Moore, Kenneth A.; Bohnstedt, Bradley N.; Shah, Sanket U.; Abdulkader, Marwah M.; Bonnin, Jose M.; Ackerman, Laurie L.; Shaikh, Kashif A.; Kralik, Stephen F.; Shah, Mitesh V.
Background: Chordomas are rare, slow-growing malignant neoplasms derived from remnants of the embryological notochord. Pediatric cases comprise only 5% of all chordomas, but more than half of the reported pediatric chordomas are intracranial. For patients of all ages, intracranial chordomas typically present with symptoms such as headaches and progressive neurological deficits occurring over several weeks to many years as they compress or invade local structures. There are only reports of these tumors presenting acutely with intracranial hemorrhage in adult patients. Case Description: A 10-year-old boy presented with acute onset of headache, emesis, and diplopia. Head computed tomography and magnetic resonance imaging of brain were suspicious for a hemorrhagic mass located in the left petroclival region, compressing the ventral pons. The mass was surgically resected and demonstrated acute intratumoral hemorrhage. Pathologic examination was consistent with chordoma. Conclusion: There are few previous reports of petroclival chordomas causing acute intracranial hemorrhage. To the authors’ knowledge, this is the first case of a petroclival chordoma presenting as acute intracranial hemorrhage in a pediatric patient. Although uncommon, it is important to consider chordoma when evaluating a patient of any age presenting with a hemorrhagic lesion of the clivus. PMID:25949851
Yoshida, H; Moriyama, Y; Tatekawa, T; Tominaga, N; Teshima, H; Hiraoka, A; Masaoka, T; Yoshinaga, T
This manuscript reports Bacillus cereus sepsis in two cases with acute myelogenous leukemia (AML) who suffered complications of fatal intracranial hemorrhage during remission induction therapy. The first case was 43-year-old male with AML (M0) receiving first consolidation chemotherapy who developed sudden diarrhea, abdominal pain and spiking fever. Two days later, he died of intracranial hemorrhage. The second case was 15-year-old male with AML (M5b) who was receiving first induction chemotherapy. He developed headache and vomiting following spiking fever and diarrhea. He died of subarachnoid hemorrhage the next day. In both cases, Bacillus cereus was isolated from blood culture. Fatal intracranial hemorrhage due to severe bleeding tendency caused rapid to death in both cases. These bleeding tendencies might have been induced by B. cereus sepsis. In addition, we should not overlook B. cereus as contamination, but rather consider it as a potential pathogen, when isolated from blood culture.
Fischbein, Nancy J; Wijman, Christine A C
Nontraumatic (or spontaneous) intracranial hemorrhage most commonly involves the brain parenchyma and subarachnoid space. This entity accounts for at least 10% of strokes and is a leading cause of death and disability in adults. Important causes of spontaneous intracranial hemorrhage include hypertension, cerebral amyloid angiopathy, aneurysms, vascular malformations, and hemorrhagic infarcts (both venous and arterial). Imaging findings in common and less common causes of spontaneous intracranial hemorrhage are reviewed.
Heit, Jeremy J.; Iv, Michael; Wintermark, Max
Intracranial hemorrhage is common and is caused by diverse pathology, including trauma, hypertension, cerebral amyloid angiopathy, hemorrhagic conversion of ischemic infarction, cerebral aneurysms, cerebral arteriovenous malformations, dural arteriovenous fistula, vasculitis, and venous sinus thrombosis, among other causes. Neuroimaging is essential for the treating physician to identify the cause of hemorrhage and to understand the location and severity of hemorrhage, the risk of impending cerebral injury, and to guide often emergent patient treatment. We review CT and MRI evaluation of intracranial hemorrhage with the goal of providing a broad overview of the diverse causes and varied appearances of intracranial hemorrhage. PMID:28030895
Study objective The acute management of patients on warfarin with spontaneous or traumatic intracranial hemorrhage continues to be debated in the medical literature. The objective of this paper was to conduct a structured review of the medical literature and summarize the advantages and risks of the available treatment options for reversing warfarin anticoagulation in patients who present to the emergency department with acute intracranial hemorrhage. Methods A structured literature search and review of articles relevant to intracranial hemorrhage and warfarin and treatment in the emergency department was performed. Databases for PubMed, CINAHL, and Cochrane EBM Reviews were electronically searched using keywords covering the concepts of anticoagulation drugs, intracranial hemorrhage (ICH), and treatment. The results generated by the search were limited to English- language articles and reviewed for relevance to our topic. The multiple database searches revealed 586 papers for review for possible inclusion. The final consensus of our comprehensive search strategy was a total of 23 original studies for inclusion in our review. Results Warfarin not only increases the risk of but also the severity of ICH by causing hematoma expansion. Prothrombin complex concentrate is statistically significantly faster at correcting the INR compared to fresh frozen plasma transfusions. Recombinant factor VIIa appears to rapidly reverse warfarin's effect on INR; however, this treatment is not FDA-approved and is associated with a 5% thromboembolic event rate. Slow intravenous dosing of vitamin K is recommended in patients with ICH. The 30-day risk for ischemic stroke after discontinuation of warfarin therapy was 3-5%. The risks of not reversing the anticoagulation in ICH generally outweigh the risk of thrombosis in the acute setting. Conclusions Increasing numbers of patients are on anticoagulation including warfarin. There is no uniform standard for reversing warfarin in intracranial
Pierce, J.N.; Taber, K.H.; Hayman, L.A. )
To describe the in vivo CT appearance of acute intracerebral blood clots formed from anemic platelet-depleted blood. Three patients with intracerebral hemorrhage secondary only to thrombocytopenia were examined with CT within 2 1/2 hours after the onset of clinical symptoms. There were no unusual CT features found in the intracerebral hemorrhages of patients with only thrombocytopenia. Specifically, a hyperdense zone(s) surrounded by areas of decreased density was identified. Clot retraction (which cannot occur in patients with severe thrombocytopenia) is not necessary for the CT appearance of acute intracerebral hemorrhage. 22 refs., 3 figs., 1 tab.
Fernandez, James; Deshpande, Ruchi; Wang, Ximing; Liu, Brent; Brazaitis, Michael; Munter, Fletcher; Liu, Margaret
Acute intra-cranial hemorrhage (AIH) may result from traumatic brain injury (TBI). Successful management of AIH depends heavily on the speed and accuracy of diagnosis. Timely diagnosis in emergency environments in both civilian and military settings is difficult primarily due to severe time restraints and lack of resources. Often, diagnosis is performed by emergency physicians rather than trained radiologists. As a result, added support in the form of computer-aided detection (CAD) would greatly enhance the decision-making process and help in providing faster and more accurate diagnosis of AIH. This paper discusses the implementation of a CAD system in an emergency environment, and its efficacy in aiding in the detection of AIH.
Freidberg, S R
The acute cerebellar hematoma and the subdural hematoma resent urgent surgical problems and treatment early in the clinical course should result in an excellent outcome. The subdural hematoma may be especially difficult to diagnose early, but may be suspected in patients on anticoagulant therapy or with shunze, and surgery, especially in the acute stage, should be avoided if possible. The CT scan supplemented when necessary by angiography is the diagnostic procedure of choice and will clearly demonstrate the lesions.
Gulati, Deepak; Dua, Dharti; Torbey, Michel T.
Spontaneous non-traumatic intracerebral hemorrhage (ICH) is associated with high morbidity and mortality throughout the world with no proven effective treatment. Majority of hematoma expansion occur within 4 h after symptom onset and is associated with early deterioration and poor clinical outcome. There is a vital role of ultra-early hemostatic therapy in ICH to limit hematoma expansion. Patients at risk for hematoma expansion are with underlying hemostatic abnormalities. Treatment strategy should include appropriate intervention based on the history of use of antithrombotic use or an underlying coagulopathy in patients with ICH. For antiplatelet-associated ICH, recommendation is to discontinue antiplatelet agent and transfuse platelets to those who will undergo neurosurgical procedure with moderate quality of evidence. For vitamin K antagonist-associated ICH, administration of 3-factor or 4-factor prothrombin complex concentrates (PCCs) rather than fresh frozen plasma to patients with INR >1.4 is strongly recommended. For patients with novel oral anticoagulant-associated ICH, administering activated charcoal to those who present within 2 h of ingestion is recommended. Idarucizumab, a humanized monoclonal antibody fragment against dabigatran (direct thrombin inhibitor) is approved by FDA for emergency situations. Administer activated PCC (50 U/kg) or 4-factor PCC (50 U/kg) to patients with ICH associated with direct thrombin inhibitors (DTI) if idarucizumab is not available or if the hemorrhage is associated with a DTI other than dabigatran. For factor Xa inhibitor-associated ICH, administration of 4-factor PCC or aPCC is preferred over recombinant FVIIa because of the lower risk of adverse thrombotic events. PMID:28360881
Xu, J.; Sisniega, A.; Zbijewski, W.; Dang, H.; Stayman, J. W.; Wang, X.; Foos, D. H.; Aygun, N.; Koliatsos, V. E.; Siewerdsen, J. H.
Purpose: Prompt and reliable detection of intracranial hemorrhage (ICH) has substantial clinical impact in diagnosis and treatment of stroke and traumatic brain injury. This paper describes the design, development, and preliminary performance characterization of a dedicated cone-beam CT (CBCT) head scanner prototype for imaging of acute ICH. Methods: A task-based image quality model was used to analyze the detectability index as a function of system configuration, and hardware design was guided by the results of this model-based optimization. A robust artifact correction pipeline was developed using GPU-accelerated Monte Carlo (MC) scatter simulation, beam hardening corrections, detector veiling glare, and lag deconvolution. An iterative penalized weighted least-squares (PWLS) reconstruction framework with weights adjusted for artifact-corrected projections was developed. Various bowtie filters were investigated for potential dose and image quality benefits, with a MC-based tool providing estimates of spatial dose distribution. Results: The initial prototype will feature a source-detector distance of 1000 mm and source-axis distance of 550 mm, a 43x43 cm2 flat panel detector, and a 15° rotating anode x-ray source with 15 kW power and 0.6 focal spot size. Artifact correction reduced image nonuniformity by ~250 HU, and PWLS reconstruction with modified weights improved the contrast to noise ratio by 20%. Inclusion of a bowtie filter can potentially reduce dose by 50% and improve CNR by 25%. Conclusions: A dedicated CBCT system capable of imaging millimeter-scale acute ICH was designed. Preliminary findings support feasibility of point-of-care applications in TBI and stroke imaging, with clinical studies beginning on a prototype.
Kim, Tae Jin; Koh, Eun Jung
Very rarely, spinal subarachnoid hemorrhage (SSAH) can occur without any direct spinal injury in patients with traumatic intracranial SAH. A-59-year-old male with traumatic intracranial subarachnoid hemorrhage (SAH) presented with pain and numbness in his buttock and thigh two days after trauma. Pain and numbness rapidly worsened and perianal numbness and voiding difficulty began on the next day. Magnetic resonance imaging showed intraspinal hemorrhage in the lumbosacral region. The cauda equina was displaced and compressed. Emergent laminectomy and drainage of hemorrhage were performed and SSAH was found intraoperatively. The symptoms were relieved immediately after the surgery. Patients with traumatic intracranial hemorrhage who present with delayed pain or neurological deficits should be evaluated for intraspinal hemorrhage promptly, even when the patients had no history of direct spinal injury and had no apparent symptoms related to the spinal injury in the initial period of trauma. PMID:27857928
Xu, J; Sisniega, A; Zbijewski, W; Dang, H; Stayman, J; Aygun, N; Koliatsos, V; Siewerdsen, JH; Wang, X; Foos, DH
Purpose: To design a dedicated x-ray cone-beam CT (CBCT) system suitable to deployment at the point-of-care and offering reliable detection of acute intracranial hemorrhage (ICH), traumatic brain injury (TBI), stroke, and other head and neck injuries. Methods: A comprehensive task-based image quality model was developed to guide system design and optimization of a prototype head scanner suitable to imaging of acute TBI and ICH. Previously reported models were expanded to include the effects of x-ray scatter correction necessary for detection of low contrast ICH and the contribution of bit depth (digitization noise) to imaging performance. Task-based detectablity index provided the objective function for optimization of system geometry, x-ray source, detector type, anti-scatter grid, and technique at 10–25 mGy dose. Optimal characteristics were experimentally validated using a custom head phantom with 50 HU contrast ICH inserts imaged on a CBCT imaging bench allowing variation of system geometry, focal spot size, detector, grid selection, and x-ray technique. Results: The model guided selection of system geometry with a nominal source-detector distance 1100 mm and optimal magnification of 1.50. Focal spot size ∼0.6 mm was sufficient for spatial resolution requirements in ICH detection. Imaging at 90 kVp yielded the best tradeoff between noise and contrast. The model provided quantitation of tradeoffs between flat-panel and CMOS detectors with respect to electronic noise, field of view, and readout speed required for imaging of ICH. An anti-scatter grid was shown to provide modest benefit in conjunction with post-acquisition scatter correction. Images of the head phantom demonstrate visualization of millimeter-scale simulated ICH. Conclusions: Performance consistent with acute TBI and ICH detection is feasible with model-based system design and robust artifact correction in a dedicated head CBCT system. Further improvements can be achieved with incorporation of
Shoamanesh, Ashkan; Kwok, Chun Shing; Lim, Patricia Annabelle; Benavente, Oscar R.
It has been questioned whether patients with cerebral microbleeds are at a greater risk for the development of symptomatic intracerebral hemorrhage following thrombolytic therapy in the management of acute ischemic stroke. Thus far, observational studies have not shown a statistically significant increased risk; however, these have been limited by small sample size. The aim is to better quantify the risk of postthrombolysis intracerebral hemorrhage in patients with acute ischemic stroke and cerebral microbleeds on magnetic resonance imaging. A systematic review of controlled studies investigating the presence of microbleeds on magnetic resonance imaging as a risk factor for intracerebral hemorrhage following thrombolysis in acute stroke patients was conducted. A random effects model meta-analysis was performed. In pooled analysis of five studies totaling 790 participants, the prevalence of microbleeds was 17%. The presence of microbleeds revealed a trend toward an increased risk of postthrombolysis symptomatic intracerebral hemorrhage [odds ratio: 1·98 (95% confidence interval, 0·90 to 4·35; P = 0·09), I2 = 0%]. Adjusted analysis minimizing potential bias resulted in an increased absolute risk of 4·6% for the development of symptomatic intracerebral hemorrhage in patients with cerebral microbleeds [odds ratio: 2·29 (95% confidence interval, 1·01 to 5·17), I2 = 0%] reaching borderline significance (P = 0·05). A significant relationship between increasing microbleed burden and symptomatic intracerebral hemorrhage (P = 0·0015) was observed. Isolated analysis of studies using exclusively intravenous tissue plasminogen activator was insignificant. Our data suggest that patients with cerebral microbleeds are at increased risk for symptomatic intracerebral hemorrhage following thrombolysis for acute ischemic stroke. However, current data are insufficient to justify withholding thrombolytic therapy from acute ischemic stroke patients solely of the basis of
Severe injuries such as intracranial hemorrhage (ICH) are the most serious problem after falls in hospital, but they have not been considered in risk assessment scores for falls. We tried to determine the risk factors for ICH after falls in 20,320 inpatients (696,364 patient-days) aged from 40 to 90 years who were admitted to a tertiary-care university hospital. Possible risk factors including STRATIFY risk score for falls and FRAX™ risk score for fractures were analyzed by univariate and multivariate analyses. Fallers accounted for 3.2% of the patients, and 5.0% of the fallers suffered major injuries, including peripheral bone fracture (59.6%) and ICH (23.4%). In addition to STRATIFY, FRAX™ was significantly associated not only with bone fractures but also ICH. Concomitant use of risk score for falls and risk score for fractures might be useful for the prediction of major injuries such as ICH after falls. PMID:22980233
Akhavan, Reza; Zandi, Behrouz; Pezeshki-Rad, Masoud; Farrokh, Donya
Colloid cysts are benign slow-growing cystic lesions located on the roof of the third ventricle that usually present with symptoms related to gradual rise of intracranial pressure. They mostly remain asymptomatic and sometimes grow progressively and cause diverse symptoms associated with increased intracranial pressure such as headache, diplopia, and sixth cranial nerve palsy. Here we report a 47-year-old female who presented to the emergency department with acute severe headache and nausea/vomiting. On MRI examination acute hydrocephaly due to hemorrhagic colloid cyst was detected. Acute hemorrhage in colloid cysts is extremely rare and may present with symptoms of acute increase in the intracranial pressure. Intracystic hemorrhage is very rarely reported as a complication of colloid cyst presenting with paroxysmal symptoms of acute hydrocephaly. PMID:28210514
Yang, Yang; Zhang, Yan; Wang, Zhaotao; Wang, Shanshan; Gao, Mou; Xu, Ruxiang; Liang, Chunyang; Zhang, Hongtian
The outcome of intracerebral hemorrhage (ICH) is mainly determined by the volume of the hemorrhage core and the secondary brain damage to penumbral tissues due to brain swelling, microcirculation disturbance and inflammation. The present study aims to investigate the protective effects of cerebrolysin on brain edema and inhibition of the inflammation response surrounding the hematoma core in the acute stage after ICH. The ICH model was induced by administration of type VII bacterial collagenase into the stratum of adult rats, which were then randomly divided into three groups: ICH + saline; ICH + Cerebrolysin (5 ml/kg) and sham. Cerebrolysin or saline was administered intraperitoneally 1 h post surgery. Neurological scores, extent of brain edema content and Evans blue dye extravasation were recorded. The levels of pro-inflammatory factors (IL-1β, TNF-α and IL-6) were assayed by Real-time PCR and Elisa kits. Aquaporin-4 (AQP4) and tight junction proteins (TJPs; claudin-5, occludin and zonula occluden-1) expression were measured at multiple time points. The morphological and intercellular changes were characterized by Electron microscopy. It is found that cerebrolysin (5 ml/kg) improved the neurological behavior and reduced the ipsilateral brain water content and Evans blue dye extravasation. After cerebrolysin treated, the levels of pro-inflammatory factors and AQP4 in the peri-hematomal areas were markedly reduced and were accompanied with higher expression of TJPs. Electron microscopy showed the astrocytic swelling and concentrated chromatin in the ICH group and confirmed the cell junction changes. Thus, early cerebrolysin treatment ameliorates secondary injury after ICH and promotes behavioral performance during the acute phase by reducing brain edema, inflammatory response, and blood-brain barrier permeability.
Lerario, Michael P.; Gialdini, Gino; Lapidus, Daniel M.; Shaw, Mesha M.; Navi, Babak B.; Merkler, Alexander E.; Lip, Gregory Y. H.; Healey, Jeff S.; Kamel, Hooman
Background We aimed to estimate the risk of ischemic stroke after intracranial hemorrhage in patients with atrial fibrillation. Materials and Methods Using discharge data from all nonfederal acute care hospitals and emergency departments in California, Florida, and New York from 2005 to 2012, we identified patients at the time of a first-recorded encounter with a diagnosis of atrial fibrillation. Ischemic stroke and intracranial hemorrhage were identified using validated diagnosis codes. Kaplan-Meier survival statistics and Cox proportional hazard analyses were used to evaluate cumulative rates of ischemic stroke and the relationship between incident intracranial hemorrhage and subsequent stroke. Results Among 2,084,735 patients with atrial fibrillation, 50,468 (2.4%) developed intracranial hemorrhage and 89,594 (4.3%) developed ischemic stroke during a mean follow-up period of 3.2 years. The 1-year cumulative rate of stroke was 8.1% (95% CI, 7.5–8.7%) after intracerebral hemorrhage, 3.9% (95% CI, 3.5–4.3%) after subdural hemorrhage, and 2.0% (95% CI, 2.0–2.1%) in those without intracranial hemorrhage. After adjustment for the CHA2DS2-VASc score, stroke risk was elevated after both intracerebral hemorrhage (hazard ratio [HR], 2.8; 95% CI, 2.6–2.9) and subdural hemorrhage (HR, 1.6; 95% CI, 1.5–1.7). Cumulative 1-year rates of stroke ranged from 0.9% in those with subdural hemorrhage and a CHA2DS2-VASc score of 0, to 33.3% in those with intracerebral hemorrhage and a CHA2DS2-VASc score of 9. Conclusions In a large, heterogeneous cohort, patients with atrial fibrillation faced a substantially heightened risk of ischemic stroke after intracranial hemorrhage. The risk was most marked in those with intracerebral hemorrhage and high CHA2DS2-VASc scores. PMID:26701759
Castellani, Rudy J.; Mojica, Gruschenka; Perry, George
The timing of the breakdown of red blood cells and organization of hemorrhage has significance in the catabolism of heme and the processing of iron, but also has a practical application in terms of assigning, or attempting to assign, a time course with respect to traumatic events (e.g. contusions and hemorrhages). Attempts to date contusions, however, have generally been unsuccessful by macroscopic observation, whereas the microscopic observations provide broad data but are also anatomically imprecise as a function of time. Intracranial lesions are of particular significance with respect to the timing of organizing hemorrhage given the acute, and often life-threatening nature of the hemorrhages, and the medicolegal investigation into potential crimes. Of concern is that the Prussian Blue reaction for iron, a relatively straightforward histochemical reaction that has been in use for over 150 years, is sometimes suggested as a diagnostic test for chronicity. Therefore, this study examined the utility of the Prussian Blue iron stain in living patients with intracranial hemorrhages and well-defined symptom onset, to test whether the presence of Prussian Blue reactivity could be correlated with chronicity. It was found that out of 12 cases with intracranial hemorrhage, eight cases showed at least focal iron reactivity. The duration from symptom onset to surgery in those eight cases ranged from < 24 hours to more than 3 days. Of those cases with no iron reactivity, the duration from symptom onset to surgery ranged from < 24 hours to six days. In conclusion, the Prussian Blue reaction was unreliable as an indicator of timing in intracranial hemorrhage. The use of the Prussian blue reaction as an independent indicator of chronicity is therefore not valid and can be misleading. Caution is indicated when employing iron staining for timing purposes, as its only use is to highlight, as opposed to identify, pre-existing lesions. With respect to brain lesions, the Prussian blue
Macdonald, Robert Loch; Leung, Ming; Tice, Tom
Tice and colleagues pioneered site-specific, sustained-release drug delivery to the brain almost 30 years ago. Currently there is one drug approved for use in this manner. Clinical trials in subarachnoid hemorrhage have led to approval of nimodipine for oral and intravenous use, but other drugs, such as clazosentan, hydroxymethylglutaryl CoA reductase inhibitors (statins) and magnesium, have not shown consistent clinical efficacy. We propose that intracranial delivery of drugs such as nimodipine, formulated in sustained-release preparations, are good candidates for improving outcome after subarachnoid hemorrhage because they can be administered to patients that are already undergoing surgery and who have a self-limited condition from which full recovery is possible.
Koffie, Robert M; Stapleton, Christopher J; Torok, Collin M; Yoo, Albert J; Leslie-Mazwi, Thabele M; Codd, Patrick J
Infectious intracranial aneurysms are rare vascular lesions that classically occur in patients with infective endocarditis. We present a 49-year-old man with altered mental status and headache with rapid growth and rupture of an infectious intracranial aneurysm with catastrophic intracranial hemorrhage, and review issues related to open neurosurgical and endovascular interventions.
Wang, Anthony C; Gemmete, Joseph J; Keegan, Catherine E; Witt, Cordelie E; Muraszko, Karin M; Than, Khoi D; Maher, Cormac O
Roberts/SC phocomelia syndrome (RBS) is a rare but distinct genetic disorder with an autosomal recessive inheritance pattern. It has been associated with microcephaly, craniofacial malformation, cavernous hemangioma, encephalocele, and hydrocephalus. There are no previously reported cases of RBS with intracranial aneurysms. The authors report on a patient with a history of RBS who presented with a spontaneous posterior fossa hemorrhage. Multiple small intracranial aneurysms were noted on a preoperative CT angiogram. The patient underwent emergency craniotomy for evacuation of the hemorrhage. A postoperative angiogram confirmed the presence of multiple, distal small intracranial aneurysms.
Hassan, Ali; Ahmad, Bakhtiar; Ahmed, Zahoor; Al-Quliti, Khalid W.
Ruptured cerebral aneurysm is the most common cause of spontaneous subarachnoid hemorrhage (SAH). Rarely cerebral venous sinus thrombosis (CVST) may present initially as acute SAH, and clinically mimics aneurysmal bleed. We report 2 cases of CVST who presented with severe headache associated with neck pain and focal seizures. Non-contrast brain CT showed SAH, involving the sulci of the convexity of hemisphere (cSAH) without involving the basal cisterns. Both patients received treatment with anticoagulants and improved. Awareness of this unusual presentation of CVST is important for early diagnosis and treatment. The purpose of this paper is to emphasize the inclusion of vascular neuroimaging like MRI with venography or CT venography in the diagnostic workup of SAH, especially in a patient with strong clinical suspicion of CVST or in a patient where neuroimaging showed cSAH. PMID:25630784
Objective: Oral anticoagulants are widely administered to patients with atrial fibrillation in order to prevent the onset of cardiogenic embolisms. However, intracranial bleeding during anticoagulant therapy often leads to fatal outcomes. Accordingly, the use of novel oral anticoagulants (NOACs), which less frequently have intracranial bleeding as a complication, is expanding. A nationwide survey of intracranial bleeding and its prognosis in Japan reported that intracranial bleeding of advanced severity was not common after NOAC administration. In this report, two cases from our institute are presented. Patients: Case 1 was an 85-year-old man with a right frontal lobe hemorrhage while under dabigatran therapy. Case 2 was an 81-year-old man who had cerebellar hemorrhage while under rivaroxaban therapy. Result: In both patients, the clinical course progressed without aggravation of bleeding or neurological abnormalities once anticoagulant therapy was discontinued. Conclusion: These observations suggest that intracranial hemorrhage during NOAC therapy is easily controlled by discontinuation of the drug. NOAC administration may therefore be appropriate despite the risk of such severe complications. Further case studies that include a subgroup analysis with respect to each NOAC or patient background will be required to establish appropriate guidelines for the prevention of cardiogenic embolisms in patients with atrial fibrillation. PMID:27928459
Dunham, C. Michael; Hoffman, David A.; Huang, Gregory S.; Omert, Laurel A.; Gemmel, David J.; Merrell, Renee
Background The impact of antithrombotic agents (warfarin, clopidogrel, ASA) on traumatic brain injury outcomes is highly controversial. Although cerebral atrophy is speculated as a risk for acute intracranial hemorrhage, there is no objective literature evidence. Materials and Methods This is a retrospective, consecutive investigation of patients with signs of external head trauma and age ≥60 years. Outcomes were correlated with antithrombotic-agent status, coagulation test results, admission neurologic function, and CT-based cerebral atrophy dimensions. Results Of 198 consecutive patients, 36% were antithrombotic-negative and 64% antithrombotic-positive. ASA patients had higher arachidonic acid inhibition (p = 0.04) and warfarin patients had higher INR (p<0.001), compared to antithrombotic-negative patients. Antithrombotic-positive intracranial hemorrhage rate (38.9%) was similar to the antithrombotic-negative rate (31.9%; p = 0.3285). Coagulopathy was not present on the ten standard coagulation, thromboelastography, and platelet mapping tests with intracranial hemorrhage and results were similar to those without hemorrhage (p≥0.1354). Hemorrhagic-neurologic complication (intracranial hemorrhage progression, need for craniotomy, neurologic deterioration, or death) rates were similar for antithrombotic-negative (6.9%) and antithrombotic-positive (8.7%; p = 0.6574) patients. The hemorrhagic-neurologic complication rate was increased when admission major neurologic dysfunction was present (63.2% versus 2.2%; RR = 28.3; p<0.001). Age correlated inversely with brain parenchymal width (p<0.001) and positively with lateral ventricular width (p = 0.047) and cortical atrophy (p<0.001). Intracranial hemorrhage correlated with cortical atrophy (p<0.001) and ventricular width (p<0.001). Conclusions Intracranial hemorrhage is not associated with antithrombotic agent use. Intracranial hemorrhage patients have no demonstrable coagulopathy. The association
Matute, Esmeralda; O’Callaghan, Erin T.; Murray, Joan; Tlacuilo-Parra, Alberto
Background The goal of this study was to examine the impact of focal brain injuries on the outcomes of visual perception and visuospatial abilities in Mexican children with hemophilia who have experienced intracranial hemorrhages. Methods We assessed ten boys who had hemophilia with intracranial hemorrhage (HIC), six boys who had hemophilia without intracranial hemorrhage (HH), and ten boys without hemophilia (CTL). The Verbal (VIQ), Performance IQs (PIQ), and Full Scale IQs (FSIQ) from the Wechsler Intelligence Scale for Children—Mexican Revision, Visual Perception, and Visuospatial Abilities domains, which are from a neuropsychological assessment battery for Spanish-speaking children (ENI), were employed for our analysis. Results The results showed that the HIC group performed in the low-average range on the PIQ and FSIQ, which was lower than the HH group. The HIC group showed low performance on visual perception tests, such as line orientation, fragmented objects, and overlapping figures, compared with their matched controls. Conclusions The results suggest that it is not the ability to recognize objects that is impaired in the HIC group, but the ability to identify objects under less favorable conditions. Our findings may have therapeutic and rehabilitative implications for the management of children with hemophilia and early focal brain lesions. PMID:26835360
Elikowski, Waldemar; Małek-Elikowska, Małgorzata; Kudliński, Bartosz; Skrzywanek, Paweł; Smól, Sławomir; Rzymski, Stanisław
In typical takotsubo cardiomyopathy (TC) apical transient left ventricular dysfunction with concomitant ECG changes mimicking acute anterior myocardial infarction can be observed. Reverse TC (RTC) characterized by contractile disturbances in all basal and often simultaneous mid-ventricular segments is definitely less frequent. ECG pattern of RTC is less known. The authors present ECG findings in 5 cases of RTC in course of intracranial hemorrhage (ICH); 3 patients were diagnosed with subarachnoid hemorrhage (SAH) and the other two with intracerebral hemorrhage or subdural posttraumatic hematoma. In all patients, initial ECG appearance was dominated by ST segment depression in inferior leads (II, III, avF) and/or lateral leads (V4-6). In 4 patients, concurrent ST segment elevation in avR and avL leads was seen, additionally 4 patients had low QRS voltage in high lateral leads (I, avL). Potential normalization of these changes did not influence the patient`s survival. In one woman, immediately before death, early repolarization was recorded. In subjects with an increased risk of TC, for example in intracranial hemorrhage, particularly in SAH, the ECG abnormalities presented may indicate a need for further search of its atypical echocardiographic variants.
Rama-Maceiras, P; Fàbregas Julià, N; Ingelmo Ingelmo, I; Hernández-Palazón, J
The high rates of morbidity and mortality after subarachnoid hemorrhage due to spontaneous rupture of an intracranial aneurysm are mainly the result of neurologic complications. Sixty years after cerebral vasospasm was first described, this problem remains unsolved in spite of its highly adverse effect on prognosis after aneurysmatic rupture. Treatment is somewhat empirical, given that uncertainties remain in our understanding of the pathophysiology of this vascular complication, which involves structural and biochemical changes in the endothelium and smooth muscle of vessels. Vasospasm that is refractory to treatment leads to cerebral infarction. Prophylaxis, early diagnosis, and adequate treatment of neurologic complications are key elements in the management of vasospasm if neurologic damage, lengthy hospital stays, and increased use of health care resources are to be avoided. New approaches to early treatment of cerebral lesions and cortical ischemia in cases of subarachnoid hemorrhage due to aneurysm rupture should lead to more effective, specific management.
Serra E Moura Garcia, C; Sokolova, A; Torre, M L; Amaro, C
Acute Hemorrhagic Edema of Infancy is a small vessel leucocytoclastic vasculitis affecting young infants. It is characterized by large, target-like, macular to purpuric plaques predominantly affecting the face, ear lobes and extremities. Non-pitting edema of the distal extremities and low-grade fever may also be present. Extra-cutaneous involvement is very rare. Although the lesions have a dramatic onset in a twenty-four to forty-eight hour period, usually the child has a non-toxic appearance. In most cases there are no changes in laboratory parameters. The cutaneous biopsy reveals an inflammatory perivascular infiltrate. It is a benign and auto-limited disease, with complete resolution within two to three weeks leaving no sequelae in the majority of cases. No recurrences are described. We report a case of a 42-day old girl admitted at our hospital with Acute Hemorrhagic Edema of Infancy.
Yilmaz, C; Yuca, S A; Yilmaz, N; Bektaş, M S; Caksen, H
The hospital records of 30 infants with a diagnosis of intracranial hemorrhage (ICH) due to late onset of vitamin K deficiency, seen during a 5-year period (2001-2005) were retrospectively evaluated. Signs and symptoms of the patients were convulsions (80%), poor sucking (50%), irritability (40%), vomiting (47%), acute diarrhea (33%), and fever (40%). On physical examination there were bulging or full fontanel in 19 patients (63%), collapsed fontanel in one (3%), diminished or absent neonatal reflexes in 11 (37%), pallor in 14 (47%), and cyanosis in one (3%) patient. Gastrointestinal disorder, skin hemorrhagic findings, and epistaxis each were noted in two (7%) patients. All the infants had prolonged prothrombin time (PT) and seven had prolonged activated partial thromboplastin time (APTT), both of which were corrected by the administration of vitamin K. All the infants had ICH, with the most common being intraparenchymal hemorrhage, followed by multiple type ICH (27%). Neurosurgical intervention was performed in five patients (17%). The overall case fatality rate was 33%. In conclusion, we would like to stress that ICH due to vitamin K deficiency in infants is still an important health problem in Turkey resulting in high mortality rate.
Kim, Hye-Jeong; Na, Joo-Young; Lee, Young-Jik; Park, Jong-Tae; Kim, Hyung-Seok
The major component of car washer fluid is a methanol. Intracranial hemorrhage is a rare but lethal complication in methanol poisoning. We report a case of massive bilateral basal ganglia hematoma in a 32-year-old man with methanol poisoning. He drank car washer solution twice time (about 500 ml), and was admitted to a territorial hospital 10 hours post-ingestion for depressed mental status, lower blood pressure, and high anion gap metabolic acidosis. Computed tomographic (CT) scan showed lesions in both putamen and cerebral deep white matter. Twenty-one days after methanol exposure, he suddenly developed cardiorespiratory arrest. In autopsy, external examination revealed moderate cerebral edema, but no evidence of herniation. Coronal sections of the brain showed softening and about 34 g hematoma in the bilateral putamen and 3rd ventricles. The toxic effect of methanol on the visual system has been noted in the absence of neurologic manifestations; however, there have also been a report of concomitant brain in Korea.
Fan, Zhenzeng; Yuan, Yunchao; Wang, Feng; Qi, Yuepeng; Han, Haie; Wu, Jianliang; Zhang, Gengshen; Yang, Lijun
Intracranial hemorrhage (ICH) is a common subtype of stroke with high morbidity and mortality. However, few studies have examined the effects of diabetes on the recovery from ICH-induced brain injury. Therefore, we examined the effects of diabetes on protein levels of aquaporins, neuronal loss, angiogenesis, blood brain barrier (BBB) integrity, and neurological deficits following intra-DH collagenase-induced ICH in the hippocampus. We found that diabetic rats exhibited enhanced AQP9 expression in the hippocampus relative to non-diabetic rats, which was associated with increased behavioral deficits. Additionally, ICH induced neovascularization, proliferation of brain microvascular endothelial cells, and hippocampal neuronal loss. However, ICH-induced neovascularization and proliferation of brain microvascular endothelial cells was severely impaired in diabetic rats. Furthermore, ICH-induced hippocampal neuronal loss was exaggerated in diabetic rats. Finally, ICH impaired BBB integrity in the ipsilateral hemisphere, which was increased in diabetic rats. Taken together, the attenuated brain angiogenesis, increased hippocampal neuronal loss, and impaired BBB integrity in diabetic rats after ICH were associated with enhanced AQP9 expression. This may suggest that AQP9 is one of the underlying mechanisms that can mitigate the recovery from ICH in diabetic populations.
Al-Hameed, Fahad M.
The Middle East respiratory syndrome corona virus (MERS-CoV) is a novel positive sense singlestranded ribonucleic acid virus of the genus Beta corona virus. This virus was first isolated from a patient who died from severe respiratory illness in June 2012 in Jeddah, Kingdom of Saudi Arabia. We describe an unusual case of a 42 year old healthcare worker who was admitted to our Intensive Care Unit (ICU) King Abdul-Aziz Medical City, with MERS-CoV and severe acute respiratory distress Syndrome and developed a sudden-onset diabetes insipidus and spontaneous massive intracranial hemorrhage with intra-ventricular extension and tonsillar herniation. Computed angiogram of the brain did not reveal any aneurysm or structural defects. She never had uncontrolled hypertension, or coagulopathy, nor she received antiplatelets. We are reporting a rare case of structural neurological damage associated with MERS-CoV infection. PMID:28133694
Auschwitz, Tyler; DeCuypere, Michael; Khan, Nickalus; Einhaus, Stephanie
Intracranial arachnoid cysts are a rare condition thought to be congenital in nature. Treatment of intracranial arachnoid cysts remains controversial based on their variable presentation. Treatment options include CSF shunting, endoscopic fenestration, or craniotomy and open fenestration for larger cysts. The complications of these procedures can include hydrocephalus, subdural hematomas, hygromas, and--more rarely--intraparenchymal hemorrhage. The authors found very few reports of hemorrhagic infarction as a complication of arachnoid cyst fenestration in the literature. The authors report a case of an 18-year-old female patient who suffered an ipsilateral hemorrhagic infarction after craniotomy for open fenestration of an arachnoid cyst.
Lopes, Renato D; Guimarães, Patricia O; Kolls, Bradley J; Wojdyla, Daniel M; Bushnell, Cheryl D; Hanna, Michael; Easton, J Donald; Thomas, Laine; Wallentin, Lars; Al-Khatib, Sana M; Held, Claes; de Barros E Silva, Pedro Gabriel Melo; Alexander, John H; Granger, Christopher B; Diener, Hans-Christoph
We investigated the frequency and characteristics of intracranial hemorrhage (ICH), factors associated with risk of ICH, and outcomes post-ICH overall and by randomized treatment. We identified patients in ARISTOTLE with ICH who received ≥1 dose of study drug (n=18,140). ICH was adjudicated by a central committee. Cox regression models were used to identify factors associated with ICH. ICH occurred in 174 patients; most ICH events were spontaneous (71.2%) versus traumatic (28.8%). Apixaban resulted in significantly less ICH (0.33%/year), regardless of type and location, than warfarin (0.80%/year). Independent factors associated with increased risk of ICH were enrollment in Asia or Latin America, older age, prior stroke/transient ischemic attack, and aspirin use at baseline. Among warfarin-treated patients, the median (25th, 75th) time from most recent international normalized ratio (INR) to ICH was 13 (6, 21) days. Median INR prior to ICH was 2.6 (2.1, 3.0); 78.5% of patients had a pre-ICH INR <3.0. After ICH, the modified Rankin scale at discharge was ≥4 in 55.7%, and mortality at 30 days was 43.3%. No difference was observed in the rates of all-cause death post-ICH, regardless of treatment. ICH occurred at a rate of 0.80%/year with warfarin regardless of INR control and 0.33%/year with apixaban, and was associated with high short-term morbidity and mortality. This highlights the clinical relevance of reducing ICH by using apixaban rather than warfarin and avoiding concomitant aspirin, especially in patients with older age.
Sarohia, Dani; Javan, Ramin; Aziz, Salim
We present a case in which intraocular silicone injection for complex retinal detachment resulted in migration and distribution of silicone along the intracranial visual pathway, and ultimately throughout the ventricular system. Misinterpretation of this material as intracranial hemorrhage on outside computed tomography imaging delayed emergent repair of a Type A aortic dissection until the diagnosis was made on repeat imaging. A discussion of this case and salient computed tomography and magnetic resonance imaging characteristics of silicone is provided. PMID:27761189
Alcalá-Cerra, Gabriel; Gutiérrez Paternina, Juan J.; Buendía de Ávila, María E.; Preciado Mesa, Edgar I.; Barrios, Rubén Sabogal; Niño-Hernández, Lucía M.; Jaramillo, Keith Suárez
Background: Trends in management of aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysms among neurosurgeons is very variable and had not been previously described in any Latin American country. This study was conducted to determine the preferences of Colombian neurosurgeons in pharmacologic, surgical, and endovascular management of patients with aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysms. Methods: A survey-based descriptive study was performed in a sample of members from the Colombian Association of Neurosurgery. Questions about pharmacologic, surgical, and endovascular management of aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysm were carried out. We calculated the mean and the standard deviation of the results obtained from the continuous variables. The results of the categorical variables are presented as percentages. Results: The preference of medication with poor clinical evidence, such as magnesium sulfate, aspirin, statins, and anti-fibrinolytics was lower than 10%. The use of intravenous nimodipine and systemic glucocorticoids was as high as 31%. The availability of endovascular therapy was 69%. The indication for treatment of patients with unruptured intracranial aneurysms that required intervention was less than 13.8%. In patients with ruptured or unruptured intracranial aneurysms, coiling was the preferred method for exclusion. Conclusions: Reported compliance of evidence-based clinical guidelines was similar to that described in developed countries, and even better. However, there is little agreement in treating patients with unruptured intracranial aneurysms. For other issues, the conducts reported by Colombian neurosurgeons are in accordance with the current guidelines. PMID:22059120
Frölich, Andreas M.; Buhk, Jan-Hendrik; Fiehler, Jens; Kemmling, Andre
Objectives Flat-panel CT (FPCT) allows cross-sectional parenchymal, vascular and perfusion imaging within the angiography suite, which could greatly facilitate acute stroke management. We hypothesized that FPCT offers equal diagnostic accuracy compared to multi-detector CT (MDCT) as a primary tool to exclude intracranial hemorrhage. Methods 22 patients with intracranial hematomas who had both MDCT and FPCT performed within 24 hours were retrospectively identified. Patients with visible change in hematoma size or configuration were excluded. Two raters independently segmented hemorrhagic lesions. Data sets and corresponding binary lesion maps were co-registered to compare hematoma volume. Diagnostic accuracy of FPCT to detect hemorrhage was calculated from voxel-wise analysis of lesion overlap compared to reference MDCT. Results Mean hematoma size was similar between MDCT (16.2±8.9 ml) and FPCT (16.1±8.6 ml), with near perfect correlation of hematoma sizes between modalities (ρ = 0.95, p<0.001). Sensitivity and specificity of FPCT to detect hemorrhagic voxels was 61.6% and 99.8% for intraventricular hematomas and 67.7% and 99.5% for all other intracranial hematomas. Conclusions In this small sample containing predominantly cases with subarachnoid hemorrhage, FPCT based assessment of hemorrhagic volume in brain yields acceptable accuracy compared to reference MDCT, albeit with a limited sensitivity on a voxel level. Further assessment and improvement of FPCT is necessary before it can be applied as a primary imaging modality to exclude intracranial hemorrhage in acute stroke patients. PMID:27806106
Schievink, Wouter I; Wasserstein, Philip; Maya, M Marcel
Spontaneous intracranial hypotension due to a spinal CSF leak has become a well-recognized cause of headaches, but such spinal CSF leaks also are found in approximately half of patients with superficial siderosis of the CNS. It has been hypothesized that friable vessels at the site of the spinal CSF leak are the likely source of chronic bleeding in these patients, but such an intraspinal hemorrhage has never been visualized. The authors report on 2 patients with spontaneous intracranial hypotension and intraspinal hemorrhage, offering support for this hypothesis. A 33-year-old man and a 62-year-old woman with spontaneous intracranial hypotension were found to have a hemorrhage within the ventral spinal CSF collection and within the thecal sac, respectively. Treatment consisted of microsurgical repair of a ventral dural tear in the first patient and epidural blood patching in the second patient. The authors suggest that spontaneous intracranial hypotension should be included in the differential diagnosis of spontaneous intraspinal hemorrhage, and that the intraspinal hemorrhage can account for the finding of superficial siderosis when the CSF leak remains untreated.
Rennert, Robert C.; Steinberg, Jeffrey A.; Sack, Jayson; Pannell, J. Scott; Khalessi, Alexander A.
Penetrating brain trauma commonly results in occult neurovascular injury. Detailed cerebrovascular imaging can evaluate the relationship of intracranial foreign bodies to major vascular structures, assess for traumatic pseudoaneurysms, and ensure hemostasis during surgical removal. We report a case of a self-inflicted intracranial nail gun injury causing a communicating ventricular tract hemorrhage upon removal, as well as a delayed pseudoaneurysm. Pre- and post-operative vascular imaging, as well as intra-operative endovascular assistance, was critical to successful foreign body removal in this patient. This report demonstrates the utility of endovascular techniques for the assessment and treatment of occult cerebrovascular injuries from intracranial foreign bodies. PMID:27471490
Banaama, Saeed; van Overbeeke, Jacobus; Temel, Yasin
Background: Symptomatic intratumoral hemorrhage (ITH) in vestibular schwannoma (VS) is rare. A repeated hemorrhage is, therefore, even more exceptional. Repeated ITH has been reported in four cases thus far in English literature. Here, we describe a patient with a Koos grade D VS who presented to our Skull Base team with repeated ITH and an unexpected disease course. Case Description: A 76-year-old woman presented with hearing loss due to polycystic VS on the left side. Five years later, the patient was presented with facial palsy caused by hemorrhage in the VS. The patient had an eventful medical history that necessitated the use of anti-coagulants. The patient suffered from three subsequent hemorrhages preoperatively and one hemorrhage 36 h postoperatively. Conclusion: We have experienced multiple repeated hemorrhages in a patient with a polycystic VS, and despite surgical intervention, the outcome was unfavorable. PMID:27999710
Oh, Seung-Young; Lee, Hannah; Park, Yang-Hyo
Seizure is the second most common neurologic complication after liver transplantation and may be caused by metabolic abnormalities, electrolyte imbalance, infection, and immunosuppressant toxicity. A 61-year-old male patient underwent liver transplantation due to hepatitis B virus-related liver cirrhosis with portal systemic encephalopathy. The immediate postoperative course of the patient was uncomplicated. However, on postoperative day (POD) 6, weakness developed in both lower extremities. No abnormal findings were detected on a brain computed tomography (CT) scan on POD 8, but a generalized tonic clonic seizure developed which was difficult to control even with multiple antiepileptic drugs. A follow-up brain CT scan on POD 15 showed a 2.7 cm sized acute intracranial hemorrhage (ICH) in the left parietal lobe. The patient's mental status improved after 2 months and he was able to communicate through eye blinking or head shaking. Our case reports an acute ICH that manifested into a refractory seizure in a patient who underwent a liver transplant. PMID:27703637
Sivakumar, Walavan; Ravindra, Vijay M; Cutler, Aaron; Couldwell, William T
Although most patients with intracranial hypotension typically present with headaches, the rest of the clinical spectrum is characteristically non-specific and often quite variable. In a patient with concurrent pathologies that can produce a similar clinical picture, a high index of suspicion must be maintained to achieve the correct diagnosis. The authors report a patient with intracranial hypotension in the setting of concurrent perineural cyst rupture and subarachnoid hemorrhage. A 63-year-old woman with a family history of ruptured intracranial aneurysms presented after a sudden thunderclap headache and was found to have diffuse subarachnoid hemorrhage. Imaging revealed anterior communicating and superior hypophyseal artery aneurysms. Following the uneventful clipping of both aneurysms, the patient experienced a delayed return to her neurological baseline. After it was noted that the patient had an improved neurological examination when she was placed supine, further investigation confirmed intracranial hypotension from perineural cyst rupture. The patient improved and returned to her neurological baseline after undergoing a high-volume blood patch and remained neurologically intact at postoperative follow-up. Although intracranial hypotension is known to be commonly associated with cerebrospinal fluid leak, its causal and temporal relationship with subarachnoid hemorrhage has yet to be elucidated.
