclusion Patients with hemorrhagic CVT without other contraindication for anticoagulation should be treated either with dose-adjusted intravenous heparin or body-weight-adjusted subcutaneous low molecular-weight heparin.
Riasi, Hamid Reza; Noureddine, Ali; Masoudinezhad, Shahram; Yazdani, Siamak; Mirzae, Mohammad Mousavi; Razavi, Atena Sharifi; Ghandehari, Kosar
In recent years, endoscopic third ventriculostomy has become a well-established procedure for the treatment of various forms of noncommunicating hydrocephalus. Endoscopic third ventriculostomy is considered to be an easy and safe procedure. Complications have rarely been reported in the literature. The authors present a case in which the patient suffered a fatal subarachnoid hemorrhage (SAH) after endoscopic third ventriculostomy. This 63-year-old man presented with confusion and drowsiness and was admitted in to the hospital in poor general condition. Computerized tomography scanning revealed an obstructive hydrocephalus caused by a tumor located in the cerebellopontine angle. An endoscopic third ventriculostomy was performed with the aid of a Fogarty balloon catheter. Some hours postoperatively, the patient became comatose. Computerized tomography scanning revealed a severe perimesencephalic-peripontine SAH and progressive hydrocephalus. Despite emergency external ventricular drainage, the patient died a few hours later. Although endoscopic third ventriculostomy is considered to be a simple and safe procedure, one should be aware that severe and sometimes fatal complications may occur. To avoid vascular injury, perforation of the floor of the third ventricle should be performed in the midline, halfway between the infundibular recess and the mammillary bodies, just behind the dorsum sellae. PMID:10413171
Schroeder, H W; Warzok, R W; Assaf, J A; Gaab, M R
Object When patients present to the emergency department (ED) with acute headache concerning for subarachnoid hemorrhage (SAH) and a lumbar puncture (LP) shows blood in the CSF, it is difficult to distinguish the results of a traumatic LP from those of SAH. CT angiography (CTA) is often performed, but the long-term outcome for patients with a positive LP and normal neurovascular imaging remains uncertain. The primary objective of this study was to determine whether patients who presented to the ED with acute headache and had red blood cells (RBCs) in their CSF on LP but negative cerebrovascular imaging suffered subsequent SAH. Methods A case series study of consecutive adult ED patients who incurred charges for LP between 2001 and 2009 was performed from 2010 through 2011. Inclusion criteria were: headache, > 5 RBCs/mm(3) in CSF, noncontrast head CT with no evidence of hemorrhage, and cerebrovascular CTA or MRA without aneurysm or vascular lesion within 2 weeks of the ED visit. Patients with less than 6 months of available follow-up were excluded. The primary outcomes were 1) subsequent nontraumatic SAH and 2) new vascular lesion. Secondary outcomes were complications related to SAH, or LP or angiography. Results Of 4641 ED patients billed for an LP, 181 patients (mean age 42 years) were included in this study. Over a median follow-up of 53 months, 0 (0%) of 181 patients (95% CI 0%-2.0%) had a subsequent SAH or new vascular lesion identified. Although not the primary outcome, there was 1 patient who was ultimately diagnosed with vasculitis. Eighteen (9.9%) of 181 patients (95% CI 6.0%-15.3%) had an LP-related complication and 0 (0%) of 181 patients (95% CI 0%-2.0%) had an angiography-related complication. Conclusions Patients who present to the ED with acute headache concerning for SAH and have a finding of bloody CSF on LP but negative findings on cerebrovascular imaging are at low risk for subsequent SAH and thus are likely to be safe for discharge. Replacement of the CT/LP with a CT/CTA diagnostic algorithm merits further investigation. PMID:24745707
Thomas, Lisa E; Czuczman, Amanda D; Boulanger, Alyson B; Peak, David A; Miller, Emily S; Brown, David F M; Marill, Keith A
Background Translocation of high-mobility group box 1 (HMGB1) from nucleus could trigger inflammation. Extracellular HMGB1 up-regulates inflammatory response in sepsis as a late mediator. However, little was known about its role in subarachnoid hemorrhage-inducible inflammation, especially in the early stage. This study aims to identify whether HMGB1 translocation occurred early after SAH and also to clarify the potential role of HMGB1 in brain injury following SAH. Methods Sprague-Dawley (SD) rats were randomly divided into sham group and SAH groups at 2 h, 12 h and on day 1, day 2. SAH groups suffered experimental subarachnoid hemorrhage by injection of 0.3 ml autoblood into the pre-chiasmatic cistern. Rats injected by recombinant HMGB1(rHMGB1) solution were divided into four groups according to different time points. Cultured neurons were assigned into control group and four hemoglobin (Hb) incubated groups. Mixed glial cells were cultured and stimulated in medium from neurons incubated by Hb. HMGB1 expression is measured by western blot analysis, real-time polymerase chain reaction (PCR), immunohistochemistry and immunofluorescence. Downstream nuclear factor kappa B (NF-?B) subunit P65 and inflammatory factor Interleukin 1? (IL-1?) were measured by western blot and real-time PCR, respectively. Brain injury was evaluated by cleaved caspase-3 staining. Results Our results demonstrated HMGB1 translocation occurred as early as 2 h after experimental SAH with mRNA and protein level increased. Immunohistochemistry and immunofluorescence results indicated cytosolic HMGB1 was mainly located in neurons while translocated HMGB1 could also be found in some microglia. After subarachnoid injection of rHMGB1, NF-?B, downstream inflammatory response and cleaved caspase-3 were up-regulated in the cortex compared to the saline control group. In-vitro, after Hb incubation, HMGB1 was also rapidly released from neurons to medium. Incubation with medium from neurons up-regulated IL-1? in mixed glial cells. This effect could be inhibited by HMGB1 specific inhibitor glycyrrhizic acid (GA) treatment. Conclusion HMGB1 was released from neurons early after SAH onset and might trigger inflammation as an upstream inflammatory mediator. Extracellular HMGB1 contributed to the brain injury after SAH. These results might have important implications during the administration of specific HMGB1 antagonists early in order to prevent or reduce inflammatory response following SAH.
\\u000a \\u000a Background: The pathophysiology of delayed neurological deficits (DNDs) following aneurysmal subarachnoid hemorrhage (SAH) is complex,\\u000a and is not limited to arterial narrowing (vasospasm) and classical ischemia. Thus, combined drug approaches, or therapies\\u000a with multiple effects, may have the greatest potential for benefit. Statins are known to have pleiotropic vascular effects,\\u000a some of which may interrupt the pathogenesis of DNDs. Based
Andreas H. Kramer
The incidence of oral anticoagulation-associated intracerebral hemorrhage (OAC-ICH) is growing due to the increasing use of\\u000a warfarin and the older age of treated patients. Recent population studies reveal that OAC-ICH currently occurs at a frequency\\u000a comparable to that of subarachnoid hemorrhage. Most frequently, OAC-ICH are located in deep or lobar regions of the brain,\\u000a although it may also occur in
Álvaro Cervera; Sergio Amaro; Ángel Chamorro
The treatment of bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid hemorrhage (SAH) is still challenging. The authors report a rare case of bilateral VADA treated with coil trapping of ruptured VADA and covered stents implantation after multiple unsuccessful stent assisted coiling of the contralateral unruptured VADA. A 44-year-old woman was admitted to our hospital because of severe headache and sudden stuporous consciousness. Brain CT showed thick SAH and intraventricular hemorrhage. Cerebral angiography demonstrated bilateral VADA. Based on the SAH pattern and aneurysm configurations, the right VADA was considered ruptured. This was trapped with endovascular coils without difficulty. One month later, the contralateral unruptured VADA was protected using a stent-within-a-stent technique, but marked enlargement of the left VADA was detected by 8-months follow-up angiography. Subsequently two times coil packing for pseudosacs resulted in near complete occlusion of left VADA. However, it continued to grow. Covered stents graft below the posterior inferior cerebellar artery (PICA) origin and a coronary stent implantation across the origin of the PICA resulted in near complete obliteration of the VADA. Covered stent graft can be used as a last therapeutic option for the management of VADA, which requires absolute preservation of VA flow.
Shim, Jai-Joon; Kim, Sung-Ho; Chang, Jae-Chil
Hemorrhagic stroke accounts for approximately half of stroke in childhood. Unlike arterial ischemic stroke, there are no consensus guidelines to assist in the evaluation and treatment of these children. This article reviews the literature on the evaluation, treatment, etiology, and neurologic outcome of hemorrhagic stroke in children. Important differences between pediatric and adult hemorrhage are highlighted, as treatment guidelines for adults may not be applicable in all cases. Required future research and potential therapies are also discussed. PMID:17275656
Jordan, Lori C; Hillis, Argye E
Submacular hemorrhage may cause secondary retinal degeneration. Evacuation of a traumatic submacular hemorrhage in a young man (Case II) was carried out successfully using transbulbar endodiathermy. Final visual acuity was 20\\/20. A 74-year-old man (Case IV) suffered a big subretinal hemorrhage in his remaining good eye. That same day strong Argon laser coagulations were applied to the retina over the
A. N. Dellaporta
The results of treatment of 235 patients with pulmonary hemorrhage of various etiology which stayed in clinic in 1980-1992 yrs. were analyzed. Of 216 patients, whom diagnostic bronchoscopy was performed, the hemorrhage origin was found in 137, of whom in 13 its localization was imprecise. Seventeen patients have died, of whom 11--before operative intervention was done. The method of temporary occlusion of presumably bleeding lobar or segmental bronchus with the help of obturator containing the leaded out transnasally catheter was proposed to localize precisely the pulmonary hemorrhage origin. The hemorrhage origin localization is confirmed by subsequent appearance of blood from the external end of catheter. PMID:7602915
Vecherko, V N; Kolkin, Ia G; Pannotov, A P; Pershin, E S
... hemorrhage remains poorly understood. While there are various theories regarding CCM hemorrhagic behavior, none have been unequivocally ... critical for patients whose lesions have demonstrated recent growth or hemorrhage. According to Dr. Issam Awad, chair ...
The authors describe a rare case of central auditory dysfunction induced by cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). A 55-year-old woman who was admitted after aneurysmal SAH developed cerebral vasospasm on Day 3 affecting mainly the right middle cerebral artery (MCA) and partly the left MCA. The vasospasm became refractory to conventional therapy and was ultimately improved by intraarterial infusion of nimodipine in the right MCA and angioplasty. Severe auditory dysfunction was apparent from Day 10 as the patient was not reactive to speech or environmental sounds. Brain MRI on Day 17 demonstrated infarcted areas mainly in the right hippocampus, medial occipital lobe, and thalamus. The patient underwent further examination using audiometry, speech testing, auditory evoked potentials, functional MRI, and cerebral PET. The initial diagnosis was extended nonverbal agnosia and total pure word deafness. The central auditory dysfunction improved over 6 months, with persisting hyperacusis, tinnitus, and amusia. Central auditory dysfunction is a rare complication after SAH. While cortical deafness may be associated with bilateral lesions of the temporal cortex, partly reversible central auditory dysfunction was observed in this patient after prominently unilateral right temporal lesions. The role of the interthalamic connections can be discussed, as well as the possibility that a less severe vasospasm on the left MCA could have transiently impaired the left thalamocortical auditory pathways. PMID:23971951
Ponzetto, Ester; Vinetti, Marco; Grandin, Cécile; Duprez, Thierry; van Pesch, Vincent; Deggouj, Naïma; Lhommel, Renaud; Hantson, Philippe
Endothelin (ET)-mediated vasoconstriction has been implicated in the pathophysiology of various disorders, e.g. hypertension, chronic heart failure, acute renal failure, pulmonary hypertension, and subarachnoid hemorrhage (SAH)-induced cerebral vasospasm. The potential involvement of ETs in cerebral vasospasm following SAH has triggered considerable interest in designing therapeutic strategies to inhibit biological effects of ET. Major approaches include: (a) reducing the levels of circulating ET- 1 by the the specific anti- ET- 1 antibodies, (b) antagonizing the ET receptors, and (c) suppressing the biosynthesis of ET-1. To date, numerous antagonists of ET(A) and/or ET(B) receptors have been discovered, and some are under clinical evaluation. Inhibitors of endothelin-converting enzymes (ECEs), which catalyze the biosynthesis of ET-1, have also been synthesized. Two types of ECE-1 inhibitors have been evaluated in various animal disease models: dual ECE-1/neutral endopeptidase 24.11 (NEP) inhibitors and selective ECE-1 inhibitors. In this article, the effects of ET receptor antagonists and ECE-1 inhibitors on the prevention and reversal of SAH-induced cerebral vasospasm in preclinical animal models are reviewed. PMID:15279581
Lin, Chih-Lung; Jeng, Arco Y; Howng, Shen-Long; Kwan, Aij-Lie
In 39 patients with a proven subarachnoid hemorrhage (SAH), the clinical status, the amount of subarachnoid blood on a computerized tomography scan obtained within 5 days after SAH, and the flow velocities (FV's) in both middle cerebral arteries (MCA's) measured by transcranial Doppler sonography were recorded daily and correlated. All patients had pathological FV's over 80 cm/sec between Day 4 and Day 10 after SAH. The side of the ruptured aneurysm showed higher FV's than did the unaffected side in cases of laterally localized aneurysms. Increase in FV preceded clinical manifestation of ischemia. A step early increase of FV's portended severe ischemia and impending infarction. Maximum FV's in the range of 120 to 140 cm/sec were not critical and in no case led to brain infarction. Maximum FV's over 200 cm/sec were associated with a tendency for ischemia, but the patients may remain clinically asymptomatic. In cases of no or only a little blood in the basal cisterns, mean FV's in both MCA's increased only moderately whereas, with thick clots of subarachnoid blood, there was a steeper and higher increase of mean FV's. PMID:3512799
Seiler, R W; Grolimund, P; Aaslid, R; Huber, P; Nornes, H
Delayed vasospasm that develops 3–7 days after aneurysmal subarachnoid hemorrhage (SAH) has traditionally been considered the most important determinant of delayed ischemic injury and poor outcome. Consequently, most therapies against delayed ischemic injury are directed towards reducing the incidence of vasospasm. The clinical trials based on this strategy, however, have so far claimed limited success; the incidence of vasospasm is reduced without reduction in delayed ischemic injury or improvement in the long-term outcome. This fact has shifted research interest to the early brain injury (first 72 h) evoked by SAH. In recent years, several pathological mechanisms that activate within minutes after the initial bleed and lead to early brain injury are identified. In addition, it is found that many of these mechanisms evolve with time and participate in the pathogenesis of delayed ischemic injury and poor outcome. Therefore, a therapy or therapies focused on these early mechanisms may not only prevent the early brain injury but may also help reduce the intensity of later developing neurological complications. This manuscript reviews the pathological mechanisms of early brain injury after SAH and summarizes the status of current therapies.
Pluta, Ryszard M.; Zhang, John H.
Developmental processes are closely connected to certain states of epigenetic information which, among others, rely on methylation of chromatin. S-adenosylmethionine (SAM) and S-adenosylhomocysteine (SAH) are key cofactors of enzymes catalyzing DNA and histone methylation. To study the consequences of altered SAH/SAM levels on plant development we applied 9-(S)-(2,3-dihydroxypropyl)-adenine (DHPA), an inhibitor of SAH-hydrolase, on tobacco seeds during a short phase of germination period (6 days). The transient drug treatment induced: (1) dosage-dependent global DNA hypomethylation mitotically transmitted to adult plants; (2) pleiotropic developmental defects including decreased apical dominance, altered leaf and flower symmetry, flower whorl malformations and reduced fertility; (3) dramatic upregulation of floral organ identity genes NTDEF, NTGLO and NAG1 in leaves. We conclude that temporal SAH-hydrolase inhibition deregulated floral genes expression probably via chromatin methylation changes. The data further show that plants might be particularly sensitive to accurate setting of SAH/SAM levels during critical developmental periods. PMID:21274566
Fulne?ek, Jaroslav; Matyášek, Roman; Votruba, Ivan; Holý, Antonín; K?ížová, Kate?ina; Kova?ík, Aleš
Background. First described in 2005, inverted takotsubo is one of the four stress-induced cardiomyopathy patterns. It is rarely associated with subarachnoid hemorrhage but was not previously reported after intraparenchymal bleeding. Purpose. We reported a symptomatic case of inverted takotsubo pattern following a cerebellar hemorrhage. Case Report. A 26-year-old woman presented to the emergency department with sudden headache and hemorrhage of the posterior fossa was diagnosed, probably caused by a vascular malformation. Several hours later, she developed acute pulmonary edema due to acute heart failure. Echocardiography showed left ventricular dysfunction with hypokinetic basal segments and hyperkinetic apex corresponding to inverted takotsubo. Outcome was spontaneously favorable within a few days. Conclusion. Inverted takotsubo pattern is a stress-induced cardiomyopathy that could be encountered in patients with subarachnoid hemorrhage and is generally of good prognosis. We described the first case following a cerebellar hematoma.
Pierard, Sophie; Vinetti, Marco
Background A frequent complication in patients with subarachnoid hemorrhage (SAH) is recurrent bleeding from the aneurysm. The risk is highest within the first 6 hours after the initial hemorrhage. Securing the aneurysm within this timeframe is difficult owing to logistical delays. The rate of recurrent bleeding can also be reduced by ultra-early administration of antifibrinolytics, which probably improves functional outcome. The aim of this study is to investigate whether ultra-early and short-term administration of the antifibrinolytic agent tranexamic acid (TXA), as add-on to standard SAH management, leads to better functional outcome. Methods/Design This is a multicenter, prospective, randomized, open-label trial with blinded endpoint (PROBE) assessment. Adult patients with the diagnosis of non-traumatic SAH, as proven by computed tomography (CT) within 24 hours after the onset of headache, will be randomly assigned to the treatment group or the control group. Patients in the treatment group will receive standard treatment with the addition of a bolus of TXA (1 g intravenously) immediately after randomization, followed by continuous infusion of 1 g per 8 hours until the start of aneurysm treatment, or a maximum of 24 hours after the start of medication. Patients in the control group will receive standard treatment without TXA. The primary outcome measure is favorable functional outcome, defined as a score of 0 to 3 on the modified Rankin Scale (mRS), at 6 months after SAH. Primary outcome will be determined by a trial nurse blinded for treatment allocation. We aim to include 950 patients in 3 years. Discussion The strengths of this study are: 1. the ultra-early and short-term administration of TXA, resulting in a lower dose as compared to previous studies, which should reduce the risk for delayed cerebral ischemia (DCI), an important risk factor in the long-term treatment with antifibrinolytics; 2. the power calculation is based on functional outcome and calculated with use of recent study results of our own population, supported by data from prominent studies; and 3. the participation of several specialized SAH centers, and their referring hospitals, in the Netherlands with comparative treatment protocols. Trial registration Nederlands Trial Register (Dutch Trial Registry) number NTR3272
Submacular hemorrhage may cause secondary retinal degeneration. Evacuation of a traumatic submacular hemorrhage in a young man (Case II) was carried out successfully using transbulbar endodiathermy. Final visual acuity was 20/20. A 74-year-old man (Case IV) suffered a big subretinal hemorrhage in his remaining good eye. That same day strong Argon laser coagulations were applied to the retina over the dark, brown hemorrhage with perforation of the retina and visible escape of blood into the vitreous. Four weeks after the treatment the subretinal hemorrhage showed patchy absorption and the visual acuity was 20/60. The visual acuity remained 20/60 and J3, 27 months after the treatment, and useful vision continued for another 15 months. PMID:7960412
Dellaporta, A N
Previous studies with small sample size have shown that cilostazol can reduce the risk of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study was to determine whether cilostazol is effective in patients with aneurysmal SAH. Studies investigating the effect of cilostazol in patients with aneurysmal SAH were identified using Embase.com without language or publication-type restrictions. We used the random-effect model to combine data. Pooled risk ratios (RR) and 95% confidence intervals (CI) were calculated. Two randomized controlled trials and two quasi-randomized controlled trials with a total of 340 patients were included. The incidence of symptomatic vasospasm (RR=0.47; 95% CI, 0.31-0.72; p<0.001), severe vasospasm (RR=0.48; 95% CI, 0.28-0.82; p=0.007), vasospasm-related new cerebral infarctions (RR=0.38; 95% CI, 0.22-0.67; p=0.001), and poor outcome (RR=0.57; 95% CI, 0.37-0.88; p=0.011) were significantly lower in the cilostazol group. The numbers needed to treat for these outcomes were 6.4, 6.3, 5.7, and 5.4, respectively. Mortality rate differences between the two groups were insignificant. No statistical heterogeneity was found for all outcomes. These results show that cilostazol can decrease the incidence of symptomatic vasospasm, severe vasospasm, vasospasm-related new cerebral infarctions, and poor outcome in patients with aneurysmal SAH. PMID:24211059
Niu, Peng-Peng; Yang, Ge; Xing, Ying-Qi; Guo, Zhen-Ni; Yang, Yi
Spinal hematoma is a rare and usually severe neurological disorder that, without adequate treatment, often leads to death or permanent neurological deficit. Epidural as well as subdural and subarachnoid hematomas have been investigated in some studies. A 66-year-old man referred to our hospital because of acute onset paraplegia and incontinency started 3 h before admission. With impression of spinal hemorrhage, emergent cervicothoracic spinal MRI performed. On magnetic resonance imagination (MRI) mixed hyper/iso intense lesion in anterior subarachnoid space from C7 to T5 was seen. On brain A computerised tomography (CT) scan, subarachnoid hemorrhage and intraventricular hemorrhage in posterior parts of brain was seen. Unfortunately, the patient died 10 days later. About our patient, severe back pain accompanying by immediate paraplegia, sphincter disturbances, sensory level, and prominent meningeal signs guided us clinically to spinal subarachnoid hemorrhage. Further brain CT scan revealed diffusion of blood to brain subarachnoid space and ventricles. An outstanding finding on brain CT was the presence of blood only in posterior horn of lateral ventricles and dorsal fissures of brain supporting our theory that blood has diffused from spinal subarachnoid space to dorsal subarachnoid space of brain because of supine position of patient. In this patient anticoagulation may be the only sinister factor for developing complications. PMID:23961296
Fatehi, Farzad; Basiri, Keivan; Ghorbani, Askar
Spinal hematoma is a rare and usually severe neurological disorder that, without adequate treatment, often leads to death or permanent neurological deficit. Epidural as well as subdural and subarachnoid hematomas have been investigated in some studies. A 66-year-old man referred to our hospital because of acute onset paraplegia and incontinency started 3 h before admission. With impression of spinal hemorrhage, emergent cervicothoracic spinal MRI performed. On magnetic resonance imagination (MRI) mixed hyper/iso intense lesion in anterior subarachnoid space from C7 to T5 was seen. On brain A computerised tomography (CT) scan, subarachnoid hemorrhage and intraventricular hemorrhage in posterior parts of brain was seen. Unfortunately, the patient died 10 days later. About our patient, severe back pain accompanying by immediate paraplegia, sphincter disturbances, sensory level, and prominent meningeal signs guided us clinically to spinal subarachnoid hemorrhage. Further brain CT scan revealed diffusion of blood to brain subarachnoid space and ventricles. An outstanding finding on brain CT was the presence of blood only in posterior horn of lateral ventricles and dorsal fissures of brain supporting our theory that blood has diffused from spinal subarachnoid space to dorsal subarachnoid space of brain because of supine position of patient. In this patient anticoagulation may be the only sinister factor for developing complications.