Lorenzo, A V; Greene, C S; Hornig, G W; Zavala, L M; Welch, K
The hypothesis that intracranial hypotension due to excessive postnatal fluid loss places the premature infant at risk for germinal matrix and intraventricular hemorrhage (GM-IVH) was tested in preterm rabbits delivered at 28 and 29 days of gestation (term 32 days). Furosemide administered to newborn pups induced a diuresis that resulted in a 11% to 22% loss in body weight and a concomitant decline in muscle water (13% to 16%) and sodium (18% to 21%). Paradoxically, no change occurred in the water or electrolyte content of the brain even though cerebrospinal fluid and brain tissue pressure, but not blood pressure, declined. These changes were absent in littermates treated with saline. Microscopic examination of brain sections revealed a greater incidence of intracranial hemorrhage, particularly in the germinal matrix and choroid plexus, in furosemide-treated than in saline-treated preterm rabbit pups. These results are consistent with the hypothesis that intracranial hypotension promotes the incidence of GH-IVH in preterm animals.
Yasaka, Masahiro; Okada, Yasushi
Novel anticoagulants including dabigatran and rivaroxaban have lower incidence of intracranial hemorrhage compared to warfarin. Therefore, in patients with high risks for intracranial hemorrhage, such as past history of brain infarction, brain hemorrhage, microbleeds on MRI, or concomitant use of antiplatelet, novel anticoagulant may be appropriate. Irrespective of any anticoagulants, it is essential to manage controllable risk factors, such as hypertension, diabetes mellitus, smoking habit, and excessive alcohol drinking. Combination therapy of other antithrombotic agents had better be avoided as long as possible. In emergency of hemorrhage complications, discontinuation of anticoagulants, procedure to stop bleeding, and appropriate intravenous infusion is quite important and lowering blood pressure is also important when intracranial hemorrhage happens. There is no antidote to novel anticoagulants. However, oral activated charcoal may be effective if early after taking medicine. The dabigatran can be dialysed. Some experimental evidences support the role of prothrombin complex concentrate to stop bleeding. However, their usefulness in clinical setting has not been established. Collecting and analyzing data regarding immediate reversal of novel anticoagulants is required in near future.
Alexander, Matthew D.; Cooke, Daniel L.; Nelson, Jeffrey; Guo, Diana E.; Dowd, Christopher F.; Higashida, Randall T.; Halbach, Van V.; Lawton, Michael T.; Kim, Helen; Hetts, Steven W.
Background and Purpose Intracranial hemorrhage is the most serious outcome for brain arteriovenous malformations (AVM). This study examines associations between venous characteristics of these lesions and intracranial hemorrhage. Materials and Methods Statistical analysis was performed on a prospectively maintained database of brain AVMs evaluated at an academic medical center. DSA, CT, and MRI studies were evaluated to classify lesion side, drainage pattern, venous stenosis, number of draining veins, venous ectasia, and venous reflux. Logistic regression analyses were performed to identify association of these angiographic features with intracranial hemorrhage of any age at initial presentation. Results Exclusively deep drainage (OR 3.42, 95% CI 1.87–6.26, p<0.001) and a single draining vein (OR 1.98, 95% CI 1.26–3.08, p=0.002) were associated with hemorrhage, whereas venous ectasia (OR 0.52, 95% CI 0.34–0.78, p=0.002) was inversely associated with hemorrhage. Conclusion Analysis of venous characteristics of brain AVMs may help determine their prognosis and thereby identify lesions most appropriate for treatment. PMID:25634722
Kamiya, K; Kuyama, H; Symon, L
A baboon model of subarachnoid hemorrhage (SAH) has been developed to study the changes in cerebral blood flow (CBF), intracranial pressure (ICP), and cerebral edema associated with the acute stage of SAH. In this model, hemorrhage was caused by avulsion of the posterior communicating artery via a periorbital approach, with the orbit sealed and ICP restored to normal before SAH was produced. Local CBF was measured in six sites in the two hemispheres, and ICP monitored by an implanted extradural transducer. Following sacrifice of the animal, the effect of the induced SAH on ICP, CBF, autoregulation, and CO2 reactivity in the two hemispheres was assessed. Brain water measurements were also made in areas of gray and white matter corresponding to areas of blood flow measurements, and also in the deep nuclei. Two principal patterns of ICP change were found following SAH; one group of animals showed a return to baseline ICP quite quickly and the other maintained high ICP for over an hour. The CBF was reduced after SAH to nearly 20% of control values in all areas, and all areas showed impaired autoregulation. Variable changes in CO2 reactivity were evident, but on the side of the hemorrhage CO2 reactivity was predominantly reduced. Differential increase in pressure lasting for over 7 minutes was evident soon after SAH on the side of the ruptured vessel. There was a significant increase of water in all areas, and in cortex and deep nuclei as compared to control animals.
Matsuda, Ryosuke; Hironaka, Yasuo; Takeshima, Yasuhiro; Park, Young-Su; Nakase, Hiroyuki
The authors report the rare case of a 58-year-old man with segmental arterial mediolysis (SAM) with associated intracranial and intraabdominal aneurysms, who suffered subarachnoid hemorrhage (SAH) due to rupture of an intracranial aneurysm. This disease primarily involves the intraabdominal arterial system, resulting in intraabdominal and retroperitoneal hemorrhage in most cases. The patient presented with severe headache and vomiting. The CT scans of the head revealed SAH. Cerebral angiography revealed 3 aneurysms: 1 in the right distal anterior cerebral artery (ACA), 1 in the distal portion of the A(1) segment of the right ACA, and 1 in the left vertebral artery. The patient had a history of multiple intraabdominal aneurysms involving the splenic, gastroepiploic, gastroduodenal, and bilateral renal arteries. He underwent a right frontotemporal craniotomy and fibrin coating of the dissecting aneurysm in the distal portion of the A(1) segment of the right ACA, which was the cause of the hemorrhage. Follow-up revealed no significant changes in the residual intracranial and intraabdominal aneurysms. An SAH due to SAM with associated multiple intraabdominal aneurysms is extremely rare. The authors describe their particular case and review the literature pertaining to SAM with associated intracranial and intraabdominal aneurysms.
Dang, H.; Stayman, J. W.; Xu, J.; Sisniega, A.; Zbijewski, W.; Wang, X.; Foos, D. H.; Aygun, N.; Koliatsos, V. E.; Siewerdsen, J. H.
Prompt and reliable detection of acute intracranial hemorrhage (ICH) is critical to treatment of a number of neurological disorders. Cone-beam CT (CBCT) systems are potentially suitable for detecting ICH (contrast 40-80 HU, size down to 1 mm) at the point of care but face major challenges in image quality requirements. Statistical reconstruction demonstrates improved noise-resolution tradeoffs in CBCT head imaging, but its capability in improving image quality with respect to the task of ICH detection remains to be fully investigated. Moreover, statistical reconstruction typically exhibits nonuniform spatial resolution and noise characteristics, leading to spatially varying detectability of ICH for a conventional penalty. In this work, we propose a spatially varying penalty design that maximizes detectability of ICH at each location throughout the image. We leverage theoretical analysis of spatial resolution and noise for a penalized weighted least-squares (PWLS) estimator, and employ a task-based imaging performance descriptor in terms of detectability index using a nonprewhitening observer model. Performance prediction was validated using a 3D anthropomorphic head phantom. The proposed penalty achieved superior detectability throughout the head and improved detectability in regions adjacent to the skull base by ~10% compared to a conventional uniform penalty. PWLS reconstruction with the proposed penalty demonstrated excellent visualization of simulated ICH in different regions of the head and provides further support for development of dedicated CBCT head scanning at the point-of-care in the neuro ICU and OR.
McArdle, C B; Richardson, C J; Hayden, C K; Nicholas, D A; Crofford, M J; Amparo, E G
The authors prospectively evaluated 82 neonates, ranging in gestational age from 29 to 44 weeks postconception, with magnetic resonance (MR) imaging at 0.6 T. Twenty-two cases of hemorrhage in 15 infants were identified. Ultrasound (US) and computed tomography (CT) were superior to MR in the first few days after parenchymal hemorrhage, since at this time lesions were apparent on only T2-weighted images. After the first 3 days, MR was the single best modality because (a) hemorrhage on CT became imperceptible in the 2d week, whereas the high signal of hemorrhage on MR persisted for 2-11 weeks; (b) MR permitted rough dating of hemorrhage according to changes in signal intensity; and (c) MR was superior in identifying subdural or epidural hemorrhage. Because of the nonspecificity and restricted field of view of US and the inability of CT to depict hemorrhage after 7-10 days, the authors conclude that MR significantly improves the detection of intracranial hemorrhage in neonates.
ZHOU, JIANDA; LIU, JINYAN; LUO, CHENGQUN; HU, FENG; LIU, RUI; CHEN, ZIZI; CHEN, YAO; XIONG, WU; XIE, JIANFEI; HE, QUANYONG; YIN, CHAOQI; WANG, SHAOHUA; ZHANG, YANWEN; ZENG, SAINAN
The aim of this study was to explore the etiology and diagnosis of multiple intracranial hemorrhages (ICHs) following severe burns, with a retrospective review of 16 cases of severe burns further complicated by multiple ICHs. Using cranial CT scans of the brains, we identified that all patients presented with low platelet counts and coagulation abnormalities prior to intracranial hemorrhaging. Following conventional treatment and various supporting treatments, five cases succumbed following a progressive reduction in blood platelet levels and the ICHs were cured in 11 cases following the restoration of normal platelet levels. We conclude that low platelet counts and coagulation abnormalities may cause multiple ICHs following severe burns and early diagnosis and treatment is the key to successful treatment. PMID:23935750
Zaki, W. Mimi Diyana W.; Fauzi, M. Faizal A.; Besar, Rosli
We investigate the use of a new binary coherent vector approach, integrated in a proposed content-based medical retrieval (CBMIR) system, to retrieve computed tomography (CT) brain images. Five types of hemorrhages consisting of 150 plain axial CT brain images are queried from a database of 2500 normal and abnormal CT brain images. Possible combinations of shape features are portrayed as feature vectors and are evaluated based on precision-recall plots. Solidity, form factor, equivalent circular diameter (ECD), and Hu moment are proposed as identifying features of intracranial hemorrhages in CT brain images. In addition to identifying hemorrhages, the proposed approach significantly improves the CBMIR system performance. This retrieval system can be widely useful due to rapid development in computer vision and computer database management, both of which motivated this application of CBMIR.
Filipce, Venko; Caparoski, Aleksandar
Vasospasm and re-bleeding after subarachnoid hemorrhage from ruptured intracranial aneurysm are devastating complication that can severely affect the outcome of the patients. We are presenting a series of total number of 224 patients treated and operated at our Department due to subarachnoid hemorrhage, out of which certain number developed vasospasm and re-bleeding. We are evaluating the effect of these complications on the outcome of the patients according to the Glasgow Outcome Scale at the day of discharge. In our experience both vasospasm and ReSAH can significantly influence the outcome of patients with subarachnoid hemorrhage from ruptured intracranial aneurysm.
Naranjo, Daniel; Arkuszewski, Michal; Rudzinski, Wojciech; Melhem, Elias R.; Krejza, Jaroslaw
Summary Patients with intracranial hemorrhage have to be managed aggressively to avoid or minimize secondary brain damage due to ischemia, which contributes to high morbidity and mortality. The risk of brain ischemia, however, is not the same in every patient. The risk of complications associated with an aggressive prophylactic therapy in patients with a low risk of brain ischemia can outweigh the benefits of therapy. Accurate and timely identification of patients at highest risk is a diagnostic challenge. Despite the availability of many diagnostic tools, stroke is common in this population, mostly because the pathogenesis of stroke is frequently multifactorial whereas diagnosticians tend to focus on one or two risk factors. The pathophysiological mechanisms of brain ischemia in patients with intracranial hemorrhage are not yet fully elucidated and there are several important areas of ongoing research. Therefore, this review describes physiological and pathophysiological aspects associated with the development of brain ischemia such as the mechanism of oxygen and carbon dioxide effects on the cerebrovascular system, neurovascular coupling and respiratory and cardiovascular factors influencing cerebral hemodynamics. Consequently, we review investigations of cerebral blood flow disturbances relevant to various hemodynamic states associated with high intracranial pressure, cerebral embolism, and cerebral vasospasm along with current treatment options. PMID:24355179
Zhou, James; Agarwal, Nitin; Hamilton, D Kojo; Koltz, Michael T
The study of intracranial aneurysms has grown at an astounding rate since Sir Charles Symond's association of hemorrhage within the subarachnoid space to intracranial aneurysms in 1923. These associations led to the first surgical treatment of an intracranial aneurysm with wrapping by Norman Dott in 1931, and shortly thereafter, clip ligation by Walter Dandy in 1938. Surgical outcomes were improved by the introduction of the operative microscope in the 1960s and perioperative care utilizing induced hypertension, hypovolemia, and hemodilution ("HHH therapy"). Recent monumental advancements, such as coil embolization in 1990 by Guglielmi, have continued to advance the field forward. The authors hope to highlight some of the most seminal and influential works. Herein, we utilize the technique of citation analysis to assemble a list of the 100 most influential works pertaining to aneurysmal subarachnoid hemorrhage published between the years 1900 and 2015 to honor these individuals and to provide guidance to current and future researchers in the field. We additionally calculate the effects of author, journal, topic, and study design on the overall influence of publications in this field.
Ma, Xiaoyue; Bai, Yan; Lin, Yusong; Hong, Xiaohua; Liu, Taiyuan; Ma, Lun; Haacke, E Mark; Zhou, Jinyuan; Wang, Jian; Wang, Meiyun
Amide proton transfer (APT) imaging is a noninvasive molecular magnetic resonance imaging (MRI) technique based on the chemical exchange-dependent saturation transfer mechanism. The purpose of this study was to investigate the diagnostic performance of APT MRI in detecting intracranial hemorrhage (ICH) at hyperacute, acute and subacute stages by comparing with susceptibility weighted imaging (SWI). APT MRI and SWI were performed on 33 included patients with ICH by using a 3-T MRI unit. A two-sided Mann-Whitney U test was used to detect differences in APT-weighted (APTw) and SWI signal intensities of ICH at hyperacute, acute and subacute stages. Receiver operating characteristic analysis was used to assess the diagnostic utilities of APT MRI and SWI. Our results showed that APT MRI could detect ICH at hyperacute, acute and subacute stages. Therefore, APTw signal intensity may serve as a reliable, noninvasive imaging biomarker for detecting ICH at hyperacute, acute and subacute stages. Moreover, APT MRI could provide additional information for the ICH compared with SWI. PMID:28374764
Bonow, Robert H; Bales, James W; Morton, Ryan P; Levitt, Michael R; Zhang, Fangyi
Intracranial hypotension is a rare condition caused by spontaneous or iatrogenic CSF leaks that alter normal CSF dynamics. Symptoms range from mild headaches to transtentorial herniation, coma, and death. Duret hemorrhages have been reported to occur in some patients with this condition and are traditionally believed to be associated with a poor neurological outcome. A 73-year-old man with a remote history of spinal fusion presented with syncope and was found to have small subdural hematomas on head CT studies. He was managed nonoperatively and discharged with a Glasgow Coma Scale score of 15, only to return 3 days later with obtundation, fixed downward gaze, anisocoria, and absent cranial nerve reflexes. A CT scan showed Duret hemorrhages and subtle enlargement of the subdural hematomas, though the hematomas remained too small to account for his poor clinical condition. Magnetic resonance imaging of the spine revealed a large lumbar pseudomeningocele in the area of prior fusion. His condition dramatically improved when he was placed in the Trendelenburg position and underwent repair of the pseudomeningocele. He was kept flat for 7 days and was ultimately discharged in good condition. On long-term follow-up, his only identifiable deficit was diplopia due to an internuclear ophthalmoplegia. Intracranial hypotension is a rare condition that can cause profound morbidity, including tonsillar herniation and brainstem hemorrhage. With proper identification and treatment of the CSF leak, patients can make functional recoveries.
Maitreyi, R. S.; Dar, L.; Muthukumar, A.; Vajpayee, M.; Xess, I.; Vajpayee, R. B.; Seth, P.; Broor, S.
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
Growing skull fracture is an extremely rare complication of pediatric head injury, especially in infants. Repair of the dural tear early in the course of development of growing skull fracture has been suggested for a better outcome. Surgical repair of large, tense growing skull fractures, especially those in the communication of the ventricles can lead to potentially life-threatening complications. The author reports a rare case of remote intracranial hemorrhage following surgery for large, tense growing skull fracture in a 12-year-old girl and discusses the likely pathogenesis and possible ways to avoid this life-threatening complication.
Prigatano, George P; Matthes, Jessica; Hill, Stacy W; Wolf, Thomas R; Heiserman, Joseph E
A 51-year-old woman presented with anosognosia for hemiplegia (AHP), neglect, and a complete loss of vision, for which she was almost immediately aware. Neuroimaging studies revealed intracranial hemorrhages in the medial temporal lobes bilaterally, extending back to the occipital cortex, but sparing the calcarine cortex. A large right frontal-parietal hemorrhage which extended to the posterior body of the corpus callosum was also observed. The patient's vision slowly improved, and by 11 months post onset, formal visual fields revealed improvement primarily in the left upper quadrants only. In contrast, resolution of her AHP occurred between the 26th and 31st day post onset. Awareness of motor impairment was correlated with her ability to initiate finger tapping in her left hemiplegic/paretic hand. During the time she was unaware of her motor deficits but aware of her visual impairments, her dreams did not reflect concerns over visual or motor limitations. The findings support a "modular" theory of anosognosia.
Kandzari, David E; Granger, Christopher B; Simoons, Maarten L; White, Harvey D; Simes, John; Mahaffey, Kenneth W; Gore, Joel; Weaver, W Douglas; Longstreth, William T; Stebbins, Amanda; Lee, Kerry L; Califf, Robert M; Topol, Eric J
Of 592 patients in the Global Utilization of Streptokinase and tPA for Occluded Arteries-I trial who had a stroke during initial hospitalization, the risk for intracranial hemorrhage was significantly greater in those with recent facial or head trauma (odds ratio 13.0, 95% confidence interval 3.4 to 85.5); dementia was additionally associated with an increased risk for intracranial hemorrhage (odds ratio 3.4, 95% confidence interval 1.2 to 10.2). Because facial or head trauma may greatly influence treatment decisions, this risk factor should be incorporated into models designed to estimate the risks and benefits of fibrinolytic therapy.
Lévêque, N; Huguet, P; Norder, H; Chomel, J-J
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.
Leigh, Richard; Jen, Shyian S.; Hillis, Argye E.; Krakauer, John W.; Barker, Peter B.
Background and Purpose Early blood brain barrier (BBB) damage after acute ischemic stroke (AIS) has previously been qualitatively linked to subsequent intracranial hemorrhage (ICH). In this quantitative study, it was investigated whether the amount of BBB damage evident on pre-tPA MRI scans was related to the degree of post-tPA ICH in patients with AIS. Methods Analysis was performed on a database of patients with AIS provided by the STIR and VISTA Imaging Investigators. Patients with perfusion-weighted imaging (PWI) lesions >10mL and negative gradient-recalled echo (GRE) imaging prior to IV tPA were included. Post processing of the PWI source images was performed to estimate changes in BBB permeability within the perfusion deficit relative to the unaffected hemisphere. Follow-up GRE images were reviewed for evidence of ICH and divided into three groups according to ECASS criteria: no hemorrhage (NH), hemorrhagic infarction (HI), and parenchymal hematoma (PH). Results 75 patients from the database met the inclusion criteria, 28 of whom experienced ICH, of which 19 were classified as HI, and nine were classified as PH. The mean permeability (±standard deviations), expressed as an index of contrast leakage, was 17.0%±8.8 in the NH group, 19.4%±4.0 in the HI group, and 24.6%±4.5 in the PH group. Permeability was significantly correlated with ICH grade in univariate (p=0.007) and multivariate (p=0.008) linear regression modeling. Conclusions A PWI-derived index of BBB damage measured prior to IV tPA is associated with the severity of ICH after treatment in patients with AIS. PMID:24876245
Pavlov, A. N.; Semyachkina-Glushkovskaya, O. V.; Lychagov, V. V.; Bibikova, O. A.; Sindeev, S. S.; Pavlova, O. N.; Shuvalova, E. P.; Tuchin, V. V.
Using Doppler optical coherence tomography (DOCT) we study stress-related intracranial hemorrhages (ICHs) in newborn rats. We investigate a masked stage of ICH development that corresponds to the first 4 h after the stress. We show that this period is characterized by significant changes in the diameter of the sagittal vein and the velocity of the cerebral venous blood flow (CVBF). We discuss diagnostic abilities of wavelet-based methods and consider an adaptive technique allowing us to reveal clearest distinctions in the dynamics of CVBF between normal and stressed newborn rats. Finally, we conclude that the venous insufficiency in newborns and a reduced response of the sagittal vein to adrenaline are related to important prognostic markers of the risk of ICH development.
Kyogoku, T; Manabe, T; Tobe, T
Ischemia has been considered to play a role in the development of acute pancreatitis. The aim of this study was to investigate the effect of ischemia, caused by hemorrhagic shock, on cerulein-induced acute pancreatitis in rats. Acute pancreatitis was induced by the intravenous infusion of a supramaximally stimulating dose of cerulein (10 micrograms/kg/hr) for 6 hr. Hemorrhagic shock was induced by the removal of blood until the mean arterial blood pressure reached 35 mm Hg. This level was maintained for 30 min, after which time all the blood was reinfused. Hemorrhagic shock alone induced no morphological change in the pancreas. However, after the induction of hemorrhagic shock in animals treated with cerulein, hemorrhage and parenchymal necrosis were frequently observed in the pancreas. Seven of 20 rats (35%) receiving cerulein plus hemorrhagic shock had died by 48 hr after the start of cerulein infusion, whereas none of the rats in the cerulein or shock group died during this experiment. Cathepsin B activity in the pancreas of the cerulein plus shock group was significantly higher than in the other groups at 48 hr. These results suggest that ischemia may be a contributing factor in the pathogenesis of acute pancreatitis.
Betjes, M G; Koopmans, R P
Hyponatraemia is a frequent finding in the course of an acute intracranial disease, especially after a subarachnoid haemorrhage. The fall in plasma sodium concentration is usually mild and not below 124 mmol/l but may reach dangerously low levels with serious neurological complications. In the early 1950s the cause of the hyponatraemia was believed to be primarily excessive natriuresis and therefore named 'cerebral salt wasting'. After the description of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) this was favoured as the most likely explanation. Only in recent years has it become evident that many hyponatraemic patients with acute brain disease are actually hypovolaemic. This is compatible with the original diagnosis of cerebral salt wasting. The increased plasma concentrations of natriuretic peptides are likely to mediate the increased natriuresis. Cerebral salt wasting can be treated with a simple regimen of water and salt suppletion. If needed a mineralocorticoid like fludrocortisone can be given to increase renal tubular sodium reabsorption.
In acute vitreal hemorrhage, echography is the method of choice for evaluation of the vitreous body. Echography ist capable of providing information on the localization, the density, and the mobility, and in certain diseases, also on the cause of the hemorrhage. The echographic findings (standardized echography) recorded in 216 patients with acute vitreal hemorrhage examined within 14 months (Jan. 1988 to Feb. 1989) were evaluated. In 91 patients (42%) diabetic retinopathy was known: in such cases echography can disclose proliferative changes and traction-detachment of the retina. In 58 patients (27%) echography revealed a posterior vitreous detachment, while in 17 patients (8%) an additional retinal detachment was found. In 39 patients (18%) a degenerative, disciform lesion of the macula was revealed as the cause of the hemorrhage, in 5 patients (2%) a malignant melanoma of the choroid, and in 2 patients a (large) retinal tear. In 5 patients, apart from the vitreous opacities no changes in the posterior segment could be found.
Lescher, Stephanie Czeppan, Katja; Porto, Luciana; Singer, Oliver C.; Berkefeld, Joachim
PurposeDue to high thrombus load, acute stroke patients with tandem obstructions of the extra- and intracranial carotid arteries or the middle cerebral artery show a very limited response to systemic thrombolysis. Interventional treatment with mechanical thrombectomy—often in combination with acute stenting of underlying atherosclerotic stenosis or dissection—is increasingly used. It has been shown that such complex interventions are technically feasible. The lack of optimal management strategies and clinical data encouraged us to review our acute stroke interventions in patient with anterior circulation tandem lesions to determine lesion patterns, interventional approaches, and angiographic or clinical outcomes.Patients and MethodsWe retrospectively analyzed a series of 39 consecutive patients with intracranial vessel occlusion of the anterior circulation simultaneously presenting with high-grade cervical internal carotid artery (ICA) stenosis or occlusion.ResultsEmergency ICA stent implantation was technically feasible in all patients, and intracranial recanalization with TICI ≥ 2b was reached in a large number of patients (64 %). Good clinical outcomes (mRS ≤ 2 at 3 months) were achieved in one third of the patients (36 %). Symptomatic hemorrhages occurred in four patients (10 %). Mortality was 10 %.ConclusionEndovascular recanalization of acute cervical carotid artery occlusion was technically feasible in all patients, and resulted in high extra- and intracranial revascularization rates. A trend for favorable clinical outcome was seen in a higher TICI score, younger age, good collateral status, and combined IV rTPA and endovascular therapy.
Wang, Hong Liang; Xu, Chun Yang; Wang, Hong Hui; Xu, Wei
The aims of this study were to identify arteriographic manifestations of acute renal hemorrhage and to evaluate the efficacy of emergency embolization. Emergency renal artery angiography was performed on 83 patients with acute renal hemorrhage. As soon as bleeding arteries were identified, emergency embolization was performed using gelatin sponge, polyvinyl alcohol particles, and coils. The arteriographic presentation and the effect of the treatment for acute renal hemorrhage were analyzed retrospectively. Contrast extravasation was observed in 41 patients. Renal arteriovenous fistulas were found in 12 of the 41 patients. In all, 8 other patients had a renal pseudoaneurysm, 5 had pseudoaneurysm rupture complicated by a renal arteriovenous fistula, and 1 had pseudoaneurysm rupture complicated by a renal artery-calyceal fistula. Another 16 patients had tumor vasculature seen on arteriography. Before the procedure, 35 patients underwent renal artery computed tomography angiography (CTA). Following emergency embolization, complete hemostasis was achieved in 80 patients, although persistent hematuria was present in 3 renal trauma patients and 1 patient who had undergone percutaneous nephrolithotomy (justifying surgical removal of the ipsilateral kidney in this patient). Two-year follow-up revealed an overall effective rate of 95.18 % (79/83) for emergency embolization. There were no serious complications. Emergency embolization is a safe, effective, minimally invasive treatment for renal hemorrhage. Because of the diversified arteriographic presentation of acute renal hemorrhage, proper selection of the embolic agent is a key to successful hemostasis. Preoperative renal CTA plays an important role in diagnosing and localizing the bleeding artery.
Wang, Hong Liang; Xu, Chun Yang; Wang, Hong Hui; Xu, Wei
Abstract The aims of this study were to identify arteriographic manifestations of acute renal hemorrhage and to evaluate the efficacy of emergency embolization. Emergency renal artery angiography was performed on 83 patients with acute renal hemorrhage. As soon as bleeding arteries were identified, emergency embolization was performed using gelatin sponge, polyvinyl alcohol particles, and coils. The arteriographic presentation and the effect of the treatment for acute renal hemorrhage were analyzed retrospectively. Contrast extravasation was observed in 41 patients. Renal arteriovenous fistulas were found in 12 of the 41 patients. In all, 8 other patients had a renal pseudoaneurysm, 5 had pseudoaneurysm rupture complicated by a renal arteriovenous fistula, and 1 had pseudoaneurysm rupture complicated by a renal artery-calyceal fistula. Another 16 patients had tumor vasculature seen on arteriography. Before the procedure, 35 patients underwent renal artery computed tomography angiography (CTA). Following emergency embolization, complete hemostasis was achieved in 80 patients, although persistent hematuria was present in 3 renal trauma patients and 1 patient who had undergone percutaneous nephrolithotomy (justifying surgical removal of the ipsilateral kidney in this patient). Two-year follow-up revealed an overall effective rate of 95.18 % (79/83) for emergency embolization. There were no serious complications. Emergency embolization is a safe, effective, minimally invasive treatment for renal hemorrhage. Because of the diversified arteriographic presentation of acute renal hemorrhage, proper selection of the embolic agent is a key to successful hemostasis. Preoperative renal CTA plays an important role in diagnosing and localizing the bleeding artery. PMID:26496273
Dang, H.; Stayman, J. W.; Xu, J.; Sisniega, A.; Zbijewski, W.; Wang, X.; Foos, D. H.; Aygun, N.; Koliatsos, V. E.; Siewerdsen, J. H.
Intracranial hemorrhage (ICH) is associated with pathologies such as hemorrhagic stroke and traumatic brain injury. Multi-detector CT is the current front-line imaging modality for detecting ICH (fresh blood contrast 40-80 HU, down to 1 mm). Flat-panel detector (FPD) cone-beam CT (CBCT) offers a potential alternative with a smaller scanner footprint, greater portability, and lower cost potentially well suited to deployment at the point of care outside standard diagnostic radiology and emergency room settings. Previous studies have suggested reliable detection of ICH down to 3 mm in CBCT using high-fidelity artifact correction and penalized weighted least-squared (PWLS) image reconstruction with a post-artifact-correction noise model. However, ICH reconstructed by traditional image regularization exhibits nonuniform spatial resolution and noise due to interaction between the statistical weights and regularization, which potentially degrades the detectability of ICH. In this work, we propose three regularization methods designed to overcome these challenges. The first two compute spatially varying certainty for uniform spatial resolution and noise, respectively. The third computes spatially varying regularization strength to achieve uniform "detectability," combining both spatial resolution and noise in a manner analogous to a delta-function detection task. Experiments were conducted on a CBCT test-bench, and image quality was evaluated for simulated ICH in different regions of an anthropomorphic head. The first two methods improved the uniformity in spatial resolution and noise compared to traditional regularization. The third exhibited the highest uniformity in detectability among all methods and best overall image quality. The proposed regularization provides a valuable means to achieve uniform image quality in CBCT of ICH and is being incorporated in a CBCT prototype for ICH imaging.
Rouchaud, Aymeric; Brinjikji, Waleed; Lanzino, Giuseppe; Cloft, Harry J.; Kadirvel, Ramanthan; Kallmes, David F.
Background Delayed aneurysm rupture and delayed intraparenchymal hemorrhages (DIPH) are poorly understood and often fatal complications of flow diversion (FD) for intracranial aneurysms. The purpose of this study was to identify risk factors for these complications. Materials and Methods We performed a systematic review on post-FD delayed aneurysm rupture and DIPH. For each reported case we collected the following information: aneurysm location, size and rupture status, type of flow-diverter used, timing of the hemorrhage, and neurological outcome. We reported descriptive statistics of patients suffering DIPH and delayed aneurysm rupture to determine if there were any characteristics consistently present among patients with these complications. Results We identified 81 delayed aneurysms ruptures and 101 DIPH. 76.6% (45/58) of the delayed ruptures occurred within one month. The prognosis of delayed ruptures was poor, with 81.3% (61/75) experiencing death or poor neurological outcome. Giant aneurysms accounted for 46.3% of ruptures (31/67). 80.9% (55/68) of these aneurysms were initially unruptured. 17.8% (13/73) of the delayed ruptured aneurysms had prior or concomitant coiling. DIPHs were ipsilateral to the treated aneurysm in 82.2% (60/73) of cases. 86.0% (43/50) of the DIPH occurred within one month after FDS. Combined morbidity/mortality rate was 68.5% (50/73 following DIPH. 23.0% of DIPHs (14/61) occurred in patients with giant aneurysms. Conclusions Our study demonstrates that giant aneurysms represent almost 50% of delayed aneurysm ruptures in the flow-diverter literature. About 20% of delayed ruptures occurred despite associated coiling. A substantial proportion of DIPHs occur early following FDS treatment of giant aneurysms. PMID:26553302
Chaidemenos, George C; Mourellou, Olga; Karakatsanis, George; Koussidou, Thallia; Xenidis, Efthimios; Charalampidou, Haroula; Avgoloupis, Dimitris
We report a peculiar case of hemorrhagic pellagra in an exhausted Albanian refugee who had walked for 3 days under sunny skies on his way from his country to Greece. The peculiarities of the case are the fulminant course of the disorder; the "terrifying" appearance of the patient (initially he was admitted to an emergency unit); the gangrenous appearance of the hemorrhagic lesions of the palms and fingernails; the disturbed hepatic function that gradually returned to normal; and the absence of a history of alcohol consumption, alcohol malabsorption, or drug intake.
Jiao, Xiaoyang; He, Ping; Li, Yazhen; Fan, Zhicheng; Si, Mengya; Xie, Qingdong; Chang, Xiaolan; Huang, Dongyang
Brain injury after intracranial hemorrhage (ICH) results in significant morbidity and mortality. Blood brain barrier (BBB) disruption is a hallmark of ICH-induced brain injury; however, data mirroring BBB disruption in human ICH are scarce. The aim of this study was to assess the significance of circulating biomarkers in evaluating BBB disruption after ICH. Twenty-two patients with ICH were recruited in this study. Concentrations of the tight junction proteins (TJs) Claudin-5 (CLDN5), Occludin (OCLN), and zonula occludens 1 (ZO-1) and vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 (MMP-9) were measured by using enzyme-linked immunosorbent assay in serum and cerebrospinal fluid (CSF) samples obtained from patients with ICH. The white blood cell (WBC) count in blood and CSF, albumin (ALB) levels in the CSF (ALBCSF), and the BBB ratio were significantly higher in the ICH than in controls (p < 0.05). Significantly higher levels of CLDN5, OCLN, ZO-1, MMP-9, and VEGF in CSF were observed in the ICH group; these biomarkers were also positively associated with BBB ratio (p < 0.05). Our data revealed that circulating TJs could be considered the potential biomarkers reflecting the integrity of the BBB in ICH.
Jiao, Xiaoyang; He, Ping; Li, Yazhen; Fan, Zhicheng; Si, Mengya; Xie, Qingdong; Chang, Xiaolan; Huang, Dongyang
Brain injury after intracranial hemorrhage (ICH) results in significant morbidity and mortality. Blood brain barrier (BBB) disruption is a hallmark of ICH-induced brain injury; however, data mirroring BBB disruption in human ICH are scarce. The aim of this study was to assess the significance of circulating biomarkers in evaluating BBB disruption after ICH. Twenty-two patients with ICH were recruited in this study. Concentrations of the tight junction proteins (TJs) Claudin-5 (CLDN5), Occludin (OCLN), and zonula occludens 1 (ZO-1) and vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 (MMP-9) were measured by using enzyme-linked immunosorbent assay in serum and cerebrospinal fluid (CSF) samples obtained from patients with ICH. The white blood cell (WBC) count in blood and CSF, albumin (ALB) levels in the CSF (ALBCSF), and the BBB ratio were significantly higher in the ICH than in controls (p < 0.05). Significantly higher levels of CLDN5, OCLN, ZO-1, MMP-9, and VEGF in CSF were observed in the ICH group; these biomarkers were also positively associated with BBB ratio (p < 0.05). Our data revealed that circulating TJs could be considered the potential biomarkers reflecting the integrity of the BBB in ICH. PMID:26586924
Hankey, Graeme J
Intracranial hemorrhage (ICH) affects 0.2-0.5 % of atrial fibrillation (AF) patients taking a novel oral anticoagulant (NOAC) each year. About two thirds of ICHs are intracerebral and one quarter subdural. The 30-day case fatality of NOAC-associated ICH was similar to that of warfarin-associated ICH in two trials. Consistent predictors of ICH are increasing age, a history of prior stroke or TIA, and concomitant use of an antiplatelet drug. Compared to warfarin, the NOACs significantly reduce the risk of ICH by half (risk ratio = 0.44; 95 % CI: 0.37 to 0.51). Compared to aspirin, apixaban has a similar risk of ICH (risk ratio = 0.84; 95 % CI, 0.38 to 1.87). Current treatments for NOAC-associated ICH include nonactivated and activated prothrombin complex concentrate, which reverse the anticoagulant effects of the NOACs, but their effects on bleeding and patient outcome are not known. Future treatments for NOAC-associated ICH promise to include specific antidotes to dabigatran (e.g., aDabi-Fab, PER977) and factor Xa inhibitors (e.g., r-Antidote PRT064445, PER977).
Carrasco, Rodrigo; Pascual, José M.; Medina-López, Diego; Burdaspal-Moratilla, Ana
Background: Acute neurological deterioration and death in a patient harboring a colloid cyst of the third ventricle remains a poorly understood phenomenon. Sudden neurological derangement caused by spontaneous bleeding within a colloid cyst is a rare and potentially fatal event, usually requiring immediate diagnosis and emergency surgical treatment. Case Description: A 47-year-old male presented with acute right-sided hemiparesis and speech impediment, followed by rapid deterioration of consciousness. Neuroimaging studies showed a rounded mass at the roof of the anterior third ventricle, causing biventricular hydrocephalus along with a left-sided basal ganglia hematoma. The lesion showed scattered foci of a recent hemorrhage which extended into the left lateral ventricle. Surgical treatment involved emergency external ventricular drainage followed by the prompt elective total resection of the lesion via a transcallosal route. Pathological findings confirmed the diagnosis of a colloid cyst with focal areas of vascular congestion and blood extravasation within its wall. Conclusions: Spontaneous bleeding into a colloid cyst of the third ventricle may cause acute obstructive hydrocephalus and intracranial hypertension due to rapid enlargement of the lesion. This event may account for the sudden neurological deterioration and/or death observed in a previously asymptomatic patient. The diagnosis of hemorrhagic phenomena within a colloid cyst represents a challenge due to the variable signal usually displayed by these lesions on computed tomography (CT) and magnetic resonance imaging (MRI). Emergency ventricular drainage followed by elective tumoral removal constitutes a valid and safe treatment strategy. PMID:22439115
Schafer, Sebastian; Wang, Adam; Otake, Yoshito; Stayman, J. W.; Zbijewski, Wojciech; Kleinszig, Gerhard; Xia, Xuewei; Gallia, Gary L.; Siewerdsen, Jeffrey H.
Intraoperative imaging could improve patient safety and quality assurance (QA) via the detection of subtle complications that might otherwise only be found hours after surgery. Such capability could therefore reduce morbidity and the need for additional intervention. Among the severe adverse events that could be more quickly detected by high-quality intraoperative imaging is acute intracranial hemorrhage (ICH), conventionally assessed using post-operative CT. A mobile C-arm capable of high-quality cone-beam CT (CBCT) in combination with advanced image reconstruction techniques is reported as a means of detecting ICH in the operating room. The system employs an isocentric C-arm with a flat-panel detector in dual gain mode, correction of x-ray scatter and beam-hardening, and a penalized likelihood (PL) iterative reconstruction method. Performance in ICH detection was investigated using a quantitative phantom focusing on (non-contrast-enhanced) blood-brain contrast, an anthropomorphic head phantom, and a porcine model with injection of fresh blood bolus. The visibility of ICH was characterized in terms of contrast-to-noise ratio (CNR) and qualitative evaluation of images by a neurosurgeon. Across a range of size and contrast of the ICH as well as radiation dose from the CBCT scan, the CNR was found to increase from ~2.2-3.7 for conventional filtered backprojection (FBP) to ~3.9-5.4 for PL at equivalent spatial resolution. The porcine model demonstrated superior ICH detectability for PL. The results support the role of high-quality mobile C-arm CBCT employing advanced reconstruction algorithms for detecting subtle complications in the operating room at lower radiation dose and lower cost than intraoperative CT scanners and/or fixedroom C-arms. Such capability could present a potentially valuable aid to patient safety and QA.
Hughes, Adrienne; Brown, Alisha; Valento, Matthew
Baking soda is a readily available household product composed of sodium bicarbonate. It can be used as a home remedy to treat dyspepsia. If used in excessive amounts, baking soda has the potential to cause a variety of serious metabolic abnormalities. We believe this is the first reported case of hemorrhagic encephalopathy induced by baking soda ingestion. Healthcare providers should be aware of the dangers of baking soda misuse and the associated adverse effects.
Hughes, Adrienne; Brown, Alisha; Valento, Matthew
Baking soda is a readily available household product composed of sodium bicarbonate. It can be used as a home remedy to treat dyspepsia. If used in excessive amounts, baking soda has the potential to cause a variety of serious metabolic abnormalities. We believe this is the first reported case of hemorrhagic encephalopathy induced by baking soda ingestion. Healthcare providers should be aware of the dangers of baking soda misuse and the associated adverse effects. PMID:27625729
Nadarajah, Jeyaseelan; Madhusudhan, Kumble Seetharama; Yadav, Ajay Kumar; Gupta, Arun Kumar; Vikram, Naval Kumar
Dengue is a common viral infection worldwide with presentation varying from clinically silent infection to dengue fever, dengue hemorrhagic fever, and severe fulminant dengue shock syndrome. Neurological manifestation usually results from multisystem dysfunction secondary to vascular leak. Presentation as hemorrhagic encephalitis is very rare. Here we present the case of a 13-year-old female admitted with generalized tonic clonic seizures. Plain computed tomography (CT) scan of head revealed hypodensities in bilateral deep gray matter nuclei and right posterior parietal lobe without any hemorrhage. Cerebrospinal fluid (CSF) and serology were positive for IgM and IgG antibodies to dengue viral antigen. Contrast-enhanced magnetic resonance imaging (MRI) revealed multifocal T2 and fluid attenuated inversion recovery (FLAIR) hyperintensities in bilateral cerebral parenchyma including basal ganglia. No hemorrhage was seen. She was managed with steroids. As her clinical condition deteriorated, after being stable for 2 days, repeat MRI was done which revealed development of hemorrhage within the lesions, and diagnosis of acute hemorrhagic encephalitis of dengue viral etiology was made. PMID:25709166
Nadarajah, Jeyaseelan; Madhusudhan, Kumble Seetharama; Yadav, Ajay Kumar; Gupta, Arun Kumar; Vikram, Naval Kumar
Dengue is a common viral infection worldwide with presentation varying from clinically silent infection to dengue fever, dengue hemorrhagic fever, and severe fulminant dengue shock syndrome. Neurological manifestation usually results from multisystem dysfunction secondary to vascular leak. Presentation as hemorrhagic encephalitis is very rare. Here we present the case of a 13-year-old female admitted with generalized tonic clonic seizures. Plain computed tomography (CT) scan of head revealed hypodensities in bilateral deep gray matter nuclei and right posterior parietal lobe without any hemorrhage. Cerebrospinal fluid (CSF) and serology were positive for IgM and IgG antibodies to dengue viral antigen. Contrast-enhanced magnetic resonance imaging (MRI) revealed multifocal T2 and fluid attenuated inversion recovery (FLAIR) hyperintensities in bilateral cerebral parenchyma including basal ganglia. No hemorrhage was seen. She was managed with steroids. As her clinical condition deteriorated, after being stable for 2 days, repeat MRI was done which revealed development of hemorrhage within the lesions, and diagnosis of acute hemorrhagic encephalitis of dengue viral etiology was made.
Objectives The first non-vitamin K antagonist oral anticoagulant (NOAC) introduced to the market in Japan was dabigatran in March 2011, and three more NOACs, rivaroxaban, apixaban, and edoxaban, have since become available. Randomized controlled trials of NOACs have revealed that intracranial hemorrhage (ICH) occurs less frequently with NOACs compared with warfarin. However, the absolute incidence of ICH associated with NOACs has increased with greater use of these anticoagulants, and we wanted to explore the incidence, clinical characteristics, and treatment course of patients with NOACs-associated ICH. Methods We retrospectively analyzed the characteristics of symptomatic ICH patients receiving NOACs between March 2011 and September 2014. Results ICH occurred in 6 patients (5 men, 1 woman; mean ± SD age, 72.8 ± 3.2 years). Mean time to onset was 146.2 ± 111.5 days after starting NOACs. Five patients received rivaroxaban and 1 patient received apixaban. None received dabigatran or edoxaban. Notably, no hematoma expansion was observed within 24 h of onset in the absence of infusion of fresh frozen plasma, activated prothrombin complex concentrate, recombinant activated factor VIIa or hemodialysis. When NOAC therapy was initiated, mean HAS-BLED and PANWARDS scores were 1.5 ± 0.5 and 39.5 ± 7.7, respectively. Mean systolic blood pressure was 137.8 ± 15.9 mmHg within 1 month before spontaneous ICH onset. Conclusion Six symptomatic ICHs occurred early in NOAC therapy but hematoma volume was small and did not expand in the absence of infusion of reversal agents or hemodialysis. The occurrence of ICH during NOAC therapy is possible even when there is acceptable mean systolic blood pressure control (137.8 ± 15.9 mmHg) and HAS-BLED score ≤ 2. Even stricter blood pressure lowering and control within the acceptable range may be advisable to prevent ICH during NOAC therapy. PMID:26171862
Weeks, Dianne; Sullivan, Sarah; Kilbaugh, Todd; Smith, Colin; Margulies, Susan S
This study investigated the age-dependent injury response of diffuse traumatic axonal injury (TAI) and regional subdural and subarachnoid intracranial hemorrhage (ICH) in two pediatric age groups using a porcine head injury model. Fifty-five 5-day-old and 40 four-week-old piglets-which developmentally correspond to infants and toddlers, respectively-underwent either a sham injury or a single rapid non-impact rotational injury in the sagittal plane and were grouped by post-TBI survival time (sham, 3-8 h, one day, 3-4 days, and 5-6 days). Both age groups exhibited similar initial levels of ICH and a significant reduction of ICH over time (p<0.0001). However, ICH took longer to resolve in the five-day-old age group. At 5-6 days post-injury, ICH in the cerebrum had returned to sham levels in the four-week-old piglets, while the five-day-olds still had significantly elevated cerebral ICH (p=0.012). Both ages also exhibited similar resolution of axonal injury with a peak in TAI at one day post-injury (p<0.03) and significantly elevated levels even at 5-6 days after the injury (p<0.008), which suggests a window of vulnerability to a second insult at one day post-injury that may extend for a prolonged period of time. However, five-day-old piglets had significantly more TAI than four-week-olds overall (p=0.016), which presents some evidence for an increased vulnerability to brain injury in this age group. These results provide insight into an optimal window for clinical intervention, the period of increased susceptibility to a second injury, and an age dependency in brain injury tolerance within the pediatric population.
Choi, Jay Chol; Lee, Ji Sung; Park, Tai Hwan; Cho, Yong-Jin; Park, Jong-Moo; Kang, Kyusik; Lee, Kyung Bok; Lee, Soo Joo; Kim, Jae Guk; Lee, Jun; Park, Man-Seok; Choi, Kang-Ho; Kim, Joon-Tae; Yu, Kyung-Ho; Lee, Byung-Chul; Oh, Mi-Sun; Cha, Jae-Kwan; Kim, Dae-Hyun; Nah, Hyun-Wook; Kim, Dong-Eog; Ryu, Wi-Sun; Kim, Beom Joon; Bae, Hee-Joon; Kim, Wook-Joo; Shin, Dong-Ick; Yeo, Min-Ju; Sohn, Sung Il; Hong, Jeong-Ho; Lee, Juneyoung; Hong, Keun-Sik
Background and Purpose About 30%-40% of stroke patients are taking antiplatelet at the time of their strokes, which might increase the risk of symptomatic intracranial hemorrhage (SICH) with intravenous tissue plasminogen activator (IV-TPA) therapy. We aimed to assess the effect of prestroke antiplatelet on the SICH risk and functional outcome in Koreans treated with IV-TPA. Methods From a prospective stroke registry, we identified patients treated with IV-TPA between October 2009 and November 2014. Prestroke antiplatelet use was defined as taking antiplatelet within 7 days before the stroke onset. The primary outcome was SICH. Secondary outcomes were discharge modified Rankin Scale (mRS) score and in-hospital mortality. Results Of 1,715 patients treated with IV-TPA, 441 (25.7%) were on prestroke antiplatelet. Prestroke antiplatelet users versus non-users were more likely to be older, to have multiple vascular risk factors. Prestroke antiplatelet use was associated with an increased risk of SICH (5.9% vs. 3.0%; adjusted odds ratio [OR] 1.79 [1.05-3.04]). However, at discharge, the two groups did not differ in mRS distribution (adjusted OR 0.90 [0.72-1.14]), mRS 0-1 outcome (34.2% vs. 33.7%; adjusted OR 1.27 [0.94-1.72), mRS 0-2 outcome (52.4% vs. 52.9%; adjusted OR 1.21 [0.90-1.63]), and in-hospital mortality (6.1% vs. 4.2%; adjusted OR 1.19 [0.71-2.01]). Conclusions Despite an increased risk of SICH, prestroke antiplatelet users compared to non-users had comparable functional outcomes and in-hospital mortality with IV-TPA therapy. Our results support the use of IV-TPA in eligible patients taking antiplatelet therapy before their stroke onset. PMID:27733024
Hamilton, Jason C.; Korn-Naveh, Lauren; Crago, Elizabeth A.
Patients with acute aneurysmal subarachnoid hemorrhage (SAH) often present with more than just neurological compromise. A wide spectrum of complicating cardiopulmonary abnormalities have been documented in patients with acute SAH, presenting additional challenges to the healthcare providers who attempt to treat and stabilize these patients. The patients described in this article presented with both acute aneurysmal SAH and cardiopulmonary compromise. Education and further research on this connection is needed to provide optimal care and outcomes for this vulnerable population. Nurses play a key role in balancing the critical and diverse needs of patients presenting with these symptoms. PMID:18856247
Mueller-Wille, R. Heiss, P.; Herold, T.; Jung, E. M. Schreyer, A. G. Hamer, O. W. Rennert, J. Hoffstetter, P. Stroszczynski, C.; Zorger, N.
Purpose: This study was designed to determine the feasibility and efficacy of endovascular embolization with liquid embolic agent ethylene vinyl alcohol copolymer (Onyx) in patients with acute traumatic arterial bleeding. Methods: This is a retrospective review of 13 patients (9 men and 4 women; mean age 45 years) with severe trauma who underwent embolotherapy using Onyx from November 2003 to February 2009. Bleeding was located in the pelvis (5 patients), kidney (3 patients), mesenteric region (2 patients), retroperitoneal space (2 patients), neck (1 patient), and thigh (1 patient). In three cases (23.1%), Onyx was used in conjunction with coils. We evaluate the technical and clinical success, procedural and embolization time, occurrence of rebleeding, and embolotherapy-related complications, such as necrosis or migration of Onyx into nontarget vessels. Results: In all patients, embolotherapy was technically and clinically successful on the first attempt. Control of bleeding could be reached with a mean time of 19 (range, 4-63) min after correct placement of the microcatheter in the feeding artery. No recurrent bleeding was detected. No unintended necrosis or migration of Onyx into a nontarget region was observed. During the follow-up period, three patients (23.1%) died due to severe intracranial hemorrhage, cardiac arrest, and sepsis. Conclusions: Transcatheter embolization with new liquid embolic agent Onyx is technically feasible and effective in trauma patients with acute arterial hemorrhage.
Glimåker, Martin; Johansson, Bibi; Halldorsdottir, Halla; Wanecek, Michael; Elmi-Terander, Adrian; Bellander, Bo-Michael
To evaluate the efficacy of intracranial pressure (ICP)-targeted treatment, compared to standard intensive care, in adults with community acquired acute bacterial meningitis (ABM) and severely impaired consciousness, a prospectively designed intervention-control comparison study was performed. Included were patients with confirmed ABM and severely impaired mental status on admission. Fifty-two patients, given ICP-targeted treatment at a neuro-intensive care unit, and 53 control cases, treated with conventional intensive care, were included. All patients received intensive care with me-chanical ventilation, sedation, antibiotics and corticosteroids according to current guidelines. ICP-targeted treatment was performed in the intervention group, aiming at ICP 50 mmHg. The mortality was significantly lower in the intervention group compared to controls, 5/52 (10%) versus 16/53 (30%). Furthermore, only 17 patients (32%) in the control group fully recovered, compared to 28 (54%) in the intervention group. Early neuro-intensive care using ICP-targeted therapy reduces mortality and improves the overall outcome in adult patients with ABM and severely impaired mental status on admission.
Breccia, Massimo; Lo Coco, Francesco
Acute promyelocytic leukemia (APL) has become the most curable form of acute myeloid leukemia after the advent of all-trans retinoic acid (ATRA). However, early deaths (ED) mostly due to the disease-associated coagulopathy remain the major cause of treatment failure. In particular, hemorrhagic events account for 40-65% of ED and several prognostic factors have been identified for such hemorrhagic deaths, including poor performance status, high white blood cell (WBC) count and coagulopathy. Occurrence of thrombosis during treatment with ATRA may be associated with differentiation syndrome (DS) or represent an isolated event. Some prognostic factors have been reported to be associated with thrombosis, including increased WBC or aberrant immunophenotype of leukemic promyelocytes. Aim of this review is to report the incidence, severity, possible pathogenesis and clinical manifestations of thrombo-haemorrhagic deaths in APL.
SATOMI, Junichiro; HADEISHI, Hiromu; YOSHIDA, Yasuji; SUZUKI, Akifumi; NAGAHIRO, Shinji
Patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) are likely to die due to irreversible acute-stage primary brain damage. However, the mechanism(s) and pathology responsible for their high mortality rate remain unclear. We report our findings on the brains of individuals who died in the acute stage of SAH. An autopsy was performed on the brains of 11 SAH patients (World Federation of Neurosurgical Societies grade 5) who died within 3 days of admission and who did not receive respiratory assistance. All brains were free of intracranial hematoma and hydrocephalus; all harbored ruptured aneurysms. In all brains, multiple infarcts with perifocal edema were scattered throughout the cortex and subcortical white matter of the whole brain. Infarcts with a patchy – were more often seen than infarcts with a wedge-shaped pattern. Microscopic examination revealed multiple areas with cytotoxic edema and neuronal death indicative of acute ischemic changes. Edema and congestion were more obvious in areas where the subarachnoid clot tightly adhered to the pia mater. Pathologically, the brains of deceased patients with acute poor-grade SAH were characterized by edema and multifocal infarcts spread throughout the whole brain; they were thought to be attributable to venous ischemia. Diffuse disturbance in venous drainage attributable to an abrupt increase in the intracranial pressure and focal disturbances due to tight adhesion of the subarachnoid clot to the pia mater, may contribute strongly to irreversible brain damage in the acute stage of SAH. PMID:27357086
de Oliveira Manoel, Airton Leonardo; Goffi, Alberto; Zampieri, Fernando Godinho; Turkel-Parrella, David; Duggal, Abhijit; Marotta, Thomas R; Macdonald, R Loch; Abrahamson, Simon
Spontaneous intracerebral hemorrhage (ICH), defined as nontraumatic bleeding into the brain parenchyma, is the second most common subtype of stroke, with 5.3 million cases and over 3 million deaths reported worldwide in 2010. Case fatality is extremely high (reaching approximately 60 % at 1 year post event). Only 20 % of patients who survive are independent within 6 months. Factors such as chronic hypertension, cerebral amyloid angiopathy, and anticoagulation are commonly associated with ICH. Chronic arterial hypertension represents the major risk factor for bleeding. The incidence of hypertension-related ICH is decreasing in some regions due to improvements in the treatment of chronic hypertension. Anticoagulant-related ICH (vitamin K antagonists and the newer oral anticoagulant drugs) represents an increasing cause of ICH, currently accounting for more than 15 % of all cases. Although questions regarding the optimal medical and surgical management of ICH still remain, recent clinical trials examining hemostatic therapy, blood pressure control, and hematoma evacuation have advanced our understanding of ICH management. Timely and aggressive management in the acute phase may mitigate secondary brain injury. The initial management should include: initial medical stabilization; rapid, accurate neuroimaging to establish the diagnosis and elucidate an etiology; standardized neurologic assessment to determine baseline severity; prevention of hematoma expansion (blood pressure management and reversal of coagulopathy); consideration of early surgical intervention; and prevention of secondary brain injury. This review aims to provide a clinical approach for the practicing clinician.
Ling, Geoffrey S. F.; Riechers, Ronald G., Sr.; Riechers, Ronald G., Jr.; Pasala, Krishna M.; Zeidman, Seth M.; Rhee, Peter; Wiesmann, William P.
A novel method for identifying and localizing brain hemorrhage is presented. This method uses electromagnetic waves in the microwave and RF region and a modified algorithm previously used for the estimation of the angle of arrival of radar signals. Results are presented applying this device for detecting epidural and intracerebroventricular hemorrhages in anesthetized pig.
Lin, Li-Te; Tsui, Kuan-Hao; Cheng, Jiin-Tsuey; Cheng, Jin-Shiung; Huang, Wei-Chun; Liou, Wen-Shiung; Tang, Pei-Ling
Abstract Pregnancy-induced hypertension (PIH) may be a major predictor of pregnancy-associated intracranial hemorrhage (ICH). However, the relationship between PIH and long-term ICH risk is unknown. The objective of the study was to determine the association between PIH and ICH and to identify the predictive risk factors. Patients with newly diagnosed PIH were recruited from the Taiwan National Health Insurance Research Database. PIH patients were divided into gestational hypertension (GH) and preeclampsia groups. The 2 groups were separately compared with matched cohorts of patients without PIH based on age and date of delivery. The occurrence of ICH was evaluated in both cohorts. The overall observational period was from January 1, 2000 to December 31, 2013. Among the 23.3 million individuals registered in the National Health Insurance Research Database, 28,346 PIH patients, including 7390 with GH and 20,956 with preeclampsia, were identified. The incidences of ICH were increased in both groups (incidence rate ratio [IRR] = 3.72 in the GH group, 95% confidence interval [CI] 3.63–3.81, P < 0.0001 and IRR = 8.21 in the preeclampsia group, 95% CI 8.12–8.31, P < 0.0001, respectively). In addition, according to the results of stratification of follow-up years, both groups were associated with a highest risk of ICH at 1 to 5 years of follow-up (IRR = 11.99, 95% CI 11.16–12.88, P < 0.0001 and IRR = 21.83, 95% CI 21.24–22.44, P < 0.0001, respectively). After adjusting for age, parity, severity of PIH, number of PIH occurrences, gestational age, and comorbidities in the multivariate survival analysis using Cox regression model, age ≥30 years (hazard ratio [HR] 1.99, 95% CI 1.27–3.10, P = 0.0026), patients with preeclampsia (HR 2.18, 95% CI 1.22–3.90, P = 0.0089), multiple PIH occurrences (HR 4.08, 95% CI 1.85–9.01, P = 0.0005), hypertension (HR 4.51, 95% CI 1.89–10.74, P = 0.0007), and obesity (HR 7.21, 95
Torné, Ramon; Rodríguez-Hernández, Ana; Romero-Chala, Fabián; Arikan, Fuat; Vilalta, Jordi; Sahuquillo, Juan
Acute subdural hematomas (aSDH) secondary to intracranial aneurysm rupture are rare. Most patients present with coma and their functional prognosis has been classically considered to be very poor. Previous studies mixed good-grade and poor-grade patients and reported variable outcomes. We reviewed our experience by focusing on patients in coma only and hypothesized that aSDH might worsen initial mortality but not long-term functional outcome. Between 2005 and 2013, 440 subarachnoid hemorrhage (SAH) patients were admitted to our center. Nineteen (4.3%) were found to have an associated aSDH and 13 (2.9%) of these presented with coma. Their prospectively collected clinical and outcome data were reviewed and compared with that of 104 SAH patients without aSDH who presented with coma during the same period. Median aSDH thickness was 10mm. Four patients presented with an associated aneurysmal cortical laceration and only one had good recovery. Overall, we observed good long-term outcomes in both SAH patients in coma with aSDH and those without aSDH (38.5% versus 26.4%). Associated aSDH does not appear to indicate a poorer long-term functional prognosis in SAH patients presenting with coma. Anisocoria and brain herniation are observed in patients with aSDH thicknesses that are smaller than those observed in trauma patients. Despite a high initial mortality, early surgery to remove the aSDH results in a good outcome in over 60% of survivors. Aneurysmal cortical laceration appears to be an independent entity which shows a poorer prognosis than other types of aneurysmal aSDH.
Chitsaz, Ahmad; Norouzi, Rasul; Marashi, Seyed Mohammad Javad; Salimianfard, Marzieh; Fard, Salman Abbasi
Cerebral amyloid angiopathy (CAA) is the most common cause of lobar intracerebral hemorrhage. Repeated bleeding may be presented with vascular dementia. We have reported a 68-year-old normotensive demented patient with probable CAA presented with hemiparesia, headache and vomiting. According to the experience of this case, it is recommended to consider CAA for normotensive elderly patients presented with multiple and superficial intracerebral hemorrhage.
Chitsaz, Ahmad; Norouzi, Rasul; Marashi, Seyed Mohammad Javad; Salimianfard, Marzieh; Fard, Salman Abbasi
Cerebral amyloid angiopathy (CAA) is the most common cause of lobar intracerebral hemorrhage. Repeated bleeding may be presented with vascular dementia. We have reported a 68-year-old normotensive demented patient with probable CAA presented with hemiparesia, headache and vomiting. According to the experience of this case, it is recommended to consider CAA for normotensive elderly patients presented with multiple and superficial intracerebral hemorrhage. PMID:23248664
Smelley, Christopher; Specian, Robert D; Tang, Jiping; Zhang, John H
Severe intracerebral hemorrhage (ICH) produces gastric pathology in about 30% of the patient population, even after the standard treatment of H2 receptor blockers or proton pump inhibitors. This study was undertaken to establish a rat model of ICH-induced gastric ulcer. Adult male Sprague-Dawley rats (300-350 g) were divided into two hemorrhage groups and a sham control group. ICH was produced either by injection of 100 microl of autologous arterial blood or by injection of 4 microl saline containing 0.6 unit of bacterial collagenase VII into the right basal ganglia. Rats were sacrificed at 24, 48, 72 h, and 7 days after ICH to harvest brains and stomachs. Greater degrees of hemorrhage and brain edema were observed in collagenase-induced ICH. Motor behavior decreased significantly after 24 h in both models. The incidence of acute ulceration with destruction of the forestomach epithelium was extremely low at 8.7% in the collagenase injection model and 4.8% in the blood injection rats. Small, pinpoint hemorrhages (petechiae) were noticed in 38% of rats after blood injection and 22% after collagenase injection, in the glandular portion of the gastric mucosa with penetration of red blood cells and inflammatory cells into the gastric mucosa. Enhanced tumor necrosis factor alpha (TNFalpha) and cyclooxygenase 2 (COX-2) expressions were observed in gastric tissues after ICH with more intense staining occurring at 24 and 48 h. Due to the low incidence of ulceration, ICH-induced gastric ulceration in rodents may not appropriate for evaluating the potential human risk of gastric ulceration after ICH.
Khademi, Gholam Reza; Aelami, Mohammad Hasan
Acute hemorrhagic leukoencephalitis (AHLE) is a rare demyelinating disease characterized by an acute rapidly progressive fulminant inflammation of the white matter. In this case report, we introduce a case of AHLE in children with an interesting and lengthy process and successful treatment. A previously healthy 13-year-old girl was admitted to the hospital because of fever and loss of consciousness. After 4 days, she was referred to our pediatric intensive care unit in Mashhad, Iran. On admission, she had right-sided parotiditis. With a diagnosis of AHLE, our patient was treated with methylprednisolone, intravenous immunoglobulin, acyclovir, and plasmapheresis. AHLE is a rare and severe demyelinating disease, the mortality and morbidity of which can be decreased by early detection and treatment with steroid therapy, intravenous immunoglobulin, acyclovir, and plasmapheresis. PMID:27217610
Ivan, Michael E; Nathan, Jay K; Manley, Geoffery T; Huang, Michael C
A 22-year-old man was admitted with a severe traumatic brain injury developed a hyperacute subdural hematoma (SDH) following attempted brain tissue oxygen monitor placement. This patient was successfully treated by placement of a subdural evacuation portal system (SEPS). The patient presented to a Level I trauma center after a severe bike versus auto accident. On admission, he was found to have a Glasgow Coma Scale (GCS) score of 3. The patient had small areas of intraparechymal hemorrhage as well as suspicion for diffuse axonal injury in the midbrain. Based on the patient's GCS score, neurological monitoring was indicated as a part of his intensive care unit treatment, however a SDH occurred during an attempted placement of a brain tissue oxygen monitor. This iatrogenic hyperacute SDH after burr hole monitoring device placement was treated with a SEPS drain. The SEPS drain has been shown to provide complete and/or temporary decompression of liquefied SDH. To our knowledge, this is the first report of using the SEPS to treat iatrogenic SDH associated with an intracranial monitoring device. This technique should be added to the armament of treatment options for a neurosurgeon to treat or temporize a hyperacute SDH with increased intracranial pressure in specific patients.
Rheinboldt, Matt; Francis, Kirenza; Parrish, David; Harper, Derrick; Blase, John
Terson syndrome, the presence of intraocular hemorrhage in the setting of acutely elevated intracranial pressure, was historically described in conjunction with acute subarachnoid hemorrhage; however, more recently, it has been associated with a gamut of intracranial pathophysiology ranging from blunt or penetrating injury to neurosurgical procedures. We describe two cases of profound intracranial injury, secondary to ballistic injury, and a ruptured intracranial aneurysm, in which posterior chamber ocular hemorrhage was noted on CT imaging. Though the outcome in such cases, as with ours, is often poor, the findings are germane to clinical care as the presence of Terson syndrome has been noted to be a negative prognostic factor in multiple clinical reviews. Additionally, clinical recovery can be impacted adversely by lasting visual deficits or retinal degradation in the absence of timely ophthalmologic intervention.
Kubota, S; Asakura, T; Kitamura, K
The experiment was performed on 86 cases under intraperitoneal pentobarbital anesthesia. One balloon was placed in the extradural space of right frontal region, and the other balloon was placed in the left extradural space and the intracranial pressure was measured. A needle was stereotaxically inserted into the subcortical area in order to measure the cerebral blood flow. Systemic blood pressure was recorded by inserting a catheter into the femoral artery, and electrocorticogram was also recorded. An expanding intracranial lesion was made by inflating the extradural balloon with physiological saline. The animals were arbitrarily divided into two groups.: 1) light or moderate groups which intracranial pressure before the injection of drug was below 400 mmH2O. 2) severe groups above 400 mmH2O. After the maintenance of the pressure, Solcoseryl was infused intravenously. The investigation was focused to observe whether Solcoseryl reveales any potent effect on cerebral blood flow, intracranial pressure, systemic blood pressure and on electroencephalogram in acute intracranial hypertension. Results 1) Intravenous injection of Solcoseryl had the effect of lowering intracranial pressure in the light or moderate and severe groups. Particularly, dose of 80 mg/kg showed the marked effect, though with a rebound phenomenon in the light or moderate groups. Furthermore, the effect was more marked and lasting by drip infusion of Solcoseryl and also by intravenous injection of Solcoseryl after pretreatment with hydrocortisone, and at this time no rebound phenomenon was recognized. 2) Solcoseryl had the effect of increasing the cerebral blood flow accompained with the lowering of intracranial pressure. 3) Systemic blood pressure was transiently lowered by the injection of Solcoseryl 20 mg/kg or 80 mg/kg and recovered immediately. 4) Solcoseryl had no effect on electroencephalogram in the severe groups. Conclusion On the basis of these results, it is rational to conclude that
... brain. Many conditions can increase intracranial pressure. Common causes include: Aneurysm rupture and subarachnoid hemorrhage Brain tumor Encephalitis Head injury Hydrocephalus (increased fluid around ...
Hori, Satoshi; Kashiwazaki, Daina; Akioka, Naoki; Hamada, Hideo; Kuwayama, Naoya; Kuroda, Satoshi
A 39-year-old man had been diagnosed with moyamoya disease and underwent a bilateral encephalo-duro-arterio-synangiosis(EDAS)intervention at the age of 9 years. During the 30 years after his bilateral EDAS, he experienced no cerebrovascular events. However, at age 39, he suddenly presented with mild consciousness disturbance and vomiting and was transferred to a local hospital. Brain CT showed an intracerebral hemorrhage associated with ventricular hematoma. He was referred to our hospital for further investigation and treatment. Cerebral angiography showed faint collaterals through the site of the bilateral EDAS and development of basal moyamoya vessels. SPECT showed decreased cerebral blood flow(CBF)and cerebrovascular reactivity(CVR)in the right frontal lobe. We diagnosed him with delayed cerebral hemorrhage due to delayed rupturing of fragile moyamoya vessels after indirect bypass. The patient underwent a repeat bypass surgery(STA-MCA anastomosis and encephalo-duro-myo-arterio-pericranial synangiosis;EDMAPS)on the right side. He showed improvement in cerebral hemodynamics after surgery, and has since remained free from cerebrovascular events. Hemorrhagic events occurring a very long time after indirect bypass surgery in pediatric-onset moyamoya disease are rare. In such cases, a lifelong follow-up strategy may be necessary. Repeat bypass surgery may be a powerful tool to prevent such hemorrhagic events.
Christova, Iva; Younan, Rasha; Taseva, Evgenia; Gladnishka, Teodora; Trifonova, Iva; Ivanova, Vladislava; Spik, Kristin; Schmaljohn, Connie; Mohareb, Emad
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.
de Aguiar, Guilherme Brasileiro; Veiga, José Carlos Esteves; Silva, João Miguel de Almeida; Conti, Mario Luiz Marques
Dural arteriovenous fistulas are acquired lesions between the meningeal arteries and their associated draining veins. They may have highly variable clinical presentations and evolution, from severe neurological deficit to no or trivial symptoms. Intracranial hemorrhage occurs in less than 24% of all dural fistulas, and the bleeding is usually subarachnoid, more infrequently intracerebral, and rarely in the subdural space. Here, we present a rare case of a patient who presented with a subdural spontaneous hemorrhage. After investigation by cerebral angiography, the diagnosis of a dural arteriovenous fistula was made. The patient underwent uneventful endovascular treatment. As there are with only a few reports in the literature of such a presentation, we present this patient and perform a brief review of the literature.
Lehnerdt, G; Peraud, A; Berghaus, A; Hoffmann, T K; Sommer, K; Rotter, N; Lang, S
Orbital and intracranial complications of acute sinusitis occur more frequently in the pediatric population compared to adults due to anatomic differences. Since the introduction of antibiotics the frequency of such complications has been dramatically reduced. Nevertheless, even in the era of modern antibiotics these complications continue to occur and it is therefore of utmost importance not only to know about these complications but also to include them in the differential diagnosis. Appropriate diagnosis mainly based on CT scanning or magnetic resonance tomography is the basis for a rapid and sufficient and if necessary interdisciplinary treatment. In this CME article the diagnostic and therapeutic interventions in four young patients suffering from orbital or intracranial complications due to acute sinusitis are described and discussed in the context of the current literature and a clinical algorithm is introduced.
Varga, T; Szabó, A
Myocardial lesions occuring in diseases with acute increase of intracranial pressure were investigated. Morphologic alterations in heart muscle in spite of different lengh of surviving and various causes of the death were of similar type. In every case subendocardial haemorrhage could be observed on the septal surface and on the papillary muscle of the left ventricle. Focal intracellular edema, myocytolysis were revealed in 76%, focal necrosis of hypercontractic type developed in 52% of the cases. Cellular infiltration occurred around the alternations observed in 3 cases. It is concluded, that damage to the heart muscle is not caused directly by the increased intracranial pressure or catecholamine mobilisation, but seems to be the consequence of the acute myocardial hypoxia.
Shenkar, R; Coulson, W F; Abraham, E
Acute pulmonary injury occurs frequently following hemorrhage and injury. In order to better examine the sequence of events leading to lung injury in this setting, we investigated lung histology as well as in vivo mRNA levels for cytokines with proinflammatory and immunoregulatory properties (IL-1 beta, IL-6, IL-10, TNF-alpha, TGF-beta, IFN-gamma) over the 3 days following hemorrhage and resuscitation. Significant increases in mRNA levels for IL-1 beta, IL-6, IL-10, and IFN-gamma, but not TNF-alpha, were present among intraparenchymal pulmonary mononuclear cells obtained 1 and 3 days after hemorrhage. Among alveolar macrophages, TNF-alpha and IL-1 beta mRNA levels were increased 3 days after hemorrhage. Few changes in cytokine mRNA levels, with the exception of TNF-alpha at 3 days after hemorrhage, were present among peripheral blood mononuclear cells. Histologic examination of lungs from hemorrhaged animals showed no alterations 1 day after hemorrhage, but neutrophil and mononuclear cell infiltrates, edema, intra-alveolar hemorrhage, and fibrin generation were present 3 days after hemorrhage. These results suggest that hemorrhage-induced enhancement of proinflammatory cytokine gene transcription may be an important mechanism contributing to the frequent development of acute lung injury following blood loss and injury.
Nute, J; Jacobsen, M; Popnoe, D; Wei, W; Baiu, C; Schellingerhout, D; Cody, D
Purpose: Intracranial hemorrhage and calcification with Single-Energy CT (SECT) attenuation below 100HU cannot be reliably identified using currently clinically available means. Calcification is typically benign but hemorrhage can carry a risk of intracranial bleeding and contraindicate use of anticoagulant therapies. A biologically-relevant phantom was used to investigate identification of unknown intracranial lesions using dual-energy CT (DECT) as a verification of prior lesion differentiation results. Methods: Prior phantom work investigating calcification and hemorrhage differentiation resulted in 3D-DECT raw data (water density, calcium density, 68keV) for a range of DECT protocol variations: image thicknesses (1.25, 2.5, 3.75, 5mm), CTDIvol (36.7 to 132.6mGy) and reconstruction algorithms (Soft, Standard, Detail). Acquisition-specific raw data were used to create a plane of optimal differentiation based on the geometric bisector of 3D-linear regression of the two lesion distributions. Verification hemorrhage and calcification lesions, ranging in size from 0.5 to 1.5cm, were created at varying attenuation from 50 to 100HU. Lesions were inserted into a biologically-relevant brain phantom and scanned using SECT (3.75mm images, Standard, 67mGy) and a range of DECT protocols (3.75mm images, Standard, [67, 105.6, 132.6mGy]). 3D-DECT data were collected and blinded for analysis. The 3D-DECT distribution of the lesion was then compared to the acquisition-matched geometric bisector plane and the mean lesion value’s position relative to the plane, indicating lesion identity, and the percentage of voxels on the identified side of the plane, indicating identification confidence, were derived. Results: 98% of the 120 lesions investigated were identified correctly as hemorrhage or calcification. 74% were identified with greater than 80% confidence. Increases in CTDIvol and lesion diameter were associated with increased identification confidence. Conclusion: Intracranial
Yamaki, Vitor Nagai; Júnior, Fernando Mendes Paschoal; Piske, Ronie Leo; Teixeira, Manoel Jacobsen; Bor-Seng-Shu, Edson
Carotid rete mirabile (CRM) is a rare physiological vascular network in humans that is most often found in Eastern populations. This paper describes a CRM associated with an aneurysmal subarachnoid hemorrhage (aSAH) and discusses the details of the patient’s treatment. A 28-year-old woman was admitted to our service with clinical signs and symptoms of a spontaneous aSAH. Computed tomography revealed a diffuse and extensive SAH (Fisher group IV), while an angiogram showed an abnormal collateral network in the right carotid system and a hypoplastic aspect to the internal carotid artery (ICA) on the same side. In addition, a saccular aneurysm with a diameter of 9.5 mm was present in the ophthalmic segment of the left ICA. This case is extremely uncommon. To avoid rebleeding in the patient, we successfully treated the patient by clipping the aneurysmal lesion. No procedure was performed for the CRM. PMID:25934776
Hauerberg, J; Xiaodong, M; Willumsen, L; Pedersen, D B; Juhler, M
The present series of experiments was performed to investigate the influence of acute intracranial hypertension on the upper limit (UL) of cerebral blood flow (CBF) autoregulation. Three groups of eight rats each--one with normal intracranial pressure (ICP) (2 mmHg), one with ICP = 30 mmHg, and one with ICP = 50 mmHg--were investigated. Intracranial hypertension was maintained by continuous infusion of lactated Ringer's solution into the cisterna magna, where the pressure was used as ICP. Cerebral perfusion pressure (CPP), calculated as mean arterial blood pressure (MABP)-ICP, was increased stepwise by continuous intravenous infusion of norepinephrine. CBF was calculated by the intracarotid 133Xe method. In all three groups the corresponding CBF/CPP curve included a plateau where CBF was independent of changes in CPP, showing intact autoregulation. At normal ICP the UL was found at a CPP of 141 +/-2 mmHg, at ICP = 30 mmHg the UL was 103+/-5 mmHg, and at ICP = 50 mmHg the UL was found at 88+/-7 mmHg. This shift of the UL was more pronounced than the shift of the lower limit (LL) of the CBF autoregulation found previously. We conclude that intracranial hypertension is followed by both a shift toward lower CPP values and a narrowing of the autoregulated interval between the LL and the UL.
Chan, Edward; Anderson, Craig S.; Wang, Xia; Arima, Hisatomi; Saxena, Anubhav; Moullaali, Tom J.; Delcourt, Candice; Wu, Guojun; Wang, Jinchao; Chen, Guofang; Lavados, Pablo M.; Stapf, Christian; Robinson, Thompson; Chalmers, John
Background Intraventricular hemorrhage (IVH) extension is common following acute intracerebral hemorrhage (ICH) and is associated with poor prognosis. Aim To determine whether intensive blood pressure (BP)-lowering therapy reduces IVH growth. Methods Pooled analyses of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials (INTERACT1 and INTERACT2) computed tomography (CT) substudies; multicenter, open, controlled, randomized trials of patients with acute spontaneous ICH and elevated systolic BP, randomly assigned to intensive (<140 mm Hg) or guideline-based (<180 mm Hg) BP management. Participants had blinded central analyses of baseline and 24-hour CT. Association of BP lowering to IVH growth was assessed in analysis of covariance. Results There was no significant difference in adjusted mean IVH growth following intensive (n = 228) compared to guideline-recommended (n = 228) BP treatment (1.6 versus 2.2 ml, respectively; p = 0.56). Adjusted mean IVH growth was nonsignificantly greater in patients with a mean achieved systolic BP ≥160 mm Hg over 24 h (3.94 ml; p trend = 0.26). Conclusions Early intensive BP-lowering treatment had no clear effect on IVH in acute ICH. PMID:27603933
Cornejo, Rodrigo; Romero, Carlos; Ugalde, Diego; Bustos, Patricio; Diaz, Gonzalo; Galvez, Ricardo; Llanos, Osvaldo; Tobar, Eduardo
We report the successful treatment of two patients with aneurismal subarachnoid hemorrhage complicated by severe respiratory failure and refractory septic shock using simultaneous prone position ventilation and high-volume hemofiltration. These rescue therapies allowed the patients to overcome the critical situation without associated complications and with no detrimental effects on the intracranial and cerebral perfusion pressures. Prone position ventilation is now an accepted therapy for severe acute respiratory distress syndrome, and high-volume hemofiltration is a non-conventional hemodynamic support that has several potential mechanisms for improving septic shock. In this manuscript, we briefly review these therapies and the related evidence. When other conventional treatments are insufficient for providing safe limits of oxygenation and perfusion as part of basic neuroprotective care in subarachnoid hemorrhage patients, these rescue therapies should be considered on a case-by-case basis by an experienced critical care team. PMID:25028955
Eide, Per K.; Rapoport, Benjamin I.; Gormley, William B.; Madsen, Joseph R.
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
Mobashsher, Ahmed Toaha; Mahmoud, A.; Abbosh, A. M.
Intracranial hemorrhage is a medical emergency that requires rapid detection and medication to restrict any brain damage to minimal. Here, an effective wideband microwave head imaging system for on-the-spot detection of intracranial hemorrhage is presented. The operation of the system relies on the dielectric contrast between healthy brain tissues and a hemorrhage that causes a strong microwave scattering. The system uses a compact sensing antenna, which has an ultra-wideband operation with directional radiation, and a portable, compact microwave transceiver for signal transmission and data acquisition. The collected data is processed to create a clear image of the brain using an improved back projection algorithm, which is based on a novel effective head permittivity model. The system is verified in realistic simulation and experimental environments using anatomically and electrically realistic human head phantoms. Quantitative and qualitative comparisons between the images from the proposed and existing algorithms demonstrate significant improvements in detection and localization accuracy. The radiation and thermal safety of the system are examined and verified. Initial human tests are conducted on healthy subjects with different head sizes. The reconstructed images are statistically analyzed and absence of false positive results indicate the efficacy of the proposed system in future preclinical trials.
Mobashsher, Ahmed Toaha; Mahmoud, A.; Abbosh, A. M.
Intracranial hemorrhage is a medical emergency that requires rapid detection and medication to restrict any brain damage to minimal. Here, an effective wideband microwave head imaging system for on-the-spot detection of intracranial hemorrhage is presented. The operation of the system relies on the dielectric contrast between healthy brain tissues and a hemorrhage that causes a strong microwave scattering. The system uses a compact sensing antenna, which has an ultra-wideband operation with directional radiation, and a portable, compact microwave transceiver for signal transmission and data acquisition. The collected data is processed to create a clear image of the brain using an improved back projection algorithm, which is based on a novel effective head permittivity model. The system is verified in realistic simulation and experimental environments using anatomically and electrically realistic human head phantoms. Quantitative and qualitative comparisons between the images from the proposed and existing algorithms demonstrate significant improvements in detection and localization accuracy. The radiation and thermal safety of the system are examined and verified. Initial human tests are conducted on healthy subjects with different head sizes. The reconstructed images are statistically analyzed and absence of false positive results indicate the efficacy of the proposed system in future preclinical trials. PMID:26842761
Mobashsher, Ahmed Toaha; Mahmoud, A; Abbosh, A M
Intracranial hemorrhage is a medical emergency that requires rapid detection and medication to restrict any brain damage to minimal. Here, an effective wideband microwave head imaging system for on-the-spot detection of intracranial hemorrhage is presented. The operation of the system relies on the dielectric contrast between healthy brain tissues and a hemorrhage that causes a strong microwave scattering. The system uses a compact sensing antenna, which has an ultra-wideband operation with directional radiation, and a portable, compact microwave transceiver for signal transmission and data acquisition. The collected data is processed to create a clear image of the brain using an improved back projection algorithm, which is based on a novel effective head permittivity model. The system is verified in realistic simulation and experimental environments using anatomically and electrically realistic human head phantoms. Quantitative and qualitative comparisons between the images from the proposed and existing algorithms demonstrate significant improvements in detection and localization accuracy. The radiation and thermal safety of the system are examined and verified. Initial human tests are conducted on healthy subjects with different head sizes. The reconstructed images are statistically analyzed and absence of false positive results indicate the efficacy of the proposed system in future preclinical trials.
Weinsheimer, Shantel; Kim, Helen; Pawlikowska, Ludmila; Chen, Yongmei; Lawton, Michael T.; Sidney, Stephen; Kwok, Pui-Yan; McCulloch, Charles E.; Young, William L.
Background Brain arteriovenous malformations (BAVM) are a tangle of abnormal vessels directly shunting blood from the arterial to venous circulation and an important cause of intracranial hemorrhage (ICH). EphB4 is involved in arterial-venous determination during embryogenesis; altered signaling could lead to vascular instability resulting in ICH. We investigated the association of single-nucleotide polymorphisms (SNPs) and haplotypes in EPHB4 with risk of ICH at clinical presentation in BAVM patients. Methods and Results Eight haplotype-tagging SNPs spanning ∼29 kb were tested for association with ICH presentation in 146 Caucasian BAVM patients (phase I: 56 ICH, 90 non-ICH) using allelic, haplotypic, and principal components analysis. Associated SNPs were then genotyped in 102 additional cases (phase II: 37 ICH, 65 non-ICH) and data combined for multivariable logistic regression. Minor alleles of 2 SNPs were associated with reduced risk of ICH presentation (rs314313 C, P=0.005; rs314308 T, P=0.0004). Overall, haplotypes were also significantly associated with ICH presentation (χ2=17.24, 6 df, P=0.008); 2 haplotypes containing the rs314308 T allele (GCCTGGGT, P=0.003; GTCTGGGC, P=0.036) were associated with reduced risk. In principal components analysis, 2 components explained 91% of the variance, and complemented haplotype results by implicating 4 SNPs at the 5′ end, including rs314308 and rs314313. These 2 SNPs were replicated in the phase II cohort, and combined data resulted in greater significance (rs314313, P=0.0007; rs314308, P=0.00008). SNP association with ICH presentation persisted after adjusting for age, sex, BAVM size, and deep venous drainage. Conclusions EPHB4 polymorphisms are associated with risk of ICH presentation in BAVM patients, warranting further study. PMID:20031623
Fanous, Andrew A; Jowdy, Patrick K; Lipinski, Lindsay J; Balos, Lucia L; Li, Veetai
OBJECTIVE Cavernous hemangiomas are benign congenital vascular abnormalities. Intracerebral cavernous hemangiomas have an appreciable risk of spontaneous hemorrhage. Little is known as to whether head trauma increases the risk of bleeding for these lesions. In this study, the authors present a case series of 3 patients with posttraumatic nonspontaneous hemorrhage of intracerebral cavernous malformations (CMs). For the first time, to the authors' knowledge, they propose that trauma might constitute a risk factor for acute hemorrhage in intracerebral cavernomas. METHODS The authors reviewed the charts of all patients with a new diagnosis of intracerebral cavernoma at their pediatric hospital between 2010 and 2014. Patients with a history of head trauma prior to presentation were subsequently studied to identify features common to these posttraumatic, hemorrhage-prone lesions. RESULTS A history of head trauma was identified in 3 of 19 cases. These 3 patients presented with seizures and/or headaches and were found to have acute hemorrhage within a cavernous hemangioma. None of these patients had any history of abnormal neurological symptoms. All 3 abnormal vascular lesions had associated developmental venous anomalies (DVAs). The 3 patients underwent resection of their respective vascular abnormalities, and the diagnosis of cavernous hemangioma was confirmed with postsurgical tissue pathology. All 3 patients had complete resolution of symptoms following complete excision of their lesions. CONCLUSIONS Trauma may represent a risk factor for acute hemorrhage in patients with CMs. The presence of associated DVAs may represent a risk factor for posttraumatic hemorrhage of cavernomas. Excision should be considered in such cases, if feasible.
Long, Simon Y.; Latimer, Erin M.; Hayward, Gary S.
More than 100 young captive and wild Asian elephants are known to have died from a rapid-onset, acute hemorrhagic disease caused primarily by multiple distinct strains of two closely related chimeric variants of a novel herpesvirus species designated elephant endotheliotropic herpesvirus (EEHV1A and EEHV1B). These and two other species of Probosciviruses (EEHV4 and EEHV5) are evidently ancient and likely nearly ubiquitous asymptomatic infections of adult Asian elephants worldwide that are occasionally shed in trunk wash secretions. Although only a handful of similar cases have been observed in African elephants, they also have proved to harbor their own multiple and distinct species of Probosciviruses—EEHV2, EEHV3, EEHV6, and EEHV7—found in lung and skin nodules or saliva. For reasons that are not yet understood, approximately 20% of Asian elephant calves appear to be susceptible to the disease when primary infections are not controlled by normal innate cellular and humoral immune responses. Sensitive specific polymerase chain reaction (PCR) DNA blood tests have been developed, routine monitoring has been established, the complete large DNA genomes of each of the four Asian EEHV species have now been sequenced, and PCR gene subtyping has provided unambiguous evidence that this is a sporadic rather than epidemic disease that it is not being spread among zoos or other elephant housing facilities. Nevertheless, researchers have not yet been able to propagate EEHV in cell culture, determine whether or not human antiherpesvirus drugs are effective inhibitors, or develop serology assays that can distinguish between antibodies against the multiple different EEHV species. PMID:26912715
Kongbunkiat, Kannikar; Wilson, Duncan; Kasemsap, Narongrit; Tiamkao, Somsak; Jichi, Fatima; Palumbo, Vanessa; Hill, Michael D.; Buchan, Alastair M.; Jung, Simon; Mattle, Heinrich P.; Henninger, Nils
Objective: To perform a systematic review and pooled meta-analysis of published studies to assess whether the presence of leukoaraiosis on neuroimaging before treatment with thrombolysis (IV or intra-arterial) is associated with an increased risk of symptomatic intracerebral hemorrhage (sICH) or poor functional outcome. Methods: We included studies of patients with acute ischemic stroke, treated with IV or intra-arterial thrombolysis, which assessed functional outcome (3-month modified Rankin Scale [mRS]) or sICH in relation to leukoaraiosis on pretreatment neuroimaging (CT or MRI). We used random-effects models to calculate pooled relative risks (RR) of sICH and poor functional outcome (mRS ≥ 2) for any vs no leukoaraiosis (using any rating scale) and for no to mild vs moderate to severe leukoaraiosis (using the Van Swieten or Fazekas Schmidt scale). Results: We identified 15 studies (total n = 6,967). For sICH outcome, the RR was 1.65 (n = 5,551; 95% confidence interval [CI] 1.26–2.16, p = 0.001) with an absolute risk (AR) increase of 2.5% for any leukoaraiosis vs none. The RR was 2.4 (n = 4,192; 95% CI 1.83–3.14, p = 0.001) with an AR increase of 6.2% for moderate to severe vs no to mild leukoaraiosis. For poor functional outcome; the RR was 1.30 (n = 3,401; 95% CI 1.19–1.42, p = 0.001) with an AR increase of 15.4% for any leukoaraiosis vs none. The RR was 1.31 (n = 3,659; 95% CI 1.22–1.42, p = 0.001) with an AR increase of 17.5% for moderate to severe vs no to mild leukoaraiosis. No statistical heterogeneity was noted for any of the analyses. Conclusions: Leukoaraiosis presence and severity are consistently associated with an increased risk of sICH and poor functional outcome after IV or intra-arterial thrombolysis for acute ischemic stroke. PMID:28130468
Abraham, E; Carmody, A; Shenkar, R; Arcaroli, J
Acute lung injury is characterized by accumulation of neutrophils in the lungs, accompanied by the development of interstitial edema and an intense inflammatory response. To assess the role of neutrophils as early immune effectors in hemorrhage- or endotoxemia-induced lung injury, mice were made neutropenic with cyclophosphamide or anti-neutrophil antibodies. Endotoxemia- or hemorrhage-induced lung edema was significantly reduced in neutropenic animals. Activation of the transcriptional regulatory factor nuclear factor-kappaB after hemorrhage or endotoxemia was diminished in the lungs of neutropenic mice compared with nonneutropenic controls. Hemorrhage or endotoxemia was followed by increases in pulmonary mRNA and protein levels for interleukin-1beta (IL-1beta), macrophage inflammatory protein-2 (MIP-2), and tumor necrosis factor-alpha (TNF-alpha). Endotoxin-induced increases in proinflammatory cytokine expression were greater than those found after hemorrhage. The amounts of mRNA or protein for IL-1beta, MIP-2, and TNF-alpha were significantly lower after hemorrhage in the lungs of neutropenic versus nonneutropenic mice. Neutropenia was associated with significant reductions in IL-1beta and MIP-2 but not in TNF-alpha expression in the lungs after endotoxemia. These experiments show that neutrophils play a central role in initiating acute inflammatory responses and causing injury in the lungs after hemorrhage or endotoxemia.