Fatehi, Farzad; Basiri, Keivan; Ghorbani, Askar
Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed therapies worldwide. Meta-analysis data indicate the potential for myocardial infarction, cerebrovascular incident, heart failure, renal failure and arterial hypertension. Here we review the mechanisms of their actions and the potential for therapeutic use in subarachnoid hemorrhage. Searches were performed using PubMed with the search terms "subarachnoid hemorrhage", "NSAID", "treatment", "management", "cerebral aneurysm", and "vasospasm" from 1970 to February, 2012. Articles were also identified through searches of the Cochrane library and searches of the authors' own files. Only papers published in English were reviewed.There are considerably mixed views on the potential impact of NSAIDs on the treatment and prevention of SAH. Whilst theoretically, the potential for positive intervention in the condition is huge, little effect appears to be measurable in clinical practice. PMID:22950380
Young, Adam M H; Karri, Surya K; Ogilvy, Christopher S
Classical experimental models of hemorrhage are characterized by the use of anesthetics that may interfere with the typical immune responses and pathology of hemorrhage/resuscitation. Thus, therapeutic strategies successful in anesthetized animals might not be beneficial in clinical trials. In this study, we analyzed whether ethyl pyruvate could provide therapeutic benefits during resuscitation in awake (unanesthetized) hemorrhage. Our results indicate that hemorrhage in unanesthetized animals required approximately 25% higher blood withdrawal than anesthetized animals to achieve the same targeted mean arterial blood pressure. Resuscitation with Hextend reestablished circulatory volume and improved survival during resuscitation of awake rodents. Yet, over 75% of the animals resuscitated with Hextend died within the first hours after hemorrhage. Resuscitation with Hextend containing 50 mM ethyl pyruvate protected over 87% of the animals. This survival benefit did not correlate with significant changes in the metabolic markers but with an anti-inflammatory potential during resuscitation. Unlike classical hemorrhage in anesthetized animals, ethyl pyruvate reestablished mean arterial blood pressure significantly earlier than Hextend in unanesthetized rodents. Unanesthetized animals showed twofold higher serum tumor necrosis factor (TNF)-alpha than anesthetized animals subjected to the same blood pressure. This process was not due to the response of a single organ, but affected all the analyzed organs including the lung, heart, spleen, and liver. Although resuscitation with Hextend failed to attenuate systemic TNF-alpha levels, it inhibited TNF-alpha levels in the lung, heart, and liver but not in the spleen. Unlike Hextend, resuscitation with ethyl pyruvate prevented high serum TNF-alpha levels and blunted TNF-alpha responses in all the organs including the spleen. These studies indicate that the inflammatory responses in anesthetized animals differ from that in unanesthetized animals and that awake hemorrhage can provide advantages in the study of anti-inflammatory strategies during resuscitation. Ethyl pyruvate may attenuate systemic inflammatory responses during resuscitation and improve survival in experimental models of awake hemorrhage. PMID:19172241
Cai, Bolin; Brunner, Michael; Wang, Haichao; Wang, Ping; Deitch, Edwin A; Ulloa, Luis
Classical experimental models of hemorrhage are characterized by the use of anesthetics that may interfere with the typical immune responses and pathology of hemorrhage/resuscitation. Thus, therapeutic strategies successful in anesthetized animals might not be beneficial in clinical trials. In this study, we analyzed whether ethyl pyruvate could provide therapeutic benefits during resuscitation in awake (unanesthetized) hemorrhage. Our results indicate that hemorrhage in unanesthetized animals required approximately 25% higher blood withdrawal than anesthetized animals to achieve the same targeted mean arterial blood pressure. Resuscitation with Hextend reestablished circulatory volume and improved survival during resuscitation of awake rodents. Yet, over 75% of the animals resuscitated with Hextend died within the first hours after hemorrhage. Resuscitation with Hextend containing 50 mM ethyl pyruvate protected over 87% of the animals. This survival benefit did not correlate with significant changes in the metabolic markers but with an anti-inflammatory potential during resuscitation. Unlike classical hemorrhage in anesthetized animals, ethyl pyruvate reestablished mean arterial blood pressure significantly earlier than Hextend in unanesthetized rodents. Unanesthetized animals showed twofold higher serum tumor necrosis factor (TNF)-? than anesthetized animals subjected to the same blood pressure. This process was not due to the response of a single organ, but affected all the analyzed organs including the lung, heart, spleen, and liver. Although resuscitation with Hextend failed to attenuate systemic TNF-? levels, it inhibited TNF-? levels in the lung, heart, and liver but not in the spleen. Unlike Hextend, resuscitation with ethyl pyruvate prevented high serum TNF-? levels and blunted TNF-? responses in all the organs including the spleen. These studies indicate that the inflammatory responses in anesthetized animals differ from that in unanesthetized animals and that awake hemorrhage can provide advantages in the study of anti-inflammatory strategies during resuscitation. Ethyl pyruvate may attenuate systemic inflammatory responses during resuscitation and improve survival in experimental models of awake hemorrhage.
Cai, Bolin; Brunner, Michael; Wang, Haichao; Wang, Ping; Deitch, Edwin A.
Objective: Deep venous thrombosis (DVT) and pulmonary embolus (PE) are serious problems for patients admitted to the hospital with stroke, subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and transient ischemic attack (TIA). The purpose of this paper is to further understand the factors that place certain patients at increased risk of DVT/PE. Methods: At a 600 bed hospital, a retrospective analysis of data from 2613 patients admitted with a diagnosis of stroke, SAH, ICH or TIA in the time range 1/2008 through 3/2012 was carried out. The data was taken from the hospital’s Get with the Guidelines database and included 28 variables. These included initial NIH stroke scale, length of stay, heart failure, ambulatory by day 2 after admission, altered mental status,and renal failure among others. Multiple analyses were carried out to determine whether there were univariable or multivariable effects of any of the factors on the risk for DVT/PE. Results: The risk of DVT/PE was highest in patients with SAH and ICH and smallest with TIA. Multivariable analyses were performed and revealed only altered level of consciousness or heart failure as significant risks for DVT/PE. With the limited available data, administration of subcutaneous heparin or other chemoprophylaxis did not reduce the risk of DVT/PE. Conclusion: Although many of the variables used to describe the stroke patient are correlated, in multivariable analyses only heart failure and altered level of consciousness were important risk factors for DVT/PE. The risk of DVT/PE was 7 fold greater in patients in patients with both of these risk factors.
Stecker, Mark; Michel, Kathleen; Antaky, Karin; Cherian, Sarah; Koyfmann, Feliks
The signal transduction of tumor necrosis factor-alpha (TNF-alpha) is complex and regulated via a vast number of interconnecting pathways. The TNF-alpha signaling pathway plays a major role in the pathogenesis of subarachnoid hemorrhage (SAH). The advent of molecular mimicry has provided a number of opportunities to tackle disease with improved specificity. Here we review the mechanisms of their action and the potential for TNF-alpha inhibitors as a treatment for subarachnoid hemorrhage. Searches were performed using PubMed with the search terms "subarachnoid haemorrhage", "TNF alpha", "novel drugs" TNF alpha inhibition", "management", "cerebral aneurysm", and "vasospasm" from 1970 to February, 2012. Articles were also identified through searches of the Cochrane library and searches of the authors' own files. Only papers published in English were reviewed. In conclusion, there is considerable theoretical evidence for the potential of TNF-alpha inhibitors to impact on the pathogenesis of aneurismal SAH. Such indications demonstrate the potential for specific targeting of molecular signaling pathways to prevent the growth and rupture of cerebral aneurysm. PMID:22950379
Young, Adam M H; Karri, Surya K; You, Wanchun; Ogilvy, Christopher S
Between 10 July and 23 October 1966 an epidemic of dengue hemorrhagic fever occurred on an island in the Gulf of Thailand. Fourteen cases of dengue-shock syndrome (with one death) and 20 of hemorrhagic-fever syndrome due to dengue occurred. An additional ...
P. E. Winter T. M. Yuill S. Udomaskdi D. Gould S. Nantapanich
Pleural effusion is considered to be a rare manifestation of pulmonary sarcoidosis, but hemorrhagic effusion secondary to it is a very uncommon clinical presentation. This case is reported due to the rare manifestation in pulmonary sarcoidosis presenting clinically as hemorrhagic pleural effusion.
Kumar, Santosh; Verma, Sanjay Kumar; Singh, Rajni; Prasad, Rajendra
This study aimed to characterize hypoxic, but salvageable, tissue imaged by 18F-fluoromisonidazole (18F-FMISO), combining with perfusion-computed tomography (PCT) for regional cerebral blood flow (rCBF) measurement and metabolism by microdialysis (MD) in aneurysmal subarachnoidal hemorrhage (SAH) patients. 18F-FMISO positron-emission tomography (PET)/CT was performed within the period of possible vasospasm (day 6.8±3 after SAH) in seven SAH patients. In parallel, rCBF was determined within the MD region of interest (MD-ROI) (n=5). The MD catheter was inserted into the brain parenchyma with highest risk for ischemia; extracellular levels of glutamate and energy metabolites were registered at time of PET and hourly for 10 days. Twelve-month outcome was evaluated. In asymptomatic patients (n=3) no hypoxia was detected and glutamate levels were low (<10?mmol/L), whereas symptomatic patients had higher glutamate concentrations (P<0.001). Increased 18F-FMISO uptake within the MD-ROI (n=3) was related to higher glutamate levels, while rCBF was above the ischemic range. Hypoxia (increased 18F-FMISO uptake) was present in symptomatic patients and associated with relevant metabolic derangement of extracellular glutamate levels, whereas energy metabolism and rCBF were preserved. This technique has the potential to improve our understanding of the role of cellular hypoxia in aneurysmal SAH.
Sarrafzadeh, Asita S; Nagel, Alexandra; Czabanka, Marcus; Denecke, Timm; Vajkoczy, Peter; Plotkin, Michail
Acute spontaneous cerebellar hemorrhage presenting with ataxia, dysarthria, vomiting, dizziness, and coma is commonly the result of hypertension. Early diagnosis is possible, and appropriate treatment, if timely executed, may be lifesaving. ImagesFigure 1Figure 2Figure 3
Dayes, Lloyd A.; Purtzer, Thomas J.; Shahhal, Imad; Cojocaru, Traian; Knierim, David; Soloniuk, Donald
Traumatic basal subarachnoid hemorrhage (TBSAH) is infrequent but of forensic neuropathological importance because of its high mortality and complex causal mechanisms. The source of the hemorrhage is most frequently identified in the vertebro-basilar arteries but often cannot be identified in these arteries. We present a case of TBSAH possibly originating from hemorrhagic cerebellar contusions due to fist blows to the
Jian-Hua Chen; Takaki Ishikawa; Tomomi Michiue; Hitoshi Maeda
BACKGROUND:: Severe pelvic hemorrhage after low-energy trauma has been described in some reports of single cases only. However, it might not be as rare and unique as generally expected. The aim of this study was therefore to present a case series of 11 patients with severe pelvic hemorrhage after sustaining low-energy trauma and to discuss relevant considerations for the management of these patients. METHODS:: A consecutive series of eleven patients with pelvic hemorrhage and the need for arterial embolization after sustaining low-energy pelvic trauma was identified. A contrast-enhanced computed tomography (CT) scan was performed in all patients, if pelvic hemorrhage was suspected due to a relevant hemoglobin (Hb) drop. After the CT scans showed active arterial bleeding, arterial embolization was immediately performed. RESULTS:: All patients sustained low-energy pelvic injuries after simple falls from standing height. The mean initial Hb level was 13.0 g/dL. Contrast-enhanced CT scans were performed after a mean of 14.3 hours after trauma and showed contrast medium extravasations in all patients. The mean Hb level at the time of CT scan was 9.0 g/dL. Embolization was successfully performed in all patients within a mean of 4.5 hours. CONCLUSIONS:: Geriatric patients are prone to arterial hemorrhage after low-energy pelvic trauma. They should be admitted as an inpatient for observation with repeated control of the Hb level to diagnose hemorrhage at an early stage. Contrast-enhanced CT scans is the preferred imaging method for the assessment of pelvic hemorrhage, whereas arterial embolization is highly successful in terms of hemostasis. PMID:21841508
Krappinger, Dietmar; Zegg, Michael; Jeske, Christian; El Attal, Rene; Blauth, Michael; Rieger, Michael
Ten percent of all strokes are due to spontaneous cerebral hemorrhages. They are associated to drugs (licit and illicit) in 9.5% of all cases in young adults. This is a case report of a 44-year-old man, without previous morbidities, who presented a sudden onset headache and arterial hypertension 24 hours after use of naphazoline as nasal decongestant. Cranial tomography showed right thalamus hemorrhage. Cerebral angiography showed no aneurisms, vascular malformations or vasculitis. No other risk factors were found during investigation in this patient and the stroke was attributed to naphazoline exposition. PMID:15476091
Zavala, Jorge A A; Pereira, Eduardo R; Zétola, Viviane H F; Teive, Hélio A G; Nóvak, Edison M; Werneck, Lineu C
Inter-observer variability in diagnosing radiological features of aneurysmal subarachnoid hemorrhage; a preliminary single centre study comparing observers from different specialties and levels of training
Background: A noncontrast computed tomography (CT) scan remains the initial radiological investigation of choice for a patient with suspected aneurysmal subarachnoid hemorrhage (aSAH). This initial scan may be used to derive key information about the underlying aneurysm which may aid in further management. The interpretation, however, is subject to the skill and experience of the interpreting individual. The authors here evaluate the interpretation of such CT scans by different individuals at different levels of training, and in two different specialties (Radiology and Neurosurgery). Methods: Initial nonontrast CT scan of 35 patients with aSAH was evaluated independently by four different observers. The observers selected for the study included two from Radiology and two from Neurosurgery at different levels of training; a resident currently in mid training and a resident who had recently graduated from training of each specialty. Measured variables included interpreter's suspicion of presence of subarachnoid blood, side of the subarachnoid hemorrhage, location of the aneurysm, the aneurysm's proximity to vessel bifurcation, number of aneurysm(s), contour of aneurysm(s), presence of intraventricular hemorrhage (IVH), intracerebral hemorrhage (ICH), infarction, hydrocephalus and midline shift. To determine the inter-observer variability (IOV), weighted kappa values were calculated. Results: There was moderate agreement on most of the CT scan findings among all observers. Substantial agreement was found amongst all observers for hydrocephalus, IVH, and ICH. Lowest agreement rates were seen in the location of aneurysm being supra or infra tentorial. There were, however, some noteworthy exceptions. There was substantial to almost perfect agreement between the radiology graduate and radiology resident on most CT findings. The lowest agreement was found between the neurosurgery graduate and the radiology graduate. Conclusion: Our study suggests that although agreements were seen in the interpretation of some of the radiological features of aSAH, there is still considerable IOV in the interpretation of most features among physicians belonging to different levels of training and different specialties. Whether these might affect management or outcome is unclear.
Siddiqui, Usman T.; Khan, Anjum F.; Shamim, Muhammad Shahzad; Hamid, Rana Shoaib; Alam, Muhammad Mehboob; Emaduddin, Muhammad
Objective Subarachnoid hemorrhage (SAH) is associated with marked sympathetic activation at the time of ictus. The purpose of this study is to determine whether early central catecholamine levels measured from cerebrospinal fluid (CSF) relate to outcome in patients with SAH. Methods Observational study of consecutive SAH grade 3–5 patients who underwent ventriculostomy placement, but did not undergo open craniotomy for aneurysm obliteration. CSF samples were obtained during the first 48 h following symptom onset and assayed for catecholamine levels. Statistical analyses were performed to determine whether the levels predicted mortality by day 15 or mortality/disability by day 30. Results For the 102 patients included, mean age was 58, and 73% were female ? 21% experienced day-15 mortality, and 32% experienced mortality/disability by day 30. Early mortality was related to Hunt-Hess (H/H) grade (p < 0.001), neurogenic cardiomyopathy (NC) (p = 0.003), cerebral infarction (p = 0.001), elevated intracranial pressure (ICP) (p = 0.029), epinephrine (EPI) level (p = 0.002) and norepinephrine/3,4-dihydroxyphenylglycol (NE/DHPG) ratio (p = 0.003). Mortality/disability was related to H/H grade (p < 0.001), NC (p = 0.018), infarction (p < 0.001), elevated ICP (p = 0.002), EPI (p = 0.004) and NE/DHPG (p = 0.014). Logistic regression identified age [OR 1.09 (95% CI 1.01–1.17)], H/H grade [9.52 (1.19–77)], infarction [10.87 (1.22–100)], ICP elevation [32.26 (2–500)], EPI [1.06 (1.01–1.10)], and (inversely) DHPG [0.99 (0.99–1.00)] as independent predictors of early mortality. For mortality/disability, H/H grade [OR 21.74 (95% CI 5.62?83)], ICP elevation [18.52 (1.93–166)], and EPI [1.05 (1.02–1.09)] emerged as independent predictors. Proportional-hazards analysis revealed age [HR 1.041 (95% CI 1.003–1.08)], H/H grade [6.9 (1.54–31.25)], NC [4.31 (1.5–12.35)], and EPI [1.032 (1.009–1.054)] independently predicted early mortality. Conclusions CSF catecholamine levels are elevated in SAH patients who experience early mortality or disability. EPI may potentially serve as useful index of outcome in this population of patients with SAH.
Moussouttas, Michael; Huynh, Thanh T.; Khoury, John; Lai, Edwin W.; Dombrowski, Keith; Pello, Scott; Pacak, Karel
The central question explored in this commentary is whether the beneficial effects of an Aloe vera derived drag-reducing polymer during hemorrhagic shock is due to its O2 radical scavenging properties or to changes in blood rheology.
Gutierrez, Guillermo; Fuller, Stephanie P
Novel therapeutic advances in the field of trauma management depend upon animal models that can accurately predict the clinical efficacy of interventions. In the battlefield, traumatic brain injury (TBI) and hemorrhagic shock often occur concomitantly due...
L. Qi R. Wu X. Cui
Postpartum hemorrhage is the outstanding cause of maternal mortality, and a redoubtable contributor to puerperal death from other causes, notably infection and renal failure. The clinical situations in which hemorrhage is liable to occur must be better known, so that anticipatory and preventive measures can be taken. Recent knowledge about defibrinated blood in women with degenerative changes at the placental site must be incorporated in the thinking and practice of physicians dealing with obstetrical cases. The indications, limitations, and hazards of the various anesthetic methods available for parturient women should be carefully considered in the circumstances of each case. ImagesFigure 1.Figure 2.Figure 3.
Melody, George F.
Introduction Diclofenac, a nonsteroidal antiinflammatory drug, is commonly used as antipyretic therapy in intensive care. The purpose of this study was to investigate the effects of parenteral diclofenac infusion on brain homeostasis, including brain-tissue oxygen tension (PbtO2) and brain metabolism after aneurysmal subarachnoid hemorrhage (aSAH). Methods We conducted a prospective, observational study with retrospective analysis of 21 consecutive aSAH patients with multimodal neuromonitoring. Cerebral perfusion pressure (CPP), mean arterial pressure (MAP), intracranial pressure (ICP), body temperature, and PbtO2 were analyzed after parenteral diclofenac infusion administered over a 34-minute period (20 to 45 IQR). Data are given as mean ± standard error of mean and median with interquartile range (IQR), as appropriate. Time-series data were analyzed by using a general linear model extended by generalized estimation equations (GEEs). Results One-hundred twenty-three interventions were analyzed. Body temperature decreased from 38.3°C ± 0.05°C by 0.8°C ± 0.06°C (P < 0.001). A 10% decrease in MAP and CPP (P < 0.001) necessitated an increase of vasopressors in 26% (n = 32), colloids in 33% (n = 41), and crystalloids in 5% (n = 7) of interventions. PbtO2 decreased by 13% from a baseline value of 28.1 ± 2.2 mm Hg, resulting in brain-tissue hypoxia (PbtO2 <20 mm Hg) in 38% (n = 8) of patients and 35% (n = 43) of interventions. PbtO2 <30 mm Hg before intervention was associated with brain-tissue hypoxia after parenteral diclofenac infusion (likelihood ratio, 40; AUC, 93%; 95% confidence interval (CI), 87% to 99%; P < 0.001). Cerebral metabolism showed no significant changes after parenteral diclofenac infusion. Conclusions Parenteral diclofenac infusion after aSAH effectively reduces body temperature, but may lead to CPP decrease and brain-tissue hypoxia, which were both associated with poor outcome after aSAH.
Herein, we report our experience in treating extensive traumatic submacular hemorrhage with a single dose of intravitreal ranibizumab. A 23-year-old healthy Malay man presented with a progressive reduction of central vision in the left eye of 2 days’ duration following a history of blunt trauma. Visual acuity was reduced to counting fingers. Examination revealed infero-temporal subconjunctival hemorrhage, traumatic anterior uveitis, and an extensive sub-macular hemorrhage with suspicion of a choroidal rupture in the affected eye. He was initially treated conservatively with topical prednisolone acetate 1%. The subconjunctival hemorrhage and anterior uveitis resolved but his vision remained poor with minimal resolution of the submacular hemorrhage at 1 week follow-up (day 12 post-trauma). In view of the poor resolution of submacular hemorrhage, he was treated with a single dose of 0.5 mg intravitreal ranibizumab at day 20 post-trauma. At 4 weeks post-intravitreal ranibizumab, there was an improvement in visual acuity (from counting fingers to 6/45) and complete resolution of the submacular hemorrhage with presence of a choroidal rupture scar temporal to the fovea, which was not seen clearly at presentation due to obscuration by blood. His visual acuity further improved to 6/18 at 3 months post-trauma. Although this single case had a favorable outcome, a large population cohort study is needed to establish the effectiveness of intravitreal ranibizumab in treating extensive traumatic submacular hemorrhage.