Uchino, Hayaki; Tamura, Nobuichiro; Echigoya, Ryosuke; Ikegami, Tetsunori; Fukuoka, Toshio
Patient: Female, 86 Final Diagnosis: Polytrauma Symptoms: Shock Medication: — Clinical Procedure: Resuscitative endovascular balloon occlusion of the aorta Specialty: Orthopedics and Traumatology Objective: Unusual or unexpected effect of treatment Background: Non-compressible torso hemorrhage continues to be the leading cause of preventable death in trauma patients. Recent case series report that resuscitative endovascular balloon occlusion of the aorta (REBOA) in the trauma population is a technically feasible method to manage the patients with exsanguinating hemorrhage. On the other hand, it seems that REBOA is being widely promoted prematurely. Complications due to REBOA haven’t been reported much in the literature, and they could have been underestimated. Case Report: An 86-year-old female presented to our emergency department following a pedestrian-vehicle accident. On admission, she was hemodynamically unstable with systolic blood pressure (SBP) of 78 mm Hg. She responded to fluid administration, and computed tomography (CT) scan showed cerebral contusion, subarachnoid hemorrhage, pelvic fracture with contrast extravasation, and thoracic spine fracture. Her condition deteriorated after the CT scan, and she became hemodynamically unstable. REBOA was inserted and inflated. Her blood pressure recovered and even became as high as SBP of 180 mm Hg. Transarterial embolization for pelvic fracture was successfully performed. A subsequent head CT scan showed massive intracranial hemorrhage with penetration to the ventricle, which was fatal. She died on the same day due to cerebral herniation. Conclusions: REBOA is now considered as an alternative to resuscitative thoracotomy or even widely indicated to control hemorrhage. We should be more cautious about using REBOA for polytrauma patients since it could make hemorrhage worse. Further research, assessing its potential complications and safety, will be required to elucidate clear indications for REBOA in trauma
Atefi, Seyed Reza; Seoane, Fernando; Kamalian, Shervin; Rosenthal, Eric S.; Lev, Michael H.; Bonmassar, Giorgio
Purpose: Current diagnostic neuroimaging for detection of intracranial hemorrhage (ICH) is limited to fixed scanners requiring patient transport and extensive infrastructure support. ICH diagnosis would therefore benefit from a portable diagnostic technology, such as electrical bioimpedance (EBI). Through simulations and patient observation, the authors assessed the influence of unilateral ICH hematomas on quasisymmetric scalp potential distributions in order to establish the feasibility of EBI technology as a potential tool for early diagnosis. Methods: Finite element method (FEM) simulations and experimental left–right hemispheric scalp potential differences of healthy and damaged brains were compared with respect to the asymmetry caused by ICH lesions on quasisymmetric scalp potential distributions. In numerical simulations, this asymmetry was measured at 25 kHz and visualized on the scalp as the normalized potential difference between the healthy and ICH damaged models. Proof-of-concept simulations were extended in a pilot study of experimental scalp potential measurements recorded between 0 and 50 kHz with the authors’ custom-made bioimpedance spectrometer. Mean left–right scalp potential differences recorded from the frontal, central, and parietal brain regions of ten healthy control and six patients suffering from acute/subacute ICH were compared. The observed differences were measured at the 5% level of significance using the two-sample Welch t-test. Results: The 3D-anatomically accurate FEM simulations showed that the normalized scalp potential difference between the damaged and healthy brain models is zero everywhere on the head surface, except in the vicinity of the lesion, where it can vary up to 5%. The authors’ preliminary experimental results also confirmed that the left–right scalp potential difference in patients with ICH (e.g., 64 mV) is significantly larger than in healthy subjects (e.g., 20.8 mV; P < 0.05). Conclusions: Realistic
Koskimäki, Janne; Tarkia, Miikka; Ahtola-Sätilä, Tuula; Saloranta, Lasse; Laakso, Aki; Frantzén, Janek
Nimodipine is a widely used medication for treating delayed cerebral ischemia (DCI) after subarachnoid hemorrhage. When administrated orally or intravenously, systemic hypotension is an undesirable side effect. Intracranial subarachnoid delivery of nimodipine during aneurysm clipping may be more efficient way of preventing vasospasm and DCI due to higher concentration of nimodipine in cerebrospinal fluid (CSF). The risk of systemic hypotension may also be decreased with intracranial delivery. We used animal models to evaluate the feasibility of surgically implanting a silica-based nimodipine releasing implant into the subarachnoid space through a frontotemporal craniotomy. Concentrations of released nimodipine were measured from plasma samples and CSF samples. Implant degradation was followed using CT imaging. After completing the recovery period, full histological examination was performed on the brain and meninges. The in vitro characteristics of the implant were determined. Our results show that the biodegradable silica-based implant can be used for an intracranial drug delivery system and no major histopathological foreign body reactions were observed. CT imaging is a feasible method for determining the degradation of silica implants in vivo. The sustained release profiles of nimodipine in CSF were achieved. Compared to a traditional treatment, higher nimodipine CSF/plasma ratios can be obtained with the implant. PMID:25685803
Not only the Sugar, Early infarct sign, hyperDense middle cerebral artery, Age, Neurologic deficit score but also atrial fibrillation is predictive for symptomatic intracranial hemorrhage after intravenous recombinant tissue plasminogen activator
Muengtaweepongsa, Sombat; Prapa-Anantachai, Pornpoj; Dharmasaroja, Pornpat A.
Background: Symptomatic intracranial hemorrhage (sICH) is the most unwanted adverse event in patients with acute ischemic stroke who received intravenous recombinant tissue plasminogen activator (i.v. rt-PA). Many tool scores are available to predict the probability of sICH. Among those scores, the Sugar, Early infarct sign, hyperDense middle cerebral artery, Age, Neurologic deficit (SEDAN) gives the highest area under the curve-receiver operating characteristic value. Objective: We aimed to examine any factors other than the SEDAN score to predict the probability of sICH. Methods: Patients with acute ischemic stroke treated with i.v. rt-PA within 4.5 h time window from January 2010 to July 2012 were evaluated. Compiling demographic data, risk factors, and comorbidity (hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation (AF), ischemic heart disease, valvular heart disease, previous stroke, gout, smoking cigarette, drinking alcoholic beverage, family history of stroke, and family history of ischemic heart disease), computed tomography scan of patients prior to treatment with rt-PA, and assessing the National Institutes of Health Stroke Scale (NIHSS) score for the purpose of calculating SEDAN score were analyzed. Results: Of 314 patients treated with i.v. rt-PA, there were 46 ICH cases (14.6%) with 14 sICH (4.4%) and 32 asymptomatic intracranial hemorrhage cases (10.2%). The rate of sICH occurrence was increased in accordance with the increase in the SEDAN score and AF. Age over 75 years, early infarction, hyperdense cerebral artery, baseline blood sugar more than 12 mmol/l, NIHSS as 10 or more, and AF were the risk factors to develop sICH after treated with rt-PA at 1.535, 2.501, 1.093, 1.276, 1.253, and 2.492 times, respectively. Conclusions: Rather than the SEDAN score, AF should be a predictor of sICH in patients with acute ischemic stroke after i.v. rt-PA treatment in Thai population. PMID:28149081
Paliwal, Prakash; Low, Adrian F.; Tay, Edgar L.W.; Gopinathan, Anil; Nadarajah, Mahendran; Ting, Eric; Venketasubramanian, Narayanaswamy; Seet, Raymond C.S.; Ahmad, Aftab; Chan, Bernard P.L.; Teoh, Hock L.; Soon, Derek; Rathakrishnan, Rahul; Sharma, Vijay K.
Objective: We compared intracranial collaterals on pretreatment and day 2 brain CT angiograms (CTA) to assess their evolution and relationship with functional outcomes in acute ischemic stroke (AIS) patients treated with IV tissue plasminogen activator (tPA). Methods: Consecutive AIS patients who underwent pretreatment and day 2 CTA and received IV tPA during 2010–2013 were included. Collaterals were evaluated by 2 independent neuroradiologists using 3 predefined criteria: the Miteff system, the Maas system, and 20-point collateral scale by the Alberta Stroke Program Early CT Score methodology. We stratified our cohort by baseline pre-tPA state of their collaterals and by recanalization status of the primary vessel for analysis. Good outcomes at 3 months were defined by a modified Rankin Scale score of 0–1. Results: This study included 209 patients. Delayed collateral recruitment by any grading system was not associated with good outcomes. All 3 scoring systems showed that collateral recruitment on the follow-up CTA from a baseline poor collateral state was significantly associated with poor outcome and increased bleeding risk. When the primary vessel remained persistently occluded, collateral recruitment was significantly associated with worse outcomes. Interestingly, collateral recruitment was significantly associated with increased mortality in 2 of the 3 grading systems. Conclusions: Not all collateral recruitment is beneficial; delayed collateral recruitment may be different from early recruitment and can result in worse outcomes and higher mortality. Prethrombolysis collateral status and recanalization are determinants of how intracranial collateral evolution affects functional outcomes. PMID:26740681
Foreman, N K; Laitt, R D; Chambers, E J; Duncan, A W; Cummins, B H
A child was diagnosed in 1969 as having acute lymphoblastic leukaemia (ALL) and received chemotherapy. On bone marrow relapse in 1973, he was treated with cranial irradiation (20 Gy) in addition to chemotherapy. He continues in complete remission 19 years after his relapse. At age 25 years, he presented with headaches and left hemiparesis. Computerised tomograph demonstrated a large, enhancing right-sided intracranial tumour. Angiography was performed and showed the right internal carotid artery was occluded. Most of the right hemisphere was supplied from the external carotid via the middle meningeal artery. The left posterior cerebral artery and the left anterior cerebral artery were absent presumably as a result of radiation-induced arteritis. A resection of an anaplastic meningioma arising from the right sphenoidal ridge was achieved. There was a rapid improvement in function and he returned to work. Vasculopathy of the large intracranial arteries has been described after high dose radiation. It may occur as in this case after moderate dose radiation. There is a correlation with meningioma. There is a possibility that large artery vasculopathy will be present in a proportion of patients irradiated for ALL. The long lag time between irradiation and the development of meningioma may mean that, as survivors of childhood ALL enter their third decade since cure, this tumour may be seen increasingly.
Chen, Yuefu; Liu, Yajie; Luo, Chenghong; Lu, Weiheng; Su, Binru
In order to identify the potential factors involved in the development of acute progressive cerebral infarction (PCI), the association between potential risk factors and extra- and intracranial arterial lesions was investigated. A total of 608 patients underwent cerebral angiography to analyze the morphological characteristics between the PCI and NPCI groups. In addition, data from numerous cases of extra- and intracranial arterial lesions were collected and compared with the control groups, and the associations between the severity of arterial lesions and the potential influential factors were analyzed. In the blood vessels responsible for cerebral infarction, various degrees of atherosclerotic plaques and stenosis were observed. Age, high-density lipoprotein (HDL) levels, glycosylated hemoglobin and blood pressure affected the degrees of hardening, plaques and stenosis. Analysis of cerebral artery stenosis revealed that age, diabetes mellitus and plasma fibrinogen were risk factors for cerebral artery stenosis, while the HDL/low density lipoprotein ratio was a protective factor. Therefore, the results of the present study indicate that the lesions of blood vessels are a major pathological change in PCI and multiple factors are involved in the pathogenesis.
Zhang, Heng-Zhu; Li, Yuping; Han, Yang; Wang, Xiaodong; She, Lei; Yan, Zhengcun; Dong, Lun
Cellular schwannoma, an unusual histological subtype of schwannoma, is a benign hypercellular variant of a peripheral nerve sheath tumor. We report a 48-year-old woman with sudden onset of paraplegia. The complete surgical resection was achieved. This is the first report about intraspinal canal cellular schwannoma following spontaneous acute hemorrhage and paraplegia.
Shen, Tao; Baker, Keith
Venous return is a major determinant of cardiac output. Adjustments within the venous system are critical for maintaining venous pressure during loss in circulating volume. This article reviews two factors that are thought to enable the venous system to compensate during acute hemorrhage: 1) changes in venous elastance and 2) mobilization of…
Kang, M. H.; Park, H. M.
Two dogs with generalized seizures were evaluated. The dogs were diagnosed with traumatic intracranial hemorrhages based on the history, neurological examinations, and magnetic resonance imaging (MRI) of the brain. Treatment was started with oxygen, prednisolone and anticonvulsant agents. No further seizure activity was observed after treatment in both dogs, however cushing reflex was detected in case 1 and a left-sided hemi-paresis was detected in case 2. Further supportive treatment with recombinant human granulocyte colony-stimulating factor (rhG-CSF) was attempted. No abnormal signs were noted in either of the dogs and no recurrence was noted 16 and 14 months later, in case 1 and 2, respectively. These cases indicate that a combination of rhG-CSF treatment with previous therapy could be used in dogs with traumatic brain injury. PMID:27656233
O'Donnell, C. P.; Keil, L. C.; Thrasher, T. N.
The effect of acute cardiac nerve blockade (CNB) on the increases in plasma renin activity (PRA), arginine vasopressin (AVP), and cortisol in response to a 30 ml/kg hemorrhage was determined in conscious dogs (n = 9). Procaine was infused into the pericardial space to produce acute reversible CNB, or saline was infused in the control hemorrhage. Blood was removed from the inferior vena cava at a rate of 1 ml.kg-1.min-1. In the control hemorrhage, plasma AVP increased from 1.8 +/- 0.3 to 219 +/- 66 pg/ml, PRA increased from 0.63 +/- 0.20 to 3.08 +/- 0.91 ng angiotensin I (ANG I).ml-1.3 h-1, and cortisol increased from 1.4 +/- 0.2 to 4.0 +/- 0.7 micrograms/dl. When the hemorrhage was repeated during acute CNB, plasma AVP increased from 2.8 +/- 1.6 to 185 +/- 59 pg/ml, PRA increased from 0.44 +/- 0.14 to 2.24 +/- 0.27 ng ANG I.ml-1.3 h-1, and cortisol increased from 1.9 +/- 0.3 to 5.4 +/- 0.6 micrograms/dl, and none of the increases differed significantly from the responses during the control hemorrhage. Left atrial pressure fell significantly after removal of 6 ml/kg of blood, but mean arterial pressure was maintained at control levels until blood loss reached 20 ml/kg during pericardial infusion of either saline or procaine. The declines in MAP at the 30 ml/kg level of hemorrhage in both treatments were similar. These results demonstrate that acutely blocking input from cardiac receptors does not reduce the increases in plasma AVP, cortisol, and PRA in response to a 30 ml/kg hemorrhage. The results of this study do not support the hypothesis that input from cardiac receptors is required for a normal AVP response to hemorrhage and suggest that other receptors, presumably arterial baroreceptors, can stimulate AVP and cortisol secretion in the absence of signals from the heart.
Priest, J R; Ramsay, N K; Latchaw, R E; Lockman, L A; Hasegawa, D K; Coates, T D; Coccia, P F; Edson, J R; Nesbit, M E; Krivit, W
Sudden cerebrovascular insults occurred during or immediately following remission induction therapy in 4 children with acute lymphoblastic leukemia. In 3, cerebral infarction was due to thrombosis. In the fourth, an intracerebral hematoma developed representing either frank hemorrhaging or a hemorrhagic infarction. None of the patients had central nervous system leukemia or extreme leukocytosis at the time of diagnosis. Symptoms were obtundation, hemiparesis, seizures, and headache. The induction chemotherapy included L-asparaginase which causes deficiencies of antithrombin, plasminogen, fibrinogen, and factors IX and XI. These hemostatic abnormalities may explain the thromboses and bleeding observed in these children.
Rojas-Hernandez, Cristhiam M; Oo, Thein Hlaing; García-Perdomo, Herney Andrés
Intracranial hemorrhage (ICH) in cancer patients can result from tumor bleeding and from antitumor and anticoagulation therapy. The effect of anticoagulation on the incidence of ICH in cancer patients has not been quantified. Our objective was to determine the risk of intracranial hemorrhage associated with anticoagulation therapy for cancer-associated venous thromboembolism (VTE). Systematic review and meta-analysis of studies assessing the safety of anticoagulation therapy in patients with cancer-associated VTE. The primary endpoint of interest was the incidence of ICH and secondary outcomes included all major bleeding, and the time to ICH and major bleeding. After identifying 595 studies, five studies and 2089 patients were included in the analyses. We found that the relative risk (RR) for ICH was 0.494, 95 % CI (0.105-2.331) when low molecular weight heparin (LMWH) with vitamin K antagonist (VKA) anticoagulants were compared. No statistically significant differences in risk were measured. The risk of major bleeding using any type of anticoagulation therapy in patients with cancer-associated VTE was RR 0.853, 95 % CI (0.549, 1.327). After meta-analytic review of data published through August 2015, we conclude that therapeutic anticoagulation with LMWH given ≤6 months does not increase the risk of ICH in cancer patients compared to VKA. The risk of ICH in cancer patients is also similar to that of non-cancer patients. Available data were insufficient to determine if the ICH risk increase changes when the duration of anticoagulation is >6 months.
Jha, Vikas; Behari, Sanjay; Jaiswal, Awadhesh K.; Bhaisora, Kamlesh Singh; Shende, Yogesh P.; Phadke, Rajendra V.
Context: Concurrent arterial aneurysms (AAs) occurring in 2.7-16.7% patients harboring an arteriovenous malformation (AVM) aggravate the risk of intracranial hemorrhage. Aim: We evaluate the variations of aneurysms simultaneously coexisting with AVMs. A classification-based management strategy and an abbreviated nomenclature that describes their radiological features is also proposed. Setting: Tertiary care academic institute. Statistics: Test of significance applied to determine the factors causing rebleeding in the groups of patients with concurrent AVM and aneurysm and those with only AVMs. Subjects and Methods: Sixteen patients (5 with subarachnoid hemorrhage and 11 with intracerebral/intraventricular hemorrhage; 10 with low flow [LF] and 6 with high flow [HF] AVMs) underwent radiological assessment of Spetzler Martin (SM) grading and flow status of AA + AVM. Their modified Rankin's score (mRS) at admission was compared with their follow-up (F/U) score. Results: Pre-operative mRS was 0 in 5, 2 in 6, 3 in 1, 4 in 3 and 5 in 1; and, SM grade I in 5, II in 3, III in 3, IV in 4 and V in 1 patients, respectively. AA associated AVMs were classified as: (I) Flow-related proximal (n = 2); (II) flow-related distal (n = 3); (III) intranidal (n = 5); (IV) extra-intranidal (n = 2); (V) remote major ipsilateral (n = 1); (VI) remote major contralateral (n = 1); (VII) deep perforator related (n = 1); (VIII) superficial (n = 1); and (IX) distal (n = 0). Their treatment strategy included: Flow related AA, SM I-III LF AVM: aneurysm clipping with AVM excision; nidal-extranidal AA, SM I-III LF AVM: Excision or embolization of both AA + AVM; nidal-extranidal and perforator-related AA, SM IV-V HF AVM: Only endovascular embolization or radiosurgery. Surgical decision-making for remote AA took into account their ipsilateral/contralateral filling status and vessel dominance; and, for AA associated with SM III HF AVM, it varied in each patient based on diffuseness of AVM nidus, flow
Kuchuloria, Tinatin; Imnadze, Paata; Chokheli, Maiko; Tsertsvadze, Tengiz; Endeladze, Marina; Mshvidobadze, Ketevan; Clark, Danielle V; Bautista, Christian T; Abdel Fadeel, Moustafa; Pimentel, Guillermo; House, Brent; Hepburn, Matthew J; Wölfel, Silke; Wölfel, Roman; Rivard, Robert G
Minimal information is available on the incidence of Crimean-Congo hemorrhagic fever (CCHF) virus and hantavirus infections in Georgia. From 2008 to 2011, 537 patients with fever ≥ 38°C for ≥ 48 hours without a diagnosis were enrolled into a sentinel surveillance study to investigate the incidence of nine pathogens, including CCHF virus and hantavirus. Of 14 patients with a hemorrhagic fever syndrome, 3 patients tested positive for CCHF virus immunoglobulin M (IgM) antibodies. Two of the patients enrolled in the study had acute renal failure. These 2 of 537 enrolled patients were the only patients in the study positive for hantavirus IgM antibodies. These results suggest that CCHF virus and hantavirus are contributing causes of acute febrile syndromes of infectious origin in Georgia. These findings support introduction of critical diagnostic approaches and confirm the need for additional surveillance in Georgia.
Goonasekera, Chulananda; Bedford, James; Harpreet, Sodhi; Giombini, Mariangela; Sheikh, Asme
A previously healthy 1-year-old child with a traumatic acute subdural hemorrhage received 10 times higher dose of hypertonic saline inadvertently immediately before surgery. This case report describes deviations in fluid management needed to alleviate salt toxicity and its adverse effects during surgery under anesthesia perioperatively. The child made an uneventful recovery with no evident residual damage at follow-up. PMID:28217157
Van Gelder, Howard; Wu, Kim M.; Gharibian, Nayiri; Patel, Dharmi B.; Clements, Philip J.; Heinze, Emil R.; Morris, Robert I.; Wong, Andrew L.
We describe two patients with dermatomyositis that presented with interstitial lung disease, positive V and Shawl sign who developed acute spontaneous abdominal/retroperitoneal bleed. Both patients expired despite aggressive treatment and resuscitation. Hemorrhagic myositis in these two patients with inflammatory myopathy is a very rare complication. The association of anti-Ro52 with this potentially very serious complication remains unclear. This potential relationship should be further evaluated in future studies. PMID:25379317
Moreno, A.J.; Byrd, B.F.; Berger, D.E.; Turnbull, G.L.
Abdominal varices consisting of a caput medusae and dilated mesenteric veins resulted in pooling of Tc-99m tagged red blood cells (RBC) within these dilated vessels in a 57-year-old man with severe Laennec's cirrhosis. The atypical radiotracer localization within the abdomen mimicked an acute gastrointestinal hemorrhage. Clinical suspicion and careful evaluation of scintigraphic gastrointestinal bleeding studies will avoid false-positive interpretations.
Rossi, S; Zanier, E; Mauri, I; Columbo, A; Stocchetti, N
OBJECTIVES—To assess the frequency of hyperthermia in a population of acute neurosurgical patients; to assess the relation between brain temperature (ICT) and core temperature (Tc); to investigate the effect of changes in brain temperature on intracranial pressure (ICP). METHODS—The study involved 20 patients (10 severe head injury, eight subarachnoid haemorrhage, two neoplasms) with median Glasgow coma score (GCS) 6. ICP and ICT were monitored by an intraventricular catheter coupled with a thermistor. Internal Tc was measured in the pulmonary artery by a Swan-Ganz catheter. RESULTS—Mean ICT was 38.4 (SD 0.8) and mean Tc 38.1 (SD 0.8)°C; 73% of ICT and 57.5% of Tc measurements were ⩾38°C. The mean difference between ICT and Tc was 0.3 (SD 0.3)°C (range −0.7 to 2.3°C) (p=0. 0001). Only in 12% of patients was Tc higher than ICT. The main reason for the differences between ICT and Tc was body core temperature: the difference between ICT and Tc increased significantly with body core temperature and fell significantly when this was lowered. The mean gradient between ICT and Tc was 0.16 (SD 0.31)°C before febrile episodes (ICT being higher than Tc), and 0.41 (SD 0.38)°C at the febrile peak (p<0.05). When changes in temperature were considered, ICT had a profound influence on ICP. Increases in ICT were associated with a significant rise in ICP, from 14.9(SD 7.9) to 22 (SD 10.4) mm Hg (p<0.05). As the fever ebbed there was a significant decrease in ICP, from 17.5 (SD 8.62) to 16 (SD 7.76) mm Hg (p=0.02). CONCLUSIONS—Fever is extremely frequent during acute cerebral damage and ICT is significantly higher than Tc. Moreover, Tc may underestimate ICT during the phases when temperature has the most impact on the intracranial system because of the close association between increases in ICT and ICP. PMID:11561026
Koivunen, Riku-Jaakko; Haapaniemi, Elena; Satopää, Jarno; Niemelä, Mika; Tatlisumak, Turgut; Putaala, Jukka
Background. Frequency and impact of medical complications on short-term mortality in young patients with intracerebral hemorrhage (ICH) have gone unstudied. Methods. We reviewed data of all first-ever nontraumatic ICH patients between 16 and 49 years of age treated in our hospital between January 2000 and March 2010 to identify medical complications suffered. Logistic regression adjusted for known ICH prognosticators was used to identify medical complications associated with mortality. Results. Among the 325 eligible patients (59% males, median age 42 [interquartile range 34–47] years), infections were discovered in 90 (28%), venous thrombotic events in 13 (4%), cardiac complications in 4 (1%), renal failure in 59 (18%), hypoglycemia in 15 (5%), hyperglycemia in 165 (51%), hyponatremia in 146 (45%), hypernatremia in 91 (28%), hypopotassemia in 104 (32%), and hyperpotassemia in 27 (8%). Adjusted for known ICH prognosticators and diabetes, the only independent complication associated with 3-month mortality was hyperglycemia (plasma glucose >8.0 mmol/L) (odds ratio: 5.90, 95% confidence interval: 2.25–15.48, P < 0.001). Three or more separate complications suffered also associated with increased mortality (7.76, 1.42–42.49, P = 0.018). Conclusions. Hyperglycemia is a frequent complication of ICH in young adults and is independently associated with increased mortality. However, multiple separate complications increase mortality even further. PMID:25722917
Loffroy, Romaric; Estivalet, Louis; Cherblanc, Violaine; Favelier, Sylvain; Pottecher, Pierre; Hamza, Samia; Minello, Anne; Hillon, Patrick; Thouant, Pierre; Lefevre, Pierre-Henri; Krausé, Denis; Cercueil, Jean-Pierre
Acute variceal hemorrhage, a life-threatening condition that requires a multidisciplinary approach for effective therapy, is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy, the presence of large esophageal varices with recent stigmata of bleeding, or fresh blood visible in the stomach with no other source of bleeding identified. Transfusion of blood products, pharmacological treatments and early endoscopic therapy are often effective; however, if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs, transjugular intrahepatic portosystemic shunt (TIPS) is recommended as rescue treatment. The TIPS represents a major advance in the treatment of complications of portal hypertension. Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS, which has a 90% to 100% success rate. However, TIPS is associated with a mortality of 30% to 50% in such a setting. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure, before the clinical condition worsens. Furthermore, admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively. This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage, particularly as a rescue therapy following failure of endoscopic approaches. PMID:24115809
Based on the analysis of heritable autoregulatory functions and adaptive developments which occur long course of in response to inner and outer environment, FCMCK therapy was first designed to mobilize the autoregulatory system and resist the stress of acute hemorrhagic cerebral stroke. In this paper, 44 cases of acute hemorrhagic cerebral stroke were treated with FCMCK therapy, with another 44 cases treated with mannitol as control. The result showed that the mortality rate of the treated group was 4.5% (2/44), significantly lower than that of the control (47.7%, 21/44, P less than 0.01). FCMCK therapy in acute hemorrhagic cerebral stroke has the following advantages: 1) effectiveness in maintenance of adequate blood pressure; 2) effectiveness in reduction of cardiac arrhythmias and other complications; 3) i.v. drip of Ca and repeated use of digitalis shows atoxic effect; and 4) respiratory failure improves without stopping i.v. drip of Mg. The mechanism of FCMCK therapy is briefly discussed by the authors.
Miyamoto, Kenji; Kozu, Seiki; Arakawa, Akiko; Tsuboi, Tatsuo; Hirao, Jun-Ichi; Ono, Kazuyuki; Arisaka, Osamu
Acute disseminated encephalomyelitis confined to the brainstem is associated with poor prognosis. We describe a case of a 10-year-old boy with acute disseminated encephalomyelitis in the brainstem that developed after influenza A infection. A 10-year-old boy presented with fever and prolonged disturbance of consciousness and was admitted to our hospital. Magnetic resonance imaging (MRI) of the midbrain, with T2-weighted and fluid-attenuated inversion recovery images, suggested acute disseminated encephalomyelitis accompanied by a brainstem lesion. Lumbar puncture showed pleocytosis and increased protein content, including myelin basic protein, interleukin-6, and immunoglobulin G, all suggestive of acute disseminated encephalomyelitis. Treatments such as methylprednisolone pulse therapy, intravenous immunoglobulin, and therapeutic hypothermia were performed. Although the patient presented with anisocoria with increased intracranial pressure monitoring during hypothermia, prompt therapy with d-mannitol and dopamine was effective. Our case results suggest that hypothermia could be included in the choice of therapy for acute disseminated encephalomyelitis with brainstem lesions.
Satoh, Etsuko; Nei, Takahito; Kuzu, Shinichi; Chubachi, Kumi; Nojima, Daisuke; Taniuchi, Namiko; Yamano, Yoshimitsu; Gemma, Akihiko
Flu vaccinations are administered worldwide every winter for prevention. We herein describe a case of acute lung injury resulting from a pathologically confirmed alveolar hemorrhage, which may have been closely related to a preceding vaccination for pandemic influenza A of 2009/10. The present patient had been hospitalized with an acute lung injury after flu vaccination one year prior to the present hospitalization, however, he received another flu vaccination. We should consider a vaccine-related adverse reaction as a potential cause of pulmonary disease if patients present with this illness during the winter season.
Timbó, Luciana Sátiro; Rosemberg, Laercio Alberto; Brandt, Reynaldo André; Peres, Ricardo Botticini; Nakamura, Olavo Kyosen; Guimarães, Juliana Frota
Lumbar synovial cysts are an uncommon cause of back pain and radiculopathy, usually manifesting with gradual onset of symptoms, secondary to involvement of the spinal canal. Rarely, intracyst hemorrhage occurs, and may acutely present as radicular - or even spinal cord - compression syndrome. Synovial cysts are generally associated with degenerative facets, although the pathogenesis has not been entirely established. We report a case of bleeding complication in a synovial cyst at L2-L3, adjacent to the right interfacet joint, causing acute pain and radiculopathy in a patient on anticoagulation therapy who required surgical resection. PMID:25628207
Castro, Pedro; Azevedo, Elsa; Serrador, Jorge; Rocha, Isabel; Sorond, Farzaneh
Background Hemorrhagic transformation and cerebral edema are feared complications of acute ischemic stroke but mechanisms are poorly understood and reliable early markers are lacking. Early assessment of cerebrovascular hemodynamics may advance our knowledge in both areas. We examined the relationship between dynamic cerebral autoregulation (CA) in the early hours post ischemia, and the risk of developing hemorrhagic transformation and cerebral edema at 24 h post stroke Methods We prospectively enrolled 46 patients from our center with acute ischemic stroke in the middle cerebral artery territory. Cerebrovascular resistance index was calculated. Dynamic CA was assessed by transfer function analysis (coherence, phase and gain) of the spontaneous blood flow velocity and blood pressure oscillations. Infarct volume, hemorrhagic transformation, cerebral edema, and white matter changes were collected from computed tomography performed at presentation and 24 h. Results At admission, phase was lower (worse CA) in patients with hemorrhagic transformation [6.6 ± 30 versus 45 ± 38°; adjusted odds ratio 0.95 (95% confidence internal 0.94–0.98), p = 0.023] and with cerebral edema [6.6 ± 30 versus 45 ± 38°, adjusted odds ratio 0.96 (0.92–0.999), p = 0.044]. Progression to edema was associated with lower cerebrovascular resistance (1.4 ± 0.2 versus 2.3 ± 1.5 mm Hg/cm/s, p = 0.033) and increased cerebral blood flow velocity (51 ± 25 versus 42 ± 17 cm/s, p = 0.033) at presentation. All hemodynamic differences resolved at 3 months Conclusions Less effective CA in the early hour post ischemic stroke is associated with increased risk of hemorrhagic transformation and cerebral edema, possibly reflecting breakthrough hyperperfusion and microvascular injury. Early assessment of dynamic CA could be useful in identifying individuals at risk for these complications. PMID:28017224
and treatment. The results generated by the search were limited to English- language articles and reviewed for relevance to our topic. The...of 23 original studies for inclusion in our review. Results Warfarin not only increases the risk of but also the severity of ICH by causing hematoma...This search resulted in a total of 382 (/29 December 2009) abstracts. Two independent reviewers (BFB, TCN) examined the abstracts and made
Robbins, Matthew S
Stabbing headache can be encountered in both primary and secondary forms, but has been infrequently reported among patients with stroke, and is not known to be associated with a small well-circumscribed brain lesion. A 95-year-old woman taking warfarin presented with the sudden onset of stabbing headache strictly in the right frontal and supraorbital regions, along with gait imbalance and dysarthria. Neuroimaging revealed a small left thalamic hematoma. This association of an acute thalamic lesion with stabbing headache in the contralateral trigeminal distribution is discussed, along with a brief review of stabbing headache occurring in cerebrovascular disease.
Santos, Emilie M. M.; Marquering, Henk A.; Berkhemer, Olvert A.; van Zwam, Wim H.; van der Lugt, Aad; Majoie, Charles B.; Niessen, Wiro J.
Background and Purpose Thrombus characterization is increasingly considered important in predicting treatment success for patients with acute ischemic stroke. The lack of intensity contrast between thrombus and surrounding tissue in CT images makes manual delineation a difficult and time consuming task. Our aim was to develop an automated method for thrombus measurement on CT angiography and validate it against manual delineation. Materials and Methods Automated thrombus segmentation was achieved using image intensity and a vascular shape prior derived from the segmentation of the contralateral artery. In 53 patients with acute ischemic stroke due to proximal intracranial arterial occlusion, automated length and volume measurements were performed. Accuracy was assessed by comparison with inter-observer variation of manual delineations using intraclass correlation coefficients and Bland–Altman analyses. Results The automated method successfully segmented the thrombus for all 53 patients. The intraclass correlation of automated and manual length and volume measurements were 0.89 and 0.84. Bland-Altman analyses yielded a bias (limits of agreement) of −0.4 (−8.8, 7.7) mm and 8 (−126, 141) mm3 for length and volume, respectively. This was comparable to the best interobserver agreement, with an intraclass correlation coefficients of 0.90 and 0.85 and a bias (limits of agreement) of −0.1 (−11.2, 10.9) mm and −17 (−216, 185) mm3. Conclusions The method facilitates automated thrombus segmentation for accurate length and volume measurements, is relatively fast and requires minimal user input, while being insensitive to high hematocrit levels and vascular calcifications. Furthermore, it has the potential to assess thrombus characteristics of low-density thrombi. PMID:25032691
Kawatani, Eri; Kishikawa, Yuki; Sankoda, Chikahiro; Kuwahara, Nobuo; Mori, Daisuke; Osoegawa, Kouichi; Matsuishi, Eijo; Gondo, Hisashi
A 64-year-old man with acute myelogenous leukemia (FAB classification, M7) in remission received consolidation chemotherapy with mitoxantrone/cytosine arabinoside. WBC counts decreased to 0/microl on day 14, and fever (39.3 degrees C) and epigastralgia developed on day 15. Cefozopran was instituted for febrile neutropenia; however, on day 16, he was found to be in cardiac arrest. CT scan on day 16 revealed subarachnoid hemorrhage. Gram-positive rods were isolated from blood cultures on day 15, and were later identified as B.cereus. He recovered transiently, but eventually died on day 19. Postmortem examination demonstrated many colonies of B. cereus in the cerebrum, cerebellum, lung, and liver. Hepatocyte necrosis was also observed in the liver. Bacterial aneurysms or septic emboli were not identified in the arachnoid vessels, but necrosis of cerebral vessels was prominent, which was considered to be the cause of subarachnoid hemorrhage. Fatal subarachnoid hemorrhage has been reported to be associated with B. cereus sepsis, which developed at nadir following chemotherapy for leukemia patients. Because of the aggressive clinical course of B. cereus sepsis, including the risk for subarachnoid hemorrhage, early treatment with effective antibiotics for B. cereus sepsis would be important in the management of leukemia patients after chemotherapy.
Osawa, Aiko; Maeshima, Shinichiro
Thalamic hemorrhages are associated with a variety of cognitive dysfunctions, and it is well known that such cognitive changes constitute a limiting factor of recovery of the activities of daily living (ADL). The relationship between cognitive dysfunction and hematomas is unclear. In this study, we investigated the relationship between aphasia/neglect and hematoma volume, hematoma type, and the ADL. One hundred fifteen patients with thalamic hemorrhage (70 men and 45 women) were studied. Their mean age was 68.9 ± 10.3 years, and patients with both left and right lesions were included. We calculated hematoma volume and examined the presence or absence of aphasia/neglect and the relationships between these dysfunctions and hematoma volume, hematoma type, and the ADL. Fifty-nine patients were found to have aphasia and 35 were found to have neglect. Although there was no relationship between hematoma type and cognitive dysfunction, hematoma volume showed a correlation with the severity of cognitive dysfunction. The ADL score and ratio of patient discharge for patients with aphasia/neglect were lower than those for patients without aphasia/neglect. We observed a correlation between the hematoma volume in thalamic hemorrhage and cognitive dysfunction. Aphasia/neglect is found frequently in patients with acute thalamic hemorrhage and may influence the ADL.
Background Recombinant factor VIIa (rFVIIa) may be used for rapid hemostasis in life-threatening hemorrhage. In warfarin-associated intracerebral hemorrhage (wICH), FVIIa use is controversial and may carry significant thromboembolic risks. We compared incidence of baseline thromboembolic risk factors and thromboembolism rates in wICH patients treated with additional rFVIIa to those treated with standard therapy of fresh frozen plasma (FFP) and vitamin K alone. Methods We identified 45 consecutive wICH patients treated with additional rFVIIa over 5-year period, and 34 consecutive wICH patients treated with standard therapy alone as comparison group. We compared the incidence of post-hemorrhage cardiac and extra-cardiac thromboembolic complications between two treatment groups, and used logistic regression to adjust for significant confounders such as baseline thromboembolic risk factors. We performed secondary analysis comparing the quantity of FFP transfused between two treatment cohorts. Results Both rFVIIa-treated and standard therapy-treated wICH patients had a high prevalence of pre-existing thromboembolic diseases including atrial fibrillation (73% vs 68%), deep venous thrombosis (DVT) or pulmonary embolism (PE) (22% vs 18%), coronary artery disease (CAD) (38% vs 32%), and abnormal electrocardiogram (EKG) (78% vs 85%). Troponin elevation following wICH was prevalent in both groups (47% vs 41%). Clinically significant myocardial infarction (MI), defined as troponin > 1.0 ng/dL, occurred in 13% of rFVIIa-treated and 6% of standard therapy-treated patients (p=0.52). Past history of CAD (p=0.0061) and baseline abnormal EKG (p=0.02) were independently associated with clinically significant MI following wICH while rFVIIa use was not. The incidences of DVT/PE (2% vs 9%; p=0.18) and ischemic stroke (2% vs 0%; p=0.38) were similar between two treatment groups. Recombinant FVIIa-treated patients had lower mean INR at 3 (p=0.0001) and 6 hours (p<0.0001) and received
Frič, Radek; Hald, John K.; Antal, Ellen-Ann
BACKGROUND AND STUDY OBJECT We report an unusual case of a benign lateral sphenoid wing meningioma that presented with, and was masked by, an acute intracerebral hemorrhage. CASE REPORT A 68-year-old woman was admitted after sudden onset of coma. Computed tomography (CT) revealed an intracerebral hemorrhage, without any underlying vascular pathology on CT angiography. During the surgery, we found a lateral sphenoid wing meningioma with intratumoral bleeding that extended into the surrounding brain parenchyma. RESULTS We removed the hematoma and resected the tumor completely in the same session. The histopathological classification of the tumor was a WHO grade I meningothelial meningioma. The patient recovered very well after surgery, without significant neurological sequelae. CONCLUSIONS: Having reviewed the relevant references from the medical literature, we consider this event as an extremely rare presentation of a benign sphenoid wing meningioma in a patient without any predisposing medical factors. The possible mechanisms of bleeding from this tumor type are discussed. PMID:27127413
Reddy, Subhash; Sharma, Rohit; Grotts, Jonathan; Ferrigno, Lisa; Kaminski, Stephen
Antiplatelet and anticoagulant medication increases the risk of intracranial hemorrhage (ICH) after a fall in geriatric patients. We sought to determine whether there were differences in ICH rates and outcomes based on type of anticoagulant or antiplatelet agent after a ground-level fall (GLF). Our institutional trauma registry was used to identify patients 65 years old or older after a GLF while taking warfarin, clopidogrel, or aspirin over a 2-year period. Rates and types of ICH and patient outcomes were evaluated. Of 562 patients who met inclusion and exclusion criteria, 218 (38.8%) were on warfarin, 95 (16.9%) were on clopidogrel, and 249 (44.3%) were on aspirin. Overall ICH frequency was 15 per cent with no difference in ICH rate, type of ICH, need for craniotomy, mortality, or intensive care unit or hospital length of stay between groups. Patients with ICH were more likely to present with abnormal Glasgow Coma Score, history of hypertension, and/or loss of consciousness.
Solodov, A A; Petrikov, S S; Klychnikova, E V; Tazina, E V; Krylov, V V; Godkov, M A; Khamidova, L T
The development of cerebral vasospasm in subarachnoid hemorrhage (SAH) due to cerebral aneurysms rupture results in cerebral circulation disturbances. Application of normobaric hyperoxia can be an effective way for improving of oxygen delivery to injured brain tissues. The purpose of this study was to assess of normobaric hyperoxia influence on intracranial pressure (ICP), cerebral oxygenation and metabolism, oxidative stress and endogenous factors of vascular regulation in II critically ill patients with nontraumatic SAH due to cerebral aneurysms rupture. Increase of FiO2 from 0.3 to 0.5 and 1.0 was accompanied with brain oxygen tension (PbrO2) increase and cerebral extraction ratio for oxygen (O2ER) decrease. Application of normobaric hyperoxia had no effect on ICP, cerebral perfusion pressure, arterial blood pressure and cerebral metabolism. The results obtained from patients with nontraumatic SAH showed an evident increase of oxidative stress which had a significant effect on vascular endothelial function, causing an imbalance in the endogenous regulation of vascular tone. Application of normobaric hyperoxia was not accompanied by an increase of free-radical processes in critically ill patients with nontraumatic SAH due to cerebral aneurysms rupture.
Yin, Xiao-ping; Chen, Zhi-ying; Zhou, Jun; Wu, Dan; Bao, Bing
Background It has been found that nuclear factor erythroid 2-related factor 2/antioxidant response element (Nrf2–ARE) signaling pathway plays a role in antioxidative response, anti-inflammatory response, and neuron-protection in intracerebral hemorrhage (ICH). The aim of this study is to explore mechanisms underlying the perifocal neuroprotective effect of the Nrf2–ARE signaling pathway after ICH. Methods There were a total of 90 rats with basal ganglia hemorrhage, which were randomly divided into the following four groups: ICH (Sprague–Dawley rats with autologous femoral arterial blood injection into the basal ganglia), sulforaphane (SFN) (SFN was intraperitoneally administered into rats), retinoic acid (RA) (RA was intraperitoneally administered into rats), and dimethyl sulfoxide (the rats were treated with dimethyl sulfoxide). We observed the neurological score of the rats in the different groups, and collected brain tissues for immunofluorescence, Western blot, and reverse transcription polymerase chain reaction to detect expression of Nrf2, heme oxygenase (HO-1), nuclear factor-κB (NF-κB), and tumor necrosis factor-α (TNF-α). Results The results indicated that neurological dysfunction of rats was significantly improved in the SFN group, and the expressions of Nrf2 and HO-1 in tissues surrounding the hemorrhage were increased. Also, the level of NF-κB and TNF-α were reduced compared to the ICH group. The RA group exhibited more severe neurological dysfunction and lower levels of Nrf2 and HO-1 than the SFN and ICH groups. Compared to the ICH group, the NF-κB and TNF-α expression in the RA groups was increased. In conclusion, RA inhibits Nrf2 dissociation and translocation into nucleus, thereby suppressing the anti-inflammatory effect of Nrf2–ARE signaling pathway. The activation of Nrf2–ARE signaling pathway by SFN can elevate expression of antioxidant enzyme HO-1, reduce perifocal inflammatory response after ICH, and thus may play a
Yoshida, Masahiro; Yamakawa, Hideaki; Yabe, Masami; Ishikawa, Takeo; Takagi, Masamichi; Matsumoto, Kei; Hamaguchi, Akihiko; Ogura, Makoto; Kuwano, Kazuyoshi
We herein report a case of pulmonary renal syndrome with nephritis in a 17-year-old boy with diffuse alveolar hemorrhage (DAH) associated with acute poststreptococcal glomerulonephritis (APSGN). The patient exhibited hemoptysis two weeks after developing impetigo, and DAH was diagnosed on bronchoscopy. Respiratory failure progressed, and high-dose methylprednisolone therapy was administered; the respiratory failure regressed immediately after the onset of therapy. Streptococcus pyogenes was detected in an impetigo culture, and, together with the results of the renal biopsy, a diagnosis of APSGN was made. This case demonstrates the effects of high-dose methylprednisolone therapy in improving respiratory failure.
Louagie, Y; Hancotte-Lahaye, C; Delloye, C; Mairy, Y; De Muylder, C
The effect of phenylbutazone on acute experimental pancreatitis was investigated in the rat. Severe necrotico-hemorrhagic pancreatitis was produced by intraductal injection of trypsin. Pretreatment by phenylbutazone did not alter the mortality rate but reduced the severity of pancreatitis as was demonstrated by histological quantification (total score 13.35 +/- 0.80 in treated rats versus 17.67 +/- 0.69 in the control group; P less than 0.01). The protective effect of phenylbutazone seems to be related to the specific anti-inflammatory properties of the drug and not to inhibition of prostaglandin synthesis.
Matveev, S B; Marchenko, V V; Golikov, P P
The accumulation of lipid peroxidation (LP) products and decrease of alpha-tocopherol (TP) content were demonstrable in the heart, lungs, kidneys and liver after acute blood loss. Injection of TP acetate inhibited LP and raised the content of endogenous TP in the heart, lungs and liver. The antioxidant emoxypin increased the reduced oxygen tension in the liver and kidneys after blood loss. The drug prevented the reduction of the glucocorticoid type II receptor level and increased the content of the type III receptors in liver cytosol of hemorrhagic animals.
Fomin, P D; Zaplavskiĭ, A V; Ivanchov, P V; Peresh, E E; Lissov, A I; Tikhonenko, A M
The experience of solcoseryl application in 70 patients, operated on for an acute hemorrhage from gastroduodenal ulcer, was summarized. The preparation was injected intravenously in the dose of 10 ml in 5% solution of glucose every other day during 6 days and then in the dose of 5 ml intramuscularly during 4-5 days. High efficacy of solcoseryl, manifesting by more earlier elimination of pain and oedema, healing of mucosa by first intention, shortening of the treatment duration in stationary by 3-5 days, was established.
Muraoka, Yuki; Uji, Akihito; Tsujikawa, Akitaka; Murakami, Tomoaki; Ooto, Sotaro; Suzuma, Kiyoshi; Takahashi, Ayako; Iida, Yuto; Miwa, Yuko; Hata, Masayuki; Yoshimura, Nagahisa
This prospective study included 63 eyes with acute branch retinal vein occlusion (BRVO) to evaluate the retinal hemorrhagic patterns at the posterior poles and explore their clinical relevance in macular perfusion differentiation. Retinal hemorrhagic patterns and macular perfusion status were evaluated via fundus photography and fluorescein angiography, respectively. Macular perfusion was judged as nonischemic in 30, ischemic in 28, and undeterminable in 5 among the 63 eyes. Predominant hemorrhagic patterns were flame-shaped in 39 (67.2%) and non-flame-shaped in 19 (32.8%) eyes. All 39 eyes with a flame-shaped hemorrhage showed a nonischemic macula. Of the 19 eyes classified as having a non-flame-shaped hemorrhage, 13 (68.4%) had an ischemic macula and 6 (31.6%) had a nonischemic macula (P < 0.001). Parallelism in eyes with a flame-shaped hemorrhage was higher than in those with a non-flame-shaped hemorrhage (P < 0.001), and in those with a nonischemic macula versus those with an ischemic macula (P < 0.001). The area under the curve for parallelism was 0.975 (P < 0.001), suggesting an accurate diagnostic parameter for macular perfusion differentiation. In conclusion, we objectively evaluated retinal hemorrhagic patterns at the posterior pole in BRVO using the parallelism method, which was useful in differentiating macular perfusion status. PMID:27334338
Foerch, Christian; Rosidi, Nathanael L.; Schlunk, Frieder; Lauer, Arne; Cianchetti, Flor A.; Mandeville, Emiri; Arai, Ken; Yigitkanli, Kazim; Fan, Xiang; Wang, Xiaoying; van Leyen, Klaus; Steinmetz, Helmuth; Schaffer, Chris B.; Lo, Eng H.