Abdul-Salim, Ismail; Embong, Zunaina; Khairy-Shamel, Sonny-Teo; Raja-Azmi, Mohd-Noor
Computerized tomography, carotid angiograms, and arteriography were used to diagnose several cases of cerebral hemorrhage following the use of phenylpropanolamine. The angiographic picture in one of the three cases was similar to that previously described in association with amphetamine abuse and pseudoephedrine overdose, both substances being chemically and pharmacologically similar to phenylpropanolamine. The study suggests that the arterial change responsible
J. R. McDowell; H. J. LeBlanc
An association between hyperglycemia and outcome in spontaneous subarachnoid hemorrhage (SAH) has been sporadically reported. Our hypothesis was that hyperglycemia is a sign of central metabolic disturbance linked with specific appearances on computerized tomography (CT) scans reflecting different degrees of corresponding brain injury. The admission plasma glucose level, initial CT findings, and outcome after 6 months were analysed in a cohort of 99 patients with SAH in Hunt & Hess Grade IV or V. The CT scans were quantitatively assessed for subarachnoid blood, intracerebral hematoma, intraventricular hemorrhage, hydrocephalus, midline shift and compression of the perimesencephalic cisterns. These findings were combined to determine a three-point CT severity score. All patients showed elevated (>5.8 mmol/l) plasma glucose levels on admission. Mortality among 33 patients with glucose concentration below 9.0 mmol/l was 33.3%, 71.1% for the 45 patients with glucose level between 9.0 and 13.0 mmol/l, and 95.2% for the 21 patients with concentration above 13.0 mmol/l (P<0.0001). Glucose level was higher in Grade V than in Grade IV patients (mean+/-SD) (11.8+/-3.2 vs 9.8+/-2.9 mmol/l; P=0.0012). Patients with mild CT findings (n=10) had the lowest glucose level (8.9+/-1.8 mmol/l; P=0.0082), whereas patients with severe findings (n=56) had the highest glucose (11.4+/-3.5 mmol/l; P=0.011). Despite association with clinical grade and extent of CT findings, logistic multiple regression revealed the admission plasma glucose level to be an independent prognosticator of outcome. The prognostic potential of the initial plasma glucose level may be beneficial in management protocols of poor-grade SAH patients. PMID:10817893
Alberti, O; Becker, R; Benes, L; Wallenfang, T; Bertalanffy, H
We present a case of oculomotor palsy due to hypertensive hemorrhage in the caudate nucleus, with intraventricular extension. To our knowledge, this is the only instance of this complication occurring due to hypertensive hemorrhage. Our patient initially developed headache at the time of her hemorrhage; 8 days later, she developed complete third nerve palsy, which showed improvement at follow-up 4 months later. This was due to tracking of blood into the perimesencephalic cistern. The presence of hemorrhage in the basal cisterns was not visible on the initial CT scans and highlights the role of MRI in evaluating the brainstem for the presence of blood products.
Dardis, C.; Sharfstein, S.
Background Chronic shunt-dependent hydrocephalus is a complication of aneurysmal subarachnoid hemorrhage (aSAH). Its incidence and risk factors have been described while the hydrocephalus onset in terms of days after treatment (microsurgical or endovascular) has not been yet analyzed. Materials and Methods 45 patients, treated for aSAH in 4 Italian Neurosurgical Departments, were retrospectively analyzed. It was calculated the time that elapses between treatment and hydrocephalus onset in 36 patients. Results Of the 45 shunted patients, 15 (33.3%) were included in the microsurgical group (group A) and 30 (66.6%) were in the endovascular one (group B). There was no difference of the hydrocephalus onset between the two groups (24,1 days, group A vs. 27,7 days, group B). The presence of intracerebral hematoma (ICH) caused a delay in the hydrocephalus onset after endovascular treatment in terms of 11,5 days compared to microsurgical group as well the absence of vasospasm determined a delay of 13,7 days (not statistically significant). Conclusion No difference in terms of hydrocephalus onset after microsurgical or endovascular treatment has been demonstrated. Only the presence of ICH or the absence of vasospasm can cause a slight delay in the time of hydrocephalus onset in the endovascular series (not statistically significant). Long-term follow-up studies involving higher numbers of subjects are needed to better demonstrate this issue.
Gangemi, Michelangelo; Cavallo, Luigi Maria; Di Somma, Alberto; Mazzucco, Grazia Marina; Bono, Paolo Sebastiano; Ghetti, Giovanni; Zambon, Giampaolo
Volume management is critical for assessment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). This multicenter prospective cohort study compared the impact of surgical clipping versus endovascular coiling on postoperative hemodynamics and pulmonary edema in patients with SAH. Hemodynamic parameters were measured for 14 days using a transpulmonary thermodilution system. The study included 202 patients, including 160 who underwent clipping and 42 who underwent coiling. There were no differences in global ejection fraction (GEF), cardiac index, systemic vascular resistance index, or global end-diastolic volume index between the clipping and coiling groups in the early period. However, extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) were significantly higher in the clipping group in the vasospasm period. Postoperative C-reactive protein (CRP) level was higher in the clipping group and was significantly correlated with postoperative brain natriuretic peptide level. Multivariate analysis found that PVPI and GEF were independently associated with high EVLWI in the early period, suggesting cardiogenic edema, and that CRP and PVPI, but not GEF, were independently associated with high EVLWI in the vasospasm period, suggesting noncardiogenic edema. In conclusion, clipping affects postoperative CRP level and may thereby increase noncardiogenic pulmonary edema in the vasospasm period. His trial is registered with University Hospital Medical Information Network UMIN000003794.
Horie, Nobutaka; Iwaasa, Mitsutoshi; Ishizaka, Shunsuke; Inoue, Tooru; Nagata, Izumi
Objective Shunt-dependent chronic hydrocephalus (SDCH) is known to be a major complication associated with aneurysmal subarachnoid hemorrhage (aSAH). Old age is known to be one of numerous factors related to the development of SDCH. This study investigated whether postoperative cisternal drainage affects the incidence of SDCH and clinical outcome in elderly patients with aSAH. Methods Fifty-nine patients participated in this study. All patients underwent aneurysmal clipping with cisternal cerebrospinal fluid (CSF) drainage. Clinical variables relevant to the study included age, sex, location of ruptured aneurysm, CT finding and clinical state on admission, clinical outcome, and CSF drainage. We first divided patients into two groups according to age (<70 years of age and ?70 years of age) and compared the two groups. Secondly, we analyzed variables to find factors associated with SDCH in both groups (<70 years of age and ?70 years of age). Results Of 59 patients, SDCH was observed in 20 patients (33.9 %), who underwent shunt placement for treatment of hydrocephalus. Forty seven percent of cases of acute hydrocephalus developed SDCH. In the elderly group (?70 years of age), the duration and amount of CSF drainage did not affect the development of chronic hydrocephalus. Conclusion In elderly patients, although the incidence of SDCH was significantly higher, clinical outcome was acceptable. The duration and the amount of cisternal drainage did not seem to be related to subsequent development of chronic hydrocephalus within elderly patients aged 70 or older.
Kim, Sung Hun; Chung, Pil-Wook; Kwon, Young Joon; Shin, Hyun Chul; Choi, Chun Sik
Numerous studies have claimed deleterious effects of LuxS mutation on many bacterial phenotypes, including bacterial biofilm formation. Genetic complementation mostly restored the observed mutant phenotypes to WT levels, leading to the postulation that quorum sensing via a family of molecules generically termed autoinducer-2 (AI-2) is essential for many phenotypes. Because LuxS mutation has dual effects, this hypothesis needs to be investigated into the details for each bacterial species. In this study we used S. sanguinis SK36 as a model biofilm bacterium and employed physiological characterization and transcriptome approaches on WT and luxS-deficient strains, in combination with chemical, luxS, and sahH complementation experiments. SahH enables a direct conversion of SAH to homocysteine and thereby restores the activated methionine cycle in a luxS-negative background without formation of the AI-2 precursor 4,5-dihydroxy-2,3-pentanedione. With this strategy we were able to dissect the individual contribution of LuxS and AI-2 activity in detail. Our data revealed that S. sanguinis biofilm formation is independent from AI-2 substance pools and is rather supported by an intact activated methyl cycle. Of 216 differentially transcribed genes in the luxS mutant, 209 were restored by complementation with a gene encoding the S-adenosylhomocysteine hydrolase. Only nine genes, mainly involved in natural competence, were directly affected by the AI-2 quorum-sensing substance pool. Cumulatively, this suggested that biofilm formation in S. sanguinis is not under control of AI-2. Our study suggests that previously evaluated LuxS mutants in other species need to be revisited to resolve the precise contribution of AI-2 substance pools and the methionine pathways.
Redanz, Sylvio; Standar, Kerstin; Podbielski, Andreas; Kreikemeyer, Bernd
Massive intracranial hemorrhage, no history of trauma and radiographic findings that were initially interpreted as linear parietal fractures raised the possibility of nonaccidental trauma in 2 infants. Both had severe coagulopathy, 1 due to hemorrhagic disease of the newborn (vitamin K deficiency) and the other due to disseminated herpes simplex virus infection. Both infants died. At autopsy, the parietal bone
L. Z. Fenton; A. P. Sirotnak; M. H. Handler
The potent vasoconstrictor peptide, endothelin-1 (ET-1), has been implicated in the pathophysiology of cerebral vasospasm that occurs after subarachnoid hemorrhage (SAH). This peptide is synthesized as a large prepropeptide that requires a series of modifying steps for its activation. The last of these steps involves the proteolytic conversion of a relatively inactive propeptide, Big ET-1, to its active, 21-amino acid peptide form. The enzyme responsible for converting Big ET-1 to ET-1 is a metalloprotease called endothelin-converting enzyme (ECE). In the present study the authors examined the effects of a newly developed inhibitor of ECE on responses to ET peptides in the normal basilar artery and on pathophysiological constriction in the spastic basilar artery after SAH. In the first series of experiments the authors examined normal basilar arteries in the rabbit, which were exposed transclivally and measured on-line using videomicroscopy. Intravenous administration or topical application of an active inhibitor of ECE, CGS 26303, blocked vasoconstrictor responses to topically applied Big ET-1 but not to ET-1. In contrast, topical application of a structurally related compound that does not inhibit ECE, CGS 24592, was ineffective in blocking vasoconstriction that was elicited by a topical application of Big ET-1. These findings indicate that CGS 26303 when administered systemically is capable of blocking the conversion of Big ET-1 to ET-1 in the basilar artery without affecting the ability of the vessel to respond to ET-1. In the second series of experiments the authors examined the effects of the ECE inhibitor on cerebral vasospasm after experimental SAH. Intraperitoneal administration of CGS 26303 via osmotic minipumps significantly attenuated the delayed spastic response of the basilar artery to an intracisternal injection of autologous blood. This study provides the first evidence that systemic administration of an inhibitor of ECE is capable of preventing cerebral vasospasm after SAH. The results reinforce a growing body of evidence that ETs play a critical role in the development of spastic constriction after SAH. Moreover, the findings indicate that blocking the conversion of Big ET-1 to its active ET-1 form using CGS 26303 may represent a feasible strategy for ameliorating cerebral vasospasm. PMID:8893732
Caner, H H; Kwan, A L; Arthur, A; Jeng, A Y; Lappe, R W; Kassell, N F; Lee, K S
The authors present a case of a hemorrhagic adrenal cyst, one of the tumors known in literature as incidentalomas, emphasizing the clinical characteristics, since adrenal cysts or pseudocysts are generally rare and observed by chance during imaging procedures. Traditionally they are classified as pseudocysts, endothelial, epithelial or parasitic cysts. Laparoscopic adrenalectomy has been considered the treatment of choice for benign, functioning or non-functioning adrenal lesions. Small cystic adrenal tumors can be managed conservatively by laparoscopic decortication or marsupialization, but larger cysts should be treated by total or partial adrenalectomy. PMID:23045835
da Silva, Elsa Cristina Fontes Pires; Viamontez, Francisco; Silva, Vasco Sabino; Andrade, Artur; Júlio Neto, Gonçalo; Gomes, Constança de Palma; Neto, Sérgio; Quitembo, Mateus; Dimbany, Higino; Van-Dunem, Joaquim Carlos Vicente Dias; de Miranda, Sandra Maria da Rocha Neto; Bastos, Fernando; Cordeiro, Lemuel Bornelli; Guilherme, Mateus
A 55-year-old women developed an aortointestinal fistula between the bifurcation of the aorta and the distal ileum following implantation of multiple endovascular stents into both common iliac arteries for treatment of aortoiliac occlusive disease. Ten months before the acute onset of the gastrointestinal hemorrhage two balloon-expandable steel stents had been implanted into both common iliac arteries. Due to restenosis and recurrent intermittent claudication, three balloon-expandable covered stents were implanted 4 months later on reintervention. The patient presented with abdominal pain and melena, and fell into hemorrhagic shock with signs of upper gastrointestinal bleeding. After transfer to our hospital, she again developed hemorrhagic shock with massive upper and lower gastrointestinal bleeding and died during emergency laparotomy. The development of aortoenteric fistulas following endovascular surgery/stent implantation is very rare and has to be considered in cases of acute gastrointestinal hemorrhage.
Kahlke, Volker [Department of General Surgery, University of Kiel, D-24105 Kiel (Germany); Brossmann, Joachim [Department for Diagnostic Radiology, University of Kiel, D-24105 Kiel (Germany); Klomp, Hans-Juergen [Department of General Surgery, University of Kiel, D-24105 Kiel (Germany)
Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne disease caused by the arbovirus Crimean-Congo hemorrhagic fever virus (CCHFV), which is a member of the Nairovirus genus (family Bunyaviridae). CCHF was first recognized during a large outbreak among ...
C. A. Whitehouse
Here, we report a rare case of an anaplastic astrocytoma masquerading as a hypertensive basal ganglia hemorrhage. A 69-year-old woman who had been under medical management for hypertension during the past 3 years suddenly developed right hemiparesis with dysarthria. Brain computed tomography (CT) scans with contrast and CT angiograms revealed an intracerebral hemorrhage (ICH) in the left basal ganglia, without an underlying lesion. She was treated conservatively, but underwent a ventriculoperitoneal shunt operation 3 months after the initial attack due to deteriorated mental status and chronic hydrocephalus. Three months later, her mental status deteriorated further. Magnetic resonance imaging (MRI) with gadolinium demonstrated an irregular enhanced mass in which the previous hemorrhage occurred. The final histological diagnosis which made by stereotactic biopsy was an anaplastic astrocytoma. In the present case, the diagnosis of a high grade glioma was delayed due to tumor bleeding mimicking hypertensive ICH. Thus, a careful review of neuroradiological images including MRI with a suspicion of tumor bleeding is needed even in the patients with past medical history of hypertension.
Choi, Go; Kang, Shin-Hyuk; Chung, Yong-Gu
Background Aneurysmal subarachnoid hemorrhage (SAH) may be complicated by delayed cerebral ischemia, which is a major cause of unfavorable clinical outcome and death in SAH-patients. Delayed cerebral ischemia is presumably related to the development of vasospasm triggered by the presence of blood in the basal cisterns. To date, oral application of the calcium antagonist nimodipine is the only prophylactic treatment for vasospasm recognized under international guidelines. In retrospective trials lumbar drainage of cerebrospinal fluid has been shown to be a safe and feasible measure to remove the blood from the basal cisterns and decrease the incidence of delayed cerebral ischemia and vasospasm in the respective study populations. However, the efficacy of lumbar drainage has not been evaluated prospectively in a randomized controlled trial yet. Methods/Design This is a protocol for a 2-arm randomized controlled trial to compare an intervention group receiving early continuous lumbar CSF-drainage and standard neurointensive care to a control group receiving standard neurointensive care only. Adults suffering from a first aneurysmal subarachnoid hemorrhage whose aneurysm has been secured by means of coiling or clipping are eligible for trial participation. The effect of early CSF drainage (starting < 72 h after securing the aneurysm) will be measured in the following ways: the primary endpoint will be disability after 6 months, assessed by a blinded investigator during a personal visit or standardized telephone interview using the modified Rankin Scale. Secondary endpoints include mortality after 6 months, angiographic vasospasm, transcranial Doppler sonography (TCD) mean flow velocity in both middle cerebral arteries and rate of shunt insertion at 6 months after hospital discharge. Discussion Here, we present the study design of a multicenter prospective randomized controlled trial to investigate whether early application of a lumbar drainage improves clinical outcome after aneurysmal subarachnoid hemorrhage. Trial registration www.clinicaltrials.gov Identifier: NCT01258257
We herein report the fourth case of cerebral infarction, concomitant with hemorrhagic shock, in English literature. A 33-year-old male, who had been diagnosed with schizophrenia and given a prescription for Olanzapine, was discovered with multiple self-inflicted bleeding cuts on his wrist. On arrival, he was in hemorrhagic shock without verbal responsiveness, but his vital signs were normalized following infusion of Lactate Ringer's solution. The neuroradiological studies revealed multiple cerebral ischemic lesions without any vascular abnormality. He was diagnosed with speech apraxia, motor aphasia, and dysgraphia, due to multiple cerebral infarctions. As there was no obvious causative factor with regard to the occurrence of cerebral infarction in the patient, the hypoperfusion due to hemorrhagic shock, and the thromboembolic tendency due to Olanzapine, might have acted together to lead to the patient's cerebral ischemia.
Yanagawa, Youichi; Ohara, Keiichiro; Tanaka, Yasutaka; Tanaka, Ryota
We herein report the fourth case of cerebral infarction, concomitant with hemorrhagic shock, in English literature. A 33-year-old male, who had been diagnosed with schizophrenia and given a prescription for Olanzapine, was discovered with multiple self-inflicted bleeding cuts on his wrist. On arrival, he was in hemorrhagic shock without verbal responsiveness, but his vital signs were normalized following infusion of Lactate Ringer's solution. The neuroradiological studies revealed multiple cerebral ischemic lesions without any vascular abnormality. He was diagnosed with speech apraxia, motor aphasia, and dysgraphia, due to multiple cerebral infarctions. As there was no obvious causative factor with regard to the occurrence of cerebral infarction in the patient, the hypoperfusion due to hemorrhagic shock, and the thromboembolic tendency due to Olanzapine, might have acted together to lead to the patient's cerebral ischemia. PMID:23493336
Yanagawa, Youichi; Ohara, Keiichiro; Tanaka, Yasutaka; Tanaka, Ryota
Carotid artery stenting (CAS) has been accepted as a relatively safe and effective treatment modality for patients with symptomatic severe carotid stenosis. We report a rare case of 75-year-old male with spontaneous peritoneal and perirenal hemorrhage following carotid angioplasty with stent. Because this intraabdominal hemorrhage can cause delayed diagnosis and treatment due to vague symptoms and the lack of suspicion of the hemorrhage, and can induce fatal condition, physicians should be aware that the abdominal hemorrhage could occur as a rare but serious complication after CAS without puncture site problems or iatrogenic injury. PMID:21497831
Cho, Young Dae; Lee, Jong Young; Seo, Jung Hwa; Kang, Hyun-Seung; Han, Moon Hee
Endovascular treatment for hemorrhagic complications following surgery has recently gained wide acceptance due to its minimal invasiveness compared to surgery. A 56-year-old male patient underwent laparoscopic gastrectomy for gastric cancer. There were two episodes of late intraperitoneal hemorrhage and endovascular treatment was performed. Transcatheter coil embolization of the gastroduodenal artery stump was successful in controlling the bleeding initially; however, hemorrhage recurred 7 days later. Repeated angiography revealed an obvious hemorrhage from the right gastric artery stump and embolization of the hepatic artery proper was performed to achieve immediate hemostasis. The endovascular treatment process was analyzed and the literature on similar situations was reviewed. In the present case, endovascular procedures were performed successfully to control bleeding in two episodes of late intraperitoneal hemorrhage. Angiography is recommended as the first-line modality for late intraperitoneal hemorrhage following laparoscopic gastrectomy and transcatheter coil embolization of the hepatic artery proper is safe and effective in selected cases.
HUANG, QIANG; GAO, KUN; ZHAI, REN-YOU
A shift of approach from 'clinics trying to fit physiology' to the one of 'physiology to clinics', with interpretation of the clinical phenomena from their physiological bases to the tip of the clinical iceberg, and a management exclusively based on modulation of physiology, is finally surging as the safest and most efficacious philosophy in hemorrhagic shock. ATLS(®) classification and recommendations on hemorrhagic shock are not helpful because antiphysiological and potentially misleading. Hemorrhagic shock needs to be reclassified in the direction of usefulness and timing of intervention: in particular its assessment and management need to be tailored to physiology. PMID:23248495
Bonanno, Fabrizio Giuseppe
A shift of approach from ‘clinics trying to fit physiology’ to the one of ‘physiology to clinics’, with interpretation of the clinical phenomena from their physiological bases to the tip of the clinical iceberg, and a management exclusively based on modulation of physiology, is finally surging as the safest and most efficacious philosophy in hemorrhagic shock. ATLS® classification and recommendations on hemorrhagic shock are not helpful because antiphysiological and potentially misleading. Hemorrhagic shock needs to be reclassified in the direction of usefulness and timing of intervention: in particular its assessment and management need to be tailored to physiology.
Bonanno, Fabrizio Giuseppe
Adrenal hemorrhage (AH) is a rare but serious condition that is often diagnosed at autopsy. Unilateral adrenal hemorrhage (UAH) in adults is extremely rare and is often due to trauma or anticoagulation or is associated with systemic illness. The case of a 73-year-old man who was diagnosed with UAH several days after an elective total knee replacement is presented. The patient had an uncomplicated procedure and he was treated postoperatively with a prophylactic dose of subcutaneous low-molecular- weight heparin and compression sleeves. On postoperative day 8, he reported sustained epigastric and midback pain at the lower thoracic level. He had a temperature of 38.5°C. On clinical examination, the patient expressed only mild tenderness at the lumbar area. Abdominal ultrasound and computed tomography (CT) scan were inconclusive. On postoperative day 13, the patient experienced no pain but remained febrile. An abdominal CT scan revealed a high-density mass on the left adrenal gland suggestive of hemorrhage. The subcutaneous heparin as well as the antimicrobial therapy was discontinued and a serum cortisol examination was done. Serum levels were within normal values in the evening and the morning. On postoperative day 16, all laboratory values returned to normal and the patient was discharged in excellent condition. Patients who have abdominal pain, hypotension, or both soon after initiation of anticoagulation or patients who experience abdominal pain, fever, nausea, or confusion postoperatively should be screened for AH. PMID:24810831
Chronopoulos, Efstathios; Nikolaou, Vassilios S; Masgala, Aikaterini; Kaspiris, Angelos; Babis, Georgios C
Severe postpartum hemorrhage (PPH) can be defined as a blood loss of more than 1500 mL to 2500 mL. While rare, severe PPH is a significant contributor to maternal mortality and morbidity in the United States and throughout the world. Due to the maternal hematologic adaptation to pregnancy, the hypovolemia resulting from hemorrhage can be asymptomatic until a large amount of blood is lost. Rapid replacement of lost fluids can mitigate effects of severe hemorrhage. Current evidence on postpartum volume replacement suggests that crystalloid fluids should be used only until the amount of blood loss becomes severe. Once a woman displays signs of hypovolemia, blood products including packed red blood cells, fresh frozen plasma, platelets, and recombinant factor VIIa should be used for volume replacement. Overuse of crystalloid fluids increases the risk for acute coagulopathy and third spacing of fluids. A massive transfusion protocol is one mechanism to provide a rapid, consistent, and evidence-based team response to this life-threatening condition. PMID:24751109
Schorn, Mavis N; Phillippi, Julia C
Hemorrhagic fever with renal syndrome (HFRS) and Crimean-Congo hemorrhagic fever (CCHF) are the 2 widespread viral hemorrhagic fevers occurring in Europe. HFRS is distributed throughout Europe, and CCHF has been reported mainly on the Balkan Peninsula and Russia. Both hemorrhagic fevers are endemic in Bulgaria. We investigated to what extent acute undifferentiated febrile illness in Bulgaria could be due to hantaviruses or to CCHF virus. Using enzyme-linked immunosorbent assays (ELISAs), we tested serum samples from 527 patients with acute febrile illness for antibodies against hantaviruses and CCHF virus. Immunoglobulin M (IgM) antibodies against hantaviruses were detected in 15 (2.8%) of the patients. Of the 15 hantavirus-positive patients, 8 (1.5%) were positive for Dobrava virus (DOBV), 5 (0.9%) were positive for Puumala virus (PUUV), and the remaining 2 were positive for both hantaviruses. A plaque reduction neutralization test (PRNT) confirmed 4 of the 10 DOBV-positive samples. PRNT was negative for all PUUV-positive samples. Serologic evidence of recent CCHF virus infection was found in 13 (2.5%) of the patients. Interestingly, HFRS and CCHF were not only detected in well-known endemic areas of Bulgaria but also in nonendemic regions. Our results suggested that in endemic countries, CCHF and/or HFRS might appear as a nonspecific febrile illness in a certain proportion of patients. Physicians must be aware of possible viral hemorrhagic fever cases, even if hemorrhages or renal impairment are not manifested. PMID:23421884
Christova, Iva; Younan, Rasha; Taseva, Evgenia; Gladnishka, Teodora; Trifonova, Iva; Ivanova, Vladislava; Spik, Kristin; Schmaljohn, Connie; Mohareb, Emad
Cerebral ischemia is the leading cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Although 70% of the patients show angiographic vasospasm only 30% develop symptomatic vasospasm defined as delayed cerebral ischemia (DCI). Early detection and management of reversible ischemia is of critical importance in patients with SAH. Using a bedside Xenon enhanced computerized tomography (Xenon-CT) scanner makes it possible to measure quantitative regional Cerebral blood flow (CBF) bedside in the neurointensive care setting and intracerebral microdialysis (MD) is a method that offers the possibility to monitor the metabolic state of the brain continuously. Here, we present results from nine SAH patients with both MD monitoring and bedside Xenon-CT measurements. CBF measurements were performed within the first 72?h following bleeding. Six out of nine patients developed DCI at a later stage. Five out of six patients who developed DCI had initial global CBF below 26?ml/100?g/min whereas one had 53?ml/100?g/min. The three patients who did not develop clinical vasospasm all had initial global CBF above 27?ml/100?g/min. High lactate/pyruvate (L/P) ratio was associated with lower CBF values in the area surrounding the catheter. Five out of nine patients had L/P ratio ?25 and four of these patients had CBF???22?ml/100?g/min. These preliminary results suggest that patients with initially low global CBF on Xenon-CT may be more likely to develop DCI. Initially low global CBF was accompanied with metabolic disturbances determined by the MD. Most importantly, pathological findings on the Xenon-CT and MD could be observed before any clinical signs of DCI. Combining bedside Xenon-CT and MD was found to be useful and feasible. Further studies are needed to evaluate if DCI can be detected before any other signs of DCI to prevent progress to infarction. PMID:24917850
Rostami, Elham; Engquist, Henrik; Johnson, Ulf; Howells, Timothy; Ronne-Engström, Elisabeth; Nilsson, Pelle; Hillered, Lars; Lewén, Anders; Enblad, Per
Cerebral ischemia is the leading cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Although 70% of the patients show angiographic vasospasm only 30% develop symptomatic vasospasm defined as delayed cerebral ischemia (DCI). Early detection and management of reversible ischemia is of critical importance in patients with SAH. Using a bedside Xenon enhanced computerized tomography (Xenon-CT) scanner makes it possible to measure quantitative regional Cerebral blood flow (CBF) bedside in the neurointensive care setting and intracerebral microdialysis (MD) is a method that offers the possibility to monitor the metabolic state of the brain continuously. Here, we present results from nine SAH patients with both MD monitoring and bedside Xenon-CT measurements. CBF measurements were performed within the first 72?h following bleeding. Six out of nine patients developed DCI at a later stage. Five out of six patients who developed DCI had initial global CBF below 26?ml/100?g/min whereas one had 53?ml/100?g/min. The three patients who did not develop clinical vasospasm all had initial global CBF above 27?ml/100?g/min. High lactate/pyruvate (L/P) ratio was associated with lower CBF values in the area surrounding the catheter. Five out of nine patients had L/P ratio ?25 and four of these patients had CBF???22?ml/100?g/min. These preliminary results suggest that patients with initially low global CBF on Xenon-CT may be more likely to develop DCI. Initially low global CBF was accompanied with metabolic disturbances determined by the MD. Most importantly, pathological findings on the Xenon-CT and MD could be observed before any clinical signs of DCI. Combining bedside Xenon-CT and MD was found to be useful and feasible. Further studies are needed to evaluate if DCI can be detected before any other signs of DCI to prevent progress to infarction.
Rostami, Elham; Engquist, Henrik; Johnson, Ulf; Howells, Timothy; Ronne-Engstrom, Elisabeth; Nilsson, Pelle; Hillered, Lars; Lewen, Anders; Enblad, Per
The absolute transcranial Doppler (TCD) velocity threshold has been validated as a screening tool for vasospasm after subarchnoid hemorrhage (SAH). We assessed whether relative changes in velocity were superior to absolute TCD thresholds in the detection of symptomatic vasospasm. We reviewed consecutive patients with aneurysmal SAH who underwent serial TCD monitoring and survived at least 7 days. We recorded initial flow velocity (IFV) and maximal flow velocity (MFV) of the middle cerebral artery (MCA) serially up to 14 days from admission. We calculated relative flow velocity changes (MFV/IFV) and maximum change in mean flow velocity (FVmean) over any consecutive 2 days in addition to standard absolute measures of Lindegaard ratio (LR) and FVmean. We calculated receiver operating characteristic curve and area under curve (AUC) values, sensitivity, specificity, and positive predictive and negative predictive values for these parameters, optimal cutpoints, and various combinations. Forty-eight of 211 patients (23%) developed symptomatic MCA vasospasm. AUC values for various TCD parameters were 0.80 for MCA MFV >175 cm/s, 0.71 for LR >6, 0.64 for MFV/IFV >2, and 0.64 for >70% change in MFV over 2 days. The best characteristics were observed for the combination of MFV >175 cm/s and/or maximal LR >6 (AUC 0.81). Our data suggest that absolute thresholds of TCD FVmean provide the most accurate prediction of symptomatic MCA vasospasm after SAH. Other thresholds, including relative change from baseline and day-to-day changes, are inferior to established absolute thresholds. PMID:22959107
Malhotra, Konark; Conners, James J; Lee, Vivien H; Prabhakaran, Shyam
Aims: To investigate the clinical course of vitrectomized patients with recurrent diabetic vitreous hemorrhage who were treated by revitrectomy with silicone oil (SO) as a hemostyptic tamponade. Patients and Methods: Fifteen patients with recurrent vitreous hemorrhage due to proliferative diabetic vitreoretinopathy were included in this retrospective study. All eyes had had at least one vitrectomy prior to use of SO
Stefan Bodanowitz; Nur Kir; Lutz Hesse
Fabry's disease is an X-linked lysosomal storage disorder resulting from alpha-galactosidase A deficiency. Although ischemic stroke is recognized as an important manifestation of Fabry's disease, hemorrhagic stroke is considered to be rare. Here, we report our recent clinical experience with three hemizygous male patients with Fabry's disease who developed cerebral hemorrhage. One patient had classic type Fabry's disease with p.Ala37Val mutation and others had cerebrovascular variant with p.Glu66Gln mutation. Degeneration of the cerebral small arteries secondary to deposition of glycosphingolipids and aging, in addition to hypertension and antiplatelet/anticoagulant agents, are considered to be contributing factors for hemorrhage. Fabry's disease is frequently associated with not only ischemic but also hemorrhagic stroke, especially in elderly patients. PMID:20300124
Nakamura, Katsuya; Sekijima, Yoshiki; Nakamura, Kimitoshi; Hattori, Kiyoko; Nagamatsu, Kiyoshiro; Shimizu, Yusaku; Yasude, Takuji; Ushiyama, Masao; Endo, Fumio; Fukushima, Yoshimitsu; Ikeda, Shu-ichi
The ability to recognize, manage, and, most importantly, prevent hemorrhagic complications is critical to performing dermatologic procedures that have safe and high quality outcomes. This article reviews the preoperative, intraoperative, and postoperative factors and patient dynamics that are central to preventing such an adverse outcome. Specifically, the role that anticoagulants and antiplatelet agents, hypertension, and other medical conditions play in the development of postoperative hemorrhage are discussed. In addition, this article provides practical guidelines on managing bleeding during and after surgery.
Bunick, Christopher G.; Aasi, Sumaira Z.
Crimean–Congo hemorrhagic fever (CCHF) is a tick-borne disease caused by the arbovirus Crimean–Congo hemorrhagic fever virus (CCHFV), which is a member of the Nairovirus genus (family Bunyaviridae). CCHF was first recognized during a large outbreak among agricultural workers in the mid-1940s in the Crimean peninsula. The disease now occurs sporadically throughout much of Africa, Asia, and Europe and results in
Chris A. Whitehouse
The control of the massive and often fatal hemorrhage from pelvic neoplasms is a major therapeutic problem. Transcatheter embolization of the internal iliac arteries was performed in 108 patients with uncontrollable hemorrhage due to pelvic neoplasms (urinary bladder in 50, uterus in 39, ovary in 16, and prostate in three). Complete control of the hemorrhage was achieved in 74 patients, partial control in 23, and no control in 11. Seventy patients experienced postembolization syndrome (nausea, vomiting, gluteal pain, and fever due to tissue necrosis), and three had transient acute tubular necrosis caused by the contrast medium. It is important for success that the embolization be bilateral and that the embolic agent used be a permanent one. PMID:2748811
Pisco, J M; Martins, J M; Correia, M G
Delayed cerebral ischemia (DCI) is at presentation a diagnosis per exclusionem, and can only be confirmed with follow-up imaging. For treatment of DCI a diagnostic tool is needed. We performed a systematic review to evaluate the value of CT perfusion (CTP) in the prediction and diagnosis of DCI. We searched PubMed, Embase, and Cochrane databases to identify studies on the relationship between CTP and DCI. Eleven studies totaling 570 patients were included. On admission, cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-peak (TTP) did not differ between patients who did and did not develop DCI. In the DCI time-window (4 to 14 days after subarachnoid hemorrhage (SAH)), DCI was associated with a decreased CBF (pooled mean difference -11.9?mL/100?g per minute (95% confidence interval (CI): -15.2 to -8.6)) and an increased MTT (pooled mean difference 1.5?seconds (0.9-2.2)). Cerebral blood volume did not differ and TTP was rarely reported. Perfusion thresholds reported in studies were comparable, although the corresponding test characteristics were moderate and differed between studies. We conclude that CTP can be used in the diagnosis but not in the prediction of DCI. A need exists to standardize the method for measuring perfusion with CTP after SAH, and optimize and validate perfusion thresholds. PMID:24281744
Cremers, Charlotte H P; van der Schaaf, Irene C; Wensink, Emerens; Greving, Jacoba P; Rinkel, Gabriel J E; Velthuis, Birgitta K; Vergouwen, Mervyn D I
Cerebral vasospasm is a major source of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). Evidence suggests a multifactorial etiology and this concept remains supported by the assortment of therapeutic modalities under investigation. The authors provide an updated review of the literature for previous and recent clinical trials evaluating medical treatments in patients with cerebral vasospasm secondary to aSAH. Currently, the strongest evidence supports use of prophylactic oral nimodipine and initiation of triple-H therapy for patients in cerebral vasospasm. Other agents presented in this report include magnesium, statins, endothelin receptor antagonists, nitric oxide promoters, free radical scavengers, thromboxane inhibitors, thrombolysis, anti-inflammatory agents and neuroprotectants. Although promising data is beginning to emerge for several treatments, few prospective randomized clinical trials are presently available. Additionally, future investigational efforts will need to resolve discrepant definitions and outcome measures for cerebral vasospasm in order to permit adequate study comparisons. Until then, definitive recommendations cannot be made regarding the safety and efficacy for each of these therapeutic strategies and medical management practices will continue to be implemented in a wide-ranging manner.
Adamczyk, Peter; Amar, Arun Paul; Mack, William J.
Traumatic basal subarachnoid hemorrhage (TBSAH) is infrequent but of forensic neuropathological importance because of its high mortality and complex causal mechanisms. The source of the hemorrhage is most frequently identified in the vertebro-basilar arteries but often cannot be identified in these arteries. We present a case of TBSAH possibly originating from hemorrhagic cerebellar contusions due to fist blows to the neck. A 35-year-old woman, who was punched on the right side of the neck, became unconscious about 20 min later and died. Autopsy demonstrated a massive subarachnoid hemorrhage at the base of the brain, with blood clots attached to the right lower surface of the cerebellum. No tear was detected in the vertebro-basilar vessels, but there were hemorrhagic cerebellar contusions beneath the blood clots as a possible source of TBSAH. The site of impact to the neck suggested the cerebellar contusions to be a coup injury due to hard blows. PMID:20122864
Chen, Jian-Hua; Ishikawa, Takaki; Michiue, Tomomi; Maeda, Hitoshi
The prevention of Rhesus D alloimmunization through Rh immune globulin (RhIg) administration is the major indication for the accurate detection and quantification of fetomaternal hemorrhage (FMH). In the setting of D incompatibility, D-positive fetal cells can sensitize the D-negative mother, resulting in maternal anti-D alloantibody production. These anti-D alloantibodies may lead to undesirable sequelae such as hemolytic disease of the newborn (HDN). Since the widespread adoption of FMH screening and RhIg immunoprophylaxis, the overall risk of Rh alloimmunization and infant mortality from HDN has substantially decreased. The rosette screen, the initial test of choice, is highly sensitive in qualitatively detecting 10 mL of fetal whole blood in the maternal circulation. As the screen is reliant on the presence of the D antigen to distinguish fetal from maternal cells, it cannot be used to detect FMH in D-positive mothers or in D-negative mothers carrying a D-negative fetus. The Kleihauer-Betke acid-elution test, the most widely used confirmatory test for quantifying FMH, relies on the principle that fetal RBCs contain mostly fetal hemoglobin (HbF), which is resistant to acid-elution whereas adult hemoglobin is acid-sensitive. Although the Kleihauer-Betke test is inexpensive and requires no special equipment, it lacks standardization and precision, and may not be accurate in conditions with elevated F-cells. Anti-HbF flow cytometry is a promising alternative, although its use is limited by equipment and staffing costs. Hematology analyzers with flow cytometry capabilities may be adapted for fetal cell detection, thus giving clinical laboratories a potentially attractive automated alternative for quantifying FMH. PMID:22231030
Kim, Yeowon A; Makar, Robert S
Rapid progression to blindness due to intraorbital hemorrhage following various forms of trauma requires immediate, aggressive intervention, with the potential to restore vision. Orbital decompression via either an external ethmoidectomy or transantral approach is described. The diagnosis, anatomy, and pathogenetic mechanisms relevant to these cases are reviewed. PMID:3382537
Sacks, S H; Lawson, W; Edelstein, D; Green, R P
Burr hole drainage has been widely used to treat chronic subdural hematomas (SDH), and most of them are easily treated by simple trephination and drainage. However, various complications, such as, hematoma recurrence, infection, seizure, cerebral edema, tension pneumocephalus and failure of the brain to expand due to cerebro-cranial disproportion may develop after chronic SDH drainage. Among them, intracerebral hemorrhage after evacuation of a recurrent chronic SDH is very rare. Here, we report a fatal case of delayed intracerebral hemorrhage caused by coagulopathy following evacuation of a chronic SDH. Possible pathogenic mechanisms of this unfavorable complication are discussed and a review of pertinent literature is included.
Kim, Jong Kyu; Kim, Sung Hoon
Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells. The diagnosis is usually suggested by classic history in a symptomatic patient, presence of a strong family history in a patient, or discovery of an incidental mass on imaging in an asymptomatic patient. Traumatic hemorrhage into an occult pheochromocytoma presenting as hypovolemic shock is a rare presentation of pheochromocytoma. We report a case of a 48-year-old female, who presented in hypovolemic shock due to unilateral adrenal hemorrhage secondary to a fall from horse. Computed tomographic imaging revealed that the source of the hypovolemic shock was hemorrhagic right adrenal mass with active extravasation. The patient underwent emergent selective arterial embolization of right superior adrenal artery and a small adrenal branch from the right renal artery to control the hemorrhage. The patient subsequently progressed to sepsis and MODS, needing multiple surgical procedures and a protracted recovery in the ICU. In the ICU, the patient suffered from rapid cyclic fluctuation of her systolic blood pressure and was subsequently diagnosed with pheochromocytoma secondary to traumatic hemorrhage. We discuss this rare case along with the presentation and diagnostic workup of this critically ill patient with a previously undiagnosed pheochromocytoma.
Amin, Arpit; Biswas, Saptarshi; Baccay, Francis
The viral family Arenaviridae includes a number of viruses that can cause hemorrhagic fever in humans. Arenavirus infection often involves multiple organs and can lead to capillary instability, impaired hemostasis, and death. Preclinical testing for development of antiviral or therapeutics is in part hampered due to a lack of an immunologically well-defined rodent model that exhibits similar acute hemorrhagic illness or sequelae compared to the human disease. We have identified the FVB mouse strain, which succumbs to a hemorrhagic fever-like illness when infected with lymphocytic choriomeningitis virus (LCMV). FVB mice infected with LCMV demonstrate high mortality associated with thrombocytopenia, hepatocellular and splenic necrosis, and cutaneous hemorrhage. Investigation of inflammatory mediators revealed increased IFN-?, IL-6 and IL-17, along with increased chemokine production, at early times after LCMV infection, which suggests that a viral-induced host immune response is the cause of the pathology. Depletion of T cells at time of infection prevented mortality in all treated animals. Antisense-targeted reduction of IL-17 cytokine responsiveness provided significant protection from hemorrhagic pathology. F1 mice derived from FVB×C57BL/6 mating exhibit disease signs and mortality concomitant with the FVB challenged mice, extending this model to more widely available immunological tools. This report offers a novel animal model for arenavirus research and pre-clinical therapeutic testing.
Schnell, Frederick J.; Sundholm, Sarah; Crumley, Stacy; Iversen, Patrick L.; Mourich, Dan V.
One half of deaths among trauma victims occur within 1 hour of injury and are due to rapid hemorrhage or CNS trauma. We developed a rapid hemorrhage model in unanesthetized swine to simulate human exsanguination. We compared the ability of four crystalloid solutions to prevent death after an otherwise fatal hemorrhage: normal saline (NS), Ringer's lactate (RL), Plasmalyte-A (PA), and Plasmalyte-R (PR). Five days before hemorrhage swine received an aortic sideport and a central venous treatment catheter. Aortic blood (54 ml/kg) was removed in 15 minutes from 116 swine. The percentages of shed blood replaced were 14% in 5 minutes with NS, 100% in 20 minutes with NS, and 300% in 30 minutes with NS, RL, PA, or PR. We found that all mortalities were determined within 2 hours after hemorrhage and that RL provided the best survival rate of 67% (NS 300% = 50%, PR = 40%, and PA = 30%.) After an analysis of arterial blood gas, lactate, acid-base, heart rate, and aortic pressure measurements, we conclude that RL is the superior crystalloid solution because of its decreased chloride load (compared to NS) and because of the absence of acetate or magnesium (compared to PA and PR). PMID:3080602
Traverso, L W; Lee, W P; Langford, M J
Background and Purpose: Several studies report good outcomes in selected patients of aneurysmal subarachnoid hemorrhage (aSAH). The purpose of our study is to project the clinical characteristics, management, and overall outcome of patients with aSAH presenting to a tertiary care center in India. Materials and Methods: A prospective study was conducted over a period of 10 months and all patients presenting with aSAH were studied. Patients presenting in all grades and managed with any type of intervention or managed conservatively were included to characterize their clinical and radiological profile at admission, during management, and at discharge. Outcome was assessed with the Glasgow Outcome Score (GOS) at 3 months follow-up. Results: Out of the 482 patients [mean age: 51.3 (±13.5); M: F = 1:1], 330 patients were fit to be taken up for intervention of the ruptured aneurysm, while 152 patients were unfit for any intervention. At 3 months follow-up, good outcome (GOS 4 and 5) was observed in 159 (33%), poor outcome (GOS 2 and 3) in 53 (11%), and death in 219 (45.4%) patients, while 51 patients (10.6%) were lost to follow-up. Most (95%) of the patients in the non-intervention group expired, and hence the high mortality rate, as we have analyzed the results of all patients of all grades, regardless of the treatment given. The predictors of poor outcome (GOS 1, 2, and 3) at 3 months follow-up, using multinomial regression model, were: World Federation of Neurological Surgeons (WFNS) grade IV and V (at admission and after adequate resuscitation) [odds ratio (OR): 35.1, 95% confidence interval (CI): 10.8-114.7] and presence of hypertension as a co-morbid illness [OR: 2.7, 95% CI: 1.6-5.6]. All patients showing acute infarction on computed tomography scan at presentation had a poor outcome. Conclusions: Despite recent advances in the treatment of patients with aSAH, the morbidity and mortality rates have failed to improve significantly in unselected patients and natural cohorts. This may be attributed to the natural history of aSAH, and calls for new strategies to diagnose and treat such patients before the catastrophe strikes.
Sodhi, Harsimrat Bir Singh; Savardekar, Amey R.; Mohindra, Sandeep; Chhabra, Rajesh; Gupta, Vivek; Gupta, Sunil K.