Tissue plasminogen activator (tPA) is the only FDA-approved treatment for reperfusing ischemic strokes. But widespread use of tPA is still limited by fears of inadvertently administering tPA in patients with intracerebral hemorrhage (ICH). Surprisingly, however, the assumption that tPA will worsen ICH has never been biologically tested. Here, we assessed the effects of tPA in two models of ICH. In a mouse model of collagenase-induced ICH, hemorrhage volumes and neurological deficits after 24 hrs were similar in saline controls and tPA-treated mice, whereas heparin-treated mice had 3-fold larger hematomas. In a model of laser-induced vessel rupture, tPA also did not worsen hemorrhage volumes, while heparin did. tPA is known to worsen neurovascular injury by amplifying matrix metalloproteinases during cerebral ischemia. In contrast, tPA did not upregulate matrix metalloproteinases in our mouse ICH models. In summary, our experimental data do not support the assumption that intravenous tPA has a deleterious effect in acute ICH. However, due to potential species differences and the inability of models to fully capture the dynamics of human ICH, caution is warranted when considering the implications of these findings for human therapy. PMID:23408937
Foerch, Christian; Rosidi, Nathanael L; Schlunk, Frieder; Lauer, Arne; Cianchetti, Flor A; Mandeville, Emiri; Arai, Ken; Yigitkanli, Kazim; Fan, Xiang; Wang, Xiaoying; van Leyen, Klaus; Steinmetz, Helmuth; Schaffer, Chris B; Lo, Eng H
Tissue plasminogen activator (tPA) is the only FDA-approved treatment for reperfusing ischemic strokes. But widespread use of tPA is still limited by fears of inadvertently administering tPA in patients with intracerebral hemorrhage (ICH). Surprisingly, however, the assumption that tPA will worsen ICH has never been biologically tested. Here, we assessed the effects of tPA in two models of ICH. In a mouse model of collagenase-induced ICH, hemorrhage volumes and neurological deficits after 24 hrs were similar in saline controls and tPA-treated mice, whereas heparin-treated mice had 3-fold larger hematomas. In a model of laser-induced vessel rupture, tPA also did not worsen hemorrhage volumes, while heparin did. tPA is known to worsen neurovascular injury by amplifying matrix metalloproteinases during cerebral ischemia. In contrast, tPA did not upregulate matrix metalloproteinases in our mouse ICH models. In summary, our experimental data do not support the assumption that intravenous tPA has a deleterious effect in acute ICH. However, due to potential species differences and the inability of models to fully capture the dynamics of human ICH, caution is warranted when considering the implications of these findings for human therapy.
Lin, L S; Shih, C J
This paper analyzes the available literature on intracranial arteriovenous malformations (AVM) in Taiwan. The incidence and symptoms of the disease are studied with a view to assisting practitioners in its recognition. The incidence of intracranial AVM in patients who have suffered hemorrhagic stroke in Taiwan is 2.5% to 4.8%, with the male to female ratio being 1.5:1. The peak age at which bleeding from intracranial AVM occurred ranged from 10 to 40 years; bleeding showed no seasonal variation. Sudden headaches, vomiting, and disturbance of consciousness were the commonest presenting symptoms of AVM, similar to the rupture of intracranial aneurysms. However, the possibility of focal neurological deficit among patients with intracranial AVM was higher than in patients with intracranial aneurysms. Risk factors, such as hypertension, diabetes mellitus, heart disease, smoking and alcohol intake showed no close relationship to bleeding in intracranial AVM. Pregnancy is not a risk factor in female patients with intracranial AVM with no history of hemorrhage. Small intracranial AVM are more likely to bleed. Since 1961 the majority of Taiwan's intracranial AVM patients have been treated surgically, while before that date general medicine was the treatment of choice. In recent years, several developments such as operation microscope, microsurgical instruments and microsurgical techniques have enhanced the efficacy of surgical intervention in the treatment of AVM. When the mortality and morbidity rates resulting from the two forms of treatment are compared, surgical treatment shows a better prognosis for the treatment of intracranial AVM.
Wrubel, Gregory L
As acute symmetric lesions of deep gray nuclei are often associated with an impaired level of consciousness and neuroimaging by itself cannot distinguish between etiologies, diagnosis may be problematic. Appreciation of the cause of the various neuroimaging patterns in conjunction with the history, examination and laboratory investigations allows for accurate diagnosis in the vast majority of cases. Given the metabolic vulnerability of deep gray nuclei, other than bi-thalamic infarction, it follows that toxic-metabolic and hypoxic-ischemic events account for the majority of cases. Nevertheless, the differential diagnosis is broad and diverse. We here describe two cases of bilateral pallidal hemorrhage in AIDS-associated toxoplasmosis, and review conditions recently described with acute symmetric deep gray nuclei lesions on neuroimaging. PMID:26427898
Xu, Qian; Wei, Yi-ting; Fan, Shuang-bo; Wang, Liang; Zhou, Xiao-ping
Aim The role of hyperbaric oxygen therapy (HBOT) in the treatment of acute ischemic stroke is controversial. This study aims to investigate whether the peripheral insulin sensitivity of type 2 diabetes patients suffering from intracerebral hemorrhage can be increased after HBOT. Methods Fifty-two type 2 diabetes participants were recruited after being diagnosed with intracerebral hemorrhage in our hospital. Insulin sensitivity was measured by the glucose infusion rate during a hyperinsulinemic euglycemic clamp (80 mU m−2 min−1) at baseline and 10 and 30 days after HBOT sessions. Serum insulin, fasting glucose, and hemoglobin A1C were measured in fasting serum at baseline and after HBOT sessions. In addition, early (∼10 days after onset) and late (1 month after onset) outcomes (National Institutes of Health Stroke Scale, NIHSS scores) and efficacy (changes of NIHSS scores) of HBOT were evaluated. Results In response to HBOT, the glucose infusion rate was increased by 37.8%±5.76% at 1 month after onset compared with baseline. Reduced serum insulin, fasting glucose, and hemoglobin A1C were observed after HBOT. Both early and late outcomes of the HBOT group were improved compared with baseline (P<0.001). In the control group, there was significant difference only in the late outcome (P<0.05). In the assessment of efficacy, there were statistically significant differences between the groups when comparing changes in NIHSS scores at 10 days and 1 month after onset (P<0.05). Conclusion Peripheral insulin sensitivity was increased following HBOT in type 2 diabetes patients with intracerebral hemorrhage. The HBOT used in this study may be effective for diabetes patients with acute stroke and is a safe and harmless adjunctive treatment. PMID:28228657
Zimmerer, Rüdiger; Schattmann, Katrin; Essig, Harald; Jehn, Philipp; Metzger, Marc; Kokemüller, Horst; Gellrich, Nils-Claudius; Tavassol, Frank
Decreasing visual acuity secondary to orbital trauma may be caused by sudden space-occupying or expanding intraorbital lesions, including retrobulbar hemorrhage (RBH), herniation, or swelling. RBH must be diagnosed and treated immediately. This article addresses the efficacy of transcutaneous transseptal orbital decompression in a combination with a systematic review of the literature for a comparison of this method with existing treatment options. For this study the department's database was retrospectively screened for patients with acute RBH who were treated between 2009 and 2011 using the authors' approach. Patients presenting with RBH were classified into RBH classes I to III according to three different clinical and radiological manifestations of acute RBH. The efficacy of transcutaneous transseptal orbital decompression was assessed by postoperative visual acuities. The literature review was performed by using the MEDLINE database. The time period for the study was between 2009 and 2011 during which 10 patients were diagnosed with suspected RBH and 9 were treated with the authors' technique. Visual acuities were reconstituted or maintained in almost 86% of patients who were diagnosed and treated according to the authors approach and who survived initial trauma. It was concluded that transcutaneous transseptal orbital decompression provides an efficient and rapid approach for treating patients with acute RBH. By distinguishing three different manifestations of acute RBH, the authors present a diagnostic tool that may facilitate classification of RBH and determination of treatment options. PMID:24624253
Scalzo, Fabien; Alger, Jeffry R.; Hu, Xiao; Saver, Jeffrey L.; Dani, Krishna A.; Muir, Keith W.; Demchuk, Andrew M.; Coutts, Shelagh B.; Luby, Marie; Warach, Steven; Liebeskind, David S.
Permeability images derived from magnetic resonance (MR) perfusion images are sensitive to blood-brain barrier derangement of the brain tissue and have been shown to correlate with subsequent development of hemorrhagic transformation (HT) in acute ischemic stroke. This paper presents a multi-center retrospective study that evaluates the predictive power in terms of HT of six permeability MRI measures including contrast slope (CS), final contrast (FC), maximum peak bolus concentration (MPB), peak bolus area (PB), relative recirculation (rR), and percentage recovery (%R). Dynamic T2*-weighted perfusion MR images were collected from 263 acute ischemic stroke patients from four medical centers. An essential aspect of this study is to exploit a classifier-based framework to automatically identify predictive patterns in the overall intensity distribution of the permeability maps. The model is based on normalized intensity histograms that are used as input features to the predictive model. Linear and nonlinear predictive models are evaluated using a crossvalidation to measure generalization power on new patients and a comparative analysis is provided for the different types of parameters. Results demonstrate that perfusion imaging in acute ischemic stroke can predict HT with an average accuracy of more than 85% using a predictive model based on a nonlinear regression model. Results also indicate that the permeability feature based on the percentage of recovery performs significantly better than the other features. This novel model may be used to refine treatment decisions in acute stroke. PMID:23587928
Wang, Hai-Qiao; Bao, Chun-Ling; Jiao, Zhi-Hua; Dong, Gui-Rong
Abstract Background: Acupuncture, especially acupuncture treatment on head for acute intracerebral hemorrhage (ICH), has long been disputable. The aim of this study was to evaluate the efficacy and safety of penetration acupuncture on head in patients with acute ICH. Methods: Eighty-two patients with acute ICH were randomized to receive penetration acupuncture treatment on head combined with conventional treatment (treatment group [TG]) or conventional treatment only (control group [CG]). Acupuncture treatments were given in 24 sessions over 4 weeks, with 3-month follow-up period. Measures included Clinical Neurological Function Deficit Scale (CNFDS), Barthel Index (BI), vital signs (respiration, heart rate, blood pressure, and oxygen saturation), and hematoma absorption ratio. Results: Both groups showed a progressively improvement in CNFDS and BI scores from day 7 to 90. The TG showed a significantly greater improvement in CNFDS than CG over time (P < 0.05). However, BI failed to show significant difference between the 2 groups (P > 0.05). The vital signs were stable and no expansion of hematoma occurred over the course of acupuncture treatment. Conclusion: Penetration acupuncture treatment on head appeared to be safe over the course of treatment on acute ICH and may result in additional functional improvements detected in the CNFDS but not reflected in the BI. A larger-scale clinical trial with longer follow-up assessments is required to confirm these findings. PMID:27902622
Koga, Masatoshi; Toyoda, Kazunori; Naganuma, Masaki; Kario, Kazuomi; Nakagawara, Jyoji; Furui, Eisuke; Shiokawa, Yoshiaki; Hasegawa, Yasuhiro; Okuda, Satoshi; Yamagami, Hiroshi; Kimura, Kazumi; Okada, Yasushi; Minematsu, Kazuo
Acute hypertension is associated with hematoma enlargement and poor clinical outcomes in patients with intracerebral hemorrhage (ICH). However, the method of controlling blood pressure (BP) during the acute phase of ICH remains unknown. The aim of this study is to show current strategies about this issue in Japan. Questionnaires regarding antihypertensive treatment (AHT) strategies were sent to neurosurgeons, neurologists and others responsible for ICH management in 1424 hospitals. Of 600 respondents, 550 (92%) worked at hospitals wherein acute ICH patients are managed and 548 (99.6%) of them agreed with the application of AHT within 24 h of ICH onset. Most answered that the systolic BP threshold for starting AHT was 180 mm Hg (36%) or 160 mm Hg (31%), which differed significantly between neurosurgeons (median, 160 mm Hg) and neurologists/others (180 mm Hg, P<0.001). The goal of lowering systolic BP was to reach a maximum of 140, 150 or 160 mm Hg according to 448 respondents (82%) and 209 (38%) intensively lowered systolic BP to
Sterling, Sarah A.; Jones, Alan E.; Coleman, Thomas G.; Summers, Richard L.
Background: Evidence suggests that morbid obesity may be an independent risk factor for adverse outcomes in patients with traumatic injuries. Objectives: In this study, a theoretic analysis using a derivation of the Guyton model of cardiovascular physiology examines the expected impact of obesity on hemodynamic changes in Mean Arterial Pressure (MAP) and Cardiac Output (CO) during Hemorrhagic Shock (HS). Patients and Methods: Computer simulation studies were used to predict the relative impact of increasing Body Mass Index (BMI) on global hemodynamic parameters during HS. The analytic procedure involved recreating physiologic conditions associated with changing BMI for a virtual subject in an In Silico environment. The model was validated for the known effect of a BMI of 30 on iliofemoral venous pressures. Then, the relative effect of changing BMI on the outcome of target cardiovascular parameters was examined during simulated acute loss of blood volume in class II hemorrhage. The percent changes in these parameters were compared between the virtual nonobese and obese subjects. Model parameter values are derived from known population distributions, producing simulation outputs that can be used in a deductive systems analysis assessment rather than traditional frequentist statistical methodologies. Results: In hemorrhage simulation, moderate increases in BMI were found to produce greater decreases in MAP and CO compared to the normal subject. During HS, the virtual obese subject had 42% and 44% greater falls in CO and MAP, respectively, compared to the nonobese subject. Systems analysis of the model revealed that an increase in resistance to venous return due to changes in intra-abdominal pressure resulting from obesity was the critical mechanism responsible for the differences. Conclusions: This study suggests that obese patients in HS may have a higher risk of hemodynamic instability compared to their nonobese counterparts primarily due to obesity
Gao, Billy; Pollock, Jeffrey A; Hinson, Holly E
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. PMID:24904923
Zhao, Zi-Gang; Zhu, Hong-Xia; Zhang, Li-Min; Zhang, Yu-Ping; Niu, Chun-Yu
This study aimed to investigate the effect of mesenteric lymph drainage on the acute kidney injury induced by hemorrhagic shock without resuscitation. Eighteen male Wistar rats were randomly divided into sham, shock, and drainage groups. The hemorrhagic shock model (40 mmHg, 3 h) was established in shock and drainage groups; mesenteric lymph drainage was performed from 1 h to 3 h of hypotension in the drainage group. The results showed that renal tissue damage occurred; the levels of urea, creatinine, and trypsin in the plasma as well as intercellular adhesion molecule-1 (ICAM-1), receptor of advanced glycation end-products (RAGE), tumor necrosis factor-α (TNF-α), malondialdehyde (MDA), lactic acid (LA), and 2,3-DPG in the renal tissue were increased in the shock group after 3 h of hypotension. Mesenteric lymph drainage lessened the following: renal tissue damage; urea and trypsin concentrations in the plasma; ICAM-1, RAGE, TNF-α, MDA, and LA levels in the renal tissue. By contrast, mesenteric lymph drainage increased the 2,3-DPG level in the renal tissue. These findings indicated that mesenteric lymph drainage could relieve kidney injury caused by sustained hypotension, and its mechanisms involve the decrease in trypsin activity, suppression of inflammation, alleviation of free radical injury, and improvement of energy metabolism.
Yang, Qingwei; Zhuang, Xiaorong; Peng, Feng; Zheng, Weihong
In the present study, we aimed to investigate the relationship of plasma matrix metalloproteinase-9 (MMP-9) and hematoma expansion (HE) in acute hypertensive cerebral hemorrhage (AHCH) (HE-in-AHCH). Patients with hypertensive cerebral hemorrhage, confirmed by head computed tomography (CT) within 12 h of onset, were prospectively collected. Venous blood was sampled within 4 h of the confirmation to determine the serum MMP-9 concentration. The blood pressure and National Institute of Health Stroke Score of the patients were recorded on hospital admission. CT re-scanning was performed within 42-54 h of the first head CT examination or immediately after worsening of the patients' consciousness disorder. The relationship between MMP-9 level and HE was analyzed. A total of 186 patients were included. Of these patients, 41 had HE (22.0%). Multivariate logistic regression analysis showed that, in addition to the short interval between onset and the first CT examination, and the irregularity of hematoma shape, increasing MMP-9 level was an independent risk factor for HE-in-AHCH (OR value = 15.65, 95% CI: 5.30-46.15). Moreover, increasing plasma MMP-9 level was identified as an independent risk factor in patients with HE-in-AHCH.
Cetas, J S; Lee, D R; Alkayed, N J; Wang, R; Iliff, J J; Heinricher, M M
Symptomatic ischemia following aneurysmal subarachnoid hemorrhage (SAH) is common but poorly understood and inadequately treated. Severe constriction of the major arteries at the base of the brain, termed vasospasm, traditionally has been thought to be a proximal event underlying these ischemias, although microvascular changes also have been described. The vast majority of studies aimed at understanding the pathogenesis of ischemic deficits, and vasospasm have focused on the interaction of the "spasmogen" of the extravasated blood with the smooth muscle and endothelium of the arteries. This has led to a comparative neglect of the contribution of the CNS to the maintenance of cerebral perfusion. In the present study, we focused on the role of the rostral ventromedial medulla (RVM) in modulating cerebral perfusion at rest and following an experimental SAH in the rat. Changes in cerebral blood flow (CBF) were measured using laser-Doppler flowmetry and three-dimensional optical microangiography. Focal application of a GABA(A) receptor agonist and antagonist was used to respectively inactivate and activate the RVM. We show here that the RVM modulates cerebral blood flow under resting conditions, and further, contributes to restoration of cerebral perfusion following a high-grade SAH. Failure of this brainstem compensatory mechanism could be significant for acute perfusion deficits seen in patients following subarachnoid hemorrhage.
ÖCEK, Levent; GÜNER, Derya; ULUDAĞ, İrem Fatma; TİFTİKÇİOĞLU, Bedile İrem; ZORLU, Yaşar
Introduction Hemorrhagic transformation (HT) after acute ischemic stroke (AIS) can be seen at any time following ischemic stroke. Although HT usually occurs as a complication of antithrombotic, anticoagulant, or thrombolytic treatments, it can also occur spontaneously. We aimed to investigate the occurrence of early HT and its relevant risk factors in patients diagnosed with acute middle cerebral artery (MCA) infarction who were not treated with thrombolytic agents. Methods We recruited 171 patients with acute MCA infarction between January 2011 and July 2012 who were not treated with thrombolytic agents and were suitable to our inclusion criteria. Controlled neuroimaging was performed immediately in patients with deterioration, otherwise on day 7 following stroke. All patients were investigated for AIS risk factors and biochemical analyses were performed. Patients with HT in controlled neuroimaging were grouped both clinically (i.e., symptomatic or asymptomatic) and radiologically, according to “European Cooperative Acute Stroke Radiological Study” (ECASS), and risk factors were examined. Results We enrolled 171 patients [94 men (55%) and 77 women (45%)] in the study. HT developed in 37 patients (21.63%). In terms of risk factor analysis, the most frequent etiological factor was atherosclerosis in AIS patients (50.3%). National Institutes of Health Stroke Scale scores were significantly higher both in sHT patients according to asHT patients and in HT patients on day 7 compared with their initial scores. Serum low-density lipoprotein (LDL-C), triglycerides (TG), and total cholesterol (TC) levels were significantly lower in patients with HT (p<.001). Conclusion HT is a major complication in AIS that considerably increases the morbidity and mortality. To reduce the occurrence of HT, risk factors for each patient population should be determined. Acute thrombolytic therapy should be used cautiously in high-risk patients, and appropriate alternative therapies should
Chambliss, Jeffrey M.
Purpura, particularly when accompanied by fever, is a worrisome finding in children. Acute hemorrhagic edema of infancy (AHEI) is a benign type of small-vessel leukocytoclastic vasculitis that presents with progressive purpura and has an excellent prognosis. Patients with AHEI present with large, target-like purpuric plaques affecting the face, ear lobes, and extremities. While the rapid onset of these skin findings can be dramatic, the child with AHEI is usually well appearing with reassuring laboratory testing. We describe a case of a previously healthy 8-month-old female who presented with progressive purpura in a nondependent distribution, low-grade fevers, and extremity swelling. An extensive workup was performed prior to making the diagnosis of AHEI. Coronavirus was implicated as the likely triggering pathogen, and the patient suffered a recurrence of purpuric rash and swelling several weeks after her initial presentation. PMID:28243478
Kameneva, Marina V; Wu, Zhongjun J; Uraysh, Arkady; Repko, Brandon; Litwak, Kenneth N; Billiar, Timothy R; Fink, Mitchell P; Simmons, Richard L; Griffith, Bartley P; Borovetz, Harvey S
Over the past several decades, blood-soluble drag reducing polymers (DRPs) have been shown to significantly enhance hemodynamics in various animal models when added to blood at nanomolar concentrations. In the present study, the effects of the DRPs on blood circulation were tested in anesthetized rats exposed to acute hemorrhagic shock. The animals were acutely resuscitated either with a 2.5% dextran solution (Control) or using the same solution containing 0.0005% or 5 parts per million (ppm) concentration of one of two blood soluble DRPs: high molecular weight (MW=3500 kDa) polyethylene glycol (PEG-3500) or a DRP extracted from Aloe vera (AVP). An additional group of animals was resuscitated with 0.0075% (75 ppm) polyethylene glycol of molecular weight of 200 kDa (PEG-200), which possesses no drag-reducing ability. All of the animals were observed for two hours following the initiation of fluid resuscitation or until they expired. We found that infusion of the DRP solutions significantly improved tissue perfusion, tissue oxygenation, and two-hour survival rate, the latter from 19% (Control) and 14% (PEG-200) to 100% (AVP) and 100% (PEG-3500). Furthermore, the Control and PEG-200 animals that survived required three times more fluid to maintain their blood pressure than the AVP and PEG-3500 animals. Several hypotheses regarding the mechanisms underlying these observed beneficial hemodynamic effects of DRPs are discussed. Our findings suggest that the drag-reducing polymers warrant further investigation as a potential clinical treatment for hemorrhagic shock and possibly other microcirculatory disorders.
head with subsequent traumatic subdural, subarachnoid, intraventricular, intracranial hemorrhage and diffuse edema and multiple bone fragments...subdural hematoma, and pneumocephalus, diffuse subarachnoid hemorrhage, diffuse brain edema w/ sulci and brainstem effacement, small hemorrhagic bifrontal...helmet, yet suffered a TSAH, SDH, cerebral edema , and extensive skull base fractures as demonstrated by the admit CT. After administration of mannitol
Hayashi, M.; Kobayashi, H.; Fujii, H.; Yamamoto, S.
The size of the ventricular system and cerebrospinal fluid (CSF) flow were determined in 17 patients with plateau waves, using computerized tomography (CT) and isotope cisternography. Some patients had increased intracranial pressure (ICP) resulting from space-occupying lesions and other causes, and some had normal ICP observed in normal-pressure hydrocephalus. The size and shape of the ventricular system during plateau wave phases as ascertained by CT showed little or no change as compared with its size and shape during the interval phases between two waves. It was also noticed that, in patients with supratentorial masses, the midline shift showed no difference in degree between the two phases. These findings suggest that there is little change in the intracranial CSF volume between the two phases, that is, there is little compensatory outflow of the intracranial CSF for the ICP variations. These results may also support the assumption that the plateau waves are not caused by an intermittent obstruction of the CSF pathways. Isotope cisternography showed a marked delay of clearance of radioactivity from the intracranial CSF in 15 patients. The cisternographic pattern in patients with increased ICP and the absence of ventricular dilatation demonstrated an abnormally large accumulation of radioactivity over the cerebral convexities, and the pattern in patients with normal-pressure hydrocephalus showed complete obstruction of the subarachnoid space over both cerebral convexities. These observations suggest that, in patients with plateau waves, there is a marked delay in CSF absorption. The authors postulate that the reduction of CSF absorption may create a critically tight condition within the cranial cavity and act as a contributory factor in the development of the plateau waves.
Wang, Yutang; Emeto, Theophilus I; Lee, James; Marshman, Laurence; Moran, Corey; Seto, Sai-wang; Golledge, Jonathan
Subarachnoid hemorrhage secondary to rupture of an intracranial aneurysm is a highly lethal medical condition. Current management strategies for unruptured intracranial aneurysms involve radiological surveillance and neurosurgical or endovascular interventions. There is no pharmacological treatment available to decrease the risk of aneurysm rupture and subsequent subarachnoid hemorrhage. There is growing interest in the pathogenesis of intracranial aneurysm focused on the development of drug therapies to decrease the incidence of aneurysm rupture. The study of rodent models of intracranial aneurysms has the potential to improve our understanding of intracranial aneurysm development and progression. This review summarizes current mouse models of intact and ruptured intracranial aneurysms and discusses the relevance of these models to human intracranial aneurysms. The article also reviews the importance of these models in investigating the molecular mechanisms involved in the disease. Finally, potential pharmaceutical targets for intracranial aneurysm suggested by previous studies are discussed. Examples of potential drug targets include matrix metalloproteinases, stromal cell-derived factor-1, tumor necrosis factor-α, the renin-angiotensin system and the β-estrogen receptor. An agreed clear, precise and reproducible definition of what constitutes an aneurysm in the models would assist in their use to better understand the pathology of intracranial aneurysm and applying findings to patients.
Globa, M V; Lisyanyi, M I; Tsimeyko, A; Litvak, S O
A content of C-reactive protein (CRP) in the blood serum was determined in 36 patients in acute period of a ruptured intracranial arterial aneurysm (AA). It was significantly more, than in a control group, and have exceeded 10 mg/I in 1 - 4th day of the disease. The level of CRP have had differ, depending on severity of cerebral vasospasm (CVS), determined in accordance to the ultrasound investigation data. In a pronounced CVS in majority of patients the level of CRP in the blood serum have had exceed 10 mg/l, and have secured elevated in a spinal liquor on the 7 - 10th day of the disease, differing from this index in patients with moderately pronounced CVS or without it. In patients with severe invalidization or those, who have died, the level of CRP was trust-worthy higher.
Bhatt, B D; Meriano, F V; Phipps, T L; Ho, H; Zuckerman, M J
H2-antagonists are frequently used in the management of upper gastrointestinal (UGI) hemorrhage despite their lack of proven efficacy. In order to determine the pattern of H2-antagonist usage for this indication, we retrospectively reviewed the charts of 137 patients admitted with acute UGI bleeding over a 1-year period at two teaching hospitals in West Texas. An H2-antagonist was ordered in 89% of patients (77%) intravenous, 12% oral). It was administered within 2 h of admission in 25% of these patients, within 4 h in 54%, and within 8 h in 78%. An H2-antagonist was ordered among the initial six orders in 49% and among the initial 10 orders in 77% of patients. Considering orders for specific therapies, an H2-antagonist was in the initial three orders in 60% of patients and among the initial six orders in 97%. Of the patients who were prescribed an H2-antagonist and who also had upper endoscopy, the drug was ordered prior to endoscopy in 86%. This review of H2-antagonist usage in the management of acute UGI bleeding has identified a prescribing pattern of writing for these drugs early in the sequence of order writing, with the drugs being given early in the course of hospitalization.
Lozano, J. Diego; Massari, Francesco; Howk, Mary C; de Macedo Rodrigues, Katyucia; Brooks, Christopher; Perras, Mary; Rex, David E; Wakhloo, Ajay K; Kühn, Anna Luisa
The endovascular management of acute ischemic stroke (AIS) due to emergency large vessel occlusion (ELVO) has become the standard of care after the recent publication of landmark randomized, controlled trials. Mechanical thrombectomy, in addition to intravenous thrombolysis (within 4.5 hours when eligible), is now part of the algorithm of the standard of care when treating AIS in patients with ELVO in the anterior circulation up to six hours after symptom onset. A newly introduced device, the Arc™ intracranial support catheter (Medtronic, Irvine, USA), is specifically designed for the introduction of neurointerventional devices into the cerebral vasculature and facilitates the delivery of microcatheters into smaller, more distal intracranial vessels. This technical report describes the use of the Arc™ intracranial support catheter in the setting of AIS. PMID:27382525
Lozano, J Diego; Massari, Francesco; Howk, Mary C; de Macedo Rodrigues, Katyucia; Brooks, Christopher; Perras, Mary; Rex, David E; Wakhloo, Ajay K; Kühn, Anna Luisa; Puri, Ajit S
The endovascular management of acute ischemic stroke (AIS) due to emergency large vessel occlusion (ELVO) has become the standard of care after the recent publication of landmark randomized, controlled trials. Mechanical thrombectomy, in addition to intravenous thrombolysis (within 4.5 hours when eligible), is now part of the algorithm of the standard of care when treating AIS in patients with ELVO in the anterior circulation up to six hours after symptom onset. A newly introduced device, the Arc™ intracranial support catheter (Medtronic, Irvine, USA), is specifically designed for the introduction of neurointerventional devices into the cerebral vasculature and facilitates the delivery of microcatheters into smaller, more distal intracranial vessels. This technical report describes the use of the Arc™ intracranial support catheter in the setting of AIS.
Brash, Marina L.; Nagy, Éva; Pei, Yanlong; Carman, Susy; Emery, Susan; Smith, Alec E.; Turner, Patricia V.
A 1.5-year-old female rabbit (doe) was presented with a 3-day history of lethargy, anorexia, and mild facial swelling. The animal died shortly after examination and severe, acute hemorrhagic pneumonia was noted grossly. An alphaherpesvirus consistent with leporid herpesvirus-4 was isolated and characterized from this animal. This is the first confirmed report of the disease in Canada. PMID:21358932
Qureshi, Adnan I; Palesch, Yuko Y; Barsan, William G; Hanley, Daniel F; Hsu, Chung Y; Martin, Renee L; Moy, Claudia S; Silbergleit, Robert; Steiner, Thorsten; Suarez, Jose I; Toyoda, Kazunori; Wang, Yongjun; Yamamoto, Haruko; Yoon, Byung-Woo
Background Limited data are available to guide the choice of a target for the systolic blood-pressure level when treating acute hypertensive response in patients with intracerebral hemorrhage. Methods We randomly assigned eligible participants with intracerebral hemorrhage (volume, <60 cm(3)) and a Glasgow Coma Scale (GCS) score of 5 or more (on a scale from 3 to 15, with lower scores indicating worse condition) to a systolic blood-pressure target of 110 to 139 mm Hg (intensive treatment) or a target of 140 to 179 mm Hg (standard treatment) in order to test the superiority of intensive reduction of systolic blood pressure to standard reduction; intravenous nicardipine to lower blood pressure was administered within 4.5 hours after symptom onset. The primary outcome was death or disability (modified Rankin scale score of 4 to 6, on a scale ranging from 0 [no symptoms] to 6 [death]) at 3 months after randomization, as ascertained by an investigator who was unaware of the treatment assignments. Results Among 1000 participants with a mean (±SD) systolic blood pressure of 200.6±27.0 mm Hg at baseline, 500 were assigned to intensive treatment and 500 to standard treatment. The mean age of the patients was 61.9 years, and 56.2% were Asian. Enrollment was stopped because of futility after a prespecified interim analysis. The primary outcome of death or disability was observed in 38.7% of the participants (186 of 481) in the intensive-treatment group and in 37.7% (181 of 480) in the standard-treatment group (relative risk, 1.04; 95% confidence interval, 0.85 to 1.27; analysis was adjusted for age, initial GCS score, and presence or absence of intraventricular hemorrhage). Serious adverse events occurring within 72 hours after randomization that were considered by the site investigator to be related to treatment were reported in 1.6% of the patients in the intensive-treatment group and in 1.2% of those in the standard-treatment group. The rate of renal adverse events
Qureshi, Adnan I.; Palesch, Yuko Y.; Barsan, William G.; Hanley, Daniel F.; Hsu, Chung Y.; Martin, Renee L.; Moy, Claudia S.; Silbergleit, Robert; Steiner, Thorsten; Suarez, Jose I.; Toyoda, Kazunori; Wang, Yongjun; Yamamoto, Haruko; Yoon, Byung-Woo
Background Limited data are available to guide the choice of a target for the systolic blood-pressure level when treating acute hypertensive response in patients with intracerebral hemorrhage. Methods We randomly assigned eligible participants with intracerebral hemorrhage (volume, <60 cm3) and a Glasgow Coma Scale (GCS) score of 5 or more (on a scale from 3 to 15, with lower scores indicating worse condition) to a systolic blood-pressure target of 110 to 139 mm Hg (intensive treatment) or a target of 140 to 179 mm Hg (standard treatment) in order to test the superiority of intensive reduction of systolic blood pressure to standard reduction; intravenous nicardipine to lower blood pressure was administered within 4.5 hours after symptom onset. The primary outcome was death or disability (modified Rankin scale score of 4 to 6, on a scale ranging from 0 [no symptoms] to 6 [death]) at 3 months after randomization, as ascertained by an investigator who was unaware of the treatment assignments. Results Among 1000 participants with a mean (±SD) systolic blood pressure of 200.6±27.0 mm Hg at baseline, 500 were assigned to intensive treatment and 500 to standard treatment. The mean age of the patients was 61.9 years, and 56.2% were Asian. Enrollment was stopped because of futility after a prespecified interim analysis. The primary outcome of death or disability was observed in 38.7% of the participants (186 of 481) in the intensive-treatment group and in 37.7% (181 of 480) in the standard-treatment group (relative risk, 1.04; 95% confidence interval, 0.85 to 1.27; analysis was adjusted for age, initial GCS score, and presence or absence of intraventricular hemorrhage). Serious adverse events occurring within 72 hours after randomization that were considered by the site investigator to be related to treatment were reported in 1.6% of the patients in the intensive-treatment group and in 1.2% of those in the standard-treatment group. The rate of renal adverse events within
Bosone, Daniele; Ozturk, Vesile; Roatta, Silvestro; Cavallini, Anna; Tosi, Piera; Micieli, Giuseppe
The aim of this study was to evaluate, in a context of general inhibition of the sympathetic nervous system, the cerebral haemodynamic response to -30 degrees head-down tilt (HDT), a manoeuvre that produces an increase in intracranial arterial pressure. Nineteen healthy subjects were studied according to the following protocol: 10 min lying in supine position, 10 min HDT, 10 min recovery. Inhibition of the sympathetic system was confirmed by the decrease in heart rate (-3.6 bpm) and arterial blood pressure (-5.9 mmHg, p<0.05) in the late phase of the test. Blood velocity and blood pusatility index initially increased (+3.2 cm s(-1) and +9% respectively, p<0.01) then returned towards baseline before the end of HDT, while the cerebrovascular resistance index (=arterial blood pressure/blood velocity) dropped significantly and remained below control level (-7%, p<0.01) throughout the test. The changes in both these indices were opposite to those reported in several sympathetic activation tests, such as the handgrip and cold pressor tests. Conversely, arterial pressure at cranial level increased during HDT (as it also does during sympathetic activation tests), due to the development of a hydrostatic pressure gradient between heart and brain levels. Therefore, the effects observed on the pulsatility and resistance indices are not secondary to the increase in intracranial arterial pressure. It is suggested that the changes in these cerebrovascular indices are mediated by a reduction of sympathetic tone that presumably involves the cerebral as well as the peripheral vascular bed.
Bhattarai, Binod; Munakomi, Sunil; Chaudhary, Pramod
Vertebral artery fenestration is accidentally detected during angiography or autopsy. Spontaneous deep nuclear hemorrhage in association with vertebral artery fenestration is a very unusual finding in angiography. Such an unusual finding has not been reported in the English literature. Here, we report two cases of spontaneous deep nuclear hemorrhage that presented with features of raised intracranial pressure. Computed tomography revealed a deep nuclear acute bleed in both cases. Digital subtraction angiographic findings were normal other than the presence of a long segment vertebral artery fenestration. Both extracranial and intracranial variations were detected. Although the existence of vascular fenestration in the vertebrobasilar system produces less clinical importance, it may influence the management of cervical and intracranial pathologies to avoid iatrogenic injury. PMID:26918218
R. Knitter, James; Jahan, Reza; Gornbein, Jeffery; Ajani, Zahra; Feng, Lei; Meyer, Brett C.; Schwamm, Lee H.; Yoo, Albert J.; Marshall, Randolph S.; Meyers, Philip M.; Yavagal, Dileep R.; Wintermark, Max; Liebeskind, David S.; Guzy, Judy; Starkman, Sidney; Saver, Jeffrey L.; Kidwell, Chelsea S.
Background and Purpose— Patients with acute ischemic stroke are at increased risk of developing parenchymal hemorrhage (PH), particularly in the setting of reperfusion therapies. We have developed a predictive model to examine the risk of PH using combined magnetic resonance perfusion and diffusion parameters, including cerebral blood volume (CBV), apparent diffusion coefficient, and microvascular permeability (K2). Methods— Voxel-based values of CBV, K2, and apparent diffusion coefficient from the ischemic core were obtained using pretreatment magnetic resonance imaging data from patients enrolled in the MR RESCUE clinical trial (Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy). The associations between PH and extreme values of imaging parameters were assessed in univariate and multivariate analyses. Receiver-operating characteristic curve analysis was performed to determine the optimal parameter(s) and threshold for predicting PH. Results— In 83 patients included in this analysis, 20 developed PH. Univariate analysis showed significantly lower 10th percentile CBV and 10th percentile apparent diffusion coefficient values and significantly higher 90th percentile K2 values within the infarction core of patients with PH. Using classification tree analysis, the 10th percentile CBV at threshold of 0.47 and 90th percentile K2 at threshold of 0.28 resulted in overall predictive accuracy of 88.7%, sensitivity of 90.0%, and specificity of 87.3%, which was superior to any individual or combination of other classifiers. Conclusions— Our results suggest that combined 10th percentile CBV and 90th percentile K2 is an independent predictor of PH in patients with acute ischemic stroke with diagnostic accuracy superior to individual classifiers alone. This approach may allow risk stratification for patients undergoing reperfusion therapies. Clinical Trial Registration— URL: https://www.clinicaltrials.gov. Unique identifier: NCT00389467. PMID
Czuppon, A B; Kaplan, V; Speich, R; Baur, X
A 17-year-old man was occupationally exposed to pyromellitic acid dianhydride dust during the production of epoxy resin in a chemical factory. He was clinically diagnosed as having acute hemorrhagic alveolitis associated with anemia. The serologic analysis revealed a high concentration of IgG antibodies against pyromellitic acid dianhydride-treated human serum albumin (PMDA-HSA). Immunoblotting with PMDA-treated human serum as antigen and the patient's serum as the first antibody showed that additional PMDA-modified serum proteins other than HSA were recognized by the patient's IgG antibodies in the higher mol. mass range (> 67 kDa). No specific IgG could be detected against other anhydride conjugates (maleic acid, MA; phthalic acid, PA) with the exception of a reaction with the trimellitic acid anhydride-conjugated HSA (TMA-HSA). No specific IgE antibodies could be detected against any of the above mentioned antigens, but immunoblotting of the patient's serum indicated IgG4-type autoantibodies against in vitro PMDA-treated Ig molecules of normal serum proteins.
Del Santo, Molly Ann; Cordina, Steve Mario
Intracranial aneurysms in the pediatric population are rare. We report a case of a 3-month-old infant who presented with inconsolable crying, vomiting, and sunset eye sign. CT revealed a subarachnoid hemorrhage, with CT angiogram revealing a superior cerebellar artery aneurysm. An external ventricular drain was placed for acute management of hydrocephalus, with definitive treatment by endovascular technique with a total of six microcoils to embolize the aneurysm. Serial transcranial Dopplers revealed no subsequent vasospasm. Although aneurysms in the pediatric population are rare, once the diagnosis is established, early treatment results in better outcomes.
Del Santo, Molly Ann; Cordina, Steve Mario
Intracranial aneurysms in the pediatric population are rare. We report a case of a 3-month-old infant who presented with inconsolable crying, vomiting, and sunset eye sign. CT revealed a subarachnoid hemorrhage, with CT angiogram revealing a superior cerebellar artery aneurysm. An external ventricular drain was placed for acute management of hydrocephalus, with definitive treatment by endovascular technique with a total of six microcoils to embolize the aneurysm. Serial transcranial Dopplers revealed no subsequent vasospasm. Although aneurysms in the pediatric population are rare, once the diagnosis is established, early treatment results in better outcomes.
Yoon, Woong; Kim, Jae Kyu; Kim, Heoung Kil; Han, Young Min; Kang, Heoung Keun
Three patients who had undergone hemodialysis for end-stage renal disease, presented with acute small bowel hemorrhage,and were treated with superselective transcatheter arterial embolization via coaxial microcatheters. In all patients pre-procedure upper gastrointestinal (GI) endoscopy and colonoscopy had failed to demonstrate the source of the hemorrhage. Selective diagnostic angiography revealed frank extravasations of contrast from the small bowel arteries (one jejunal artery and two ileal arteries). After superselection of feeding arteries with a microcatheter, transcatheter embolization using Gelfoam and microcoils was performed in all three patients. Immediate hemostasis was achieved in all patients and the patients were discharged free from symptoms 3-5 days after embolization. No evidence of intestinal ischemia or infarction was noted, with the time from procedure to last follow-up ranging from 4 to 12 months. We conclude that superselective angiography is a valuable tool for diagnosing and treating acute small bowel hemorrhage inpatients with end-stage renal disease when endoscopic evaluation has failed.
Hammoud, Dima; Gailloud, Philippe; Olivi, Alessandro; Murphy, Kieran J
A 16-year-old male adolescent presenting with acute retro-orbital pain underwent emergent internal carotid occlusion for a giant cavernous aneurysm. Three weeks later, the patient complained of headache and right hemiparesis, which suggested an acute stroke. CT and MR imaging revealed vasogenic brain edema without infarct. The symptoms rapidly resolved with steroid therapy. Follow-up CT showed resolution of the edema. The imaging characteristics, clinical implications, and etiology of vasogenic edema occurring after thrombosis of a giant intracranial aneurysm are discussed.
Strapazzon, Giacomo; Malacrida, Sandro; Vezzoli, Alessandra; Dal Cappello, Tomas; Falla, Marika; Lochner, Piergiorgio; Moretti, Sarah; Procter, Emily; Brugger, Hermann; Mrakic-Sposta, Simona
High altitude is the most intriguing natural laboratory to study human physiological response to hypoxic conditions. In this study, we investigated changes in reactive oxygen species (ROS) and oxidative stress biomarkers during exposure to hypobaric hypoxia in 16 lowlanders. Moreover, we looked at the potential relationship between ROS related cellular damage and optic nerve sheath diameter (ONSD) as an indirect measurement of intracranial pressure. Baseline measurement of clinical signs and symptoms, biological samples and ultrasonography were assessed at 262 m and after passive ascent to 3830 m (9, 24 and 72 h). After 24 h the imbalance between ROS production (+141%) and scavenging (−41%) reflected an increase in oxidative stress related damage of 50–85%. ONSD concurrently increased, but regression analysis did not infer a causal relationship between oxidative stress biomarkers and changes in ONSD. These results provide new insight regarding ROS homeostasis and potential pathophysiological mechanisms of acute exposure to hypobaric hypoxia, plus other disease states associated with oxidative-stress damage as a result of tissue hypoxia. PMID:27579527
Pikija, Slaven; Magdic, Jozef; Trkulja, Vladimir; Unterkreuter, Peter; Mutzenbach, Johannes Sebastian; Novak, Helmut F.; Weymayr, Friedrich; Hauer, Larissa; Sellner, Johann
The aim of our study was to assess whether cerebral artery clots undergo time-dependent morphological and compositional changes in acute ischemic stroke. We performed a retrospective chart review of patients admitted within 5 h from symptom onset to three European stroke centers and evaluated non-contrast-enhanced CT (NECT) for hyperdense artery signs (HAS) in 2565 scans. The occlusion site, density of HAS expressed in Hounsfield units (HU), area of HAS, and relative density (rHU) (HU clot/HU non-affected artery) were studied and related to time from symptom onset, clinical severity, stroke etiology, and laboratory parameters. A HAS was present in the middle cerebral artery (MCA) in 185 (7.2%) and further explored. The mean time from symptom onset to CT was 100 min (range 17–300). We found a time-dependent loss of density in the occluded M1 segment within the first 5 h (N = 118, 95% CI [−15, −2], p = 0.01). Further, the thrombus area in the M2 segment decreased with time (cubic trend N = 67, 95% CI [−63, −8], p = 0.02). Overall, and especially in the M2 segment, a lower clot area was associated with higher fibrinogen (−21.7%, 95% CI [−34.8, −5.8], p = 0.009). In conclusion, our results disclosed time-dependent changes of intracranial thrombi with regard to occlusion site, density and area. PMID:27886084
Wiebelhaus, Jason M.; Walentiny, D. Matthew
Incidence of prescription opioid abuse and overdose, often led by oxycodone, continues to increase, producing twice as many overdose deaths as heroin. Surprisingly, preclinical reports relevant to oxycodone’s abuse-related effects are relatively sparse considering its history and patient usage. The goal of this study was to characterize dose- and time-dependent effects of acute and repeated oxycodone administration in a frequency-rate intracranial self-stimulation (ICSS) procedure, an assay often predictive of drug-related reinforcing effects, in male Sprague-Dawley rats. We hypothesized that oxycodone would produce a biphasic profile of rate-increasing and rate-decreasing effects maintained by ICSS similar to μ-opioid receptor agonists. Oxycodone (0.03, 0.3, 1, and 3 mg/kg, s.c.) produced dose- and time-dependent alterations on ICSS, with the predicted biphasic profile of rate-increasing effects at lower stimulation frequencies followed by rate-decreasing effects at higher frequencies. Peak effects were observed between 30 and 60 minutes, which were reversed by naloxone pretreatment (30 minutes). Tolerance to rate-decreasing effects was observed over a 5-day period when rats were treated with 1 mg/kg oxycodone twice a day. Subsequently, the dosing regimen was increased to 3 mg/kg twice a day over 10 days, although further marked tolerance did not develop. When then challenged with 10 mg/kg naloxone, a significant suppression below baseline levels of ICSS-maintained responding occurred indicative of dependence that recovered to baseline within 5 hours. The results of this study provide the first report of acute and chronic effects of oxycodone on responding maintained by ICSS presentation and the use of ICSS-maintained responding to characterize its tolerance and dependence effects. PMID:26491062
Wiebelhaus, Jason M; Walentiny, D Matthew; Beardsley, Patrick M
Incidence of prescription opioid abuse and overdose, often led by oxycodone, continues to increase, producing twice as many overdose deaths as heroin. Surprisingly, preclinical reports relevant to oxycodone's abuse-related effects are relatively sparse considering its history and patient usage. The goal of this study was to characterize dose- and time-dependent effects of acute and repeated oxycodone administration in a frequency-rate intracranial self-stimulation (ICSS) procedure, an assay often predictive of drug-related reinforcing effects, in male Sprague-Dawley rats. We hypothesized that oxycodone would produce a biphasic profile of rate-increasing and rate-decreasing effects maintained by ICSS similar to μ-opioid receptor agonists. Oxycodone (0.03, 0.3, 1, and 3 mg/kg, s.c.) produced dose- and time-dependent alterations on ICSS, with the predicted biphasic profile of rate-increasing effects at lower stimulation frequencies followed by rate-decreasing effects at higher frequencies. Peak effects were observed between 30 and 60 minutes, which were reversed by naloxone pretreatment (30 minutes). Tolerance to rate-decreasing effects was observed over a 5-day period when rats were treated with 1 mg/kg oxycodone twice a day. Subsequently, the dosing regimen was increased to 3 mg/kg twice a day over 10 days, although further marked tolerance did not develop. When then challenged with 10 mg/kg naloxone, a significant suppression below baseline levels of ICSS-maintained responding occurred indicative of dependence that recovered to baseline within 5 hours. The results of this study provide the first report of acute and chronic effects of oxycodone on responding maintained by ICSS presentation and the use of ICSS-maintained responding to characterize its tolerance and dependence effects.