Introduction Clinicians and specialty societies often emphasize the potential importance of natural light for quality care of critically ill patients, but few studies have examined patient outcomes associated with exposure to natural light. We hypothesized that receiving care in an intensive care unit (ICU) room with a window might improve outcomes for critically ill patients with acute brain injury. Methods This was a secondary analysis of a prospective cohort study. Seven ICU rooms had windows, and five ICU rooms did not. Admission to a room was based solely on availability. We analyzed data from 789 patients with subarachnoid hemorrhage (SAH) admitted to the neurological ICU at our hospital from August 1997 to April 2006. Patient information was recorded prospectively at the time of admission, and patients were followed up to 1 year to assess mortality and functional status, stratified by whether care was received in an ICU room with a window. Results Of 789 SAH patients, 455 (57.7%) received care in a window room and 334 (42.3%) received care in a nonwindow room. The two groups were balanced with regard to all patient and clinical characteristics. There was no statistical difference in modified Rankin Scale (mRS) score at hospital discharge, 3 months or 1 year (44.8% with mRS scores of 0 to 3 with window rooms at hospital discharge versus 47.2% with the same scores in nonwindow rooms at hospital discharge; adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 0.67 to 1.50, P = 0.98; 62.7% versus 63.8% at 3 months, aOR 0.85, 95% CI 0.58 to 1.26, P = 0.42; 73.6% versus 72.5% at 1 year, aOR 0.78, 95% CI 0.51 to 1.19, P = 0.25). There were also no differences in any secondary outcomes, including length of mechanical ventilation, time until the patient was able to follow commands in the ICU, need for percutaneous gastrostomy tube or tracheotomy, ICU and hospital length of stay, and hospital, 3-month and 1-year mortality. Conclusions The presence of a window in an ICU room did not improve outcomes for critically ill patients with SAH admitted to the ICU. Further studies are needed to determine whether other groups of critically ill patients, particularly those without acute brain injury, derive benefit from natural light.
In 1963, an epidemic of viral hemorrhagic fever affected several hundred natives in San Joaquin, Bolivia. The mortality was 18%. This report describes the pathologic changes of Bolivian hemorrhagic fever based upon observations on eight cases that were au...
P. L. Child R. B. MacKenzie L. R. Valverde K. M. Johsnon
... multiple abnormalities in the blood vessels. In the circulatory system, blood carrying oxygen from the lungs is normally ... hemorrhages in the brain, liver, lungs, or other organs. Forms of hereditary hemorrhagic telangiectasia include type 1, ...
Angiosarcoma is a rare malignant neoplasm of the vascular or lymphatic endothelium. Diffuse alveolar hemorrhage is a rare presenting manifestation of angiosarcoma. We describe a case of pulmonary metastasis of angiosarcoma who presented with diffuse alveolar hemorrhage as initial manifestation.
Rai, SP; Barthwal, MS; Bhattacharya, P; Bhargava, S; Pethe, M
In this paper a system for 3-D quantitative analysis of human spontaneous intracerebral brain hemorrhage (ICH) is described. The purpose of the developed system is to perform quantitative 3-D measurements of the parameters of ICH region and from computed tomography (CT) images. The measured parameter in this phase of the system development is volume of the hemorrhage region. The goal of the project is to measure parameters for a large number of patients having ICH and to correlate measured parameters to patient morbidity and mortality.
Loncaric, Sven; Dhawan, Atam P.; Cosic, Dubravko; Kovacevic, Domagoj; Broderick, Joseph; Brott, Thomas
Summary \\u000a ?Background. A rare case of a left temporal arteriovenous malformation (AVM) with bleeding 10 days after removal of another hemorrhagic\\u000a AVM in the frontal lobe is reported.\\u000a \\u000a \\u000a \\u000a ?Method. A 47-year-old man had an attack of headache and vomiting and was admitted to our hospital. On admission, a CT scan showed\\u000a subcortical hemorrhage in the left frontal lobe. Left carotid
S. Utsuki; A. Kurata; Y. Miyasaka; M. Takano; H. Ootaka; K. Fujii
Background The effectiveness of comprehensive stroke center (CSC) capabilities on stroke mortality remains uncertain. We performed a nationwide study to examine whether CSC capabilities influenced in-hospital mortality of patients with ischemic and hemorrhagic stroke. Methods and Results Of the 1,369 certified training institutions in Japan, 749 hospitals responded to a questionnaire survey regarding CSC capabilities that queried the availability of personnel, diagnostic techniques, specific expertise, infrastructure, and educational components recommended for CSCs. Among the institutions that responded, data on patients hospitalized for stroke between April 1, 2010 and March 31, 2011 were obtained from the Japanese Diagnosis Procedure Combination database. In-hospital mortality was analyzed using hierarchical logistic regression analysis adjusted for age, sex, level of consciousness on admission, comorbidities, and the number of fulfilled CSC items in each component and in total. Data from 265 institutions and 53,170 emergency-hospitalized patients were analyzed. Mortality rates were 7.8% for patients with ischemic stroke, 16.8% for patients with intracerebral hemorrhage (ICH), and 28.1% for patients with subarachnoid hemorrhage (SAH). Mortality adjusted for age, sex, and level of consciousness was significantly correlated with personnel, infrastructural, educational, and total CSC scores in patients with ischemic stroke. Mortality was significantly correlated with diagnostic, educational, and total CSC scores in patients with ICH and with specific expertise, infrastructural, educational, and total CSC scores in patients with SAH. Conclusions CSC capabilities were associated with reduced in-hospital mortality rates, and relevant aspects of care were found to be dependent on stroke type.
Iihara, Koji; Nishimura, Kunihiro; Kada, Akiko; Nakagawara, Jyoji; Ogasawara, Kuniaki; Ono, Junichi; Shiokawa, Yoshiaki; Aruga, Toru; Miyachi, Shigeru; Nagata, Izumi; Toyoda, Kazunori; Matsuda, Shinya; Miyamoto, Yoshihiro; Suzuki, Akifumi; Ishikawa, Koichi B.; Kataoka, Hiroharu; Nakamura, Fumiaki; Kamitani, Satoru
Our objective was to review current literature pertaining to antepartum fetal intracranial hemorrhage. To this goal we selected all manuscripts published in the English language regarding this topic obtained from a MEDLINE search for 1966 through January 1998. Additional sources were identified through cross-referencing. Antenatal fetal intracranial hemorrhage may occur spontaneously, or occur in association with various maternal or fetal conditions. Predisposing maternal conditions at risk for this occurrence include alloimmune and idiopathic thrombocytopenia, von Willebrand's disease, specific medications (warfarin) or illicit drug (cocaine) abuse, seizures, severe abdominal trauma inflicting subsequent fetal injury, amniocentesis, cholestasis of pregnancy and febrile disease. Predisposing fetal conditions include congenital factor-X and factor-V deficiencies, hemorrhage into various congenital tumors, twin-twin transfusion, demise of a co-twin, or fetomaternal hemorrhage. Currently, antepartum fetal intracranial hemorrhage may be diagnosed by imaging techniques including ultrasonography and less frequently, magnetic resonance imaging. Early real-time sonographic signs of intracranial hemorrhage consist of irregular echogenic patterns representing the associated hematoma that may clearly distort normal intracranial structures. Recent reports have suggested Doppler flow velocimetry and color Doppler imaging as additional tools in detecting fetal intracranial hemorrhage. Various types of antenatal fetal intracranial hemorrhages that have been visualized sonographically include intraventricular, periventricular, subependymal, parenchymal, subdural, and intracerebellar events. Active hemorrhages may be associated with fetal distress manifested by fetal heart rate changes. Infrequently, antenatal ultrasonographic depiction of intracranial hemorrhage may precede devastating sequelae such as hydrocephalus, hydranencephaly, porencephaly, or microcephaly. Due to the significant associated neonatal neurological impairment and potential medicolegal implications of antepartum fetal intracranial hemorrhage, it follows that obstetricians and sonographers should be familiar with predisposing factors and typical diagnostic imaging findings of these events. PMID:9759911
Sherer, D M; Anyaegbunam, A; Onyeije, C
Traumatic submacular hemorrhage may present with significant decrease in vision and may have varying outcomes. Following injury, the hemorrhage can collect either between the neurosensory retina and retinal pigment epithelium (RPE) or below the RPE. This differentiation may be important to prognosticate and to guide treatment. In two patients with post-traumatic submacular hemorrhage, Cirrius spectral domain high-definition optical coherence tomography (OCT) (Carl Zeiss Meditec, Dublin, CA) was used to differentiate traumatic submacular hemorrhage types using automation three-dimensional segmentation analysis. Based on the OCT findings, the patient with sub-RPE bleed was subjected to pneumatic displacement. En face C-scan imaging just below the RPE allowed for the diagnosis of the exact location of choroidal rupture that was masked due to hemorrhage. PMID:21366180
Sampangi, Raju; Chandrakumar, H V; Somashekar, Sandhya E; Joshi, Gauri R; Ganesh, Sri
Retinal hemorrhages are the most commonly reported ocular findings in nonaccidental trauma in children. Other reported ocular findings include perimacular folds, traumatic retinoschisis, choroidal hemorrhages, and retinal detachments. We report the clinical and pathologic findings in a case of a 10-month-old boy who sustained nonaccidental trauma and whose clinical presentation was characteristic of a hemorrhagic choroidal detachment. Postmortem examination revealed a large subretinal hemorrhage, with no evidence of choroidal hemorrhage. PMID:17964206
Weis, Adina; Kodsi, Sylvia R; Rubin, Steven E; Esernio-Jenssen, Debra; Ferrone, Philip J; McCormick, Steven A
Crimean hemorrhagic fever infection in Rostov Oblast was recorded for the first time in May and June 1963. The infection was distinctly of a professional character: of 12 persons, 9 were milkmaids, 2 dairy farm labourers, 1 surgeon, and one 6 year-old chi...
V. D. Perelatov
Aims: Very elderly subjects represent the fastest growing population in the world. Most of the recent studies on intracerebral hemorrhage (ICH) have been carried out on younger patients and/or preferably using novel radiological techniques. We investigated the prevalence, risk factors, and histopathological characteristics of the ICH in the oldest old. Materials and methods: The brains of 300 autopsied individuals (248 females, 52 males, mean age at death 92.4?±?3.7?years) were investigated as part of the prospective population-based Vantaa 85+ study. After macroscopic investigation, the presence and extent of microscopic brain hemorrhages (MH) were analyzed by counting the number of iron containing macrophages (siderophages) by Prussian blue staining. Deposits with >5 siderophages were defined as MH+, forming a subgroup of MH. Genotyping of apolipoprotein E (APOE) and the analysis of microscopic (MI) or larger infarctions and cerebral amyloid angiopathy (CAA) were performed using standardized methods. Regression analysis was used to predict the presence of ICH, with and without co-localized CAA, and was adjusted for age at death and gender. Results: The prevalence of macroscopic ICH was 2.3% in total; consisting of 1% large lobar hemorrhage (LH), 1% deep hemorrhage (DH), and 0.3% of subarachnoid hemorrhage (SAH). 62% had MH and 15.3% MH+. All MH+ lesions were found to be >2?mm wide. 55.9% of subjects with MH and 81.2% of those with MH+ showed MH/MH+ and CAA in the same brain region (MHCAA and MH+CAA, respectively). MH was associated with none of the neuropathological or clinical conditions, nor with the APOE carrier status. The subjects with MH+, MHCAA or MH+CAA carried the APOE ?4 allele more frequently than controls (OR 3.681, 3.291, 7.522, respectively). Siderophages in MH+CAA co-localized with CAA and with two-thirds of the MI in the tissue sections. Conclusion: Macroscopic ICH was rare in the very elderly. MH was frequent and clinically insignificant. MH+ was rare but closely related with the APOE ?4 genotype and the presence of severe CAA and infarction.
Tanskanen, Maarit; Makela, Mira; Myllykangas, Liisa; Rastas, Sari; Sulkava, Raimo; Paetau, Anders
Rivaroxaban is an oral factor Xa inhibitor used for stroke prevention in atrial fibrillation. There are currently no evidence-based guidelines for the treatment of hemorrhagic side effects of factor Xa inhibitors. We report a case of a thalamic hemorrhage in an 84 year-old right-handed female on rivaroxaban for treatment of atrial fibrillation. The patient had fallen down steps and became unresponsive. She was found to have diffuse scattered acute subarachnoid hemorrhage as well as intraventricular hemorrhage. Neurosurgical intervention was not required in this case, but controversy over decision making to pursue pro-coagulant therapy in the setting of worsening hemorrhage requiring emergent surgery is discussed.
Molina, Michelle; Hillard, Virany H.; Fekete, Robert
Each year, approximately 795,000 people experience a new or recurrent stroke. Of all strokes, 84% are ischemic, 13% are intracerebral hemorrhage (ICH) strokes, and 3% are subarachnoid hemorrhage strokes. Despite the decreased incidence of ischemic stroke, there has been no change in the incidence of hemorrhagic stroke in the last decade. ICH is a devastating disease 37–38% of patients between the ages of 45 and 64 die within 30?days. In an effort to prevent ischemic and hemorrhagic strokes we and others have been studying the role of prostaglandins and their receptors. Prostaglandins are bioactive lipids derived from the metabolism of arachidonic acid. They sustain homeostatic functions and mediate pathogenic mechanisms, including the inflammatory response. Most prostaglandins are produced from specific enzymes and act upon cells via distinct G-protein coupled receptors. The presence of multiple prostaglandin receptors cross-reactivity and coupling to different signal transduction pathways allow differentiated cells to respond to prostaglandins in a unique manner. Due to the number of prostaglandin receptors, prostaglandin-dependent signaling can function either to promote neuronal survival or injury following acute excitotoxicity, hypoxia, and stress induced by ICH. To better understand the mechanisms of neuronal survival and neurotoxicity mediated by prostaglandin receptors, it is essential to understand downstream signaling. Several groups including ours have discovered unique roles for prostaglandin receptors in rodent models of ischemic stroke, excitotoxicity, and Alzheimer disease, highlighting the emerging role of prostaglandin receptor signaling in hemorrhagic stroke with a focus on cyclic-adenosine monophosphate and calcium (Ca2+) signaling. We review current ICH data and discuss future directions notably on prostaglandin receptors, which may lead to the development of unique therapeutic targets against hemorrhagic stroke and brain injuries alike.
Mohan, Shekher; Ahmad, Abdullah S.; Glushakov, Alexander V.; Chambers, Chase; Dore, Sylvain
Snake venoms are complex mixture of enzymatic and non-enzymatic proteins. Non-covalent protein-protein interaction leads to protein complexes, which bring about enhanced pharmacological injuries by their synergistic action. Here we report identification and characterization of a new Daboia russelii hemorrhagic complex I (DR-HC-I) containing phospholipase A? (PLA?) and non-enzymatic peptide. DR-HC-I was isolated from the venom of D. russelii by CM-Shepadex-C25 and gel permeation chromatography. Individual components were purified and identified by RP-HPL chromatography, mass spectrometry and N-terminal amino acid sequencing. DR-HC-I complex was lethal to mice with the LD?? dose of 0.7 mg/kg body weight with hemorrhagic and neurotoxic properties. DR-HC-I complex consists of non-hemorrhagic PLA? and neurotoxic non-enzymatic peptide. The non-enzymatic peptide quenched the intrinsic fluorescence of PLA? in a dose dependent manner, signifying the synergistic interaction between two proteins. PLA? and peptide toxin in a 5:2 M ratio induced skin hemorrhage in mice with MHD 20 ?g. However, addition of ANS (1-Anilino-8-naphthalene sulfonate) to DR-HC-I complex inhibited skin hemorrhagic effect and also synergic interaction. But there was no impact on PLA? due to this synergistic interaction, and indirect hemolytic or plasma re-calcification activity. However, the synergistic interaction of PLA? and non-enzymatic peptide contributes to the enhanced venom-induced hemorrhage and toxicity of Daboia russellii venom. PMID:23872188
Venkatesh, Madhukumar; Gowda, Veerabasappa
Acute hemorrhagic conjunctivitis (AHC) is an epidemic form of highly contagious conjunctivitis, characterized by conjunctival hemorrhages. The first AHC outbreak was described in 1969 in Ghana, West Africa, and was called Apollo disease, from the Apollo landing on the moon. This outbreak was caused by Enterovirus 70 (EV70) together with a Coxsackievirus A24 (CVA24v) variant, which are the major etiological agents involved in AHC outbreaks worldwide. AHC is known to be directly transmitted by close person-to-person contact or indirectly through soiled ophthalmological materials or unsafe recreational water. Recently, a possible airborne virus spread was suggested which could explain the high transmission rate of the disease. In the absence of a specific antiviral therapy, a rapid diagnosis of the causative agent is required to distinguish AHC due to enteroviruses from other ocular infectious diseases, for there are active drugs, or to quickly implement proper public health measures to limit the extension of the outbreak. However, virus identification remains difficult and time-consuming. Moreover, virological diagnosis is difficult to implement in developing countries where AHC has recently become a major problem for public health. PMID:19836177
Lévêque, N; Huguet, P; Norder, H; Chomel, J-J
Introduction Vitreous hemorrhage associated with retinopathy of prematurity is often seen in childhood, but adult onset without retinal break is rare. We describe a case of recurrent vitreous hemorrhage associated with regressed retinopathy of prematurity in a 47-year-old patient. Case presentation A 47-year-old Japanese woman with a history of retinopathy of prematurity presented with a visual disturbance in her left eye due to vitreous hemorrhage. Because the vitreous hemorrhage was recurrent and refractory, we performed pars plana vitrectomy combined with lens extraction by phacoemulsification and intraocular lens implantation. No retinal break or retinal detachment was found. No vitreous hemorrhage or other complication occurred in the first six months after surgery. Conclusions Vitrectomy, potentially in combination with lens extraction, should be considered in adult-onset recurrent vitreous hemorrhage associated with retinopathy of prematurity.
We report an unusual case of cerebral aneurysmal subarachnoid hemorrage (SAH) with Fabry's disease. A 42-year-old woman presented with aneurysmal SAH originated from a saccular aneurysm of the right posterior communicating artery. The patient was treated by an endovascular coil embolization of aneurysm. Postoperatively the patient recovered favorably without any neurological deficit. During her admission, the patient had a sign of proteinuria in urine analysis. The pathologic findings of kidney needle biopsy implied nephrosialidosis (mucolipidosis of lysosomal stroage disease), which is consistent with a Fabry's disease. It is uncommon that Fabry's disease is presented with aneurysmal SAH, especially in middle-aged patients, but could be a clinical concern. Further investigations are needed to reveal risk factors, vascular anatomy, and causative mechanisms of Fabry's disease with aneurysmal SAH.
Chang, Youn Hyuk
We report an unusual case of cerebral aneurysmal subarachnoid hemorrage (SAH) with Fabry's disease. A 42-year-old woman presented with aneurysmal SAH originated from a saccular aneurysm of the right posterior communicating artery. The patient was treated by an endovascular coil embolization of aneurysm. Postoperatively the patient recovered favorably without any neurological deficit. During her admission, the patient had a sign of proteinuria in urine analysis. The pathologic findings of kidney needle biopsy implied nephrosialidosis (mucolipidosis of lysosomal stroage disease), which is consistent with a Fabry's disease. It is uncommon that Fabry's disease is presented with aneurysmal SAH, especially in middle-aged patients, but could be a clinical concern. Further investigations are needed to reveal risk factors, vascular anatomy, and causative mechanisms of Fabry's disease with aneurysmal SAH. PMID:23634271
Chang, Youn Hyuk; Hwang, Sung-Kyun
In North America, an estimated 30,000 patients annually experience an aneurysmal subarachnoid hemorrhage (SAH). In approximately five percent of these patients, the hemorrhage is not visible on computerized tomography scans due to the inability to image blood at time intervals greater than 12 hours post symptom onset. For these patients (many of which have experience a sentinel hemorrhage that is
Fred R. Beyette; B. Booher; J. Drennan; L. Carraher; J. Butler; P. Bowman; J. F. Clark; P. A. Wilsey
Objectives: Risk factors have been described for spontaneous intracerebral hemorrhage (ICH); their relative contribution to lobar vs nonlobar hemorrhage location is less clear. Our purpose here was to investigate risk factors by hemorrhage location. Methods: This case-control study prospectively enrolled subjects with first-ever spontaneous ICH and matched each with up to 3 controls by age, race, and gender. Conditional stepwise logistic regression modeling was used to determine significant independent risk factors for lobar and nonlobar ICH. Results: From December 1997 through December 2006, 597 cases and 1,548 controls qualified for the analysis. Hypertension, warfarin use, first-degree relative with ICH, personal history of ischemic stroke, less than a high school education, and APOE ?2 or ?4 genotype were more common in ICH cases. Hypercholesterolemia and moderate alcohol consumption (?2 drinks per day) were less common in ICH cases. The associations of hypertension and hypercholesterolemia were specific for nonlobar ICH. Conversely, the association of APOE ?2 or ?4 genotype was specific for lobar ICH. Conclusions: APOE ?2 or ?4 genotype was associated specifically with lobar ICH. Hypertension was associated specifically with nonlobar ICH. A protective association was seen between hypercholesterolemia and nonlobar ICH; no such association was identified for lobar ICH.
Martini, Sharyl R.; Flaherty, Matthew L.; Brown, W. Mark; Haverbusch, Mary; Comeau, Mary E.; Sauerbeck, Laura R.; Kissela, Brett M.; Deka, Ranjan; Kleindorfer, Dawn O.; Moomaw, Charles J.; Broderick, Joseph P.; Langefeld, Carl D.
Nattokinase is used as a health-promoting medicine for preventing thrombosis due to its fibrinolytic activity. Cerebral microbleed is remnant of blood extravasations from the damaged vessels related to cerebral microangiopathies. We report a patient, having used aspirin for secondary stroke prevention, who had an acute cerebellar hemorrhage after taking nattokinase 400 mg daily for 7 consecutive days. In addition to the hemorrhagic lesion, multiple microbleeds were demonstrated on brain MR images. We suggest that nattokinase may increase risk of intracerebral hemorrhage in patients who have bleeding-prone cerebral microangiopathy and are receiving other antithrombotic agent at the same time. PMID:18310985
Chang, Yung-Yee; Liu, Jia-Shou; Lai, Shung-Lon; Wu, Hsiu-Shan; Lan, Min-Yu
Background Post partum hemorrhage is defined as blood loss of 500 ml or above. It is the most common cause of pre-mature mortality of women world wide. Our objective was to evaluate the most common etiology and method of management of Post partum Hemorrhage in a tertiary care hospital of Karachi. Findings It was a cross sectional study conducted at Liaquat National Hospital Karachi, during the period of July 2011 to May 2012. Review include mode of delivery, possible cause of postpartum hemorrhage, supportive, medical and surgical interventions. All the women admitted with post partum hemorrhage or develop PPH in hospital after delivery were included in our study. Bleeding disorder and use of anticoagulants were set as exclusion criteria. Diagnosis was made on the basis of blood loss assessment which was made via subjective and objective evaluation. During the targeted months, out of total 1493 deliveries (26/1493?=?1.741%) 26 cases of post partum hemorrhage were reported with a mean age of 26.153?±?7.37. No deaths were reported and all cases were referred and unbooked cases. All Patients were conscious, tachycardiac and hypotensive. Most of the women were suffering from hemorrhage during or after the birth of their 1st child. Primary post partum hemorrhage emerge as the most common type of post partum hemorrhage and uterine atony was detected as the most common cause of primary post partum hemorrhage. Retained products of conception was the most common cause of secondary post partum hemorrhage and hysterectomy was found to be the most frequent method of management of post partum hemorrhage. Conclusion This study highlights the existing variable practices for the management of postpartum hemorrhage. Hemorrhage associated morbidity and mortality can be prevented by critical judgment, early referral and resuscitation by attendants. Introduction of an evidence-based management model can potentially reduce the practice variability and improve the quality of care.
Four patients, aged 54-84 years, presenting with life-threatening rectal bleeding from the superior hemorrhoidal artery, underwent percutaneous fibered platinum coil embolization via coaxial catheters. Preprocedure sigmoidoscopy had failed to identify the source of hemorrhage, because the rectum was filled with fresh blood. Embolization was technically and clinically successful in all four patients. Subsequent sigmoidoscopy confirmed the diagnoses in three patients as a solitary rectal ulcer, iatrogenic traumatic ulceration following manual evacuation, and a rectal Dieulafoy's lesion. The other case was angiographically seen to be due to a rectal angiodysplasia. Embolization is an effective procedure in life-threatening superior hemorrhoidal arterial bleeding when endoscopic treatment fails, and should be preferred to rectosigmoid resection.
Dobson, Craig Charles; Nicholson, Anthony A. [Hull Royal Infirmary, Department of Radiology (United Kingdom)
Four patients, aged 54-84 years, presenting with life-threatening rectal bleeding from the superior hemorrhoidal artery, underwent percutaneous fibered platinum coil embolization via coaxial catheters. Pre-procedure sigmoidoscopy had failed to identify the source of hemorrhage, because the rectum was filled with fresh blood. Embolization was technically and clinically successful in all four patients. Subsequent sigmoidoscopy confirmed the diagnoses in three patients as a solitary rectal ulcer, iatrogenic traumatic ulceration following manual evacuation, and a rectal Dieulafoy's lesion. The other case was angiographically seen to be due to a rectal angiodysplasia. Embolization is an effective procedure in life-threatening superior hemorrhoidal arterial bleeding when endoscopic treatment fails, and should be preferred to rectosigmoid resection.
Dobson, Craig Charles; Nicholson, Anthony A. [Department of Radiology, Hull Royal Infirmary, Anlaby Road, Hull, East Yorkshire HU3 2JZ (United Kingdom)
Spontaneous intracerebral hemorrhages (ICH) account for 10-30% of all strokes and are a result of acute bleeding into the brain due to ruptures of small penetrating arteries. Despite major advancements in the management of ischemic strokes and other causes of hemorrhagic strokes, such as ruptured aneurysm, arteriovenous malformations (AVMs), or cavernous angioma, during the past several decades, limited progress has been made in the treatment of ICH, and the prognosis for patients who suffer them remains poor. The societal impact of these hemorrhagic strokes is magnified by the fact that affected patients typically are a decade younger than those afflicted with ischemic strokes. The ICH continues to kill or disable most of their victims. Some studies show that those who suffer ICH have a 30-day mortality rate of 35-44% and a 6-month mortality rate approaching 50%. Approximately 700,000 new strokes occur in the United States annually and approximately 15% are hem-orrhagic strokes related to ICH. The poor outcome associated with ICH is related to the extent of brain damage. ICH produces direct destruction and compression of surrounding brain tissue. Direct compression causes poor perfusion and venous drainage to surrounding penumbra at risk, resulting in ischemia to the tissues that most need perfusion .
Pérez, Noel; Valdés, Jose; Guevara, Miguel; Silva, Augusto
Spinal-cord injury is characterized by primary damage as a direct consequence of mechanical insult, and secondary damage that is partly due to the acute inflammatory response. The extent of any hemorrhage within the injured cord is also known to be associated with the formation of intraparenchymal cavities and has been anecdotally linked to secondary damage. This study was designed to examine the contribution of blood components to the outcome of spinal-cord injury. We stereotaxically microinjected collagenase, which causes localized bleeding, into the spinal cord to model the hemorrhage associated with spinal cord injury in the absence of significant mechanical trauma. Tissue damage was observed at the collagenase injection site over time, and was associated with localized disruption of the blood-spinal-cord barrier, neuronal cell death, and the recruitment of leukocytes. The magnitude of the bleed was related to neutrophil mobilization. Interestingly, the collagenase-induced injury also provoked extended axonal damage. With this model, the down-stream effects of hemorrhage are easily discernible, and the impact of treatment strategies for spinal-cord injury on hemorrhage-related injury can be evaluated. PMID:24792308
Losey, Patrick; Young, Christopher; Krimholtz, Emily; Bordet, Régis; Anthony, Daniel C
Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS), a very rare disease that is caused by the presence of antifactor II antibodies, is usually counterbalanced by the prothrombotic effect of lupus anticoagulant (LAC). Patients with LAHPS are treated using fresh frozen plasma, steroids, immunosuppressive agents, and immunoglobulins for managing the disease and controlling hemorrhages. Notably, steroids are the important treatment for treating hypoprothrombinemia and controlling the bleeding. However, some patients suffer from severe, life-threatening hemorrhages, when factor II levels remain very low in spite of treatment with steroids. Here, we report a case of LAHPS in a 15-year-old girl who experienced pulmonary hemorrhage with rapid progression. She was referred to our hospital owing to easy bruising and prolonged bleeding. She was diagnosed with LAHPS that presented with pancytopenia, positive antinuclear antibody, proloned prothrombin time, activated partial thromboplastin time, positive LAC antibody, and factor II deficiency. Her treatment included massive blood transfusion, high-dose methylprednisolone, vitamin K, and immunoglobulin. However, she died due to uncontrolled pulmonary hemorrhage.
Kim, Ji Soo; Kim, Min Jae; Bae, E Young
To investigate if oral, nonabsorbable antibiotics prevent bacterial infections in cirrhotics with gastrointestinal hemorrhage, 140 consecutive patients were randomly allocated into two groups: 68 patients (Group I) were given oral, non absorbable antibiotics (gentamicin + vancomycin + nystatin or neomycin + colistin + nystatin) from the inclusion into the trial up to 48 hr after cessation of the hemorrhage, or until emergency surgery or death in those cases who continued bleeding; and 72 patients (Group II) did not receive oral, nonabsorbable antibiotics. Both groups were similar in relation to clinical and laboratory data and characteristics of the hemorrhage. The incidence of infection was significantly lower in Group I than in Group II (11 patients in Group I and 25 in Group II developed proved infections; p less than 0.025). This difference was due to the fact that spontaneous bacteremia and peritonitis and urinary tract infection caused by enteric bacteria occurred almost exclusively in Group II. Two patients of Group I and 10 of Group II developed spontaneous bacteremia and/or peritonitis caused by enteric bacteria (p less than 0.025). These results indicate that prophylactic administration of oral, nonabsorbable antibiotics markedly reduces the incidence of infections caused by enteric bacteria in cirrhotic patients with gastrointestinal hemorrhage. PMID:3873389
Rimola, A; Bory, F; Teres, J; Perez-Ayuso, R M; Arroyo, V; Rodes, J
The activation of hemostatic systems has been detected in spontaneous intracerebral hemorrhage (ICH) patients. The influence of plasma D-dimer levels on clinical outcome remains unclear. This study aimed to investigate the impact of elevated plasma D-dimer levels on early mortality and long-term functional outcome in spontaneous ICH. A total of 259 spontaneous ICH patients (<24hours from ictus) between November 2010 and October 2011 were included. Clinical information and radiological findings were collected at admission. Spearman correlation analyses revealed that D-dimer concentrations were correlated with midline shift, hematoma volume, intraventricular hemorrhage (IVH) score and Glasgow Coma Scale score. Patients with subarachnoid extension had significantly higher D-dimer levels than those without SAH extension. Comparison of patients with IVH and those without yielded a similar result. Multivariate stepwise backward logistic analysis identified plasma D-dimer levels as an independent risk factor for 7day mortality (adjusted odds ratio [OR]=1.237, 95% confidence interval [CI] 1.017-1.504, p=0.033) and 3month poor functional outcome (modified Rankin Scale score ?3) (adjusted OR=2.279, 95% CI 1.130-6.595, p=0.026). The mechanisms by which elevated D-dimer affects the prognoses of spontaneous ICH patients remain unclear and require clarification in future studies. PMID:24631325
Hu, Xin; Fang, Yuan; Ye, Feng; Lin, Sen; Li, Hao; You, Chao; Liu, Ming
Description of three cases of buried drusen of the disk with pseudo-papilloedema and hemorrhages. These hemorrhages are splinter hemorrhages in the substance of the disk or deep peripapillary hemorrhage lying beneath the retina. OEdema and hemorrhage can produce transient blurring of the vision. They resolve in some weeks. PMID:7204876
Saraux, H; Nou, B; Audrain, G; Offret, H
Subarachnoid hemorrhage represents a serious disease with high mortality and morbidity. Two important areas are becoming the central research interest of subarachnoid hemorrhage: cerebral vasospasm and early brain injury. The authors have reviewed the major contributions in experimental subarachnoid hemorrhage documented in the medical literature in the past 5 years. Treatments interfering with nitric oxide - or endothelin-pathways continue to show antispasmotic effects in experimental models of subarachnoid hemorrhage. Inflammation and oxidative stress play a vital role in the pathophysiology of cerebral vasospasm. Apoptosis, a relevant cause of early brain injury after subarachnoid hemorrhage, also underline the etiology of cerebral vasospasm. Future research studies will continue to elucidate the pathophysiological pathways and treatment modalities targeting cerebral vasospasm and early brain injury, enabling an improvement in outcome for patients with subarachnoid hemorrhage. PMID:23904869
Ciurea, A V; Palade, C; Voinescu, D; Nica, D A
Hereditary hemorrhagic telangiectasia, or Rendu-Osler-Weber syndrome, is an autosomal dominant multiorgan disorder. This multisystemic vascular dysplasia is determined by a mutation of one of two main genes, endoglin (ENG) or HHT1, or ACVRL1 or HHT2. These mutations induce vascular disorders that cause recurrent epistaxis and eventually multiple telangiectasia and arteriovenous visceral malformations. We report the case of a 7-year-old girl who developed severe hypoxemia due to multiple pulmonary arteriovenous malformations. PMID:24935454
Maaloul, I; Aloulou, H; Fourati, H; Sfaihi, L; Chabchoub, I; Kamoun, T; Mnif, Z; Hachicha, M
A 35-year-old man presented with simultaneous multiple intracranial hematomas in the right cerebellar dentate nucleus and left basal ganglia. The hematomas were visible by computed tomography performed within two hours of the patient's arrival. The initial computed tomography showed acute hemorrhage in the left basal ganglia and dentate nucleus in cerebellum. The patient then experienced a change of consciousness due to newly developed hydrocephalus, and emergent extra-ventricular drainage was performed. By discharge, fortunately, the patient was fully recovered.
Yi, Ho Jun; Hwang, Hyung Sik
We describe and discuss autopsy findings of bowel wall hemorrhage in a study population comprising cases of suicidal death by hanging. Intramural hemorrhages were seen in approximately 12% of the cases examined; no preexisting bowel diseases were found. In hanging deaths with a longer agonal phase, we opine that abdominal congestion during the hanging process provides a viable pathophysiological explanation for bowel wall hemorrhage. Though we are not dealing here with obligatory autopsy findings, the detection of bowel wall hemorrhage might be used as another sign of vital hanging after considering differential diagnostic aspects. PMID:21221984
Schulz, Friedrich; Schäfer, Hansjörg; Püschel, Klaus; Tsokos, Michael; Brinkmann, Bernd; Buschmann, Claas T
Severe hemorrhagic cystitis often arises from anticancer chemotherapy or radiotherapy for pelvic malignancies. Infectious etiologies are less common causes except in immunocompromised hosts. These cases can be challenging problems for the urologist and a source of substantial morbidity and sometimes mortality for the patients. A variety of modalities of treatment have been described for the management of hemorrhagic cystitis but there is none that is uniformly effective. Some progress has been made in the understanding and management of viral hemorrhagic cystitis. This article reviews the common causes of severe hemorrhagic cystitis and the currently available management options.
Manikandan, R.; Kumar, Santosh; Dorairajan, Lalgudi N.
Neurogenic bladder is a common cause of acute pyelonephritis (APN) in cauda equina syndrome (CES). Perirenal hemorrhage, a rare complication of APN, can be a life-threatening condition. To our knowledge, there is no previous report of perirenal hemorrhage as a complication of APN in CES. A 57-year-old male, diagnosed with CES, due to a L3 burst fracture 3 months earlier, was presented with fever and chills. His diagnosis was APN due to neurogenic bladder. After treatment for APN, he was transferred to the department of rehabilitation medicine for management of his CES. Because of large post-voiding residual urine volumes, he performed self-catheterization after voiding. However, he presented again with fever and chills, and recurrent APN was diagnosed. On the third day of antibiotic treatment, he had acute abdominal pains and hypovolemic shock. Abdominal computed tomography and angiography showed left APN and a perirenal hematoma with left renal capsular artery bleeding. After embolization of the left renal capsular artery, no further active bleeding occurred. Because APN due to neurogenic bladder can lead to critical complications, such as perirenal hemorrhage, the physician should pay attention to the early diagnosis and treatment of urinary tract infection and the management of neurogenic bladder after CES.
Seok, Hyun; Kim, Sang-Hyun; Ko, Yong Jae
Although inferior vena cava (IVC) filter placement has demonstrated an excellent therapeutic efficacy in preventing pulmonary\\u000a embolism, several filter-related complications have been reported. Among them, retroperitoneal hemorrhage due to IVC perforation\\u000a is one of the most serious complications. We report herein a female patient who underwent TrapEase IVC filter placement with\\u000a anticoagulation and thrombolytic therapy for treatment of pulmonary embolism,
Kazunori Inuzuka; Naoki Unno; Naoto Yamamoto; Hiroshi Mitsuoka; Daisuke Sagara; Minoru Suzuki; Motohiro Nishiyama; Hiroyuki Konno
A total of 153 consecutive patients with proven aneurysmal subarachnoid hemorrhages (SAHs) admitted immediately after diagnosis regardless of clinical condition were managed according to the same protocol. The initial evaluation included computed tomography (CT), transcranial Doppler ultrasound (TCD), angiography-CT, and/or angiography. Intravenous nimodipine (2 mg/hour) was started after confirmation of the diagnosis. The timing of operation was determined individually according to age, clinical course, and CT and TCD findings. Twenty-one Grade V patients treated with intensive care and ventriculostomy died or did not improve within 24 hours after SAH. Three patients with life-threatening intracerebral hematomas underwent emergency operation. Operation was early in 55 good risk patients and late in 57 patients because of poor initial grade, late admission, or logistic reasons. Seventeen patients had no operation because of old age, persistent poor clinical condition, medical complication, or lethal rebleeding before operation. In the total series, 90 patients (59%) made a full recovery, the overall morbidity rate was 14% (21 of 153 cases), and the mortality rate was 27% (42 of 153). Postoperative mortality including emergency evacuation of hematomas was 7.8% and mortality after elective operation was 6.2%. The causes of disability and death were the initial effect of the hemorrhage in 25 patients (16.3%), rebleeding in 15 (9.8%), delayed cerebral infarction in 8 (5.2%), surgical complications in 7 (4.5%), hydrocephalus in 4 (2.6%), and medical complications in 4 (2.6%). PMID:3059218
Seiler, R W; Reulen, H J; Huber, P; Grolimund, P; Ebeling, U; Steiger, H J
Recent studies from our laboratory demonstrated the involvement of endothelial cell reactive oxygen species (ROS) formation and activation of apoptotic signaling in vascular hyperpermeability following hemorrhagic shock (HS). The objective of this study was to determine if (-)-deprenyl, an antioxidant with anti-apoptotic properties would attenuate HS-induced vascular hyperpermeability. In rats, HS was induced by withdrawing blood to reduce the MAP to 40 mmHg for 60 minutes followed by resuscitation for 60 minutes. To study hyperpermeability, the rats were injected with FITC-albumin (50 mg/kg) and the changes in integrated optical intensity of the mesenteric post-capillary venules were obtained intra and extra vascularly utilizing intravital microscopy. Mitochondrial ROS formation and mitochondrial transmembrane potential (??m) were studied using dihydrorhodamine 123 and JC-1 respectively. Mitochondrial release of cytochrome c was determined using ELISA and caspase-3 activity by a fluorometric assay. Parallel studies were performed in rat lung microvascular endothelial cells (RLMEC) utilizing pro-apoptotic BAK as inducer of hyperpermeability. Hemorrhagic shock induced vascular hyperpermeability, mitochondrial ROS formation, decrease in ??m, release of cytochrome c and caspase-3 activation (p < 0.05). (-)-Deprenyl (0.15 mg/Kg) attenuated all these effects (p < 0.05). Similarly in RLMEC, (-)-deprenyl attenuated BAK peptide induced monolayer hyperpermeability (p < 0.05), ROS formation, decrease in ??m, cytochrome c release (p < 0.05) and activation of caspase-3 (p < 0.05). The protective effects of (-)-deprenyl on vascular barrier functions may be due to its protective effects on ??m thereby preventing mitochondrial release of cytochrome c and caspase-3 mediated disruption of endothelial adherens junctions.
J., Binu Tharakan; Whaley, Greg; Hunter, Felicia A.; Smythe, W. Roy; Childs, Ed W.
Background In the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease severity, the development of acute renal insufficiency, and increased mortality. We hypothesized that severely injured trauma patients presenting with hemorrhagic shock would demonstrate a high degree of MD. We also hypothesized that MD in these patients would be associated with increased length of stay, hypotension, fluid requirements, and acute kidney injury (AKI). Materials and methods Thirty-two trauma patients in hemorrhagic shock on admission to the trauma bay (SBP <90 mm Hg × 2) were enrolled. Blood samples were obtained on ICU admission and 8, 16, 24, and 48 hours later. Plasma aldosterone (PA) and renin (PR) were assayed by radioimmunoassay. MD was defined as a ratio of PA/PR ?2. Demographic data, injury severity score, ICU and hospital length of stay, fluid requirements, mean arterial pressure, serum sodium, hypotension, and risk for AKI were compared for patients with and without MD. Results At ICU admission, 48% of patients met criteria for MD. Patients with MD were significantly more likely to experience hypotension (MAP ?60 mm Hg) during the study period. MD patients required significantly more units of blood in 48 h than non-MD patients (13 [7–22] versus 5 [2–7], P = 0.015) and had increased crystalloid requirements (18L [14–23] versus 9L [6–10], P < 0.001). MD patients were at higher risk for AKI according to RIFLE and AKIN criteria. Conclusions MD is a common entity in trauma patients presenting in hemorrhagic shock. Patients with MD required a more aggressive resuscitative effort, were more likely to experience hypotension, and had a higher risk of AKI than non-MD patients. Future studies are needed to fully understand the impact of MD following trauma and the potential role for hormonal replacement therapy.
Tolstoy, Nikolai S.; Aized, Majid; McMonagle, Morgan P.; Holena, Daniel N.; Pascual, Jose L.; Sonnad, Seema S.; Sims, Carrie A.
Simultaneous occurrence of intracerebral hemorrhage (ICH) in different arterial territories is an uncommon event. We report on two cases of multiple spontaneous simultaneous ICH for which we could find no specific cause. A 73-year-old man, with no related medical history, was admitted to the hospital with simultaneous bithalamic ICH, and subsequently died of recurrent pneumonia. Second patient was a 60-year-old man who presented with simultaneous ICH in the pons and thalamus; he died of recurrent bleeding. We review the possible pathological mechanisms, clinical and radiologic features of simultaneous multiple ICH.
Seo, Jin-Suk; Nam, Taek-Kyun; Kwon, Jeong-Taik
Object In the search for optimal monitoring and predictive tools in neurocritical care, the relationship of the pulsatile component of intracranial pressure (ICP) and the pressure itself has long been of great interest. Higher pressure often correlates with a higher pulsatile response to the heartbeat, interpreted as a type of compliance curve. Various mathematical approaches have been used, but regardless of the formula used, it is implicitly assumed that a reproducible curve exists. The authors investigated the stability of the correlation between static and pulsatile ICPs in patients with subarachnoid hemorrhage (SAH) who were observed for several hours by using data sets large enough to allow such calculations to be made. Methods The ICP recordings were obtained in 39 patients with SAH and were parsed into 6-second time windows (1,998,944 windows in 197 recordings). The ICP parameters were computed for each window as follows: static ICP was defined as the mean ICP, and pulsatile ICP was characterized by mean ICP wave amplitude, rise time, and rise time coefficient. Results The mean ICP and ICP wave amplitudes were simultaneously high or low (the expected correlation) in only ~ 60% of observations. Furthermore, static and pulsatile ICP correlated well only over short intervals; the degree of correlation weakened over periods of hours and was inconsistent across patients and within individual patients over time. Decorrelation originated with abrupt shifting and gradual drifting of mean ICP and ICP wave amplitude over several hours. Conclusions The relationship between the static and pulsatile components of ICPs changes over time. It evolves, even in individual patients, over a number of hours. This can be one reason the observation of high pulsatile ICP (indicative of reduced intracranial compliance) despite normal mean ICP that is seen in some patients with SAH. The meaning and potential clinical usefulness of such changes in the curves is uncertain, but it implies that clinical events result not only from moving further out on a compliance curve; in practice, the curve, and the biological system that underlies the curve, may itself change.
Eide, Per K.; Rapoport, Benjamin I.; Gormley, William B.; Madsen, Joseph R.
Background Hematopoietic stem cell transplantation is being increasingly used in cancer therapy. Diffuse alveolar hemorrhage, an early complication of stem cell transplant, results from bacterial, viral and fungal infections, coagulopathy, and engraftment syndrome, or can be idiopathic. Diffuse alveolar hemorrhage associated with Strongyloides stercoralis hyperinfection in stem cell transplant patients has been rarely reported. Case presentation We describe an unusual cause of alveolar hemorrhage post hematopoietic stem cell transplant due to Strongyloides hyperinfection. Therapy with parenteral ivermectin and thiabendazole was initiated but the patient deteriorated and died of respiratory failure and septic shock. Conclusion Strongyloides stercoralis hyperinfection is an unusual cause of alveolar hemorrhage early after hematopoietic stem cell transplant with very high mortality.
Gupta, Sachin; Jain, Amit; Fanning, Tina V; Couriel, Daniel R; Jimenez, Carlos A; Eapen, Georgie A
Adrenal cortical function was studied during and following prolonged hemorrhagic shock. Seventeen mongrel dogs were subjected to hemorrhagic shock for periods of 1-20 hours. As long as perfusion through the adrenal was maintained at greater than 1 ml/min....