Hammond, Matthew D.; Taylor, Roslyn A.; Mullen, Michael T.; Ai, Youxi; Aguila, Hector L.; Mack, Matthias; Kasner, Scott E.; McCullough, Louise D.
Intracerebral hemorrhage (ICH) is a devastating type of stroke that lacks a specific treatment. An intense immune response develops after ICH, which contributes to neuronal injury, disability, and death. However, the specific mediators of inflammation-induced injury remain unclear. The objective of the present study was to determine whether blood-derived CCR2+Ly6Chi inflammatory monocytes contribute to disability. ICH was induced in mice and the resulting inflammatory response was quantified using flow cytometry, confocal microscopy, and neurobehavioral testing. Importantly, blood-derived monocytes were distinguished from resident microglia by differential CD45 staining and by using bone marrow chimeras with fluorescent leukocytes. After ICH, blood-derived CCR2+Ly6Chi inflammatory monocytes trafficked into the brain, outnumbered other leukocytes, and produced tumor necrosis factor. Ccr2−/− mice, which have few circulating inflammatory monocytes, exhibited better motor function following ICH than control mice. Chimeric mice with wild-type CNS cells and Ccr2−/− hematopoietic cells also exhibited early improvement in motor function, as did wild-type mice after inflammatory monocyte depletion. These findings suggest that blood-derived inflammatory monocytes contribute to acute neurological disability. To determine the translational relevance of our experimental findings, we examined CCL2, the principle ligand for the CCR2 receptor, in ICH patients. Serum samples from 85 patients were collected prospectively at two hospitals. In patients, higher CCL2 levels at 24 h were independently associated with poor functional outcome at day 7 after adjusting for potential confounding variables. Together, these findings suggest that inflammatory monocytes worsen early disability after murine ICH and may represent a therapeutic target for patients. PMID:24623768
Goel, Ashish; Nair, Sukesh Chandran; Viswabandya, Auro; Masilamani, Vinodh P; Rao, Shoma V; George, Alice; Regi, Annie; Jose, Ruby; Zachariah, Uday; Subramani, Kandasamy; Eapen, C E; Chandy, George
Control of postpartum hemorrhage is difficult in patients with coagulopathy due to acute liver failure. Recombinant activated factor VII (rFVIIa) can help in control of bleed; however, it has short duration of action (2-4 h). The study aimed to report the use of rFVIIa in this setting. We retrospectively analyzed all patients with acute liver failure secondary to pregnancy-related liver disorders who received rFVIIa for control of postpartum hemorrhage (six patients, all six met diagnostic criteria for acute fatty liver of pregnancy). One dose of rFVIIa achieved adequate control of bleeding in five patients, while one patient needed a second dose. rFVIIa administration corrected coagulopathy and significantly reduced requirement of packed red cells and other blood products. No patient had thrombotic complications. In conclusion, rFVIIa was a useful adjunct to standard management in postpartum hemorrhage secondary to acute liver failure of pregnancy-related liver disorders.
Goodwin, C. Rory; Sciubba, Daniel; Bydon, Ali; Wolinsky, Jean-Paul; Witham, Timothy; Gokaslan, Ziya L.
Hemorrhagic conversion of spinal schwannomas represents a rare occurrence; also rare is the development of a spinal intradural hematoma after spinal manipulation therapy. We report a unique presentation of paraplegia in a patient who underwent spinal manipulation therapy and was found to have a hemorrhagic thoracic schwannoma at time of surgery in the setting of anti-platelet therapy use. In patients with spinal schwannomas, tumor hemorrhage is a rare occasion, which can be considered in the setting of additive effects of spinal manipulation therapy and antiplatelet therapy. PMID:28377856
Cai, Jing; Cao, Shenglong; Chen, Jingyin; Yan, Feng; Chen, Gao; Dai, Yuying
This study aimed to investigate the therapeutic effect of progesterone on acute brain injury after subarachnoid hemorrhage (SAH). Subarachnoid hemorrhage was induced in male Sprague-Dawley rats (n=72) by endovascular perforation. Progesterone (8 mg/kg or 16 mg/kg) was administered to rats at 1, 6, and 12h after SAH. Mortality, neurologic deficits, cell apoptosis, expression of apoptotic markers, the level of malondialdehyde (MDA) and the activity of superoxide dismutase (SOD) were assayed at 24h after experimental SAH. Mortality, cell apoptosis and the expression of caspase-3 were decreased, and improved neurological function was observed in the progesterone-treated SAH rats. Further, exploration demonstrated that progesterone significantly reduced the ratio of Bax/Bcl-2 and attenuated the release of cytochrome c from mitochondria. Progesterone also induced anti-oxidative effects by elevating the activity of SOD and decreasing MDA content after SAH. Furthermore, dose-response relationships for progesterone treatment were observed, and high doses of progesterone enhanced the neuroprotective effects. Progesterone treatment could alleviate acute brain injury after SAH by inhibiting cell apoptosis and decreasing damage due to oxidative stress. The mechanism involved in the anti-apoptotic effect was related to the mitochondrial pathway. These results indicate that progesterone possesses the potential to be a novel therapeutic agent for the treatment of acute brain injury after SAH.
who would try medical measures on their own, or call another obstetrical practitioner. Resuscitation Once significant postpartum hemorrhage has been...Research Clinical Obstetrics and Gynaecology 2002, 16(1):81-98. 12. Roberts WE: Emergent Obstetric Management of Postpar- tum Hemorrhage . Obstetrics and...Spring, MD, USA and 4Department of Obstetrics and Gynecology, Walter Reed Army Medical Center, Washington, DC, USA Email: Allison B Weisbrod
Adami, C; Levionnois, O; Spadavecchia, C
A goat was scheduled for experimental surgery under general anesthesia. The first attempt of performing endotracheal intubation failed and provoked laryngeal spasm. After repeated succesful intubation of inhalation anesthesia was delivered in high concentrations of sevoflurane. Suddenly hypertension and tachycardia were observed, followed by foamy airway secretion and then severe airway hemorrhage. The authors hypothesize that laryngeal spasm provoked respiratory distress and pulmonary edema. The delivered high concentrations of sevoflurane probably enhanced a hyperadrenergic response, predisposing to the development of airway hemorrhage.
Dohi, K; Jimbo, H; Ikeda, Y; Fujita, S; Ohtaki, H; Shioda, S; Abe, T; Aruga, T
We evaluated the effects of a novel pharmacological brain cooling (PBC) method with indomethacin (IND), a nonselective cyclooxygenase inhibitor, without the use of cooling blankets in patients with hemorrhagic stroke. Forty-six patients with hemorrhagic stroke (subarachnoid hemorrhage; n = 35, intracerebral hemorrhage; n = 11) were enrolled in this study. Brain temperature was measured directly with a temperature sensor. Patients were cooled by administering transrectal IND (100 mg) and a modified nasopharyngeal cooling method (positive selective brain cooling) initially. Brain temperature was controlled with IND 6 mg/kg/day for 14 days. Cerebrospinal fluid concentrations of interleukin-1beta (CSF IL-1beta) and serum bilirubin levels were measured at 1, 2, 4, and 7 days. The incidence of complicating symptomatic vasospasm after subarachnoid hemorrhage was lower than in non-PBC patients. CSF IL-1beta and serum bilirubin levels were suppressed in treated patients. IND has several beneficial effects on damaged brain tissues (anticytokine, free radical scavenger, antiprostaglandin effects, etc.) and prevents initial and secondary brain damage. PBC treatment for hemorrhagic stroke in patients appears to yield favorable results by acting as an antiinflammatory cytokine and reducing oxidative stress.
Wang, Yunbo; Yan, Junling; Xi, Liang; Qian, Zhiyu; Wang, Zhenghong; Yang, Lina
Multiple organ failure is a common outcome of hemorrhagic shock followed by resuscitation, and the kidney is one of the prime target organs involved. The main objective of the study was to evaluate whether crocetin, a natural product from Gardenia jasminoides Ellis, has beneficial effects on renal dysfunction caused by hemorrhagic shock and resuscitation in rats. Anesthetized rats were bled to reduce mean arterial blood pressure to 35 (SD, 5) mmHg for 60 min and then were resuscitated with their withdrawn shed blood and normal saline. Crocetin was administered via the duodenum at a dose of 50 mg/kg 40 min after hemorrhage. The increase in creatinine and blood urea nitrogen was significantly reduced at 2 h after hemorrhage and resuscitation in crocetin-treated rats. The increases in renal nitric oxide, tumor necrosis factor α, and interleukin 6 were also attenuated by crocetin. Hemorrhagic shock resulted in a significant elevation in malondialdehyde production and was accompanied by a reduction in total superoxide dismutase activity, activation of nuclear factor κB, and overexpression of inducible nitric oxide synthase. These changes were significantly attenuated by crocetin at 2 h after resuscitation. These results suggested that crocetin blocks inflammatory cascades by inhibiting production of reactive oxygen species and restoring superoxide dismutase activity to ameliorate renal dysfunction caused by hemorrhage shock and resuscitation.
Parrot, A; Fartoukh, M; Cadranel, J
Alveolar hemorrhage occurs relatively rarely and is a therapeutic emergency because it can quickly lead to acute respiratory failure, which can be fatal. Hemoptysis associated with anemia and pulmonary infiltrates suggest the diagnosis of alveolar hemorrhage, but may be absent in one third of cases including patients in respiratory distress. The diagnosis of alveolar hemorrhage is based on the findings of a bronchoalveolar lavage. The causes are numerous. It is important to identify alveolar hemorrhage due to sepsis, then separate an autoimmune cause (vasculitis associated with antineutrophil cytoplasmic antibody, connective tissue disease and Goodpasture's syndrome) with the search for autoantibodies and biopsies from readily accessible organs, from a non-immune cause, performing echocardiography. Lung biopsy should be necessary only in exceptional cases. If the hemorrhage has an immune cause, treatment with steroids and cyclophosphamide may be started. The indications for treatment with rituximab are beginning to be established (forms that are not severe and refractory forms). The benefit of plasma exchange is unquestionable in Goodpasture's syndrome. In patients with an immune disease that can lead to an alveolar hemorrhage, removing any source of infection is the first priority.
Rowland, Matthew J; Garry, Payashi; Westbrook, Jon; Corkill, Rufus; Antoniades, Chrystalina A; Pattinson, Kyle T S
OBJECTIVE Delayed cerebral ischemia (DCI) causing cerebral infarction remains a significant cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Early brain injury in the first 72 hours following rupture is likely to play a key role in the pathophysiology underlying DCI but remains difficult to quantify objectively. Current diagnostic modalities are based on the concept of vasoconstriction causing cerebral ischemia and infarction and are either invasive or have a steep learning curve and user variability. The authors sought to determine whether saccadic eye movements are impaired following aSAH and whether this measurement in the acute period is associated with the likelihood of developing DCI. METHODS As part of a prospective, observational cohort study, 24 male and female patients (mean age 53 years old, range 31-70 years old) were recruited. Inclusion criteria included presentation with World Federation of Neurosurgical Societies (WFNS) Grades 1 or 2 ("good grade") aSAH on admission and endovascular treatment within 72 hours of aneurysmal rupture. DCI and DCI-related cerebral infarction were defined according to consensus guidelines. Saccadometry data were collected at 3 time points in patients: in the first 72 hours, between Days 5 and 10, and at 3 months after aSAH. Data from 10 healthy controls was collected on 1 occasion for comparison. RESULTS Age-adjusted saccadic latency in patients was significantly prolonged in the first 72 hours following aSAH when compared with controls (188.7 msec [95% CI 176.9-202.2 msec] vs 160.7 msec [95% CI 145.6-179.4 msec], respectively; p = 0.0054, t-test). By 3 months after aSAH, there was no significant difference in median saccadic latency compared with controls (188.7 msec [95% CI 176.9-202.2 msec] vs 180.0 msec [95% CI 165.1-197.8 msec], respectively; p = 0.4175, t-test). Patients diagnosed with cerebral infarction due to DCI had a significantly higher age-adjusted saccadic latency in the
Rincon, Fred; Mayer, Stephan A
Intracerebral hemorrhage is by far the most destructive form of stroke. The clinical presentation is characterized by a rapidly deteriorating neurological exam coupled with signs and symptoms of elevated intracranial pressure. The diagnosis is easily established by the use of computed tomography or magnetic resonance imaging. Ventilatory support, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring, osmotherapy, fever control, seizure prophylaxis, treatment of hyerglycemia, and nutritional supplementation are the cornerstones of supportive care in the intensive care unit. Dexamethasone and other glucocorticoids should be avoided. Ventricular drainage should be performed urgently in all stuporous or comatose patients with intraventricular blood and acute hydrocephalus. Emergent surgical evacuation or hemicraniectomy should be considered for patients with large (>3 cm) cerebellar hemorrhages, and in those with large lobar hemorrhages, significant mass effect, and a deteriorating neurological exam. Apart from management in a specialized stroke or neurological intensive care unit, no specific medical therapies have been shown to consistently improve outcome after intracerebral hemorrhage. PMID:19108704
Huang, Xiaojiang; Guo, Shougang; Wang, Wei
The effects of minimally invasive surgery on the blood-brain barrier (BBB) of 30 patients with cerebral hemorrhage were investigated. Difference of the BBB index and serum MBP concentration were assessed in 15 cases of conservative treatment group and 15 cases of minimally invasive surgery group. The BBB index in minimally invasive surgery group was significantly lower than in conservative treatment group (P<0.05), and the BBB index in the two treatment groups was significantly higher than in control group (P<0.01). Serum MBP concentration in minimally invasive surgery group was significantly lower than in conservative treatment group (P<0.05), and that in the two treatment groups was significantly higher than in control group (P<0.01). It was suggested the permeability of BBB in patients with cerebral hemorrhage was increased, and BBB index and serum MBP concentration in patients with cerebral hemorrhage were increased. Minimally invasive surgery can reduce the lesion of cytotoxicity to BBB and cerebral edema.
The TEAM trial: Safety and efficacy of endovascular treatment of unruptured intracranial aneurysms in the prevention of aneurysmal hemorrhages: A randomized comparison with indefinite deferral of treatment in 2002 patients followed for 10 years
Raymond, Jean; Molyneux, Andrew J; Fox, Allan J; Johnston, S Claiborne; Collet, Jean-Paul; Rouleau, Isabelle
The management of patients with unruptured aneurysms remains controversial. Patients with unruptured aneurysms may suffer intracranial haemorrhage, but the incidence of this event is still debated; endovascular treatment may prevent rupture, but involves immediate risks. Hence, the balance of risks and benefits of endovascular treatment is uncertain. Here, we report the design of the TEAM trial, the first international, randomized, controlled trial comparing conservative management with endovascular treatment. Primary endpoint is mortality and morbidity (modified Rankin Score ≥ 3) from intracranial haemorrhage or treatment. Secondary endpoints include incidence of hemorrhagic events, morbidity related to endovascular coiling, morphological results, overall clinical outcome and quality of life. Statistical tests compare between probabilities at 5- and 10-years of 1/mortality from haemorrhage related to the lesion, excluding per-operative complications; 2/mortality from haemorrhage or from complications of treatment; 3/combined disease or treatment related mortality and morbidity in the absence of other causes of death or disability. The study will be conducted in 60 international centres and will enrol 2,002 patients equally divided between the two groups, a size sufficient to achieve 80% power at a 0.0167 significance to detect differences in 1) disease or treatment-related poor outcomes from 7–9% to 3–5%; 2) overall mortality from 16 to 11%. Duration of the study is 14 years, the first three years being for patient recruitment plus a minimum of 10 years of follow-up. The TEAM trial thus offers a means to reconcile the introduction of a new approach with the necessity to acknowledge uncertainties. Current Controlled Trials ISRCTN62758344 PMID:18631395
Ho, Bo-Lin; Chen, Chien-Fu; Lin, Ruey-Tay; Liu, Ching-Kuan; Chao, A-Ching
To determine the clinical implications of hemorrhagic transformation (HT) after thrombolysis, 241 eligible patients receiving alteplase for acute ischemic stroke were studied. HT was classified, according to the European Cooperative Acute Stroke Study criteria, as hemorrhagic infarction (HI) or parenchymal hemorrhage (PH). Symptomatic intracranial hemorrhage (SICH) was defined according to the National Institute of Neurological Disorders and Stroke study. A novel classification, clinically significant intracranial hemorrhage (CSICH) was defined as HTs associated with an unfavorable clinical outcome (modified Rankin Scale 5-6) at 3 months. For all subtypes of HT, we found that patients receiving alteplase were more often in the standard-dose group (0.90 ± 0.02 mg/kg) than in the lower dose group (0.72 ± 0.07 mg/kg). PH and SICH were related to an unfavorable clinical outcome, while HI was not. There was a positive trend between age and CSICH in patients receiving the standard dose (P = 0.0101), and between alteplase dose and CSICH in patients ≥70 years old (P = 0.0228). All PHs (including asymptomatic PHs) and symptomatic HIs have been found to be associated with unfavorable outcome, and for this reason defined as CSICH. Independent predictors of CSICH were age ≥70 years and the standard dose of alteplase. Further studies of thrombolysis for ischemic stroke with different doses of alteplase are warranted.
Anokwute, Miracle C; Braca, John A; Bohnstedt, Bradley; DeNardo, Andrew; Scott, John; Cohen-Gadol, Aaron; Sahlein, Daniel H
Successful endovascular coiling of ruptured tiny saccular intracranial aneurysms (⩽3mm) is technically challenging and traditionally has been associated with technical failures, as well as morbidity related to thromboembolic events and high intraoperative rupture rates. This study analyzes the feasibility, technical efficacy, and clinical outcomes of coil embolization of ruptured tiny intracranial aneurysms using current coil and microcatheter technology and techniques. We performed a retrospective review of 20 patients with 20 ruptured tiny aneurysms treated with endovascular coil embolization from 2013 to 2016 at a single high-volume academic tertiary care practice. The mean aneurysm size was 2.4mm (median 2.5mm, 1-3). Complete occlusion was achieved in 12 of 20 patients (60%), the remaining 7 of 20 patients (35%) had a small neck remnant, and there was 1 failure (5%) converted to microsurgical clipping. Two patients had a failed attempted surgical clip reconstruction and were subsequently coiled. There was 1 intraprocedural rupture (5%) and 1 severe parent artery vasospasm (5%) during coiling. At discharge, 60% of patients were living independently. At follow-up three patients were deceased. Mean angiographic follow-up was 139days (SD 120). There were no aneurysm recurrences among occluded patients and there were no retreatments among those with neck remnants. Coiling of ruptured aneurysms ⩽3mm is feasible with high occlusion rates and low complication rates. The availability of softer coils with flexible detachment zones has led to safe and effective endovascular treatment of tiny ruptured aneurysms.
Chen, C H; Manaenko, A; Zhan, Y; Liu, W W; Ostrowki, R P; Tang, J; Zhang, J H
Hyperglycemia is one of the major factors for hemorrhagic transformation after ischemic stroke. In this study, we tested the effect of hydrogen gas on hemorrhagic transformation in a rat focal cerebral ischemia model. Sprague-Dawley rats (n=72) were divided into the following groups: sham; sham treated with hydrogen gas (H(2)); Middle Cerebral Artery Occlusion (MCAO); and MCAO treated with H(2) (MCAO+H(2)). All rats received an injection of 50% dextrose (6 ml/kg i.p.) and underwent MCAO 15 min later. Following a 90 min ischemic period, hydrogen was inhaled for 2 h during reperfusion. We measured the level of blood glucose at 0 h, 0.5 h, 4 h, and 6 h after dextrose injection. Infarct and hemorrhagic volumes, neurologic score, oxidative stress (evaluated by measuring the level of 8 Hydroxyguanosine (8OHG), 4-Hydroxy-2-Nonenal (HNE) and nitrotyrosine), and matrix metalloproteinase (MMP)-2/MMP-9 activity were measured at 24 h after ischemia. We found that hydrogen inhalation for 2 h reduced infarct and hemorrhagic volumes and improved neurological functions. This effect of hydrogen was accompanied by a reduction of the expression of 8OHG, HNE, and nitrotyrosine and the activity of MMP-9. Furthermore, a reduction of the blood glucose level from 500+/-32.51 to 366+/-68.22 mg/dl at 4 h after dextrose injection was observed in hydrogen treated animals. However, the treatment had no significant effect on the expression of ZO-1, occludin, collagen IV or aquaporin4 (AQP4). In conclusion, hydrogen gas reduced brain infarction, hemorrhagic transformation, and improved neurological function in rats. The potential mechanisms of decreased oxidative stress and glucose levels after hydrogen treatment warrant further investigation.
Aziz, Hassan A.; Kim, Jonathan W.; Munier, Francis L.; Berry, Jesse L.
Aims To report the occurrence of acute hemorrhagic retinopathy following intravitreal melphalan injection for retinoblastoma. Methods This is a retrospective case series of 2 patients with retinoblastoma treated with intravitreal melphalan for vitreous seeding who developed acute hemorrhagic retinopathy. Results Patient 1 is a 6-month-old female with bilateral retinoblastoma (Group D right eye and Group B left eye) treated with 4 cycles of systemic chemotherapy and 2 intravitreal melphalan injections in each eye. Patient 2 is a 10-month-old male with unilateral Group D retinoblastoma treated with 6 cycles of systemic chemotherapy and 2 injections of intravitreal melphalan. At the 1-week follow-up after the second injection, both patients had an acute hemorrhagic retinopathy that resulted in chorioretinal toxicity with a sharp demarcation line between the normal and abnormal retina. At the last follow-up (22 and 12 months, respectively), there was total tumor control and resolution of vitreous seeding in both patients. Conclusions Although intravitreal melphalan injection is effective for vitreous seeding in eyes with retinoblastoma, acute hemorrhagic retinopathy and diffuse chorioretinal atrophy is a possible complication of this treatment modality. Given the clinical findings observed in these patients, the development of this retinal toxicity most likely results from a retrohyaloid overdose. Consequently we suggest preventive measures aimed at limiting the risk of retrohyaloid injection.
Aksoy, Didem; Bammer, Roland; Mlynash, Michael; Venkatasubramanian, Chitra; Eyngorn, Irina; Snider, Ryan W.; Gupta, Sandeep N.; Narayana, Rashmi; Fischbein, Nancy; Wijman, Christine A. C.
Background Spontaneous intracerebral hemorrhage (ICH) is associated with blood–brain barrier (BBB) injury, which is a poorly understood factor in ICH pathogenesis, potentially contributing to edema formation and perihematomal tissue injury. We aimed to assess and quantify BBB permeability following human spontaneous ICH using dynamic contrast‐enhanced magnetic resonance imaging (DCE MRI). We also investigated whether hematoma size or location affected the amount of BBB leakage. Methods and Results Twenty‐five prospectively enrolled patients from the Diagnostic Accuracy of MRI in Spontaneous intracerebral Hemorrhage (DASH) study were examined using DCE MRI at 1 week after symptom onset. Contrast agent dynamics in the brain tissue and general tracer kinetic modeling were used to estimate the forward leakage rate (Ktrans) in regions of interest (ROI) in and surrounding the hematoma and in contralateral mirror–image locations (control ROI). In all patients BBB permeability was significantly increased in the brain tissue immediately adjacent to the hematoma, that is, the hematoma rim, compared to the contralateral mirror ROI (P<0.0001). Large hematomas (>30 mL) had higher Ktrans values than small hematomas (P<0.005). Ktrans values of lobar hemorrhages were significantly higher than the Ktrans values of deep hemorrhages (P<0.005), independent of hematoma volume. Higher Ktrans values were associated with larger edema volumes. Conclusions BBB leakage in the brain tissue immediately bordering the hematoma can be measured and quantified by DCE MRI in human ICH. BBB leakage at 1 week is greater in larger hematomas as well as in hematomas in lobar locations and is associated with larger edema volumes. PMID:23709564
neuroradiology for a four vessel cerebral angiogram. While CT and MR angiography have a high sensitivity and specificity in intracranial aneurysm ...hemorrhage have multiple intracranial aneurysms (13). Patent aneurysms are seen as a contrast filled outpouching from the vessel wall on angiography...also helpful signs of aneurysm rupture, particularly in those patients with multiple aneurysms . Risk factors for development of intracranial aneurysms
Loffroy, Romaric Rao, Pramod; Ota, Shinichi; Lin Mingde; Kwak, Byung-Kook; Geschwind, Jean-Francois
Acute nonvariceal upper gastrointestinal (UGI) hemorrhage is a frequent complication associated with significant morbidity and mortality. The most common cause of UGI bleeding is peptic ulcer disease, but the differential diagnosis is diverse and includes tumors; ischemia; gastritis; arteriovenous malformations, such as Dieulafoy lesions; Mallory-Weiss tears; trauma; and iatrogenic causes. Aggressive treatment with early endoscopic hemostasis is essential for a favorable outcome. However, severe bleeding despite conservative medical treatment or endoscopic intervention occurs in 5-10% of patients, requiring surgery or transcatheter arterial embolization. Surgical intervention is usually an expeditious and gratifying endeavor, but it can be associated with high operative mortality rates. Endovascular management using superselective catheterization of the culprit vessel, < sandwich> occlusion, or blind embolization has emerged as an alternative to emergent operative intervention for high-risk patients and is now considered the first-line therapy for massive UGI bleeding refractory to endoscopic treatment. Indeed, many published studies have confirmed the feasibility of this approach and its high technical and clinical success rates, which range from 69 to 100% and from 63 to 97%, respectively, even if the choice of the best embolic agent among coils, cyanaocrylate glue, gelatin sponge, or calibrated particles remains a matter of debate. However, factors influencing clinical outcome, especially predictors of early rebleeding, are poorly understood, and few studies have addressed this issue. This review of the literature will attempt to define the role of embolotherapy for acute nonvariceal UGI hemorrhage that fails to respond to endoscopic hemostasis and to summarize data on factors predicting angiographic and embolization failure.
Intracranial hypertension (ICH) was systematized in four categories according to its aetiology and pathogenic mechanisms: parenchymatous ICH with an intrinsic cerebral cause; vascular ICH, which has its aetiology in disorders of cerebral blood circulation; ICH caused by disorders of cerebro–spinal fluid dynamics and idiopathic ICH. The increase of intracranial pressure is the first to happen and then intracranial hypertension develops from this initial effect becoming symptomatic; it then acquires its individuality, surpassing the initial disease. The intracranial hypertension syndrome corresponds to the stage at which the increased intracranial pressure can be compensated and the acute form of intracranial hypertension is equivalent to a decompensated ICH syndrome. The decompensation of intracranial hypertension is a condition of instability and appears when the normal intrinsic ratio of intracranial pressure – time fluctuation is changed. The essential conditions for decompensation of intracranial hypertension are: the speed of intracranial pressure increase over normal values, the highest value of abnormal intracranial pressure and the duration of high ICP values. Medical objectives are preventing ICP from exceeding 20 mm Hg and maintaining a normal cerebral blood flow. The emergency therapy is the same for the acute form but each of the four forms of ICH has a specific therapy, according to the pathogenic mechanism and if possible to aetiology. PMID:20108456
Introduction Worldwide, trauma is a leading cause of death and disability. Haemorrhage is responsible for up to 40% of trauma deaths. Recent strategies to improve mortality rates have focused on optimal methods of early hemorrhage control and correction of coagulopathy. We undertook a systematic review of randomized controlled trials (RCT) which evaluated trauma patients with hemorrhagic shock within the first 24 hours of injury and appraised how the interventions affected three outcomes: bleeding and/or transfusion requirements; correction of trauma induced coagulopathy and mortality. Methods Comprehensive searches were performed of MEDLINE, EMBASE, CENTRAL (The Cochrane Library Issue 7, 2010), Current Controlled Trials, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) and the National Health Service Blood and Transplant Systematic Review Initiative (NHSBT SRI) RCT Handsearch Database. Results A total of 35 RCTs were identified which evaluated a wide range of clinical interventions in trauma hemorrhage. Many of the included studies were of low methodological quality and participant numbers were small. Bleeding outcomes were reported in 32 studies; 7 reported significantly reduced transfusion use following a variety of clinical interventions, but this was not accompanied by improved survival. Minimal information was found on traumatic coagulopathy across the identified RCTs. Overall survival was improved in only three RCTs: two small studies and a large study evaluating the use of tranexamic acid. Conclusions Despite 35 RCTs there has been little improvement in outcomes over the last few decades. No clear correlation has been demonstrated between transfusion requirements and mortality. The global trauma community should consider a coordinated and strategic approach to conduct well designed studies with pragmatic endpoints. PMID:21392371
Sarikaya-Seiwert, Sevgi; Turowski, Bernd; Hänggi, Daniel; Janssen, Giesela; Steiger, Hans-Jakob; Stummer, Walter
Pineal cysts are benign and often asymptomatic intracranial entities. Occasionally they can lead to neurological symptoms through growth or due to intracystic hemorrhage. The purpose of the current report is to describe their clinical characteristics and treatment options. In the current study, the authors illustrate the course of disease in 3 patients who developed neurological symptoms due to hemorrhage into a pineal cyst. Two of their patients had additional cerebral disease, and regular MR imaging examinations were conducted. This circumstance allowed documentation of growth and intracystic hemorrhage. After the occurrence of new neurological symptoms with severe headache, MR images showed a fluid-fluid interface due to intracystic hemorrhage. The third patient presented with acute triventricular hydrocephalus and papilledema due to aqueductal stenosis caused by intracystic hemorrhage. In all 3 cases, excision of the pineal cysts via an infratentorial/supracerebellar approach was performed. Histological examination revealed the characteristic structure of pineal cyst in all cases, with hemorrhagic residues in the form of hemosiderin deposits. All patients recovered fully after surgical removal of the cysts. Furthermore, resolution of occlusive hydrocephalus could be demonstrated in those cases with ventricular enlargement. Pineal cysts without neurological symptoms are often discovered as incidental findings on cranial MR images. In contrast, neurological symptoms such as severe headache, diplopia, or Parinaud syndrome, may occur as a result of pineal apoplexy due to intracystic hemorrhage. The authors' cases confirm that MR imaging can identify intracystic hemorrhage by a characteristic fluid-fluid interface. Their experience suggests that microsurgical resection of cysts may be an effective and curative treatment option.
Breznock, E.M.; Strack, D.
Blood volume (BV) was determined in awake, nonsplenectomized (NSPX) and splenectomized (SPX) cats before and after hemorrhage (6 ml/kg). Each NSPX cat had a determined BV at least 10 ml/kg greater than the same cat after splenectomy. The mean BV of SPX cats was 43.4 +/- 8.94. ml kg (4.3% of body weight). The calculated RBC masses of NSPX and SPX cats were 17.0 +/- 4.07 and 12.2 +/- 1.12 ml/kg, respectively. Each NSPX cat had apparent RBC masses of 5 ml/kg greater than that of the same cat after splenectomy was done. At 1 hour after a hemorrhage, the BV and RBC masses determined in SPX cats were 46.7 +/- 12.1 and 9.7 +/- 1.90 ml/kg, respectively. Extravascular-to-intravascular fluid flux (calculated from RBC masses and plasma protein dilution) was approximately 0.80% of body weight. The indirect method with /sup 51/Cr-labeled RBC for BV determination was accurate and precise in awake, SPX cats; in awake, NSPX cats, the /sup 51/Cr-labeled RBC dilution method was precise, but not accurate. The spleen in the cat resulted in marked overestimations of BV and RBC masses.
Pascoe, Michaela C.; Howells, David W.; Crewther, David P.; Constantinou, Nicki; Carey, Leeanne M.; Rewell, Sarah S.; Turchini, Giovanni M.; Kaur, Gunveen; Crewther, Sheila G.
Ischemic stroke is associated with motor impairment and increased incidence of affective disorders such as anxiety/clinical depression. In non-stroke populations, successful management of such disorders and symptoms has been reported following diet supplementation with long chain omega-3-polyunsaturated-fatty-acids (PUFAs). However, the potential protective effects of PUFA supplementation on affective behaviors after experimentally induced stroke and sham surgery have not been examined previously. This study investigated the behavioral effects of PUFA supplementation over a 6-week period following either middle cerebral artery occlusion or sham surgery in the hooded-Wistar rat. The PUFA diet supplied during the acclimation period prior to surgery was found to be associated with an increased risk of acute hemorrhage following the reperfusion component of the surgery. In surviving animals, PUFA supplementation did not influence infarct size as determined 6 weeks after surgery, but did decrease omega-6-fatty-acid levels, moderate sickness behaviors, acute motor impairment, and longer-term locomotor hyperactivity and depression/anxiety-like behavior. PMID:24567728
Chen, Chun-Chung; Chen, XianXiu; Li, Tsai-Chung; Lin, Hung-Lin; Chu, Yen-Tze; Lee, Han-Chung; Cheng, Yu-Kai; Chen, Der-Cherng; Tsai, Shiu-Chiu; Cho, Der-Yang; Hsieh, Ching-Liang
PG2 is an infusible polysaccharide extracted from Astragalus membranaceus, which is a Chinese herb traditionally used for stroke treatment. We investigated the effect of PG2 on patients with spontaneous acute intracerebral hemorrhage (ICH). A total of 61 patients with acute spontaneous ICH were randomized to either the treatment group (TG, 30 patients), which received 3 doses of PG2 (500 mg, IV) per week for 2 weeks, or the control group (CG, 31 patients), which received PG2 placebo. At 84 days after PG2 administration, the percentage of patients with a good Glasgow outcome scale (GOS 4–5) score in the TG was similar to that in the CG (69.0% vs. 48.4%; p = 0.2). The percentage of good mRS scores (0–2) in the TG was similar to that in the CG (62.1% vs. 45.2%; p = 0.3). In addition, no significant differences were seen when comparing differences in the C-reactive protein, erythrocyte sedimentation rate, interleukin-6 (IL-6), IL-1β, tumor necrosis factor-α, and S100B levels between baseline and days 4, 7, and 14 after PG2 administration (all p > 0.05). The results are preliminary, necessitating a more thorough assessment. PMID:28361971
Pascoe, Michaela C; Howells, David W; Crewther, David P; Constantinou, Nicki; Carey, Leeanne M; Rewell, Sarah S; Turchini, Giovanni M; Kaur, Gunveen; Crewther, Sheila G
Ischemic stroke is associated with motor impairment and increased incidence of affective disorders such as anxiety/clinical depression. In non-stroke populations, successful management of such disorders and symptoms has been reported following diet supplementation with long chain omega-3-polyunsaturated-fatty-acids (PUFAs). However, the potential protective effects of PUFA supplementation on affective behaviors after experimentally induced stroke and sham surgery have not been examined previously. This study investigated the behavioral effects of PUFA supplementation over a 6-week period following either middle cerebral artery occlusion or sham surgery in the hooded-Wistar rat. The PUFA diet supplied during the acclimation period prior to surgery was found to be associated with an increased risk of acute hemorrhage following the reperfusion component of the surgery. In surviving animals, PUFA supplementation did not influence infarct size as determined 6 weeks after surgery, but did decrease omega-6-fatty-acid levels, moderate sickness behaviors, acute motor impairment, and longer-term locomotor hyperactivity and depression/anxiety-like behavior.
Shimoda, Masami; Hoshikawa, Kaori; Shiramizu, Hideki; Oda, Shinri; Matsumae, Mitsunori
The diagnostic efficacy of fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging and computed tomography (CT) for acute subarachnoid hemorrhage (SAH) were compared and the problems with diagnosis were investigated in 81 patients with aneurysmal SAH within 24 hours after onset who underwent FLAIR imaging and CT on admission. The number of hematomas in the cisterns and ventricles were evaluated by clot scores. In addition, the frequency of undetected hematomas was calculated for the cisterns and ventricles. Clot scores were significantly higher for FLAIR imaging than for CT in the lateral sylvian, quadrigeminal, and convexity cisterns. On the other hand, clot scores were significantly higher for CT than for FLAIR imaging in the interhemispheric and medial sylvian cisterns. The overall frequency of undetected SAH was 2% for FLAIR imaging and 14% for CT. With the exception of the interhemispheric and medial sylvian cisterns, the frequency of undetected SAH was higher for CT than for FLAIR imaging. In this study, FLAIR imaging was more sensitive than CT for the detection of acute SAH within 24 hours after onset. However, the diagnostic efficacy of FLAIR imaging was reduced in comparatively tight cisterns.
Wu, Chris Y; Riangwiwat, Tanawan; Nakamoto, Beau K
Longitudinally extensive transverse myelitis (LETM) may be associated with viral triggers, including both infections and vaccinations. We present a case of a healthy immunocompetent 33-year-old woman who developed a hemorrhagic LETM 2 weeks after seasonal influenza vaccination. Hemorrhagic LETM has not to our knowledge been reported after influenza vaccination. It may represent a forme fruste variant of acute hemorrhagic leukoencephalitis.
Wijman, Christine A.C.; Venkatasubramanian, Chitra; Bruins, Sara; Fischbein, Nancy; Schwartz, Neil
Background The optimal diagnostic evaluation for spontaneous intracerebral hemorrhage (ICH) remains controversial. In this retrospective study, we assessed the utility of early magnetic resonance imaging (MRI) in ICH diagnosis and management. Methods Eighty-nine (72%) of 123 patients with spontaneous ICH underwent a brain CT and MRI within 30 days of ICH onset. Seventy patients with a mean age of 62 ± 15 years were included. A stroke neurologist and a general neurologist, each blinded to the final diagnosis, independently reviewed the admission data and the initial head CT and then assigned a presumed ICH cause under 1 of 9 categories. ICH cause was potentially modified after subsequent MRI review. The final ‘gold standard’ ICH etiology was determined after review of the complete medical record by an independent investigator. Change in diagnostic category and confidence and the potential impact on patient management were systematically recorded. Results Mean time to MRI was 3 ± 5 days. Final ICH diagnosis was hypertension or cerebral amyloid angiopathy (CAA) in 50% of patients. After MRI review the stroke neurologist changed diagnostic category in 14%, diagnostic confidence in an additional 23% and management in 20%, and the general neurologist did so in 19, 21 and 21% of patients, respectively. MRI yield was highest in ICH secondary to ischemic stroke, CAA, vascular malformations and neoplasms, and did not differ by age, history of hypertension, hematoma location or the presence of intraventricular hemorrhage. Conclusions The results of this study suggest potential additive clinical benefit of early MRI in patients with spontaneous ICH. PMID:20733299
Mrozek, Ségolène; Lonjaret, Laurent; Jaffre, Aude; Januel, Anne-Christine; Raposo, Nicolas; Boetto, Sergio; Albucher, Jean-François; Fourcade, Olivier; Geeraerts, Thomas
Background Reversible cerebral vasoconstriction syndrome (RCVS) is a rare cause of intracerebral hemorrhage (ICH) causing intracranial hypertension. Methods Case report. Results We report a case of RCVS-related ICH leading to refractory intracranial hypertension. A decompressive craniectomy was performed to control intracranial pressure. We discuss here the management of RCVS with intracranial hypertension. Decompressive craniectomy was preformed to avoid the risky option of high cerebral perfusion pressure management with the risk of bleeding, hemorrhagic complications, and high doses of norepinephrine. Neurological outcome was good. Conclusion RCVS has a complex pathophysiology and can be very difficult to manage in cases of intracranial hypertension. Decompressive craniectomy should probably be considered. PMID:28203185
Hankey, Graeme J; Norrving, Bo; Hacke, Werner; Steiner, Thorsten
Each year, 1·0–2·0% of individuals with atrial fibrillation and 0·1–0·2% of those with venous thromboembolism who are receiving one of the novel oral anticoagulants (dabigatran, rivaroxaban, or apixaban) can be expected to experience an acute ischemic stroke. Additionally, 0·2–0·5% of individuals with atrial fibrillation who are receiving one of the novel oral anticoagulants can be expected to experience an intracranial hemorrhage. This opinion piece addresses the current literature and offers practical approaches to the management of patients receiving novel oral anticoagulants who present with an ischemic or hemorrhagic stroke. Specifically, we discuss the role of thrombolysis in anticoagulated patients with acute ischemic stroke and factors to consider concerning restarting anticoagulation after acute ischemic and hemorrhagic stroke. PMID:24891030
Su, Cindy W
Postpartum hemorrhage (PPH) is a very common obstetric emergency with high morbidity and mortality rates worldwide. Understanding its etiology is fundamental to effectively managing PPH in an acute setting. Active management of the third stage of labor is also a key component in its prevention. Management strategies include conservative measures (medications, uterine tamponade, and arterial embolization) as well as surgical interventions (arterial ligations, compression sutures, and hysterectomy). Creating a standardized PPH protocol and running simulation-based drills with a multidisciplinary team may also help decrease maternal morbidity and improve perinatal outcomes, although further studies are needed.
Gangemi, Michelangelo; Cavallo, Luigi Maria; Di Somma, Alberto; Mazzucco, Grazia Marina; Bono, Paolo Sebastiano; Ghetti, Giovanni; Zambon, Giampaolo
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. PMID:24809036
Mutoh, Tomoko; Mutoh, Tatsushi; Nakamura, Kazuhiro; Yamamoto, Yukiko; Tsuru, Yoshiharu; Tsubone, Hirokazu; Ishikawa, Tatsuya; Taki, Yasuyuki
Early brain injury/ischemia (EBI) is a serious complication early after subarachnoid hemorrhage (SAH) that contributes to development of delayed cerebral ischemia (DCI). This study aimed to determine the role of inotropic cardiac support using milrinone (MIL) on restoring acute cerebral hypoperfusion attributable to EBI and improving outcomes after experimental SAH. Forty-three male C57BL/6 mice were assigned to either sham surgery (SAH-sham), SAH induced by endovascular perforation plus postconditioning with 2% isoflurane (Control), or SAH plus isoflurane combined with MIL with and without hypoxia-inducible factor inhibitor (HIF-I) pretreatment. Cardiac output (CO) during intravenous MIL infusion (0.25-0.75 μg/kg/min) between 1.5 and 2.5h after SAH induction was monitored with Doppler-echocardiography. MRI-continuous arterial spin labeling was used for quantitative CBF measurements. Neurobehavioral function was assessed daily by neurological score and open field test. DCI was analyzed 3 days later by determining infarction on MRI. Mild reduction of cardiac output (CO) and global cerebral blood flow (CBF) depression were notable early after SAH. MIL increased CO in a dose-dependent manner (P <0.001), which was accompanied by improved hypoperfusion, incidence of DCI and functional recovery than Control (P <0.05). The neuroprotective effects afforded by MIL or Control were attenuated by HIF inhibition (P <0.05). These results suggest that MIL improves acute hypoperfusion by its inotropic effect, leading to neurobehavioral improvement in mice after severe SAH, in which HIF may be acting as a critical mediator. This article is protected by copyright. All rights reserved.
Zhang, Li; Zhao, Na; Huang, Xiaodan; Jin, Xiuming; Geng, Xingyi; Chan, Ta-Chien; Liu, Shelan
To understand control interventions, the molecular epidemiology of acute hemorrhagic conjunctivitis (AHC) was investigated from 2004 to 2014.A total of 613,485 AHC cases (annualized cases 55,771) with two deaths were included. Our findings showed that AHC was reported in all provinces, predominantly in Southern and Eastern China. The incidence rates were highest in 2007 (5.65/100,000) and 2010 (21.78/100,000) respectively. A clear seasonal pattern was identified with a peak from August to October. AHC cases occurred in all age groups; however, five to 14 years was the predominant group [23.06%, 133, 510/578,909]. The median age was 24 years (one month~97 years). The median duration from onset to diagnosis was 1.5 days, and there was no difference between the <15, 15~60 and >60-year-old patients [p = 0.0653]. The phylogenetic analysis of 100 nonstructural proteins (3C) and 84 structural proteins (VP1) revealed that AHC outbreaks were caused by Coxsackievirus A24 variant. Genotypes G4-c5a, G4-c5b, and G4-c3 co-circulated with both temporal and geographical overlaps. In conclusion, despite the overall steady decline in the number of AHC cases since the peak in 2010, it still remains a serious public health problem in Southern and Eastern China that targets on the school aged children under 15 years old. PMID:28332617
Zhai, Yun-kai; Zhu, Wei-jun; Hou, Hong-li; Sun, Dong-xu; Zhao, Jie
The aim of this study was to assess the benefits of telemedicine in the delivery of thrombolytic therapy for patients with acute ischemic stroke. We performed a meta-analysis using combinations of the following terms: telestroke, telemedicine, tissue plasminogen activator/t-PA, and acute ischemic stroke. The primary outcome was favorable outcome based on the modified Rankin score. Secondary outcomes were incidence of symptomatic intracranial hemorrhage and overall mortality. We found no significant difference in favorable outcome between the telemedicine and control groups, and no significant difference was found between these groups in the rate of symptomatic intracranial hemorrhage or overall mortality. Patients with acute ischemic stroke who were treated with intravenous thrombolysis had similar outcomes regardless of whether telemedicine was used or they were treated in-person at a medical facility. Telemedicine can be used to support hospitals with limited experience in administering thrombolytic therapy for stroke.