R. H. Egdahl
Annually, over 500,000 women die from complications of pregnancy and childbirth; the majority die from hemorrhage and shock. Obstetrical hemorrhage of all etiologies, such as uterine atony, ruptured uterus, and ruptured ectopic, can cause massive blood loss resulting in severe shock. Unless women can access fluid replacement, blood transfusions, and, often, surgery, the shock leads to organ failure and death.
Suellen Miller; Aderinola Ojengbede; Janet Turan; Oladosu Ojengbede; Elizabeth Butrick; Paul Hensleigh
Angiosarcoma is a rare malignant neoplasm of the vascular or lymphatic endothelium. Diffuse alveolar hemorrhage is a rare presenting manifestation of angiosarcoma. We describe a case of pulmonary metastasis of angiosarcoma who presented with diffuse alveolar hemorrhage as initial manifestation. PMID:20396655
Rai, Sp; Barthwal, Ms; Bhattacharya, P; Bhargava, S; Pethe, M
Background The various autonomic control systems lead to characteristic changes in heart rate (HR) and blood pressure (BP) during acute hemorrhage. However, cardiovascular autonomic neuropathy due to diabetes mellitus may interfere with the normal compensation for hemorrhage. Materials and methods A controlled graded bleeding (6 - 36% loss of estimated total blood volume: ETBV) was performed in streptozotocin-induced diabetic rats (STZ rats) under a conscious state. Hemodynamic and autonomic responses to acute hemorrhage were examined using analysis of BP-HR variability. The effects of dextran treatment after hemorrhage were also examined. Results A significant reduction in mean arterial pressure began at 12% ETBV loss in STZ rats and 18% in the control rats, respectively. When blood loss reached 18% of TEBV, the decrease in HR was prominent in STD rats due to the activation of a parasympathetic drive, as indicated by the increase in high frequency (HF; 0.75~3.0 Hz) power in HR variability, while in the control rats this response was not observed. The administration of dextran prevented the activation of the parasympathetic drive in STZ rats during hemorrhaging. In the control rats, the dextran treatment sustained the initial increase in HR with reduced HF power in HR variability. Conclusion STZ rats showed different hemodynamic and autonomic responses to acute hemorrhage from the control rats. STZ rats were prone to develop bradycardiac hypotension characterized by marked parasympathetic activation during hemorrhaging. This finding suggests enhancement of the Bezold-Jarisch reflex in STZ rats. Dextran treatment to maintain a normovolemic hemorrhage state inhibits this reflex.
The authors describe a case of communicating hydrocephalus accompanied by an arachnoid cyst in an aneurismal subarachnoid hemorrhage. A 69-year-old female was referred to our clinic due to the sudden onset of a headache. A head computed tomography scan demonstrated an arachnoid cyst in the right middle fossa with a mass effect and diffuse subarachnoid hemorrhage. Digital subtraction angiography then revealed a left internal carotid-posterior communicating artery aneurysm. The neck of the aneurysm was clipped successfully and the post-operative period was uneventful. However, two months after discharge, the patient reported that her mental status had declined over previous weeks. A cranial computed tomography scan revealed an interval increase in the size of the ventricle and arachnoid cyst causing a midline shift. Simultaneous navigation guided ventriculoperitoneal shunt and cystoperitoneal shunt placement resulted in remarkable radiological and clinical improvements.
Choi, Jae Young; Cha, Seung Heon; Cho, Won Ho
The commonest type of simple vaginal cyst is the Mullerian cyst. These are typically lined by columnar epithelium and contain serous or mucinous fluid. If blood is found in the cyst, the source is usually due to the presence of endometrial elements in the cyst wall. The cyst is then termed an endometriotic cyst. In this case report, we have described a woman with a symptomatic 3 cm upper vaginal cyst who underwent surgical excision of the cyst. The cyst cavity was found to be full of old dark blood and mucous, however the wall contained no endometrial tissue and was lined by columnar epithelium which stained positive for mucous with mucicarmine. No cause for the intracystic hemorrhage was identified. We conclude that intracystic hemorrhage can occur in a simple Mullerian vaginal cyst in the absence of endometrial components. PMID:24303459
Rivlin, Michel E; Meeks, G Rodney; Ghafar, Mohamed A; Lewin, Jack R
The commonest type of simple vaginal cyst is the Mullerian cyst. These are typically lined by columnar epithelium and contain serous or mucinous fluid. If blood is found in the cyst, the source is usually due to the presence of endometrial elements in the cyst wall. The cyst is then termed an endometriotic cyst. In this case report, we have described a woman with a symptomatic 3 cm upper vaginal cyst who underwent surgical excision of the cyst. The cyst cavity was found to be full of old dark blood and mucous, however the wall contained no endometrial tissue and was lined by columnar epithelium which stained positive for mucous with mucicarmine. No cause for the intracystic hemorrhage was identified. We conclude that intracystic hemorrhage can occur in a simple Mullerian vaginal cyst in the absence of endometrial components.
Rivlin, Michel E; Meeks, G Rodney; Ghafar, Mohamed A; Lewin, Jack R
We report the case of a 21-yr-old female with Turner syndrome associated with cerebral hemorrhage (CH). She was transferred to our hospital for loss of consciousness and was diagnosed with right putaminal hemorrhage. Following surgical removal of the hematoma, she regained consciousness, and her left hemiplegia gradually improved after surgery. Angiography revealed absence of vascular abnormality of the cerebral artery, aorta, and renal arteries. Hypertension was noted on arrival at the hospital and persisted after surgery. A slight hypertensive change was observed in her retinas. Plasma renin activity was elevated (20 ng/ml/h) and renovascular hypertension was suspected. In this patient, CH was suspected to have occurred due to hypertension. This case emphasizes the necessity to carefully monitor the blood pressure in Turner syndrome cases, even during childhood.
Okamoto, Shingo; Morimoto, Yukari; Reza, Mohammad Selim; Kohso, Hiroshi; Ishikawa, Masatoshi; Takano, Masato; Kurematsu, Yukako; Yamao, Jun-ichi; Fukui, Hiroshi
Aim: To present the technique and efficiency of intravitreal recombinant tissue plasminogen activator (r-TPA) and gas injection in acute submacular hemorrhage (SMH) due to traumatic choroidal rupture. Patients and Methods: 0.4 ml of sulfur hexafluoride was injected into the vitreous cavity in 2 patients with SMH due to traumatic choroidal rupture. In 1 patient gas injection was combined with 50
Detlef Holland; Burkhard Wiechens
Introduction Paroxysmal sympathetic hyperactivity (PSH) is a hyperadrenergic syndrome that may follow acute brain injury characterized by episodic, hyperadrenergic alterations in vital signs. Identifying commonality in lesion localization in patients with PSH is challenging, but intraparenchymal hemorrhage (IPH) represents a focal injury that might provide insight. We describe a series of patients with IPH that developed PSH, and review the literature. Methods Patients with IPH who developed PSH were identified from OHSU hospital records. A literature review was conducted to identify similar cases through PUBMED, OVID, and Google Scholar. Results Three cases meeting criteria for PSH were identified. Hemorrhage volume ranged from 70 to 128 mL, and intracranial hemorrhage score ranged from 2 to 3. The laterality of the hemorrhage and significant volume of hemorrhage was similar in each of the patients, specifically all hemorrhages were large, subcortical, and right-sided. A literature search identified six additional cases, half of whom reported a right hemisphere hemorrhage and the majority also had subcortical localization. Conclusions Our literature review identified six cases of IPH associated with PSH with five cases having subcortical lesion locations, echoing the areas of disruption in our three cases. On the basis of these observations, we hypothesize that injuries along the pathway from the insular cortex to downstream sympathetic centers may remove tonic inhibition leading to unchecked sympathetic outflow. Prospective investigations of lesion location in patients with IPH and PSH are warranted to test this hypothesis, especially with advanced neuroimaging techniques.
Gao, Billy; Pollock, Jeffrey A.; Hinson, Holly E.
Two patients who had suffered subrachnoid hemorrhage were subjected to intensive monitoring of parameters of circulating blood flow, cardiovascular dynamics, and fluid and electrolyte balance. Among the parameters studied were red cell volume, plasma volume, and total blood volume, cardiac output, and central venous and pulmonary capillary wedge pressures. Both patients experienced acute neurological deterioration during the study. Red cell volume fell in a premonitory fashion prior to neurological deterioration in both, and in one patient plasma volume and total blood volume decreased by almost 50% in the 5 days prior to neurological deterioration. Central venous and pulmonary capillary wedge pressures fell initially but did not predict the deterioration. Systemic vascular resistance fell prior to clinical deterioration in one patient following ventriculoperitoneal shunting, and in the other following craniotomy and subarachnoid drainage. The falls in systemic vascular resistance may have caused shunting of cardiac output away from the compromised cerebral circulation, thereby triggering neurological deterioration. PMID:15815316
Brazenor, G A; Chamberlain, M J; Gelb, A W
A 37-year-old Asian woman, gravid 0 para 0, was admitted to our hospital at 34 weeks and 5 days of her pregnancy for management of preeclampsia. A few days after admission, she recognized diminished fetal movement, and a non-stress test revealed a non-reassuring fetal heart rate pattern with decreased variability. A female baby weighing 1840 g was delivered by emergency cesarean section with Apgar scores of 5 and 5 at 1 and 5 min, respectively. Significant neonatal anemia with a hemoglobin level of 4.3 g/dL was observed. The elevated level of hemoglobin F (HbF) in the maternal blood accounted for 4.6% (normal?0.5%), and was indicative of the presence of fetomaternal hemorrhage (FMH). Microscopic examination of the placenta revealed chorioangioma. We report here a rare case of FMH with intraplacental chorioangioma, and discuss the relationship between these two pathologies. PMID:22925543
Kawano, Ryosuke; Takemoto, Shuji; Shimamatsu, Kazuhide; Hori, Daizo; Kamura, Toshiharu
A morphometrical analysis of retinal hemorrhages was performed in cases of physical child abuse including the shaken baby syndrome and in controls (severe head injury, intravital brain death, non-traumatic intracranial hemorrhage, SIDS including cardiopulmonary resuscitation). The extent of the retinal hemorrhages was significantly different between both groups. In all cases of physical child abuse, massive retinal hemorrhages in at least
P. Betz; K. Püschel; E. Miltner; E. Lignitz; W. Eisenmenger
Spontaneous thymic hemorrhage in a normal thymus in neonates and infants has been reported in the literature. Only one case of spontaneous thymic hemorrhage in an adult has been reported to our knowledge. We herein report the case of an adult who had a cardiac operation 26 years previously and who was on anticoagulation. He experienced acute hemorrhage in a normal thymus, and this was not thought to be attributable to an accidental cause such as trauma or to hypertension. PMID:24792275
Sakuraba, Motoki; Tanaka, Akihiko; Tsuji, Takahiro; Mishina, Taijiro
Understanding the biological mechanism and identifying biomarkers of hemorrhagic shock is important for diagnosis and treatment. We aim to use optical imaging to study how the cerebral blood circulation and metabolism change during the progression of severe hemorrhagic shock, especially the decompensatory stage. We used a multi-parameter (blood pressure (BP), cerebral blood flow (CBF), functional vascular density (FVD), blood oxygenation and mitochondrial NADH signal) cerebral cortex optical imaging system to observe brain hemodynamic change and metabolic alteration of rats in vivo for 4 h. Cerebral circulation and mitochondrial metabolism could be well preserved in the compensatory stage but impaired during the decompensatory stage. The changes of brain hemodynamics and metabolism may provide sensitive indicators for various shock stages including the transition from compensatory stage to decompensatory stage. Our novel imaging observations of hemodynamic and metabolic signals in vivo indicated that the rat brains under hemorrhagic shock suffered irreversible damage which could not be compensated by the autoregulation mechanism, probably due to injured mitochondria. PMID:24729236
Sun, Nannan; Li, Lin Z; Luo, Weihua; Luo, Qingming
The pathogenesis of hemorrhage induced by three purified components of rattlesnake (Crotalus atrox) venom was studied at the light and electron microscopic levels. Crude venom was fractionated by anion exchange and gel filtration in four steps. beta-Alanine acetate disk gel electrophoresis was used to demonstrate electrophoretic homogeneity. White mice were injected intramuscularly with 0.1 ml of a sublethal dose of hemorrhagic toxin. Gross examination revealed extensive hemorrhage 5 minutes after the injection of hemorrhagic toxins alpha and episilon; the same amount of hemorrhage was not present until 3 hours after the injection of hemorrhagic toxin beta. Light microscopic examination of muscel after injection of the toxins revealed areas of extensive hemorrhage in which very few intact capillaries could be found and also adjacent areas of slight hemorrhage in which capillaries were in various stages of degeneration. Necrosis of muscle cells was evident in tissue injected with hemorrhagic toxin beta. Electron microscopic examination showed that capillaries from toxin-injected muscle were in various stages of degeneration. Endothelial cells became very thin and broke down into vesicles prior to complete rupture. Gaps were formed within the cells while intercellular junctions remained intact. Plasma and erythrocytes leaked through these gaps and were observed in the endomysium. Many gaps were plugged with platelet aggregations. Collagen and the basal lamina associated with capillaries were usually disorganized or absent. The experimental injection of three purified hemorrhagic toxins induced hemorrhage by the same mechanism as does the crude venom, ie, per rhexis. In addition, one of the toxins, hemorrhagic toxin beta, causes myonecrosis. Images Figure 7 Figure 8 Figure 15 Figure 16 Figure 9 Figure 10 Figure 1 Figure 2 Figure 3 Figure 4 Figure 11 Figure 12 Figure 13 Figure 14 Figure 5 Figure 6
Ownby, C. L.; Bjarnason, J.; Tu, A. T.
Studies of hemostasis were performed on 27 children with Thai hemorrhagic fever from dengue virus during September, 1962. The most common finding was moderate to severe thrombocytopenia. The platelet count was usually decreased when the patients were firs...
H. J. Weiss S. B. Halstead
We report the epidemiologic characteristics of Crimean-Congo hemorrhagic fever in Bulgaria, as well as the first genetic characterization of the virus strains circulating in the country in 2002 to 2003 that caused disease in humans.
Christova, Iva; Papadimitriou, Evangelia; Antoniadis, Antonis
Decompensation in hemorrhagic shock is the critical stage after which resuscitative efforts may prove futile. We hypothesize that decompensation results from potassium-mediated vasodilation and/or loss of cardiac contractility, and thus a method of measur...
M. B. Pamnani
Subconjunctival hemorrhage is a benign disorder that is a common cause of acute ocular redness. The major risk factors include trauma and contact lens usage in younger patients, whereas among the elderly, systemic vascular diseases such as hypertension, diabetes, and arteriosclerosis are more common. In patients in whom subconjunctival hemorrhage is recurrent or persistent, further evaluation, including workup for systemic hypertension, bleeding disorders, systemic and ocular malignancies, and drug side effects, is warranted. PMID:23843690
Tarlan, Bercin; Kiratli, Hayyam
Summary Intracranial hemorrhage is the third most common cause of stroke and involves the accumulation of blood within brain parenchyma\\u000a or the surrounding meningeal spaces. Accurate identification of acute hemorrhage and correct characterization of the underlying\\u000a pathology, such as tumor, vascular malformation, or infarction, is a critical step in planning appropriate therapy. Neuroimaging\\u000a studies are required not only for diagnosis, but
Fazeel M. Siddiqui; Simon V. Bekker; Adnan I. Qureshi
A number of distinct viruses are known as hemorrhagic fever viruses based on a shared ability to induce hemorrhage by poorly\\u000a understood mechanisms, typically involving the formation of blood clots (“disseminated intravascular coagulation”). It is\\u000a well documented that selenium plays a significant role in the regulation of blood clotting via its effects on the thromboxane\\/prostacyclin\\u000a ratio, and effects on the
Chandra Sekar Ramanathan; Ethan Will Taylor
Rivaroxaban is a newer anticoagulant initially approved by the Food and Drug Administration to treat nonvalvular atrial fibrillation. Rivaroxaban has several characteristics that are more favorable than warfarin. One of the characteristics is decreased risk of hemorrhage. We report one of the first case reports of severe intracranial hemorrhage associated with rivaroxaban in an elderly patient with decreased renal function. We aim to alert emergency medicine providers regarding the likelihood of encountering these patient as newer anticoagulants rise in popularity.
Lo, Jean Chin-Yu; Gerona, Roy R.
Rivaroxaban is a newer anticoagulant initially approved by the Food and Drug Administration to treat nonvalvular atrial fibrillation. Rivaroxaban has several characteristics that are more favorable than warfarin. One of the characteristics is decreased risk of hemorrhage. We report one of the first case reports of severe intracranial hemorrhage associated with rivaroxaban in an elderly patient with decreased renal function. We aim to alert emergency medicine providers regarding the likelihood of encountering these patient as newer anticoagulants rise in popularity. PMID:25035736
Lo, Jean Chin-Yu; Gerona, Roy R
Percutaneous transluminal angioplasty and stent placement is now an established treatment option for chronic mesenteric ischemia\\u000a and is associated with low mortality and morbidity rates. We present a case of reperfusion hemorrhage complicating endovascular\\u000a repair of superior mesenteric artery stenosis. Although a recognized complication following repair of carotid stenosis, hemorrhage\\u000a has not previously been reported following mesenteric endovascular reperfusion. We
Michael Moore; Sean McSweeney; Gregory Fulton; John Buckley; Michael Maher; Michael Guiney
An in utero female was found to have a small hemorrhage at the foramen of Monro, hydrocephalus, and what was originally interpreted as a Dandy-Walker variant. At birth she had macrocephaly and numerous cutaneous, multifocal, red-pink blanchable macules. Postnatal MRI demonstrated a hemorrhagic soft-tissue mass involving the upper brainstem, thalamus, and basal ganglia most consistent with in utero complex multifocal intracranial hemorrhage. The skin lesions were thought to be consistent with multifocal lymphangioendotheliomatosis with thrombocytopenia (MLT). The size and location of the hemorrhage precluded operative intervention, although the hydrocephalus was treated with a ventricular shunt. The child continues to have severe developmental delays. Multifocal lymphangioendotheliomatosis with thrombocytopenia is a multifocal vascular disorder most commonly involving the skin and gastrointestinal tract. Intracranial hemorrhages are rare in this context. This case is the third reported instance of MLT with associated intracranial hemorrhage and the only case described in the neurosurgical literature. The authors review the presenting features and pathophysiology of this condition. PMID:24053595
Huang, Christina; Rizk, Elias; Iantosca, Mark; Zaenglein, Andrea L; Helm, Klaus F; Choudhary, Arabinda K; Dias, Mark S
Multiple intracerebral hemorrhage may occur as rebleeding at the site of the previous lesion or in other places. However, multiple intracerebral hemorrhage occurring simultaneously in the supra-and infratentorial regions is rare. We experienced 9 such cases between May 1976 and December 1989. The clinical symptoms, CT findings and outcome of our cases and of 4 cases which were previously reported in the literature are reviewed in this paper. Out of 13 cases, 11 patients had cerebellar hemorrhage, and the others had pontine hemorrhage in the infratentorium. Among the supratentorial lesions, 11 involved hemorrhage in the putamen or the thalamus, and the others were in the subcortical region. There were no characteristic initial symptoms or neurological signs which suggested that hemorrhage had occurred in both the supra-and infratentorial regions. The only methods by which we could recognize this exceptional situation were the CT scan and MRI scan. The outcome in those patients whose initial neurological grading (NG) was 1 to 3 was good with conservative therapy or surgical treatment. On the other hand, the outcome in patients whose initial NG was 4 or 5 was very poor no matter what treatment was used. As far as surgical treatment is concerned, we believe that hematoma evacuation is necessary when the cerebellar hematoma is bigger than the supratentorial hematoma. PMID:1944777
Uno, M; Hondo, H; Matsumoto, K
A porcine model of hemorrhagic shock was used to study the effect of hypothermia on hemodynamic, metabolic, and coagulation parameters. The model was designed to simulate the events of severe blunt injury with hemorrhage occurring initially, to a systolic blood pressure of 30 mm Hg, followed by simultaneous hemorrhage and crystalloid volume replacement, followed by cessation of hemorrhage and blood replacement. Half of the animals were rendered hypothermic by external application of ice, and half remained normothermic. There was seven pigs in each group. Two deaths occurred in each during the hemorrhage phase. The hypothermic pigs demonstrated larger reduction in cardiac output than normothermic pigs. Volume replacement in the normothermic group restored cardiac output to baseline values. In the hypothermic group, cardiac output remained depressed despite volume replacement. Prothrombin times and partial thromboplastin times showed significantly more prolongation in the hypothermic group. Furthermore, this was not corrected by replacement of shed blood in the hypothermic group, as was seen in the normothermic group. We conclude that when shock and hypothermia occur together, their deleterious effect on hemodynamic and coagulation parameters are additive. The effects of hypothermia persist despite the arrest of hemorrhage and volume replacement. Thus, it is necessary to aggressively address both shock and hypothermia when they occur simultaneously. PMID:10776871
Krause, K R; Howells, G A; Buhs, C L; Hernandez, D A; Bair, H; Schuster, M; Bendick, P J
A case of cerebral venous thrombosis due to polycythemia secondary to adaptation to a high altitude is reported. A 27-year-old previously healthy man developed severe neurological symptoms after climbing 8511 m. Computerized tomography and cerebral angiography suggested hemorrhagic infarction or intratumoral hemorrhage, and a craniotomy was performed. Pathological examination confirmed the diagnosis of hemorrhagic infarction secondary to cortical venous thrombosis. The etiology and incidence of cerebral venous thrombosis secondary to polycythemia are discussed. PMID:3941339
Fujimaki, T; Matsutani, M; Asai, A; Kohno, T; Koike, M
Aims Hemorrhagic shock leads to a higher risk of mortality and morbidity in obese patients, however the mechanisms for these outcomes are unclear. We hypothesized that following severe hemorrhage, blood pressure control in conscious obese Zucker rats (OZ) is impaired. Main Methods Experiments were performed in conscious lean Zucker rats (LZ) and OZ. Blood pressure, heart rate, cardiac output, total peripheral resistance (TPR), plasma renin activity (PRA), plasma antidiuretic hormone (ADH), and blood gases were measured before and after severe hemorrhage (35% of the total blood volume). Key Findings Basal blood pressure, cardiac output, TPR, PRA, and ADH levels were not different between LZ and OZ. Compared to LZ, OZ exhibited impaired baroreflex control of heart rate and showed higher levels of vascular adrenergic tone. One hour after the hemorrhage, LZ and OZ exhibited similar decreases in cardiac output. However, blood pressure, heart rate, TPR, PRA, and ADH levels were lower in OZ than in LZ. Significance These results indicate that conscious OZ has impaired blood pressure compensation after hemorrhage due to a blunted increase in TPR. This is due at least in part to an impaired regulation of vasoconstrictor hormones. To our knowledge, the current study is the first to demonstrate that hemodynamic responses and associated hormone secretion are impaired in a conscious obese model.