Background Hyponatremia occurring as a result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) or cerebral salt wasting syndrome is a common complication in patients with subarachnoid hemorrhage (SAH). The efficacy and safety of urea as treatment for SIADH-induced hyponatremia has not been reported in this population. Methods This is a retrospective analysis of all patients admitted to our department for nontraumatic SAH between January 2003 and December 2008 (n = 368). All patients with SIADH-induced hyponatremia (plasma sodium < 135 mEq/L, urine sodium > 20 mEq/L, and osmolality > 200 mOsm/kg; absence of overt dehydration or hypovolemia; no peripheral edema or renal failure; no history of adrenal or thyroid disease) routinely received urea per os when hyponatremia was associated with clinical deterioration or remained less than 130 mEq/L despite saline solution administration. Results Forty-two patients developed SIADH and were treated with urea. Urea was started after a median of 7 (IQR, 5–10) days and given orally at doses of 15–30 g tid or qid for a median of 5 (IQR, 3–7) days. The median plasma sodium increase over the first day of treatment was 3 (IQR, 1–6) mEq/L. Hyponatremia was corrected in all patients, with median times to Na+ >130 and >135 mEq/L of 1 (IQR, 1–2) and 3 (IQR, 2–4) days, respectively. Urea was well tolerated, and no adverse effects were reported. Conclusions Oral urea is an effective and well-tolerated treatment for SIADH-induced hyponatremia in SAH patients. PMID:22647340
Evaluation of the safety and efficacy of recombinant soluble thrombomodulin for patients with disseminated intravascular coagulation associated with acute leukemia: multicenter prospective study by the Tohoku Hematology Forum.
Yokoyama, Hisayuki; Takahashi, Naoto; Katsuoka, Yuna; Inomata, Mitsue; Ito, Toshihiro; Meguro, Kuniaki; Kameoka, Yoshihiro; Tsumanuma, Riko; Murai, Kazunori; Noji, Hideyoshi; Ishizawa, Kenichi; Ito, Shigeki; Onishi, Yasushi; Harigae, Hideo
It has been suggested that use of recombinant soluble thrombomodulin (rTM) is superior to conventional drugs in treatment of disseminated intravascular coagulation (DIC) complicating acute leukemia. However, its safety and efficacy have not been fully examined in prospective studies. Here, we performed a multicenter prospective study to examine outcomes of rTM treatment for DIC in patients with acute leukemia. Of 33 patients registered in this study, 13 had acute myeloid leukemia (AML), three had acute lymphoblastic leukemia (ALL), and 17 had acute promyelocytic leukemia (APL). The cumulative rates of DIC resolution at day 7 and day 35 were 56 and 81% in AML/ALL and 53 and 77% in APL, respectively. The median time from the initiation of rTM to DIC resolution was 4 days in AML/ALL and 6 days in APL patients. Adverse events related to hemorrhage occurred in two AML/ALL patients (13%) and three APL patients (18%). Of these, one AML/ALL patient died with intracranial hemorrhage, and two APL patients died with intracranial hemorrhage and pulmonary hemorrhage. These results suggest that rTM may improve the survival of acute leukemia patients with DIC by inhibiting early death related to hemorrhagic events, as reported previously.
Lee, Ho Jin; Kim, Dong Hyun; Lee, Seul; Koh, Myeong Seok; Kim, So Yeon; Lee, Ji Hyun; Lee, Suee; Oh, Sung Yong; Han, Jin Yeong; Kim, Hyo-Jin; Kim, Sung-Hyun
Background/Aims: This study investigated whether patients with acute promyelocytic leukemia (APL) truly fulfill the diagnostic criteria of overt disseminated intravascular coagulation (DIC), as proposed by the International Society on Thrombosis and Haemostasis (ISTH) and the Korean Society on Thrombosis and Hemostasis (KSTH), and analyzed which component of the criteria most contributes to bleeding diathesis. Methods: A single-center retrospective analysis was conducted on newly diagnosed APL patients between January 1995 and May 2012. Results: A total of 46 newly diagnosed APL patients were analyzed. Of these, 27 patients (58.7%) showed initial bleeding. The median number of points per patient fulfilling the diagnostic criteria of overt DIC by the ISTH and the KSTH was 5 (range, 1 to 7) and 3 (range, 1 to 4), respectively. At diagnosis of APL, 22 patients (47.8%) fulfilled the overt DIC diagnostic criteria by either the ISTH or KSTH. In multivariate analysis of the ISTH or KSTH diagnostic criteria for overt DIC, the initial fibrinogen level was the only statistically significant factor associated with initial bleeding (p = 0.035), but it was not associated with overall survival (OS). Conclusions: Initial fibrinogen level is associated with initial presentation of bleeding of APL patients, but does not affect OS. PMID:26552464
Lee, Ji Yeoun; Son, Young-Je; Kim, Jeong Eun
Intracranial pial arteriovenous fistula (AVF) is a rare cerebrovascular lesion that has only recently been recognized as a distinct pathological entity. A 41-year-old woman (Patient 1) presented with the sudden development of an altered mental state. Brain CT showed an acute subdural hematoma. A red sylvian vein was found intraoperatively. A pial AVF was revealed on postoperative angiography, and surgical disconnection of the AVF was performed. A 10-year-old boy (Patient 2) presented with a 10-day history of paraparesis and urinary incontinence. Brain, spinal MRI and angiography revealed an intracranial pial AVF and a spinal perimedullary AVF. Endovascular embolization was performed for both lesions. The AVFs were completely obliterated in both patients. On follow-up, patient 1 reported having no difficulty in performing activities of daily living. Patient 2 is currently able to walk without assistance and voids into a diaper. Intracranial pial AVF is a rare disease entity that can be treated with surgical disconnection or endovascular embolization. It is important for the appropriate treatment strategy to be selected on the basis of patientspecific and lesion-specific factors in order to achieve good outcomes.
Wu, De; Ke, Chang-Wen; Mo, Yan-Ling; Sun, Li-Mei; Li, Hui; Chen, Qiu-Xia; Zou, Li-Rong; Fang, Ling; Huang, Ping; Zhen, Huan-ying
Acute hemorrhagic conjunctivitis (AHC) is usually caused by enterovirus 70, coxsackievirus A24(CA24v) and adenoviruses. Several outbreaks of AHC caused by a CA24v have occurred since it was imported into China in 1971. Multiple outbreaks of AHC reappeared in 10 cities of Guangdong during June to November in 2007. The epidemic began in the June, and spread extensively, with a peak in the September. A total of 31,659 cases were reported to center for disease control and prevention of Guangdong, it was estimated that the number of actual AHC was >200 thousands. Forty conjunctival swab specimens were collected from the cases diagnosed clinically with AHC. (RT)-PCR testing on these conjunctival specimens revealed the presence of an enterovirus, and this was confirmed by 16 isolates. We demonstrated the most likely etiological agent for the multiple outbreaks was a variant of coxsackievirus A24 by molecular typing using a partial VP1 sequence. Sequence comparison and phylogenetic analyses of the VP1 and 3Cpro gene regions were performed by Neighbor-joining method, the strains from different outbreaks and different geographical areas within Guangdong had no sequence divergence in 2007. The representative isolates from mainland of China including Hangzhou, Ningbo, Beijing, Yunnan, Liaoning, and Henan were analyzed in this study. Phylogenetic analysis revealed theses isolates were located in different clusters, a close phylogenetic and chronological relationship with Singaporean, South Korean and Thailand isolates had been observed. This confirms CA24v circulated in China's mainland has not evolved independently, but co-evolved with the isolates of Southeast Asia.
Rao, K. N.; Zuretti, M. F.; Baccino, F. M.; Lombardi, B.
The activity of lysosomal enzymes of the pancreas and the liver has been studied during induction and onset of acute hemorrhagic pancreatic necrosis with fat necrosis (AHPN) in mice. We induced AHPN by feeding the animals a choline-deficient (CD) diet containing 0.5% DL-ethionine (CDE). Control animals were fed either laboratory chow or a plain CD DIET. Increased total activities of cathespin B1, beta-galactosidase, and acid phosphatase were found to occur in pancreas homogenates of mice fed the CDE diet for 2 and 3 days. Release of cathespin B1 into pancreas cytosol was observed after 1 day of feeding. beta-galactosidase and acid phosphatase were increased in pancreas cytosol after 2 and 3 days of feeding. Changes in total activity and location of the lysosomal enzymes did not occur in the liver. Feeding the CD and CDE diets resulted in an increase in the free activity of lysosomal enzymes of both the pancreas and the liver, suggesting the existence of alterations in the lysosomal membrane. Pancreas and liver homogenates were stored on ice up to 3 hours, and the free activity of acid phosphatase and beta-galactosidase were determined at various time intervals. The free activity of both enzymes increased progressively for 3 hours in the pancreas but not in the liver. It is concluded that: 1) induction of AHPN in mice is accompanied by an increase in the activity of lysosomal enzymes of the acinar cells of the pancreas; 2) cathepsin B1 may be responsible for triggering an intraparenchymal activation of zymogens, and 3) pancreatic lysosomes are labilized more easily than liver lysosomes. PMID:7350817
Li, Zuowei; Zheng, Xiaonan; Li, Ping; Itoua, Eudes Saturnin Régis; Moukassa, Donatien; Ndinga Andely, Françoise
BACKGROUND To explore the time-dependent effects of acupuncture on mRNA levels of the apoptotic factors BCL-2 and BAX in a rat cerebral hemorrhage model, slow injection of autologous blood to the caudate nucleus was used to generate the cerebral hemorrhage model. MATERIAL AND METHODS A sham surgery control group, groups with acupuncture applied 3, 9, 24, and 48 hours after model induction, and time-matched model-only control groups were used. In situ hybridization was used to detect BCL-2 and BAX mRNA expression, and semi-quantitative RT-PCR was used to measure the expression. RESULTS The number of BCL-2 and BAX mRNA-positive cells significantly increased during the acute phase of cerebral hemorrhage. BCL-2 mRNA was significantly upregulated in acupuncture groups compared to other groups, whereas BAX mRNA levels in the acupuncture groups were lower in the other groups, except for the sham surgery group. Additionally, earlier acupuncture intervention was associated with a lower ratio of expression between the two genes. Changes in BCL-2 and BAX mRNA expression were consistent with changes in the number of cells positive for BCL-2 and BAX mRNA; however, the change in the expression ratio was consistent with the change in the number of cells positive for BCL-2 mRNA, but opposite to the change in the number of cells positive for BAX mRNA. CONCLUSIONS Acupuncture ameliorated changes in expression of apoptotic factors in the brain induced by acute cerebral hemorrhage and may thus protect the brain, with greater efficacy when the delay before acupuncture was minimized.
Li, Zuowei; Zheng, Xiaonan; Li, Ping; Itoua, Eudes Saturnin Régis; Moukassa, Donatien; Andely, Françoise Ndinga
Background To explore the time-dependent effects of acupuncture on mRNA levels of the apoptotic factors BCL-2 and BAX in a rat cerebral hemorrhage model, slow injection of autologous blood to the caudate nucleus was used to generate the cerebral hemorrhage model. Material/Methods A sham surgery control group, groups with acupuncture applied 3, 9, 24, and 48 hours after model induction, and time-matched model-only control groups were used. In situ hybridization was used to detect BCL-2 and BAX mRNA expression, and semi-quantitative RT-PCR was used to measure the expression. Results The number of BCL-2 and BAX mRNA-positive cells significantly increased during the acute phase of cerebral hemorrhage. BCL-2 mRNA was significantly upregulated in acupuncture groups compared to other groups, whereas BAX mRNA levels in the acupuncture groups were lower in the other groups, except for the sham surgery group. Additionally, earlier acupuncture intervention was associated with a lower ratio of expression between the two genes. Changes in BCL-2 and BAX mRNA expression were consistent with changes in the number of cells positive for BCL-2 and BAX mRNA; however, the change in the expression ratio was consistent with the change in the number of cells positive for BCL-2 mRNA, but opposite to the change in the number of cells positive for BAX mRNA. Conclusions Acupuncture ameliorated changes in expression of apoptotic factors in the brain induced by acute cerebral hemorrhage and may thus protect the brain, with greater efficacy when the delay before acupuncture was minimized. PMID:28357997
James, Robert F; Palys, Viktoras; Lomboy, Jason R; Lamm, J Richard; Simon, Scott D
New anticoagulant and antiplatelet medications have been approved and are prescribed with increased frequency. Intracranial hemorrhage is associated with the use of these medications. Therefore, neurosurgeons need to be aware of these new medications, how they are different from their predecessors, and the strategies for the urgent reversal of their effects. Utilization of intraluminal stents by endovascular neurosurgeons has resulted in the need to have a thorough understanding of antiplatelet agents. Increased use of dabigatran, rivaroxaban, and apixaban as oral anticoagulants for the treatment of atrial fibrillation and acute deep venous thrombosis has increased despite the lack of known antidotes to these medications.
Chen, Han; Xu, Ming; Yang, Yan-Lin; Chen, Kai; Xu, Jing-Qing; Zhang, Ying-Rui; Yu, Rong-Guo
Introduction There are concerns that the use of positive end-expiratory pressure (PEEP) in patients with brain injury may potentially elevate intracranial pressure (ICP). However, the transmission of PEEP into the thoracic cavity depends on the properties of the lungs and the chest wall. When chest wall elastance is high, PEEP can significantly increase pleural pressure. In the present study, we investigate the different effects of PEEP on the pleural pressure and ICP in different respiratory mechanics. Methods and analysis This study is a prospective, single-centre, physiological study in patients with severe brain injury. Patients with acute respiratory distress syndrome with ventricular drainage will be enrolled. An oesophageal balloon catheter will be inserted to measure oesophageal pressure. Patients will be sedated and paralysed; airway pressure and oesophageal pressure will be measured during end-inspiratory occlusion and end-expiratory occlusion. Elastance of the chest wall, the lungs and the respiratory system will be calculated at PEEP levels of 5, 10 and 15 cm H2O. We will classify each patient based on the maximal ΔICP/ΔPEEP being above or below the median for the study population. 2 groups will thus be compared. Ethics and dissemination The study protocol and consent forms were approved by the Institutional Review Board of Fujian Provincial Hospital. Study findings will be disseminated through peer-reviewed publications and conference presentations. Trial registration number NCT02670733; pre-results. PMID:27852713
about $7,500 higher than surgical clipping. Assuming that the total number of intracranial aneurysm repairs in Ontario increases to 750 in the fiscal year of 2007, and assuming that up to 60% (450 cases) of these will be repaired by coil embolization, the difference in device costs for the 450 cases (including a 15% recurrence rate) would be approximately $3.8 million. This figure does not include capital costs (e.g. $3 million for an angiosuite), additional human resources required, or costs of follow-up. The increase in expenditures associated with coil embolization may be offset partially, by shorter operating room times and hospitalization stays for endovascular repair of unruptured aneurysms; however, the impact of these cost savings is probably not likely to be greater than 25% of the total outlay since the majority of cases involve ruptured aneurysms. Furthermore, the recent growth in aneurysm repair has predominantly been in the area of coil embolization presumably for patients for whom surgical clipping would not be advised; therefore, no offset of surgical clipping costs could be applied in such cases. For ruptured aneurysms, downstream cost savings from endovascular repair are likely to be minimal even though the savings for individual cases may be substantial due to lower perioperative complications for endovascular aneurysm repair. Guidelines The two Guidance documents issued by the National Institute of Clinical Excellence (UK) in 2005 support the use of coil embolization for both unruptured and ruptured (SAH) intracranial aneurysms, provided that procedures are in place for informed consent, audit, and clinical governance, and that the procedure is performed in specialist units with expertise in the endovascular treatment of intracranial aneurysms. Conclusion For people in good clinical condition following subarachnoid hemorrhage from an acute ruptured intracranial aneurysm suitable for either surgical clipping or endovascular repair, coil embolization
ISSUES Intracranial hemorrhage can present itself in many different contexts, from the 85 year old woman on anticoagulation to the infant shaken...etiology for intracranial bleeds. Individuals with high blood pressure, atherosclerotic disease, atrial fibrillation, and a myriad other medical conditions...suffered an intracranial bleed involves many members of the medical community, including paramedics on site, emergency room physicians, neurologists
Harris, Andrew C; LeSage, Mark G; Shelley, David; Perry, Jennifer L; Pentel, Paul R; Owens, S Michael
Passive immunization with monoclonal antibodies (mAbs) against (+)-methamphetamine (METH) is being evaluated for the treatment of METH addiction. A human/mouse chimeric form of the murine anti-METH mAb7F9 has entered clinical trials. This study examined the effects of murine mAb7F9 on certain addiction-related behavioral effects of METH in rats as measured using intracranial self-stimulation (ICSS). Initial studies indicated that acute METH (0.1-0.56 mg/kg, s.c.) lowered the minimal (threshold) stimulation intensity that maintained ICSS. METH (0.3 mg/kg, s.c.) also blocked elevations in ICSS thresholds (anhedonia-like behavior) during spontaneous withdrawal from a chronic METH infusion (10 mg/kg/day x 7 days). In studies examining effects of i.v. pretreatment with mAb7F9 (at 30, 100, or 200 mg/kg), 200 mg/kg blocked the ability of an initial injection of METH (0.3 mg/kg, s.c.) to reduce baseline ICSS thresholds, but was less capable of attenuating the effect of subsequent daily injections of METH. MAb7F9 (200 mg/kg) also produced a small but significant reduction in the ability of METH (0.3 mg/kg, s.c.) to reverse METH withdrawal-induced elevations in ICSS thresholds. These studies demonstrate that mAb7F9 can partially attenuate some addiction-related effects of acute METH in an ICSS model, and provide some support for the therapeutic potential of mAb7F9 for the treatment of METH addiction.
Gillissen, A; Sueters, M; van Lith, J M; Walther, F J; Lopriore, E
Monochorionic (MC) twin pregnancies are at increased risk of several complications including acute or chronic twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence (TAPS). Both TTTS and TAPS result from inter-twin fetofetal transfusion through the placental vascular anastomoses. In addition, MC twin pregnancies are at increased risk of having a velamentous cord insertion, which has been linked with poor perinatal outcome due to risk of rupture of the velamentous vessels. In sporadic cases, these vascular connections may have a positive effect instead of a deleterious effect. We present a case of acute fetal distress in a MC twin pregnancy caused by acute hemorrhage following rupture of velamentous vessels. An emergency cesarean section delivery was performed at 29+2 weeks' gestation. One infant was severely anemic at birth and required immediate treatment with volume expansion and blood transfusion. Acute fetal blood loss through the ruptured vessels led to an acute fetofetal transfusion from the co-twin through the placental vascular anastomoses. Delayed intervention could have resulted in severe hypovolemic shock and acute anemia in both fetuses. Instead, in the current case, placental vascular anastomoses had a transient protective role and allowed transfusion of blood from one co-twin into the circulation of the anemic twin.
Chang, Hong; Wang, Xiaojuan; Yang, Xin; Song, Haiqing; Qiao, Yuchen; Liu, Jia
Objective Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) is considered the most effective treatment method for AIS; however, it is associated with a risk of hemorrhage. We analyzed the risk factors for digestive and urologic hemorrhage during rt-PA therapy. Methods We retrospectively analyzed patients with AIS who underwent intravenous thrombolysis with rt-PA during a 5-year period in a Chinese stroke center. Data on the demographics, medical history, laboratory test results, and clinical outcomes were collected. Results 338 patients with AIS were eligible and included. Logistic regression multivariate analysis showed that gastric catheter was significantly correlated with digestive hemorrhage, while age and urinary catheter were significantly correlated with urologic hemorrhage. Most hemorrhagic events were associated with catheterization after 1 to 24 hours of rt-PA therapy. Conclusions In summary, gastric and urinary catheters were correlated with digestive and urologic hemorrhage in patients with AIS undergoing rt-PA therapy. Well-designed controlled studies with large samples are required to confirm our findings.
Bai, Shutang; Wang, Zhiheng; Zhang, Liang; Fu, Hongdu; Zhuang, Huanwei; Cao, Xianjun; Liang, Liming; Yang, Yanqi
Interruption of the descending aorta is an extremely rare great vessel malformation. In this report, we describe a very unusual case of a 29-year-old female with a 13-year history of hypertension who was found to have an interruption of the descending aorta when she was hospitalized with a subarachnoid hemorrhage and symptoms of acute paraplegia. We successfully surgically corrected the defect using a Gore-Tex® graft to bypass the aortic interruption. The patient's blood pressure postoperatively returned to normal, and the patient recovered completely from her paraplegia by the time of her 5-month follow-up visit.
Moriyoshi, Hideyuki; Furukawa, Soma; Iwata, Mai; Suzuki, Junichiro; Nakai, Noriyoshi; Nishida, Suguru; Ito, Yasuhiro
A 78-year-old man was admitted to our hospital because of sudden right hemiparesis and dysarthria. His cranial MRI showed an area of hyperintensity in left pons on DWI and MRA revealed dilated, elongated and tortuous intracranial artery. We diagnosed as acute phase ischemic stroke and intracranial arterial dolichoectasia (IADE). Intravenous infusion of rt-PA was performed 157 minutes after the onset of symptoms, and his hemiparesis improved. However, he subsequently suffered from cerebral infarction 4 times in 6 months, and we treated him twice with thrombolytic therapy. Although thrombolytic therapy was effective in the short term and antithrombotic therapy was continued, he had bilateral hemiplegia and severe dysphagia because of repeated cerebral infarctions. Hence basilar artery was dilated with intramural hemorrhage over 6 months, and we discontinued antithrombolytic therapy. It is possible that antithrombolytic therapy affects enlargement of IADE. Antithrombolytic therapy for IADE should be done carefully.
Ali, M.S.; Amenta, P.S.; Starke, R.M.; Jabbour, P.M.; Gonzalez, L.F.; Tjoumakaris, S.I.; Flanders, A.E.; Rosenwasser, R.H.; Dumont, A.S.
Summary Intracranial vertebral artery dissection (VAD) represents the underlying etiology in a significant percentage of posterior circulation ischemic strokes and subarachnoid hemorrhages. These lesions are particularly challenging in their diagnosis, management, and in the prediction of long-term outcome. Advances in the understanding of underlying processes leading to dissection, as well as the evolution of modern imaging techniques are discussed. The data pertaining to medical management of intracranial VADs, with emphasis on anticoagulants and antiplatelet agents, is reviewed. Surgical intervention is discussed, including, the selection of operative candidates, open and endovascular procedures, and potential complications. The evolution of endovascular technology and techniques is highlighted. PMID:23217643
Mangion, Kenneth; Corcoran, David; Carrick, David; Berry, Colin
Cardiac magnetic resonance (CMR) imaging enables the assessment of left ventricular function and pathology. In addition to established contrast-enhanced methods for the assessment of infarct size and microvascular obstruction, other infarct pathologies, such as myocardial edema and myocardial hemorrhage, can be identified using innovative CMR techniques. The initial extent of myocardial edema revealed by T2-weighted CMR has to be stable for edema to be taken as a retrospective marker of the area-at-risk, which is used to calculate myocardial salvage. The timing of edema assessment is important and should be focused within 2 - 7 days post-reperfusion. Some recent investigations have called into question the diagnostic validity of edema imaging after acute STEMI. Considering the results of these studies, as well as results from our own laboratory, we conclude that the time-course of edema post-STEMI is unimodal, not bimodal. Myocardial hemorrhage is the final consequence of severe vascular injury and a progressive and prognostically important complication early post-MI. Myocardial hemorrhage is a therapeutic target to limit reperfusion injury and infarct size post-STEMI.
Wu, Chris Y.; Riangwiwat, Tanawan
Longitudinally extensive transverse myelitis (LETM) may be associated with viral triggers, including both infections and vaccinations. We present a case of a healthy immunocompetent 33-year-old woman who developed a hemorrhagic LETM 2 weeks after seasonal influenza vaccination. Hemorrhagic LETM has not to our knowledge been reported after influenza vaccination. It may represent a forme fruste variant of acute hemorrhagic leukoencephalitis. PMID:27847660
Nyberg, Christoffer; Karlsson, Torbjörn; Hillered, Lars; Engström, Elisabeth Ronne
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. PMID:24940881
Kurre, Wiebke Perez, Marta Aguilar; Horvath, Diana; Schmid, Elisabeth; Baezner, Hansjoerg; Henkes, Hans
Purpose. Mechanical thrombectomy (mTE) proved to be effective treating acute vessel occlusions with an acceptable rate of procedural complications. Potential long-term side effects of the vessel wall trauma caused by mechanical irritation of the endothelium are unknown up to now. Methods. From a retrospectively established database of 640 acute stroke treatments, we selected 261 patients with 265 embolic vessel occlusions treated successfully by mTE without permanent implantation of a stent. Analysis comprised the type of devices used and the number of passes performed. Digital subtraction angiography immediately after treatment was evaluated for vasospasm, dissection, and extravasation. Control angiographic images were evaluated for any morphological change compared to the immediate posttreatment angiographic run. Results. Recanalization was achieved with a median of one (range 1-10) mTE maneuvers. Vasospasm occurred in 69 territories (26.0 %) and was treated with glyceroltrinitrate in three. Dissection was observed in one vessel (0.4 %). Intraprocedural hemorrhage in two patients (0.8 %) was either wire or device induced. Follow-up digital subtraction angiography was available for 117 territories after a median of 107 days, revealing target vessel occlusion in one segment (0.9 %) and a de novo stenosis of four segments (3.4 %). All findings were clinically asymptomatic. Posttreatment vasospasm was more frequent in patients with de novo stenosis and occlusion (p = 0.038). Conclusion. De novo stenoses and occlusions occur in a small proportion of patients after mTE. Because all lesions were clinically asymptomatic, this finding does not affect the overall benefit of the treatment. Vasospasm may predict late vessel wall changes.
Manjila, Sunil; Miller, Benjamin R; Rao-Frisch, Anitha; Otvos, Balint; Mitchell, Anna; Bambakidis, Nicholas C; De Georgia, Michael A
Moyamoya disease is a rare cerebrovascular anomaly involving the intracranial carotid arteries that can present clinically with either ischemic or hemorrhagic disease. Moyamoya syndrome, indistinguishable from moyamoya disease at presentation, is associated with multiple clinical conditions including neurofibromatosis type 1, autoimmune disease, prior radiation therapy, Down syndrome, and Turner syndrome. We present the first reported case of an adult patient with previously unrecognized mosaic Turner syndrome with acute subarachnoid and intracerebral hemorrhage as the initial manifestation of moyamoya syndrome. A 52-year-old woman was admitted with a subarachnoid hemorrhage with associated flame-shaped intracerebral hemorrhage in the left frontal lobe. Physical examination revealed short stature, pectus excavatum, small fingers, micrognathia, and mild facial dysmorphism. Cerebral angiography showed features consistent with bilateral moyamoya disease, aberrant intrathoracic vessels, and an unruptured 4-mm right superior hypophyseal aneurysm. Genetic analysis confirmed a diagnosis of mosaic Turner syndrome. Our case report is the first documented presentation of adult moyamoya syndrome with subarachnoid and intracerebral hemorrhage as the initial presentation of mosaic Turner syndrome. It illustrates the utility of genetic evaluation in patients with cerebrovascular disease and dysmorphism.
A stroke is a medical emergency. There are two types - ischemic and hemorrhagic. Hemorrhagic stroke is the less common type. It happens when ... an artery wall that breaks open. Symptoms of stroke are Sudden numbness or weakness of the face, ...
Khalatbari, Mahmoud Reza; Moharamzad, Yashar
Myxopapillary ependymoma (MPE), a benign histological variant of ependymoma, is found most commonly in the cauda equina region. Primary intracranial MPE is very rare, and most cases are a metastatic deposit from a spinal lesion. Primary cerebral MPEs are usually well-defined solid or cystic lesions without hemorrhage. We report the first case of primary cerebral MPE with intratumoral hemorrhage.
Zuo, Feng-Tong; Liu, Hui; Wu, Hui-Jun; Su, Na; Liu, Jie-Qiong; Dong, Ai-Qin
Abstract Background: There are limited data on the effect of dual antiplatelet treatment with clopidogrel plus aspirin in patients with ischemic cerebrovascular disease and intracranial and extracranial arteriostenosis. The aim of our study was to evaluate the efficacy and safety of aspirin plus clopidogrel in the treatment of ischemic cerebrovascular disease with intracranial and extracranial arteriostenosis. Methods: Patients with clinically evident acute cerebral infarction or transient ischemic attack combined with intracranial and extracranial arteriostenosis (greater than 50%) who were unsuitable or reluctance to perform stent implantation were enrolled in this study. We randomly assigned these patients to receive clopidogrel (75 or 50 mg) plus aspirin (100 mg) or aspirin (100 mg) once daily through 90 days, and followed them for 90 days. We examined the main endpoints including the recurrence of stroke, death from cardiovascular causes, and bleeding events. Results: In all, 200 patients were recruited and followed for 90 days. Ischemic stroke occurred in 6 patients (9.1%) treated with 50 mg clopidogrel and aspirin, 6 patients (9.1%) receiving 75 mg clopidogrel and aspirin, whereas 19 patients (27.9%) in the aspirin group (aspirin alone vs copidogrel 50 mg plus aspirin; 95% confidence intervals 1.704–23.779, P < 0.05; aspirin alone vs copidogrel 75 mg plus aspirin; 95% confidence intervals 1.190–13.240, P < 0.05). There were more hemorrhagic events among recipients (3 patients [2.3%]) in the copidogrel plus aspirin group than aspirin recipients (0 patient [0%]), including 1 subcutaneous hemorrhage in the group of 50 mg clopidogrel and aspirin, doubling the number of nasal and gum bleeding in the group of 75 mg clopidogrel and aspirin (P > 0.05). No intracranial hemorrhage and gastro-intestinal hemorrhage occurred in these 3 groups. Conclusion: Accordingly, 50 mg clopidogrel plus aspirin, and 75 mg clopidogrel plus aspirin
Yoshimura, Junichi; Natsumeda, Manabu; Nishihira, Yasushi; Nishiyama, Kenichi; Saito, Akihiko; Okamoto, Kouichirou; Takahashi, Hitoshi; Fujii, Yukihiko
A 28-year-old man presented with osteosarcoma of the occipital bone 16 years after 24 Gy of craniospinal irradiation for acute lymphocytic leukemia. The tumor had both intra- and extra-cranial components. However, the affected skull appeared to be normal on imaging because of permeative infiltration by the tumor. Subtotal resection was achieved and the tumor was verified histologically as an osteosarcoma. The residual tumor soon showed remarkable enlargement and disseminated to the spinal cord. Both of the enlarged and disseminated tumor masses were treated by surgical intervention and chemotherapy. However, the patient deteriorated due to the tumor regrowth and died 11 months after the initial diagnosis. This patient had previously developed a leukemia, a colon cancer, a rectal cancer and a hepatocellular carcinoma. His brother also died of leukemia. The patient had a heterozygous TP53 germ-line mutation of codon 248 in the exon 7. In conclusion, we consider the present tumor to be a rare example of radiation-induced skull osteosarcoma in a member of the cancer-prone family with TP53 germ-line mutation which is associated with Li-Fraumeni syndrome.
Comparison of Hemostatic Durability between N-Butyl Cyanoacrylate and Gelatin Sponge Particles in Transcatheter Arterial Embolization for Acute Arterial Hemorrhage in a Coagulopathic Condition in a Swine Model
Yonemitsu, Takafumi; Kawai, Nobuyuki; Sato, Morio Sonomura, Tetsuo; Takasaka, Isao; Nakai, Motoki; Minamiguchi, Hiroki; Sahara, Shinya; Iwasaki, Yasuhiro; Naka, Toshio; Shinozaki, Masahiro
This study was designed to compare the efficacy of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) or gelatin sponge particles (GSP) for acute arterial bleeding in a coagulopathic condition using a swine model. Four healthy swine were divided into two coagulopathic conditions: mild and severe. Five hemorrhages were created in each swine (10 hemorrhages per coagulopathy). Mild coagulopathy was achieved by bloodletting 10% of the total circulatory whole blood and preserving activated clotting time (ACT) less than 200 s (ACT < 200 s state); severe coagulopathy was achieved by bloodletting 30% and preserving ACT > 400 s (ACT > 400-second state). For each state, of ACT < 200 s or ACT > 400 s, TAE was conducted with GSP or NBCA to control five hemorrhages arising from artificially created renal and splenic injuries. Angiography immediately after TAE with GSP or NBCA showed complete occlusion in both coagulopathic conditions. In the ACT < 200-second state, follow-up angiography at 5-30 min after TAE with GSP or NBCA showed no evidence of recurrent hemorrhage. In the ACT > 400-second state, follow-up angiography showed recurrent hemorrhage in four (80%) of the five hemorrhages embolized with GSP and in one (20%) of the five hemorrhages embolized with NBCA. Microscopically, red thrombi were observed densely surrounding GSP in mild coagulopathy but were scarce in severe coagulopathy. In a condition with severe coagulopathy, TAE with NBCA was more effective in durability to cease active arterial bleeding than with GSP.
Stefanits, Harald; Konstantopoulou, Vassiliki; Kuess, Magnus; Milenkovic, Ivan; Matula, Christian
The congenital disorder of glycosylation characterized by a deficiency of phosphomannomutase 2 (PMM2-CDG) is the most common variant of congenital disorders of glycosylation. Besides typical clinical features, such as dysmorphism and abnormal body fat distribution, coagulation abnormities often lead to thromboembolic and hemorrhagic events in these patients. However, only 2 cases of intracerebral bleeding in patients with PMM2-CDG have been described so far. A 4-year-old girl who initially presented with symptoms resulting from raised intracranial pressure underwent acute neurosurgical intervention for intracranial hemorrhage. The differential diagnoses after MRI included arteriovenous malformation and intraparenchymal brain tumor. However, clinical investigations promoted the diagnosis of PMM2-CDG, which was supported further by neuropathological findings and finally confirmed by isoelectric focusing and mutational analysis. No major complications or neurological deficits were evident after surgery, and the patient was able to attend an integrated kindergarten. Unexplained intracranial hemorrhage should raise suspicion of a metabolic disorder and should be discussed with specialists to rule out an orphan disease such as PMM2-CDG.
Rangel-Castillo, Leonardo; Gopinath, Shankar; Robertson, Claudia S.
Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury. PMID:18514825
Ryan, Joshua E; Tai, Alex; Armonda, Rocco A
Herpes simplex virus (HSV) is the most common cause of non-epidemic, sporadic, acute focal encephalitis in the United States. Inflammation of the vasculature makes them friable and susceptible to hemorrhage. Massive hemorrhage, though rare, can present in a delayed fashion after initiation of acyclovir and often requires surgical intervention. We report a unique case of delayed temporal lobe hemorrhage after initiation of acyclovir in an immunocompetent patient, specifically for its presentation, virology, and surgical management. A 40-year-old left-handed Caucasian female with chronic headaches, along with a 20-pack-year smoking history, presented to an outside facility with one week of diffuse, generalized headache, fever, nausea, and vomiting. Initial cranial imaging was negative for hemorrhage. Cerebrospinal fluid (CSF) studies showed a lymphocytic pleocytosis with elevated protein, along with polymerase chain reaction (PCR) positive staining for HSV, establishing the diagnosis of HSV-2 encephalitis, which is less common in adults. Acyclovir was initiated and one week later while still hospitalized, the patient developed acute altered mental status with cranial imaging showing a large right temporal lobe hemorrhage with significant midline shift. She was transferred to our facility for surgical intervention. Computed tomography angiography (CTA) was negative for any underlying vascular lesion. She was taken to the operating room for a decompressive unilateral (right) hemicraniectomy and temporal lobectomy. She had no postoperative complications and completed a three-week course of acyclovir. She was discharged to acute rehab with plans to return at a later date for cranioplasty. Intracerebral hemorrhage is an uncommon, although possible sequela, of herpes encephalitis. Despite initiation of early antiviral therapy, close monitoring is warranted, given the pathophysiology of the vasculature. Any decline in the neurological exam and/or increasing symptomatology
Arai, Nobuhiko; Nakamura, Akiyoshi; Tabuse, Masanao; Miyazaki, Hiromichi
Background: Delayed acute subdural hematoma (DASH) is a subdural hematoma which is detected later. An initial computed tomography (CT) does not reveal any intracranial hemorrhage at all. Few patients of DASH after mild traumatic brain injury associated with percutaneous coronary intervention (PCI) have been published. Patient Presentation: A 63-year-old woman presented with cardiac pulmonary arrest due to acute myocardial infarction and lethal arrhythmia. She had hit her head on the road. The initial CT did not reveal any hemorrhage in the intra-cranium. She fully recovered after PCI. However, 1 hour after PCI, she lost consciousness and immediate CT showed acute subdural hematoma and subarachnoid hemorrhage. The period from losing consciousness to brain herniation presenting as anisocoria was very short—only 30 minutes in our patient. Although emergent evacuation of hematoma and external decompression were performed, the patient died 1 day after the operation. Conclusion: The authors encountered a patient of DASH after PCI that resulted in death. Clinicians should be aware that subdural hemorrhage can occur after PCI if no hemorrhage is noted in the initial head CT, and the operation should be performed as soon as possible when the consciousness level decreases. PMID:27526240
Tomii, M; Nakajima, M; Ikeuchi, S; Ogawa, T; Abe, T
Hemorrhage in regions remote from the site of initial intracranial operations is rare, but does occur. We report three cases of cerebellar hemorrhage that developed after supratentorial surgery, all of which had similar clinical findings and CT images. The first case was a 37-year-old man with a craniopharyngioma in the suprasellar lesion. Partial removal of the tumor was performed through frontal craniotomy and the translaminaterminals approach. A large quantity of cerebospinal fluid (CSF) was suctioned from the third ventricle during the operation, resulting in marked brain shrinkage. The second and third cases were 34- and 51-year-old women with unruptured right middle cerebral aneurysms. Clipping of the aneurysms through the pterional approach was performed in both cases. In the second case, CSF was suctioned in large quantity from the carotid and prechiasmal cistern at the operation, resulting in marked brain shrinkage. In the third case, however, only a small volume of CSF was suctioned from the carotid and prechiasmal cistern during the operation, and no marked brain shrinkage was observed. CT scan showed that the hematomas were located mainly in the subdural or the subarachnoid spaces over the cerebellar hemisphere and partially extending into the cerebellar cortex. The mechanism of cerebellar hemorrhage in these series of patients was thought to be multifactorial. The possible etiology for cerebellar hemorrhage in the three cases presented was examined, including the role of CSF suction during surgery and disturbance of venous circulation in the posterior fossa. Suction of the CSF may cause intracranial hypotension. Further reduction of intracranial pressure leads to an increased transluminal venous pressure. There was no episode of hypertension or disturbed blood coagulation during or after the operation. The preoperative angiogram also revealed no abnormality at the region of the posterior fossa. Neuroimaging of infratentorial hemorrhage after
even before actual hemorrhage shock has enough time to ensue, consistent with the concept of traumatic diabetes or trauma-induced insulin resistance...1082, 1999. 14. Dunn E, Moore E, Breslich D, Galloway W. Acidosis-induced coagu- lopathy. Surg Forum 30: 471–473, 1979. 15. Foot CL, Fraser JF, Mullany...Wolfe RR, Jahoor F, Hartl WH. Protein and amino acid metabolism after injury. Diabetes Metab Rev 5: 149–164, 1989. 50. Zhang Y, Dai Y, Wen J, Zhang W
even before actual hemorrhage shock has enough time to ensue, consistent with the concept of traumatic diabetes or trauma-induced insulin resistance...1082, 1999. 14. Dunn E, Moore E, Breslich D, Galloway W. Acidosis-induced coagu- lopathy. Surg Forum 30: 471–473, 1979. 15. Foot CL, Fraser JF, Mullany...Wolfe RR, Jahoor F, Hartl WH. Protein and amino acid metabolism after injury. Diabetes Metab Rev 5: 149–164, 1989. 50. Zhang Y, Dai Y, Wen J, Zhang W
Background Spontaneous, nontraumatic intracerebral hemorrhage (ICH) is a subtype of stroke that causes a great amount of disability and economic and social burden. This is particularly true in developing countries where it accounts for between 20% and 50% of all strokes. Pharmacological and surgical interventions have been attempted to reduce the mortality and disability caused by ICH, with unsuccessful results. Recently, the use of fluoxetine in addition to physical rehabilitation has been proven useful to improve motor recovery following cerebral infarct. The purpose of this study is to test whether a 3-month treatment with fluoxetine enhances motor recovery in nondepressed patients with acute intracerebral hemorrhage. Methods/design Our study is a randomized, double-blind, placebo-controlled, multicenter clinical trial. We will recruit 86 patients with intracerebral hemorrhage of both sexes, aged >18 years, from four Mexican hospitals. The patients will receive either 20 mg of fluoxetine or a placebo once daily for 90 days. The primary outcome is the mean change in the Fugl-Meyer Motor Scale score between inclusion (day 0) and day 90. The secondary outcomes will be changes in the Barthel Index, the Modified Rankin scale and the National Institutes of Health stroke scale. The outcomes will be measured at day 42 ± 7days and at day 90, for a total of four visits with each subject (at screening and at 0, 42 and 90 days). Discussion Current guidelines recommend early supported hospital discharge and home-based rehabilitation programs as the only cost-effective intervention to aid the recovery of patients with intracerebral hemorrhage. Nevertheless, such interventions are dependent on available resources and funding, which make them very difficult to implement in developing countries. We believe that the identification of a helpful pharmacological intervention to aid the motor recovery of these patients will constitute a breakthrough that will have a major impact in
Toyoda, Kazunori; Koga, Masatoshi; Hayakawa, Mikito; Yamagami, Hiroshi
The current status of and prospects for acute stroke care in Asia in the situation where both intravenous thrombolysis and endovascular therapies have been recognized as established strategies for acute stroke are reviewed. Of 15 million people annually having stroke worldwide, ≈9 million are Asians. The burdens of both ischemic and hemorrhagic strokes are severe in Asia. The unique features of stroke in Asia include susceptibility to intracranial atherosclerosis, high prevalence of intracerebral hemorrhage, effects of dietary and lifestyle habits, and several disorders with genetic causes. These features affect acute stroke care, such as the dosage of alteplase for thrombolysis and consideration of bleeding complications during antithrombotic therapy. Acute endovascular thrombectomy, as well as intravenous thrombolysis, is relatively prevalent in East Asia, but most of the other Asian countries need to develop their human resources and fundamental medical infrastructure for stroke care. A limitation of endovascular therapy in East Asia is the high prevalence of intracranial atherosclerosis that can cause recanalization failure and require additional angioplasty or permanent stent insertion although intracranial stenting is not an established strategy. Multinational collaboration on stroke research among Asian countries is infrequent. Asians should collaborate to perform their own thrombolytic and endovascular trials and seek the optimal strategy for stroke care specific to Asia.
Rovegno, Maximiliano; Valenzuela, José Luis; Mellado, Patricio; Andresen, Max
The use of hypothermia after cardiac arrest caused by ventricular fibrillation is a standard clinical practice, however its use for neuroprotection has been extended to other conditions. We report a 23-year-old male with intracranial hypertension secondary to a parenchymal hematoma associated to acute hydrocephalus. An arterial malformation was found and embolized. Due to persistent intracranial hypertension, moderate hypothermia with a target temperature of 33°C was started. After 12 hours of hypothermia, intracranial pressure was controlled. After 13 days of hypothermia a definitive control of intracranial pressure was achieved. The patient was discharged 40 days after admission, remains with a mild hemiparesia and is reassuming his university studies.
Barut, Ibrahim; Yazkan, Rasih
Bochdalek hernia (BH) is the most common type of congenital diaphragm hernia and is rarely seen in adults. In adult patients, BH often remains asymptomatic or presents with nondiagnostic symptoms and may lead to complications, though rarely. The necrosis and perforations occurring in the hernia may lead to mortality. In this report, we present a 34-year-old pregnant woman at 24 gestational weeks who presented with Bochdalek hernia causing gastric volvulus associated with perforation and intra-abdominal hemorrhage associated with splenic rupture. PMID:28018700
Moon, Byung Hoo; Han, Young-Min; Jang, Kyung-Sool; Huh, Ryoong; Park, Young Sup
Objective This study was conducted to clarify the association factors and clinical significance of the CT angiography (CTA) spot sign and hematoma growth in Korean patients with acute intracerebral hemorrhage (ICH). Methods We retrospectively collected the data of 287 consecutive patients presenting with acute ICH who arrived within 12 hours of ictus. Baseline clinical and radiological characteristics as well as the mortality rate within one month were assessed. A binary logistic regression was conducted to obtain association factors for the CTA spot sign and hematoma growth. Results We identified a CTA spot sign in 40 patients (13.9%) and hematoma growth in 78 patients (27.2%). An elapsed time to CT scan of less than 3 hours (OR, 5.14; 95% CI, 1.76-15.02; p=0.003) was associated with the spot sign. A CTA spot sign (OR, 5.70; 95% CI, 2.70-12.01; p<0.001), elevated alanine transaminase (GPT) level >40 IU (OR, 2.01; 95% CI, 1.01-4.01; p=0.047), and an international normalized ratio ≥1.8 or warfarin medication (OR, 5.64; 95% CI, 1.29-24.57; p=0.021) were independent predictors for hematoma growth. Antiplatelet agent medication (OR, 4.92; 95% CI, 1.31-18.50; p=0.019) was significantly associated with hematoma growth within 6 hours of ictus. Conclusion As previous other populations, CTA spot sign was a strong predictor for hematoma growth especially in hyper-acute stage of ICH in Korea. Antithrombotics medication might also be associated with hyper-acute hematoma growth. In our population, elevated GPT was newly identified as a predictor for hematoma growth and its effect for hematoma growth is necessary to be confirmed through a further research. PMID:25371778
Lee, Jung Pil; Park, Jun Sang; Kwon, Oh Woong; You, Yong Sung
Purpose To evaluate the visual and anatomical outcomes for neovascular age-related macular degeneration with submacular hemorrhage after intravitreal injections of tenecteplase (TNK), anti-vascular endothelial growth factor (VEGF) and expansile gas. Methods This study was a retrospective clinical case series following 25 eyes of 25 patients. All patients received a triple injection using 0.05 mL TNK (50 µg), 0.05 mL anti-VEGF and 0.3 mL of perfluoropropane gas. Retreatment with anti-VEGF was performed as needed. Preoperative and postoperative best-corrected visual acuity and central retinal thickness were analyzed. Results The mean logarithm of the minimum angle of resolution of best-corrected visual acuity improved significantly from 1.09 ± 0.77 at baseline to 0.52 ± 0.60 at 12 months (p < 0.001). The mean central retinal thickness also improved significantly from 545 ± 156 at baseline to 266 ± 107 at 12 months (p < 0.001). A visual improvement of 0.3 logarithm of the minimum angle of resolution unit or more was achieved in 15 eyes (60%). During the 12 postoperative months, an average of 4.04 intravitreal anti-VEGF injections was applied. Conclusions A triple injection of TNK, anti-VEGF, and a gas appears to be safe and effective for the treatment of submacular hemorrhage secondary to neovascular age-related macular degeneration. PMID:27247518
Alexander, James M; Wortman, Alison C
Intrapartum hemorrhage is a serious and sometimes life-threatening event. Several etiologies are known and include placental abruption, uterine atony, placenta accreta, and genital tract lacerations. Prompt recognition of blood loss, identification of the source of the hemorrhage, volume resuscitation, including red blood cells and blood products when required, will result in excellent maternal outcomes.