Lu, Silu; Mittwede, Peter N.
We describe a case of uterine necrosis, following Gelitaspon(®) embolization for postpartum hemorrhage resulting from vaginal laceration. Previous cases published help to improve the safety of this effective method by showing the risk factors, as particles sizes, ultraselective embolization, prevention of infection. Controlling bleeding by surgery is the priority when hemorragy is due to laceration without uterin atony. In case of failure, embolization is an option which should be proposed without delay. Uterine necrosis should be suspected in case of postembolization septic syndrome. PMID:23706157
Gitz, L; Picone, O; Mas, A-E; Dagher, L; Deffieux, X
During a 14 month period from April 1989 to June 1990, human serosurveys for Crimean-Congo Hemorrhagic fever (CCHF) and Hemorrhagic Fever with Renal Syndrome (HFRS) were conducted in several counties of Greece previously not surveyed. Blood samples were t...
Hemorrhage represents the most feared complication of cerebral arteriovenous malformations (AVMs) in both untreated patients and those treated with gamma knife radiosurgery. Radiosurgery does not immediately lead to obliteration of the malformation, which often does not occur until years following treatment. Post-obliteration hemorrhage is rare, occurring months to years after radiosurgery, and has been associated with residual or recurrent AVM despite prior apparent nidus elimination. Three cases are reported of delayed intracranial hemorrhage in patients with cerebral AVMs treated with radiosurgery in which no residual AVM was found on catheter angiography at the time of delayed post-treatment hemorrhage. That the pathophysiology of these hemorrhages involves progressive venous outflow occlusion is speculated and the possible mechanistic link to subsequent vascular rupture is discussed. PMID:21990534
Alexander, Matthew D; Hetts, Steven W; Young, William L; Halbach, Van V; Dowd, Christopher F; Higashida, Randall T; English, Joey D
This study's objective was to investigate the daily dynamics of fibrinogen metabolism and coagulation function for 5 days after hemorrhagic shock in pigs. Sixteen pigs were randomized into the control (C) and the hemorrhage (H) groups. On day 1, hemorrhage was induced in H by bleeding 35% of the estimated total blood volume, followed by resuscitation with lactated Ringer's solution at three times the bled volume. Then, a primed constant infusion of stable isotopes was performed in both groups daily for 5 days to measure changes in fibrinogen metabolism, together with changes in hemodynamics and coagulation function. Hemorrhage caused a decrease in mean arterial pressure and an increase in heart rate. Fluid resuscitation corrected these changes. Compared with baseline day 1, fibrinogen levels in H were decreased to 76% ± 6% by hemorrhage and resuscitation on day 1, increased to 217% ± 16% on day 2, and remained elevated afterward; clot strength in H was decreased by hemorrhage on day 1 and returned to baseline values on day 2 and afterward. Compared with day 1 control value (1.3 ± 0.1 mg/kg per hour), fibrinogen synthesis in H was increased to 3.6 ± 0.1, 5.1 ± 0.5, 2.6 ± 0.4, 2.7 ± 0.5, and 2.3 ± 0.3 mg/kg per hour on days 1 through 5 (all P < 0.05); fibrinogen breakdown in H was elevated on days 1 and 2 but returned to control values afterward. Hemorrhage caused acute decreases in fibrinogen concentration and clot strength, followed by an increase in fibrinogen concentration and recovery of clot strength. The increase in fibrinogen appeared primarily due to a sustained increase in fibrinogen synthesis. PMID:22552021
Martini, Wenjun Z; Chung, Kevin K; Dubick, Michael A; Blackbourne, Lorne H
AIM: To evaluate the clinical characteristics of nonvariceal upper gastrointestinal hemorrhage (NGIH) in patients with chronic kidney disease (CKD). METHODS: From 2003 to 2010, a total of 72 CKD patients (male n = 52, 72.2%; female n = 20, 27.8%) who had undergone endoscopic treatments for NGIH were retrospectively identified. Clinical findings, endoscopic features, prognosis, rebleeding risk factors, and mortality-related factors were evaluated. The characteristics of the patients and rebleeding-related data were recorded for the following variables: gender, age, alcohol use and smoking history, past hemorrhage history, endoscopic findings (the cause, location, and size of the hemorrhage and the hemorrhagic state), therapeutic options for endoscopy, endoscopist experience, clinical outcomes, and mortality. RESULTS: The average size of the hemorrhagic site was 13.7 ± 10.2 mm, and the most common hemorrhagic site in the stomach was the antrum (n = 21, 43.8%). The most frequent method of hemostasis was combination therapy (n = 32, 44.4%). The incidence of rebleeding was 37.5% (n = 27), and 16.7% (n = 12) of patients expired due to hemorrhage. In a multivariate analysis of the risk factors for rebleeding, alcoholism (OR = 11.19, P = 0.02), the experience of endoscopists (OR = 0.56, P = 0.03), and combination endoscopic therapy (OR = 0.06, P = 0.01) compared with monotherapy were significantly related to rebleeding after endoscopic therapy. In a risk analysis of mortality after endoscopic therapy, only rebleeding was related to mortality (OR = 7.1, P = 0.02). CONCLUSION: Intensive combined endoscopic treatments by experienced endoscopists are necessary for the treatment of NGIH in patients with CKD, especially when a patient is an alcoholic.
Bang, Chang Seok; Lee, Yong Seop; Lee, Yun Hyeong; Sung, Hotaik; Park, Hong Jun; Kim, Hyun Soo; Kim, Jin Bong; Baik, Gwang Ho; Kim, Yeon Soo; Yoon, Jai Hoon; Kim, Dong Joon; Suk, Ki Tae
Cerebellar hemorrhage is a relatively rare phenomenon in neonates, and most cases are associated with intraventricular hemorrhage (IVH). Prenatally diagnosed intracranial hemorrhage is rare, and diagnoses of cerebellar hemorrhage are even rarer. In our literature search, we discovered 3 cases of prenatal diagnosis of cerebellar hemorrhage, all accompanied by IVH. None of the neonates survived. We report a case initially observed in utero by sonography of cerebellar hemorrhage without evidence of IVH, causing ventriculomegaly in a 32-week twin fetus who was subsequently successfully treated. PMID:12795563
Hiller, Luke; McGahan, John P; Bijan, Bijan; Melendres, Giselle; Towner, Dena
Background and Purpose Autopsy studies have suggested a relationship between intraplaque hemorrhage (IPH) and vasa vasorum, which arise primarily from the adventitia. Adventitial vasa vasorum can be characterized in the carotid arteries by estimating perfusion parameters via dynamic contrast-enhanced MRI. The purpose of this investigation was to use dynamic contrast-enhanced MRI to test in vivo in a clinical population whether adventitial perfusion, indicative of vasa vasorum microstructure, is associated with IPH. Methods Symptomatic patients with carotid plaque ipsilateral to the ischemic event underwent bilateral carotid artery MRI examination, which included multicontrast sequences for detecting IPH and a dynamic contrast-enhanced MRI sequence for characterizing adventitial perfusion. Kinetic modeling of the dynamic contrast-enhanced MRI time series was performed to estimate adventitial vp (fractional plasma volume, reflecting local blood supply) and Ktrans (transfer constant, reflecting vessel surface area, and permeability). Results From the 27 patients (22 men; 69±10 years of age) recruited, adventitial perfusion parameters were obtained in 50 arteries. The presence of IPH was associated with a significantly higher value in adventitial Ktrans (0.142±0.042 vs 0.112±0.029 min?1; P<0.001) but not in vp (0.163±0.064 vs 0.149±0.062; P=0.338). This relationship remained after adjusting for symptomatic status, degree of stenosis, and other confounding factors. Conclusions This study demonstrated an independent pathophysiological link between the adventitia and IPH and related it to the microstructure of adventitial vasa vasorum. Adventitial perfusion imaging may be useful in studying plaque pathogenesis, but further examination through prospective studies is needed.
Sun, Jie; Song, Yan; Chen, Huijun; Kerwin, William S.; Hippe, Daniel S.; Dong, Li; Chen, Min; Zhou, Cheng; Hatsukami, Thomas S.; Yuan, Chun
Objective In patients with spontaneous intracerebral hemorrhage (ICH), the risk factors for seizure and the effect of prophylactic anticonvulsants are not well known. This study aimed to determine the risk factor for seizures and the role for prophylactic anticonvulsants after spontaneous ICH. Methods Between 2005 and 2010, 263 consecutive patients with spontaneous ICH were retrospectively assessed with a mean follow-up of 19.5 months using medical records, updated clinical information and, when necessary, direct patient contact. The seizures were classified as early (within 1 week of ICH) or late (more than 1 week after ICH). The outcomes were measured with the Glasgow Outcome Scale at discharge and the modified Rankin Scale (mRS) at both 2 weeks and discharge. Results Twenty-two patients (8.4%; 9 patients with early seizures and 13 patients with late seizures) developed seizures after spontaneous ICH. Out of 263 patients, prophylactic anticonvulsants were administered in 216 patients. The prophylactic anticonvulsants were not associated with a reduced risk of early (p=0.094) or late seizures (p=0.326). Instead, the factors associated with early seizure were cortical involvement (p<0.001) and younger age (60 years or less) (p=0.046). The risk of late seizure was increased by cortical involvement (p<0.001) and communicating hydrocephalus (p=0.004). The prophylactic anticonvulsants were associated with a worse mRS at 2 weeks (p=0.024) and at last follow-up (p=0.034). Conclusion Cortical involvement may be a factor for provoked seizures. Although the incidence of early seizures tended to decrease in patients prescribed prophylactic anticonvulsants, no statistical difference was found.
Woo, Kwang-Moo; Cho, Keun-Tae
Severe bleeding may complicate the course of either acute or chronic pancreatitis, the latter being more frequently involved. Pseudocysts, severe inflammation, regional necrosis and infection may cause major vessel erosion with or without pseudoaneurysm formation which eventually may result in severe bleeding into the gastrointestinal tract, retroperitoneum and peritoneal cavity. The AA report their experience on 8 cases and analyze the data of a comprehensive review of 389 cases of massive bleeding reported in the literature during the last 100 years until December 1993. Mortality rate seems to be related to the etiology of the bleeding along with its localization and the underlying anatomo-pathologic findings. In patients with chronic pancreatitis it is 22% while in patients with acute pancreatitis or chronic pancreatitis with acute exacerbation it is 60.4% and 57.1% respectively. Splenic, gastroduodenal and superior pancreaticoduodenal arteries are the most commonly involved vessels being associated respectively with a mortality rate of 20.5%, 27.9% and 46.1%. Massive haemorrhage complicating infected necrosis or abscesses implies a worse prognosis when compared to severe bleeding associated with pseudocyst with or without pseudoaneurysm. The increasing use of diagnostic and interventional radiology appears to be the way forward to improve survival rates. Awareness of high risk predisposing condition, activism in achieving an early identification of the bleeding sources, and eventually its angiographic control are essential guidelines for successful approach to the most unpredictable complication of pancreatitis. When embolization fails or is followed by recurrence of hemorrhage, definitive surgical procedures should be immediately instituted. PMID:7668500
Flati, G; Salvatori, F; Porowska, B; Talarico, C; Flati, D; Proposito, D; Talarico, E; Carboni, M
We encountered an unusual case of an acute cerebellar hemorrhage secondary to a capillary telangiectasia in a 4-month-old infant. Prompt surgical evacuation of the cerebellar hematoma resulted in an excellent neurologic outcome. To the best of our knowledge, ours represents the only clinical case report of massive cerebellar bleed due to a capillary telangiectasia. PMID:7980112
Bland, L I; Lapham, L W; Ketonen, L; Okawara, S H
This report deals with a patient who developed hemoptysis due to unilateral intra-alveolar hemorrhage after receiving tissue-type plasminogen activator (TPA) for acute myocardial infarction; the patient had sustained an ipsilateral lung injury 2 years earlier. PMID:8818443
Hammoudeh, A J; Haft, J I; Eichman, G T
Background: Dengue is the most prevalent mosquito-borne virus, and potentially fatal dengue hemorrhagic fever (DHF) occurs mainly in secondary infections. It recently was hypothesized that, due to the presence of cross-immunity, the relationship between the incidence of DHF and transmission intensity may be negative at areas of intense transmission. We tested this hypothesis empirically, using vector abundance as a surrogate
Suwich Thammapalo; Yoshiro Nagao; Wataru Sakamoto; Seeviga Saengtharatip; Masaaki Tsujitani; Yasuhide Nakamura; Paul G. Coleman; Clive Davies
We have reviewed initial diagnostic features, treatment, and outcome in 29 patients with acute subarachnoid hemorrhage due to non-traumatic vertebrobasilar artery dissection diagnosed in our hospital between 1993 and 2003. The dissections occurred in the vertebral artery in 19 patients, the posterior inferior cerebellar artery (PICA) in two patients, the basilar artery in four patients, and in the vertebral artery
B Ramgren; M Cronqvist; B Romner; L Brandt; S Holtås; E-M Larsson
Traumatic brainstem hemorrhage after blunt head injury is an uncommon event. The most frequent site of hemorrhage is the midline rostral brainstem. The prognosis of these patients is poor because of its critical location. We experienced a case of traumatic brainstem hemorrhage. A 41-year-old male was presented with drowsy mentality and right hemiparesis after blunt head injury. Plain skull radiographs and brain computerized tomography scans revealed a depressed skull fracture, epidural hematoma, and hemorrhagic contusion in the right parieto-occipital region. But, these findings did not explain the right hemiparesis. T2-weighted magnetic resonance (MR) image of the cervical spine demonstrated a focal hyperintense lesion in the left pontomedullary junction. Brain diffusion-weighted and FLAIR MR images showed a focal hyperintensity in the ventral pontomedullary lesion and it was more prominent in the left side. His mentality and weakness were progressively improved with conservative treatment. We should keep in mind the possibility of brainstem hemorrhage if supratentorial lesions or spinal cord lesions that caused neurological deficits in the head injured patients are unexplainable.
Se, Young Bem; Bak, Koang Hum; Kim, Jae Min
Magnetization prepared rapid acquisition gradient echo (3D MPRAGE) has been shown to be a sensitive method to image carotid intraplaque hemorrhage. As the MPRAGE sequence used to identify potential intraplaque hemorrhage does not utilize cardiac gating, it is difficult to optimize the inversion times due to the dynamic nature of flowing blood. As a result, a best fit inversion time is often determined experimentally and then used for in vivo clinical examination. This results in compromised blood suppression and occasional hemorrhage mimicking flow artifacts. We demonstrate that a retrospective cardiac correlated reconstruction can be applied to the conventional MPRAGE sequence (CineMPRAGE) to more accurately identify blood signal. This CineMPRAGE reconstruction uses the data from a standard nongated MPRAGE sequence to generate a full sequence of cardiac correlated images throughout the cardiac cycle and, therefore, provides a dynamic view of the carotid artery and a better ability to discern blood signal from potential intraplaque hemorrhage. In our preliminary study of 35 patients, signal from potential hemorrhage was constant over the cardiac cycle, whereas any signal from blood flow artifact was observed as an oscillating signal over the cardiac cycle. PMID:22760825
Mendes, Jason; Parker, Dennis L; Kim, Seong-Eun; Treiman, Gerald S
Severe hemorrhage due to trauma is a major cause of death throughout the world. It has often been observed that some victims are able to withstand hemorrhage better than others. For decades investigators have attempted to identify physiological mechanisms that distinguish survivors from nonsurvivors for the purpose of providing more informed therapies. As an alternative approach to address this issue, we have initiated a research program to identify genes and genetic mechanisms that contribute to this phenotype of survival time after controlled hemorrhage. From physiogenomic studies using inbred rat strains, we have demonstrated that this phenotype is a heritable quantitative trait, and is therefore a complex trait regulated by multiple genes. Our work continues to identify quantitative trait loci as well as potential epigenetic mechanisms that might influence survival time after severe hemorrhage. Our ultimate goal is to improve survival to traumatic hemorrhage and attendant shock via regulation of genetic mechanisms and to provide knowledge that will lead to genetically-informed personalized treatments.
Klemcke, Harold G; Joe, Bina; Rose, Rajiv; Ryan, Kathy L
Although diffuse alveolar hemorrhage complicating warfarin therapy is rare, it generally has a worsening clinical course and can be a life threatening condition. A 56-year-old male who had undergone a pulmonary lobectomy for lung cancer 2 years before had received warfarin for about 5 months due to pulmonary vein thrombosis. The patient presented with severe dyspnea and had prolonged anticoagulation values. Chest X-ray and computed tomography revealed diffuse pulmonary consolidations, and bronchoalveolar lavage demonstrated diffuse alveolar hemorrhage. The reversal of anticoagulation was initiated, and extracorporeal membrane oxygenation was performed for refractory respiratory failure that did not improve despite maximal mechanical ventilatory support. The diffuse alveolar infiltrations resolved after 5 days, and we successfully weaned off both extracorporeal membrane oxygenation and mechanical ventilation. Herein we report the detailed course of a case that was successfully treated with extracorporeal membrane oxygenation as a bridge-to-recovery for warfarin- exacerbated diffuse alveolar hemorrhage.
Intracranial dermoid cysts with hemorrhage are fairly rare. Herein, we reported a 28-year-old female patient with a cerebellar dermoid cyst, which was found accidently on neuro-imaging after head trauma. MR scanning revealed that the lesion was located within the cerebellar vermis and was measured 3.5cm×3.9cm×3.0cm, with hyper-intensity on T1WI and hypo-intensity on T2WI. However, on CT imaging, it showed hyper-dense signals. It was removed completely via midline sub-occipital approach under surgical microscope. Histological examination proved it was a dermoid cyst with internal hemorrhage. In combination with literature review, we discussed the factors that might be responsible for the hemorrhage within dermoid cysts. PMID:22211083
Luan, Yongxin; Wang, Haifeng; Zhong, Yanping; Bian, Xinchao; Luo, Yinan; Ge, Pengfei
Intracranial dermoid cysts with hemorrhage are fairly rare. Herein, we reported a 28-year-old female patient with a cerebellar dermoid cyst, which was found accidently on neuro-imaging after head trauma. MR scanning revealed that the lesion was located within the cerebellar vermis and was measured 3.5cm×3.9cm×3.0cm, with hyper-intensity on T1WI and hypo-intensity on T2WI. However, on CT imaging, it showed hyper-dense signals. It was removed completely via midline sub-occipital approach under surgical microscope. Histological examination proved it was a dermoid cyst with internal hemorrhage. In combination with literature review, we discussed the factors that might be responsible for the hemorrhage within dermoid cysts.
Luan, Yongxin; Wang, Haifeng; Zhong, Yanping; Bian, Xinchao; Luo, Yinan; Ge, Pengfei
Managing trauma patients with hemorrhagic shock is complex and difficult. Despite our knowledge of the pathophysiology of hemorrhagic shock in trauma patients that we have accumulated during recent decades, the mortality rate of these patients remains high. In the acute phase of hemorrhage, the therapeutic priority is to stop the bleeding as quickly as possible. As long as this bleeding is uncontrolled, the physician must maintain oxygen delivery to limit tissue hypoxia, inflammation, and organ dysfunction. This process involves fluid resuscitation, the use of vasopressors, and blood transfusion to prevent or correct acute coagulopathy of trauma. The optimal resuscitative strategy is controversial. To move forward, we need to establish optimal therapeutic approaches with clear objectives for fluid resuscitation, blood pressure, and hemoglobin levels to guide resuscitation and limit the risk of fluid overload and transfusion.
Acute kidney injury occurs in 33-50% of patients with rhabdomyolysis and infections remain one of the major contributing factors. The incidence of rhabdomyolysis in non-hemorrhagic dengue virus infection is quite low and may go unnoticed, especially if the presentation is not florid. We report a case of a young male patient, sero-positive for dengue, with no hemorrhagic manifestations or hypotension, who developed rhabdomyolysis complicated by renal failure. The patient eventually needed dialysis support and later recovered fully. Clinicians need to be aware of the occurrence of rhabdomyolysis even in patients without the hemorrhagic manifestations of dengue viral infection and should employ early preventive strategies in such cases. PMID:24231486
Jha, Ratan; Gude, Dilip; Chennamsetty, Sashidhar
The present study was undertaken to examine the physiologic and metabolic effects of pharmacologic vasodilation on recovery from non-lethal severe hemorrhage. It was hypothesized that following hemorrhage a reduction in aortic hydrostatic afterload would ...
G. A. Millnamow J. D. O'Benar S. P. Bruttig
The purpose of this study was both to define the incidence of adrenal injury/hemorrhage in fatal motor vehicle accidents and myocardial infarctions and determine if adrenal hemorrhage is a terminal event or is caused by the traumatic event. Two hundred sixty-nine deaths were caused by motor vehicle accidents or blunt force, with 21 (7.8%) patients experiencing adrenal hemorrhage. Two hundred sixty-two deaths resulted from myocardial infarction with none of these patients experiencing adrenal hemorrhage. The 7% incidence of adrenal hemorrhage or injury is in the range previously reported in the literature. The statistically significant difference in the incidence of adrenal hemorrhage in this study suggests that the hemorrhage is the result of injury rather than a terminal event. Thus, we have concluded that some patients with severe blunt abdominal trauma may benefit from exogenous steroid administration, since the adrenal hemorrhage is caused by the traumatic event.
Porter, J. M.; Muscato, K.; Patrick, J. R.
The purpose of this study was both to define the incidence of adrenal injury/hemorrhage in fatal motor vehicle accidents and myocardial infarctions and determine if adrenal hemorrhage is a terminal event or is caused by the traumatic event. Two hundred sixty-nine deaths were caused by motor vehicle accidents or blunt force, with 21 (7.8%) patients experiencing adrenal hemorrhage. Two hundred sixty-two deaths resulted from myocardial infarction with none of these patients experiencing adrenal hemorrhage. The 7% incidence of adrenal hemorrhage or injury is in the range previously reported in the literature. The statistically significant difference in the incidence of adrenal hemorrhage in this study suggests that the hemorrhage is the result of injury rather than a terminal event. Thus, we have concluded that some patients with severe blunt abdominal trauma may benefit from exogenous steroid administration, since the adrenal hemorrhage is caused by the traumatic event. PMID:7674347
Porter, J M; Muscato, K; Patrick, J R
This invention relates to a successful procedure for the in vitro propagation of hemorrhagic enteritis virus (HEV) and to the application of this procedure to the production of an hemorrhagic enteritis (HE) vaccine and as a bioassay technique for determin...
K. Nazerian A. M. Fadly