Caranci, F; Briganti, F; Cirillo, L; Leonardi, M; Muto, M
Intracranial aneurysms are acquired lesions (5-10% of the population), a fraction of which rupture leading to subarachnoid hemorrhage with devastating consequences. Until now, the exact etiology of intracranial aneurysms formation remains unclear. The low incidence of subarachnoid hemorrhage in comparison with the prevalence of unruptured IAs suggests that the vast majority of intracranial aneurysms do not rupture and that identifying those at highest risk is important in defining the optimal management. The most important factors predicting rupture are aneurysm size and site. In addition to ambiental factors (smoking, excessive alcohol consumption and hypertension), epidemiological studies have demonstrated a familiar influence contributing to the pathogenesis of intracranial aneurysms, with increased frequency in first- and second-degree relatives of people with subarachnoid hemorrhage. In comparison to sporadic aneurysms, familial aneurysms tend to be larger, more often located at the middle cerebral artery, and more likely to be multiple. Other than familiar occurrence, there are several heritable conditions associated with intracranial aneurysm formation, including autosomal dominant polycystic kidney disease, neurofibromatosis type I, Marfan syndrome, multiple endocrine neoplasia type I, pseudoxanthoma elasticum, hereditary hemorrhagic telangiectasia, and Ehlers-Danlos syndrome type II and IV. The familial occurrence and the association with heritable conditions indicate that genetic factors may play a role in the development of intracranial aneurysms. Genome-wide linkage studies in families and sib pairs with intracranial aneurysms have identified several loci on chromosomes showing suggestive evidence of linkage, particularly on chromosomes 1p34.3-p36.13, 7q11, 19q13.3, and Xp22. For the loci on 1p34.3-p36.13 and 7q11, a moderate positive association with positional candidate genes has been demonstrated (perlecan gene, elastin gene, collagen type 1 A2 gene
Levine, Steven; Garfein, Evan S; Weiner, Howard; Yaremchuk, Michael J; Saadeh, Pierre B; Gurtner, Geoffrey; Levine, Jamie P; Warren, Stephen M
Large acquired intracranial defects can result from trauma or surgery. When reoperation is required because of infection or tumor recurrence, management of the intracranial dead space can be challenging. By providing well-vascularized bulky tissue, intracranial microvascular free flaps offer potential solutions to these life-threatening complications. A multi-institutional retrospective chart and radiographic review was performed of all patients who underwent microvascular free-flap surgery for salvage treatment of postoperative intracranial infections between 1998 and 2006. A total of six patients were identified with large intracranial defects and postoperative intracranial infections. Four patients had parenchymal resections for tumor or seizure and two patients had posttraumatic encephalomalacia. All patients underwent operative debridement and intracranial free-flap reconstruction using the latissimus dorsi muscle (N=2), rectus abdominis muscle (N=2), or omentum (N=2). All patients had titanium (N=4) or Medpor (N=2) cranioplasties. We concluded that surgery or trauma can result in significant intracranial dead space. Treatment of postoperative intracranial infection can be challenging. Vascularized free tissue transfer not only fills the void, but also provides a delivery system for immune cells, antibodies, and systemically administered antibiotics. The early use of this technique when intracranial dead space and infection coexist is beneficial.
IZUMI, Takashi; IMAMURA, Hirotoshi; SAKAI, Nobuyuki; MIYACHI, Shigeru
Of the patients enrolled in the Japanese Registry of Neuroendovascular Therapy (JR-NET), a surveillance study in Japanese, 1133 patients who underwent intracranial percutaneous transluminal angioplasty (PTA)/stenting for intracranial stenosis during the period from 2005 to 2009 were investigated. A technical success was achieved in 98.3% of the patients, and 70.5% and 7.5% had a residual stenosis of < 30% and ≥ 50%, respectively. The incidence of ischemic complications and hemorrhagic complications was as low as 7.7% and 2.5%, respectively, but tended to increase in patients who underwent stenting. While a significant correlation with ischemic complications was observed in previously untreated patients and patients who underwent stenting followed by post-dilatation, a significant correlation with hemorrhagic complications was observed in patients who received emergency treatment and those treated between 24 hours and 14 days of the onset. Flexible intracranial stents are expected to contribute to improvement in the treatment outcome. PMID:24390191
Krishnan, Kailash; Scutt, Polly; Woodhouse, Lisa; Adami, Alessandro; Becker, Jennifer L.; Cala, Lesley A.; Casado, Ana M.; Chen, Christopher; Dineen, Robert A.; Gommans, John; Koumellis, Panos; Christensen, Hanna; Collins, Ronan; Czlonkowska, Anna; Lees, Kennedy R.; Ntaios, George; Ozturk, Serefnur; Phillips, Stephen J.; Sprigg, Nikola; Szatmari, Szabolcs; Wardlaw, Joanna M.; Bath, Philip M.
Background and purpose More than 50% of patients with acute intracerebral hemorrhage (ICH) are taking antihypertensive drugs before ictus. Although antihypertensive therapy should be given long term for secondary prevention, whether to continue or stop such treatment during the acute phase of ICH remains unclear, a question that was addressed in the Efficacy of Nitric Oxide in Stroke (ENOS) trial. Methods ENOS was an international multicenter, prospective, randomized, blinded endpoint trial. Among 629 patients with ICH and systolic blood pressure between 140 and 220 mmHg, 246 patients who were taking antihypertensive drugs were assigned to continue (n = 119) or to stop (n = 127) taking drugs temporarily for 7 days. The primary outcome was the modified Rankin Score at 90 days. Secondary outcomes included death, length of stay in hospital, discharge destination, activities of daily living, mood, cognition, and quality of life. Results Blood pressure level (baseline 171/92 mmHg) fell in both groups but was significantly lower at 7 days in those patients assigned to continue antihypertensive drugs (difference 9.4/3.5 mmHg, P < .01). At 90 days, the primary outcome did not differ between the groups; the adjusted common odds ratio (OR) for worse outcome with continue versus stop drugs was .92 (95% confidence interval, .45-1.89; P = .83). There was no difference between the treatment groups for any secondary outcome measure, or rates of death or serious adverse events. Conclusions Among patients with acute ICH, immediate continuation of antihypertensive drugs during the first week did not reduce death or major disability in comparison to stopping treatment temporarily. PMID:26853137
Hilsden, R. J.; Shaffer, E. A.
Acute gastrointestinal hemorrhage is a common problem that requires prompt recognition and management to prevent serious morbidity and mortality. Management goals are stabilization of the patient with vigorous fluid resuscitation followed by investigation and definitive treatment of the bleeding source. Endoscopy is often the initial diagnostic test and allows therapeutic measures to be performed at the same time. Images Figure 1 Figure 2 PMID:8563510
Westermaier, Thomas; Jauss, Alina; Eriskat, Jörg; Kunze, Ekkehard; Roosen, Klaus
Present knowledge about hemodynamic and metabolic changes after subarachnoid hemorrhage (SAH) originates from neuromonitoring usually starting with aneurysm surgery and animal studies that have been focusing on the first 1 to 3 h after SAH. Most patients, however, are referred to treatment several hours after the insult. We examined the course of hemodynamic parameters, cerebral blood flow, and tissue oxygenation (ptiO2) in the first 6 h after experimental SAH. Sixteen Sprague-Dawley rats were subjected to SAH using the endovascular filament model or served as controls (n=8). Bilateral local cortical blood flow, intracranial pressure, cerebral perfusion pressure, and ptiO2 were followed for 6 h after SAH. After induction of SAH, local cortical blood flow rapidly declined to 22% of baseline and returned to 80% after 6 h. The decline of local cortical blood flow markedly exceeded the decline of cerebral perfusion pressure. ptiO2 declined to 57%, recovered after 2 h, and reached > or =140% of baseline after 6 h. Acute vasoconstriction after SAH is indicated by the marked discrepancy of cerebral perfusion pressure and local cortical blood flow. The excess tissue oxygenation several hours after SAH suggests disturbed oxygen utilization and cerebral metabolic depression. Aside from the sudden increase of intracranial pressure at the time of hemorrhage and delayed cerebral vasospasm, the occurrence of acute vasoconstriction and disturbed oxygen utilization may be additional factors contributing to secondary brain damage after SAH.
Alexander, Matthew D; Hetts, Steven W; Young, William L; Halbach, Van V; Dowd, Christopher F; Higashida, Randall T; English, Joey D
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.
Nakajima, K; Ito, Z; Hen, R; Uemura, K; Matsuoka, S
It is well known that congenital anomalies such as polycystic kidney, aortic coarctation, Marfan syndrome, Ehler-Danlos syndrome are apt to be complicated by intracranial aneurysms. In this report we attempt to reveal the relation and incidence between cerebrovascular anomalies and intracranial aneurysms. The etiology of aneurysms has been discussed, too. 12 cases of persistent trigeminl artery, 2 cases of persistent hypoglossal artery and 11 cases of fenestration were obtained from 3841 patients who were angiographically examined in our clinic for 5 years. The incidence is 0.31%, 0.05% and 0.29%, respectively. Persistent trigeminal arteries were complicated by 2 cases of intracranial aneurysms and one case of arterivenous malformations (AVM), persistent hypoglossal arteries were complicated by one case of aneurysm, and fenestrations were complicated by 2 cases of aneurysms and one case of AVM. One case of congenital agenesis of right internal carotid artery was obtained which was complicated by aneurysm of anterior communicating artery. Totally, 8 cases of aneurysms and AVM were obtained from 26 cases of cerebrovascular anomalies (incidence 30.8%). On the other hand, thalamic or caudate hemorrhage revealed the highest incidence of complication of intracranial aneurysms among intracerebral hematomas (10.7%). Compared with the incidence of aneurysms between cerebro vascular anomalies (30.8%) and thalamic or caudate hemorrhage (10.7%), the difference is statistically signigicant (P less than 0.05). The cause of intracranial aneurysm has not yet been clarified. But it is well accepted that the defect of tunica media vasorum is most responsible factor as to the occurrence of intracranial aneurysms. We concluded that the genetic error of cerebral vessels including defect of media caused intracranial aneurysms, and this result was supported from the evidence that cerebrovascular anomalies showed statistically high incidence of complication of intracranial aneurysms.
... snapping feeling in the head. Other symptoms: Decreased consciousness and alertness Eye discomfort in bright light ( photophobia ) ... time, the outlook is much worse. Changes in consciousness and alertness due to a subarachnoid hemorrhage may ...
Tromp, Gerard; Weinsheimer, Shantel; Ronkainen, Antti; Kuivaniemi, Helena
Intracranial aneurysms, also called cerebral aneurysms, are dilatations in the arteries that supply blood to the brain. Rupture of an intracranial aneurysm leads to a subarachnoid hemorrhage, which is fatal in about 50% of the cases. Intracranial aneurysms can be repaired surgically or endovascularly, or by combining these two treatment modalities. They are relatively common with an estimated prevalence of unruptured aneurysms of 2%-6% in the adult population, and are considered a complex disease with both genetic and environmental risk factors. Known risk factors include smoking, hypertension, increasing age, and positive family history for intracranial aneurysms. Identifying the molecular mechanisms underlying the pathogenesis of intracranial aneurysms is complex. Genome-wide approaches such as DNA linkage and genetic association studies, as well as microarray-based mRNA expression studies, provide unbiased approaches to identify genetic risk factors and dissecting the molecular pathobiology of intracranial aneurysms. The ultimate goal of these studies is to use the information in clinical practice to predict an individual's risk for developing an aneurysm or monitor its growth or rupture risk. Another important goal is to design new therapies based on the information on mechanisms of disease processes to prevent the development or halt the progression of intracranial aneurysms.
Mathew, Mariam; Salahuddin, Ayesha; Mathew, Namitha R.; Nandhagopal, Ramachandiran
Postpartum headache is described as headache and neck or shoulder pain during the first 6 weeks after delivery. Common causes of headache in the puerperium are migraine headache and tension headache; other causes include pre-eclampsia/eclampsia, post-dural puncture headache, cortical vein thrombosis, subarachnoid hemorrhage, posterior reversible leukoencephalopathy syndrome, brain tumor, cerebral ischemia, meningitis, and so forth. Idiopathic intracranial hypertension (IIH) is a rare cause of postpartum headache. It is usually associated with papilledema, headache, and elevated intracranial pressure without any focal neurologic abnormality in an otherwise healthy person. It is more commonly seen in obese women of reproductive age group, but rare during pregnancy and postpartum. We present a case of IIH who presented to us 18 days after cesarean section with severe headache and was successfully managed. PMID:26818168
Kosugi, Kenzo; Takahashi, Satoshi; Sasaki, Hikaru; Tamura, Ryota; Ohara, Kentaro; Yoshida, Kazunari
Background: Intra or peritumoral hemorrhage of brain and skull tumors sometimes presents as stroke. Skull metastasis of chondrosarcoma is relatively rare, and furthermore, a case of intratumoural hemorrhage of skull metastasis of chondrosarcoma has not been reported. Case Description: A 73-year-old man underwent right lower leg amputation in the past because of chondrosarcoma and was operated for a skull metastasis. He presented with a sudden headache, and head computed tomography revealed a right acute subdural hematoma (SDH) adjacent to the recurrent skull metastatic tumor. The removal of the SDH and tumor resection were performed emergently. The intraoperative findings included metastatic invasion beyond the dura mater to as deep as the subdural space, and the histological diagnosis was metastatic chondrosarcoma. His postoperative course was uneventful. Conclusion: In the event of subdural invasion of a metastatic lesion, intratumoral hemorrhage may induce acute SDH, as in the present case. Similar to our case, most previous reports of intracranial chondrosarcoma hemorrhage have had an unclear etiology. Despite the rarity of this event, a patient with a history of malignancy presenting with nontraumatic acute SDH should be examined for the intratumoral hemorrhage of skull metastasis in the differential diagnosis. PMID:28303203
Massalha, R; Valdman, S; Farkash, P; Merkin, L; Herishanu, Y
Although chronic arterial hypertension is the leading cause of intracranial hemorrhage, an abrupt rise in systemic arterial pressure in normotensive people may sometimes induce a hemorrhagic stroke. Dental treatment is rarely associated with such an event. We report here on two middle-aged women, apparently healthy, who suffered from a fatal intracerebral hemorrhage following a dental treatment. On admission, high levels of arterial hypertension were found. It seems that trigeminal manipulation during dental treatment as well as increased serum levels of induced epinephrine mainly by stress and pain, and the small amounts absorbed from the site of local anesthesia might produce abrupt elevation of blood pressure, subsequent increase in cerebral blood flow and severe, even fatal intracerebral hemorrhage. The addition of catecholamines to local anesthetics should be considered. We recommend the use of benzodiazepin as a premedication drug to reduce stress during dental treatment.
Prassler, R; Hendrich, H; Barnert, J; Richter, G; Fleischmann, R; Wienbeck, M
During a two year period (1992-1993) we investigated whether or not, after endoscopic therapy of bleeding ulcers, the suppression of gastric acid secretion with an administration of a proton pump blocker (Omeprazol) is more effective than the administration of H2-receptor antagonist (Ranitidin) with respect to prevention of recurrent bleeding episodes, frequency of surgical intervention and mortality. 106 patients (64 men, 42 women) were treated with the proton pump blocker and 126 patients (82 men, 44 women) received the H2-receptor antagonist. Patients were treated either with an initial dose of 80 mg Omeprazol followed by 3 x 40 mg Omeprazol i.v. or with a daily dose of 3 mg/kg body weight Ranitidin i.v. No significant differences could be detected between the two treatment regimes with respect to the parameters mentioned above. Rebleeding which could be controlled by endoscopic hemostasis occurred in 19.8% vs. 17.5% (Omeprazol/Ranitidin) of patients. Surgical intervention because of rebleeding was necessary on 8.5% vs. 8.7% of the patients. Mortality due to hemorrhage was 5.7% vs. 4.0%. From these results we conclude that, following endoscopic hemostasis of bleeding ulcers, Omeprazol has no advantage over Ranitidin using our dosage regimes.
Sato, Kazuko; Kajihara, Takeshi; Miki, Akinori; Hirabayashi, Eriko; Shintani, Daisuke; Niitsu, Mamoru; Ishihara, Osamu; Itakura, Atsuo
To determine the efficacy of computed tomography (CT) attenuation of cystic lesions measured on an image browsing system to distinguish abscess from hematoma in women with acute abdomen. The medical records of female patients of reproductive age with acute abdomen who were treated over a 7-year period in a single center and who had undergone laparotomy or laparoscopic surgery and preoperative pelvic CT scanning were retrospectively analyzed to identify those with hematoma or abscess cyst formation. Nineteen patients with tubo-ovarian abscess (abscess group) and six patients with hematoma (hematoma group) formation in the pelvis were included in the analysis. The preoperative CT images of the tubo-ovarian cyst were retrospectively investigated on the basis of cyst attenuation. CT attenuation of the cyst measured by both two gynecologists could be used to clearly distinguish inflammatory disease with abscess formation from bleeding disease with hematoma. CT attenuation on a picture archiving and communication system can distinguish hematoma from abscess in women with acute abdomen. This may significantly contribute to making differential diagnosis without interpretation by a medical radiologist.
Sorteberg, Angelika; Dahlberg, Daniel
An intracranial aneurysm in a child or adolescent is a rare, but potentially devastating condition. As little as approximately 1200 cases are reported between 1939 and 2011, with many of the reports presenting diverting results. There is consensus, though, in that pediatric aneurysms represent a pathophysiological entity different from their adult counterparts. In children, there is a male predominance. About two-thirds of pediatric intracranial aneurysms become symptomatic with hemorrhage and the rate of re-hemorrhage is higher than in adults. The rate of hemorrhage from an intracranial aneurysm peaks in girls around menarche. The most common aneurysm site in children is the internal carotid artery, in particular at its terminal ending. Aneurysms in the posterior circulation are more common in children than adults. Children more often develop giant aneurysms, and may become symptomatic from the mass effect of the aneurysm (tumorlike symptoms). The more complex nature of pediatric aneurysms poses a larger challenge to treatment alongside with higher demands to the durability of treatment. Outcome and mortality are similar in children and adults, but long-term outcome in the pediatric population is influenced by the high rate of aneurysm recurrences and de novo formation of intracranial aneurysms. This urges the need for life-long follow-up and screening protocols. PMID:24696670
Wang, Wei; Li, Mingchang; Wang, Yuefei; Li, Qian; Deng, Gang; Wan, Jieru; Yang, Qingwu
Hemorrhagic transformation (HT) is a devastating complication for patients with acute ischemic stroke who are treated with tissue plasminogen activator (tPA). It is associated with high morbidity and mortality, but no effective treatments are currently available to reduce HT risk. Therefore, methods to prevent HT are urgently needed. In this study, we used TWS119, an inhibitor of glycogen synthase kinase 3β (GSK-3β), to evaluate the role of the Wnt/β-catenin signaling pathway in recombinant tPA (rtPA)-induced HT. Sprague–Dawley rats were subjected to a middle cerebral artery occlusion (MCAO) model of ischemic stroke and then were administered rtPA, rtPA combined with TWS119, or vehicle at 4 h. The animals were sacrificed 24 h after infarct induction. Rats treated with rtPA showed evident HT, had more severe neurologic deficit, brain edema, and blood–brain barrier breakdown, and had larger infarction volume than did the vehicle group. Rats treated with TWS119 had significantly improved outcomes compared with those of rats treated with rtPA alone. In addition, Western blot analysis showed that TWS119 increased the protein expression of β-catenin, claudin-3, and ZO-1 while suppressing the expression of GSK-3β. These results suggest that TWS119 reduces rtPA-induced HT and attenuates blood–brain barrier disruption, possibly through activation of the Wnt/β-catenin signaling pathway. This study provides a potential therapeutic strategy to prevent tPA-induced HT after acute ischemic stroke. PMID:26671619
Hansen, John D; Woodson, James C; Hershberger, Paul K; Grady, Courtney; Gregg, Jacob L; Purcell, Maureen K
Infection with the aquatic rhabdovirus Viral hemorrhagic septicemia virus (VHSV) genogroup IVa results in high mortality in Pacific herring (Clupea pallasii) and is hypothesized to be a potential limiting factor for herring recovery. To investigate anti-viral immunity in the Pacific herring, four immune response genes were identified: the myxovirus resistance (Clpa-Mx), a major histocompatibility complex IB (named Clpa-UAA.001), the inducible immunoproteosome subunit 9 (Clpa-PSMB9) and the neutrophil chemotactic factor (Clpa-LECT2). Reverse transcriptase quantitative PCR (RT-qPCR) assays were developed based on these gene sequences to investigate the host immune response to acute VHSV infection following both injection and immersion challenge. Virus levels were measured by both plaque assay and RT-qPCR and peaked at day 6 during the 10-day exposure period for both groups of fish. The interferon stimulated genes (Clpa-Mx, -UAA.001, and -PSMB9) were significantly up-regulated in response to VHSV infection at both 6 and 10 days post-infection in both spleen and fin. Results from this study indicate that Pacific herring mount a robust, early antiviral response in both fin and spleen tissues. The immunological tools developed in this study will be useful for future studies to investigate antiviral immunity in Pacific herring.
Hansen, John D.; Woodson, James C.; Hershberger, Paul K.; Grady, Courtney; Gregg, Jacob L.; Purcell, Maureen K.
Infection with the aquatic rhabdovirus Viral hemorrhagic septicemia virus (VHSV) genogroup IVa results in high mortality in Pacific herring (Clupea pallasii) and is hypothesized to be a potential limiting factor for herring recovery. To investigate anti-viral immunity in the Pacific herring, four immune response genes were identified: the myxovirus resistance (Clpa-Mx), a major histocompatibility complex IB (named Clpa-UAA.001), the inducible immunoproteosome subunit 9 (Clpa-PSMB9) and the neutrophil chemotactic factor (Clpa-LECT2). Reverse transcriptase quantitative PCR (RT-qPCR) assays were developed based on these gene sequences to investigate the host immune response to acute VHSV infection following both injection and immersion challenge. Virus levels were measured by both plaque assay and RT-qPCR and peaked at day 6 during the 10-day exposure period for both groups of fish. The interferon stimulated genes (Clpa-Mx, −UAA.001, and −PSMB9) were significantly up-regulated in response to VHSV infection at both 6 and 10 days post-infection in both spleen and fin. Results from this study indicate that Pacific herring mount a robust, early antiviral response in both fin and spleen tissues. The immunological tools developed in this study will be useful for future studies to investigate antiviral immunity in Pacific herring.
Nyska, Abraham; Murphy, Elizabeth; Foley, Julie F; Collins, Bradley J; Petranka, John; Howden, Reuben; Hanlon, Paul; Dunnick, June K
Because of possible side effects of herbal medicines containing ephedrine and guarana-derived caffeine, including increased risk of stroke, myocardial infarction, and sudden death, the Food and Drug Administration recently banned the sale of ephedra-containing products, specifically over-the-counter dietary supplements. We report cardiac in 7- and 14-week-old male F344 rats exposed by gavage to ephedrine(25 mg/kg) and caffeine (30 mg/kg) administered in combination for one or two days. The ephedrine-caffeine dosage was approximately 12- and 1.4-fold, respectively, above average human exposure, based on a mg/m2 body surface-area comparison. Several (5/7) of the exposed 14-week-old rats died or were sacrificed in extremis 4-5 h after the first dosing. In these hearts, changes were observed chiefly in the interventricular septum but also left and right ventricular walls. Massive interstitial hemorrhage, with degeneration of myofibers, occurred at the subendocardial myocardium of the left ventricle and interventricular septum. Immunostaining for cleaved caspase-3 and hyperphosphorylated H2A.X, a histone variant that becomes hyperphosphorylated during apoptosis, indicated multifocal generalized positive staining of degenerating myofibers and fragmenting nuclei, respectively. The Barbeito-Lopez trichrome stain revealed generalized patchy yellow myofibers consistent with degeneration and/or coagulative necrosis. In ephedrine-caffeine-treated animals terminated after the second dosing, foci of myocardial degeneration and necrosis were already infiltrated by mixed inflammatory cells. The myocardial necrosis may occur secondarily to intense diffuse vasoconstriction of the coronary arterial system with decreased myocardial perfusion. Our work shows the direct relationship between combined ephedrine and caffeine exposure and cardiac pathology.
Kinsey, Steven G; Cole, Erica C
Nonsteroidal anti-inflammatory drugs (NSAIDs), which are among the most widely used analgesics in the world, cause gastrointestinal inflammation that is potentially life-threatening. Although inhibitors of endocannabinoid catabolic enzymes protect against gastropathy in fasted NSAID-treated mice, the gastroprotective effects of Δ(9)-tetrahydrocannabinol (THC), the primary psychoactive component of marijuana, have yet to be investigated. Male C57BL/6J mice were fasted, administered vehicle or Δ(9)-THC (.01-50mg/kg; oral or intraperitoneal), and then treated with the NSAID diclofenac sodium (100mg/kg, p.o.) to induce gastric lesions. In separate groups of mice, the cannabimimetic behavioral effects of Δ(9)-THC given via each route of administration were compared using a battery of tests, consisting of assessment of locomotor activity, nociception in the tail withdrawal test, catalepsy in the bar test, and hypothermia. Δ(9)-THC dose-dependently attenuated diclofenac-induced gastric hemorrhagic streaks through both p.o. and i.p. routes of administration (ED50 (95% confidence interval)=0.64 (0.26-1.55)mg/kg and 0.06 (0.01-0.34) mg/kg, respectively). Δ(9)-THC given i.p. was 2-3 orders of magnitude more potent in reducing diclofenac-induced gastric ulcers than in producing locomotor immobility, antinociception, hypothermia, and catalepsy, while the potency of ratio of p.o. Δ(9)-THC between each behavior measure was 7-18. These data indicate that the phytocannabinoid Δ(9)-THC protects against diclofenac-induced gastric inflammatory tissue damage at doses insufficient to cause common cannabinoid side effects.
Zhang, Xiang-Sheng; Li, Wei; Wu, Qi; Wu, Ling-Yun; Ye, Zhen-Nan; Liu, Jing-Peng; Zhuang, Zong; Zhou, Meng-Liang; Zhang, Xin; Hang, Chun-Hua
Toll-like receptor 4 (TLR4) has been proven to play a critical role in neuroinflammation and to represent an important therapeutic target following subarachnoid hemorrhage (SAH). Resveratrol (RSV), a natural occurring polyphenolic compound, has a powerful anti-inflammatory property. However, the underlying molecular mechanisms of RSV in protecting against early brain injury (EBI) after SAH remain obscure. The purpose of this study was to investigate the effects of RSV on the TLR4-related inflammatory signaling pathway and EBI in rats after SAH. A prechiasmatic cistern SAH model was used in our experiment. The expressions of TLR4, high-mobility group box 1 (HMGB1), myeloid differentiation factor 88 (MyD88), and nuclear factor-κB (NF-κB) were evaluated by Western blot and immunohistochemistry. The expressions of Iba-1 and pro-inflammatory cytokines in brain cortex were determined by Western blot, immunofluorescence staining, or enzyme-linked immunosorbent assay. Neural apoptosis, brain edema, and neurological function were further evaluated to investigate the development of EBI. We found that post-SAH treatment with RSV could markedly inhibit the expressions of TLR4, HMGB1, MyD88, and NF-κB. Meanwhile, RSV significantly reduced microglia activation, as well as inflammatory cytokines leading to the amelioration of neural apoptosis, brain edema, and neurological behavior impairment at 24 h after SAH. However, RSV treatment failed to alleviate brain edema and neurological deficits at 72 h after SAH. These results indicated that RSV treatment could alleviate EBI after SAH, at least in part, via inhibition of TLR4-mediated inflammatory signaling pathway. PMID:27529233
Kinsey, Steven G.; Cole, Erica C.
Nonsteroidal anti-inflammatory drugs (NSAIDs), which are among the most widely used analgesics in the world, cause gastrointestinal inflammation that is potentially life-threatening. Although inhibitors of endocannabinoid catabolic enzymes protect against gastropathy in fasted NSAID-treated mice, the gastroprotective effects of Δ9-tetrahydrocannabinol (THC), the primary psychoactive component of marijuana, have yet to be investigated. Male C57BL/6J mice were fasted, administered vehicle or Δ9-THC (.01–50 mg/kg; oral or intraperitoneal), and then treated with the NSAID diclofenac sodium (100 mg/kg, p.o.) to induce gastric lesions. In separate groups of mice, the cannabimimetic behavioral effects of Δ9-THC given via each route of administration were compared using a battery of tests, consisting of assessment of locomotor activity, nociception in the tail withdrawal test, catalepsy in the bar test, and hypothermia. Δ9-THC dose-dependently attenuated diclofenac-induced gastric hemorrhagic streaks through both p.o. and i.p. routes of administration (ED50 (95% confidence interval) = 0.64 (0.26 – 1.55) mg/kg and 0.06 (0.01 – 0.34) mg/kg, respectively). Δ9-THC given i.p. was 2–3 orders of magnitude more potent in reducing diclofenac-induced gastric ulcers than in producing locomotor immobility, antinociception, hypothermia, and catalepsy, while the potency of ratio of p.o. Δ9-THC between each behavior measure was 7–18. These data indicate that the phytocannabinoid Δ9-THC protects against diclofenac-induced gastric inflammatory tissue damage at doses insufficient to cause common cannabinoid side effects. PMID:23769745
Yang, Fei; Zhao, Jianning; Xu, Haidong
Hemorrhagic stroke can occur after spine and joint surgeries such as laminectomy, lumbar spinal fusion, tumor resection, and total joint arthroplasty. Although this kind of stroke rarely happens, it may cause severe consequences and high mortality rates. Typical clinical symptoms of hemorrhagic stroke after spine and joint surgeries include headache, vomiting, consciousness disturbance, and mental disorders. It can happen several hours after surgeries. Most bleeding sites are located in cerebellar hemisphere and temporal lobe. A cerebrospinal fluid (CSF) leakage caused by surgeries may be the key to intracranial hemorrhages happening. Early diagnosis and treatments are very important for patients to prevent the further progression of intracranial hemorrhages. Several patients need a hematoma evacuation and their prognosis is not optimistic.
Hemorrhagic stroke can occur after spine and joint surgeries such as laminectomy, lumbar spinal fusion, tumor resection, and total joint arthroplasty. Although this kind of stroke rarely happens, it may cause severe consequences and high mortality rates. Typical clinical symptoms of hemorrhagic stroke after spine and joint surgeries include headache, vomiting, consciousness disturbance, and mental disorders. It can happen several hours after surgeries. Most bleeding sites are located in cerebellar hemisphere and temporal lobe. A cerebrospinal fluid (CSF) leakage caused by surgeries may be the key to intracranial hemorrhages happening. Early diagnosis and treatments are very important for patients to prevent the further progression of intracranial hemorrhages. Several patients need a hematoma evacuation and their prognosis is not optimistic. PMID:28164124
Dahan, Meryl; Lim, Chetana; Salloum, Chady
Postoperative bilateral adrenal hemorrhage is a rare but potentially life-threatening complication. This diagnosis is often missed because the symptoms and laboratory results are usually nonspecific. We report a case of bilateral adrenal hemorrhage associated with acute primary adrenal insufficiency following laparoscopic cholecystectomy. The knowledge of this uncommon complication following any abdominal surgery allows timey diagnosis and rapid treatment. PMID:27275469
Dahan, Meryl; Lim, Chetana; Salloum, Chady; Azoulay, Daniel
Postoperative bilateral adrenal hemorrhage is a rare but potentially life-threatening complication. This diagnosis is often missed because the symptoms and laboratory results are usually nonspecific. We report a case of bilateral adrenal hemorrhage associated with acute primary adrenal insufficiency following laparoscopic cholecystectomy. The knowledge of this uncommon complication following any abdominal surgery allows timey diagnosis and rapid treatment.
Moraz, Marie-Laurence; Kunz, Stefan
Viral hemorrhagic fevers (VHFs) caused by arenaviruses belong to the most devastating emerging human diseases and represent serious public health problems. Arenavirus VHFs in humans are acute diseases characterized by fever and, in severe cases, different degrees of hemorrhages associated with a shock syndrome in the terminal stage. Over the past years, much has been learned about the pathogenesis of arenaviruses at the cellular level, in particular their ability to subvert the host cell's innate antiviral defenses. Clinical studies and novel animal models have provided important new information about the interaction of hemorrhagic arenaviruses with the host's adaptive immune system, in particular virus-induced immunosuppression, and have provided the first hints towards an understanding of the terminal hemorrhagic shock syndrome. The scope of this article is to review our current knowledge on arenavirus VHF pathogenesis with an emphasis on recent developments.
Ingelmo Ingelmo, I; Fàbregas Julià, N; Rama-Maceiras, P; Hernández-Palazón, J; Rubio Romero, R; Carmona Aurioles, J
Cerebrovascular disease, whether ischemic or hemorrhagic, is a worldwide problem, representing personal tragedy, great social and economic consequences, and a heavy burden on the health care system. Estimated to be responsible for up to 10% of mortality in industrialized countries, cerebrovascular disease also affects individuals who are still in the workforce, with consequent loss of productive years. Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident that leads to around 5% of all strokes. SAH is most often due to trauma but may also be spontaneous, in which case the cause may be a ruptured intracranial aneurysm (80%) or arteriovenous malformation or any other abnormality of the blood or vessels (20%). Although both the diagnosis and treatment of aneurysmal SAH has improved in recent years, related morbidity and mortality remains high: 50% of patients die from the initial hemorrhage or later complications. If patients whose brain function is permanently damaged are added to the count, the percentage of cases leading to severe consequences rises to 70%. The burden of care of patients who are left incapacitated by SAH falls to the family or to private and public institutions. The economic cost is considerable and the loss of quality of life for both the patient and the family is great. Given the magnitude of this problem, the provision of adequate prophylaxis is essential; also needed are organizational models that aim to reduce mortality as well as related complications. Aneurysmal SAH is a condition which must be approached in a coordinated, multidisciplinary way both during the acute phase and throughout rehabilitation in order to lower the risk of unwanted outcomes.
Straube, T. Stingele, Robert; Jansen, Olav
Purpose: To determine the feasibility and safety of stenting intracranial atherosclerotic stenoses.Methods: In 12 patients the results of primary intracranial stenting were evaluated retrospectively. Patient ages ranged from 49 to 79 years (mean 64 years). Six patients presented with stenoses in the anterior circulation, and six had stenosis in the posterior circulation. One patient presented with extra- and intracranial tandem stenosis of the left internal carotid artery. Three patients presented with acute basilar thrombosis, caused by high-grade basilar stenoses.Results: Intracranial stenoses were successfully stented in 11 of 12 patients. In one patient the stent could not be advanced over the carotid siphon to reach the stenosis of the ophthalmic internal carotid artery. Follow-up digital subtraction angiographic studies were obtained in two patients who had presented with new neurologic signs or symptoms. In both cases the angiogram did not show any relevant stenotic endothelial hyperplasia. In one patient, after local thrombolysis the stenosis turned out to be so narrow that balloon angioplasty had to be performed before stent deployment. All three patients treated for stenosis-related basilar thrombosis died due to brainstem infarction that had ensued before the intervention.Conclusions: Prophylactic primary stenting of intracranial stenoses of the anterior or posterior cerebral circulation can be performed with a low complication rate; technical problems such as stent flexibility must still be solved. Local thrombolysis followed by stenting in stenosis-related thrombotic occlusion is technically possible.
Ruisi, Phillip; Rosero, Hugo; Schweitzer, Paul
Prinzmetal angina or vasospastic angina is a clinical phenomenon that is often transient and self-resolving. Clinically it is associated with ST elevations on the electrocardiogram, and initially it may be difficult to differentiate from an acute myocardial infarction. The vasospasm induced in this setting occurs in normal or mildly to moderately diseased vessels and can be triggered by a number of etiologies including smoking, changes in autonomic activity, or drug ingestion. While the ischemia induced is usually transient, myocardial infarction and life-threatening arrhythmias can occur in 25% of cases. We present the case of a 65-year-old female where repetitive intermittent coronary vasospasm culminated in transmural infarction in the setting of gastrointestinal bleeding. This case highlights the mortality associated with prinzmetal angina and the importance of recognizing the underlying etiology. PMID:24826293
Cohen, José E; Moscovici, Samuel; Rajz, Gustavo; Vargas, Andres; Itshayek, Eyal
Basilar artery dissection (BAD) is a rare condition with a worse prognosis than a dissection limited to the vertebral artery. We report a rare case of chronic BAD with an associated symptomatic aneurysm presenting with massive subarachnoid hemorrhage (SAH) in a 54-year-old woman. The diagnosis of acute BAD could only be made retrospectively, based on clinical and neuroradiological studies from a hospital admission 10months earlier. Angiography performed after her SAH showed unequivocal signs of imperfect healing; she was either post-recanalization of a complete occlusion or post-dissection. Residual multi-channel intraluminal defects led to the development of a small aneurysm, which was responsible for the massive hemorrhage. The occurrence of an associated aneurysm, and wall disease, but not an intraluminal process, reinforces the diagnosis of dissection. The patient was fully recovered at 90day follow-up. This case reinforces the need for long-term neuroradiological surveillance after non-hemorrhagic intracranial dissections to detect the development of de novo aneurysms.
Cripps, Andrea; Livingston, Scott C
Clinical Scenario: A cerebral concussion is a traumatically induced transient disturbance of brain function characterized by a complex pathophysiologic process and is classified as a subset of mild traumatic brain injury. The occurrence of intracranial lesions after sport-related head injury is relatively uncommon, but the possibility of serious intracranial injury (ICI) should be included in the differential diagnosis. ICIs are potentially life threatening and necessitate urgent medical management; therefore, prompt recognition and evaluation are critical to proper medical management. One of the primary objectives of the initial evaluation is to determine if the concussed athlete has an acute traumatic ICI. Athletic trainers must be able promptly recognize clinical signs and symptoms that will enable them to accurately differentiate between a concussion (ie, a closed head injury not associated with significant ICI) and an ICI. The identification of predictors of intracranial lesions is, however, relatively broad. Focused Clinical Question: Which clinical examination findings (ie, clinical signs and symptoms) indicate possible intracranial pathology in individuals with acute closed head injuries?
Alturkustani, Murad; Ang, Lee-Cyn
Extensive nontraumatic subarachnoid hemorrhage is an important cause of unexpected death in young adults. Segmental arterial mediolysis (SAM) represents an uncommon pathologic finding in the intracranial blood vessels associated with this type of hemorrhage. Segmental arterial mediolysis is a pathologic entity with putative vasospastic etiology, which recently has been reported to be associated with Ehlers-Danlos syndrome type 4. We describe 2 additional cases of ruptured intracranial vertebral artery with features of SAM that resulted in fatal subarachnoid hemorrhage. We also review the literature on vessels with features of SAM that are either intracranial or affecting the internal carotid artery with major direct effects (ie, stroke or transient ischemic attack) on the central nervous system.
Bäuerle, J; Egger, K; Harloff, A
This review describes the clinical findings as well as thes diagnostic and therapeutic options for idiopathic intracranial hypertension (pseudotumor cerebri). Furthermore, the pathophysiological concepts are discussed. Idiopathic intracranial hypertension is characterized by signs and symptoms of raised intracranial pressure with no established pathogenesis. Common symptoms include headaches, visual loss and pulsatile tinnitus. Treatment has two major goals: the alleviation of headaches and the preservation of vision. Weight loss and acetazolamide are the cornerstones in the treatment of the disorder. Drainage of cerebrospinal fluid, optic nerve sheath fenestration and stent angioplasty of a sinus stenosis can be employed in severe cases.
Reinshagen, Clemens; Redjal, Navid; Sajed, Dipti P; Nahed, Brian V; Walcott, Brian P
Intracranial chondromas are benign, slow-growing, cartilaginous tumors, which comprise only about 0.2% of all intracranial tumors. The majority of these lesions occur at the base of the skull, where they are thought to arise from residual embryonic chondrogenic cells along the basal synchondrosis. Very rarely, they may also originate from the convexity dura, falx cerebri, or the brain parenchyma. We present a patient with a dural based chondroma to highlight the technical considerations of surgical resection. The recent literature on intracranial chondromas regarding incidence, pathophysiologic origin, clinical symptoms, imaging, histopathology and prognosis is reviewed.
Shoykhet, Michael; Cadena, Rhonda
Sustained intracranial hypertension and acute brain herniation are “brain codes,” signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, a brain code mandates the organized implementation of a stepwise management algorithm. The goal of this emergency neurological life support protocol is to implement an evidence-based, standardized approach to the evaluation and management of patients with intracranial hypertension and/or herniation. PMID:26438459
Rathia, Santosh Kumar; Sankar, Jhuma; Kandasamy, Devasenathipathy; Lodha, Rakesh
Cerebral malaria is a well-known complication of Plasmodium falciparum malaria. Over recent years, however, Plasmodium vivax also has been reported to cause cerebral malaria with or without co-infection with P. falciparum Here, we report a boy aged 10 years presenting with acute febrile encephalopathy with raised intracranial pressure to the emergency, who was later diagnosed to have P. vivax malaria. His neurological status improved gradually during 6 weeks of pediatric intensive care unit stay. We report this case to highlight the unusual radiologic findings in the patient, such as multifocal hemorrhagic infarcts in the brainstem, bilateral thalami, frontal cortex and basal ganglia, which have not been reported with P. vivax malaria.
Glew, W B
An unusual case of acute bilateral loss of vision simulating pituitary apoplexy but due instead to a fatal hemorrhage into a hypothalamic glioma is reported. The clinician dealing with abrupt loss of vision must promptly rule out ocular and orbital causes and then proceed immediately to a consideration of the variety of intracranial lesions which may cause sudden visual loss. Uihlein and Rucker have listed them in descending order of frequency: pituitary adenoma, tumors of the optic nerve and chiasm, supraclinoid aneurysm, parasellar lesion, thrombosis of the carotid artery, hydrocephalus of the third ventricle, chiasmal arachnoiditis, fracture of the anterior cranial fossa, basofrontal tumor of the skull, and pseudotumor cerebri. Neurologic, ophthalmologic, and neuroradiologic evaluations should be obtained without delay and will usually define the lesion and point to the appropriate treatment.
Leung, Lai Yee; Wei, Guo; Shear, Deborah A; Tortella, Frank C
Traumatic brain injury (TBI) often occurs in conjunction with additional trauma, resulting in secondary complications, such as hypotension as a result of blood loss. This study investigated the combined effects of penetrating ballistic-like brain injury (PBBI) and hemorrhagic shock (HS) on physiological parameters, including acute changes in regional cerebral blood flow (rCBF), brain tissue oxygen tension (P(bt)O₂), and cortical spreading depolarizations (CSDs). All recordings were initiated before injury (PBBI/HS/both) and maintained for 2.5 h. Results showed that PBBI alone and combined PBBI and HS produced a sustained impairment of ipsilateral rCBF that decreased by 70% from baseline (p<0.05). Significant and sustained reductions in P(bt)O₂ (50% baseline; p<0.05) were also observed in the injured hemisphere of the animals subjected to both PBBI and HS (PBBI+HS). In contrast, PBBI alone produced smaller, more transient reductions in P(bt)O₂ levels. The lower limit of cerebral autoregulation was significantly higher in the PBBI+HS group (p<0.05, compared to HS alone). Critically, combined injury resulted in twice the number of spontaneous CSDs as in PBBI alone (p<0.05). It also lowered the propagation speed of CSD and the threshold of CSD occurrence [induced CSD at higher mean arterial pressure (MAP)]. However, rCBF and P(bt)O₂ were not responsive to the depolarizations. Our data suggest that PBBI together with HS causes persistent impairment of CBF and brain tissue oxygen tension, increasing the probability of CSDs that likely contribute to secondary neuropathology and compromise neurological recovery.
Uhm, J; Hamad, N; Michelis, F V; Shanavas, M; Kuruvilla, J; Gupta, V; Lipton, J H; Messner, H A; Seftel, M; Kim, D D
Hemorrhagic cystitis (HC) is a common complication after allogeneic hematopoietic SCT (allo-HSCT). Several risk factors have been suggested including BU-containing myeloablative conditioning, unrelated donors and GVHD, but these have not been consistently reported. We conducted a retrospective study including 339 allo-HSCT recipients between 2009 and 2012. Of 339 patients, 79 (23.3%) developed HC with 2-year cumulative incidence of 24.0% (95% confidence interval, 19.4-28.9). The median onset time was 45 days (range, 16-430) after allo-HSCT. Sixty-two patients (84%) out of 74 evaluated for urine BK virus PCR testing showed a positive result (mean 2.0 × 10(10) copies of DNA per mL). In univariate analysis, myeloablative conditioning, HLA-mismatched donor, CMV viremia and acute GVHD (aGVHD) grade 3-4 were significantly associated with the risk of HC. Multivariate analysis confirmed all associating factors identified in univariate analysis except for HLA-mismatched donor: myeloablative conditioning (hazard ratio (HR) 2.63, P=0.003), CMV viremia (HR 1.88, P=0.014) and aGVHD grade 3-4 (HR 1.71, P=0.029). HC did not affect OS or non-relapse mortality. Symptomatic HC is a frequent complication following allo-HSCT, with a 2-year cumulative incidence of 24.0%. Three clinical factors associated with HC were identified including myeloablative conditioning, CMV viremia and severe aGVHD.
Vuong, Barry; Sun, Cuiru; Khiel, Tim-Rasmus; Gardecki, Joseph A.; Standish, Beau A.; da Costa, Leodante; de Morais, Josaphat; Tearney, Guillermo J.; Yang, Victor X. D.
Rupture of intracranial aneurysm is a common cause of subarachnoid hemorrhage. An aneurysm may undergo microscopic morphological changes or remodeling of the vessel wall prior to rupture, which could potentially be imaged. In this study we present methods of tissue sample preparation of intracranial aneurysms and correlation between optical coherence tomography imaging and routine histology. OCT has a potential future in the assessment of microscopic features of aneurysms, which may correlate to the risk of rupture.
... head. The monitor senses the pressure inside the skull and sends measurements to a recording device. ... are 3 ways to monitor pressure in the skull (intracranial pressure). INTRAVENTRICULAR CATHETER The intraventricular catheter is ...
Harada, Yukinori; Hara, Yuuta
Herpes simplex encephalitis (HSE) can be complicated by adverse events in the acute phase. We herein present the case of a 71-year-old woman with HSE complicated by cerebral hemorrhage. She presented with acute deterioration of consciousness and fever and was diagnosed with HSE based on the detection of herpes simplex virus-1 in the cerebrospinal fluid by a polymerase chain reaction. The cerebral hemorrhage developed during acyclovir therapy; however, its diagnosis was delayed for 2 days. After the conservative treatment of the cerebral hemorrhage, the patient made a near-complete recovery. Cerebral hemorrhage should be considered as an acute-phase complication of HSE. PMID:28090058
Harada, Yukinori; Hara, Yuuta
Herpes simplex encephalitis (HSE) can be complicated by adverse events in the acute phase. We herein present the case of a 71-year-old woman with HSE complicated by cerebral hemorrhage. She presented with acute deterioration of consciousness and fever and was diagnosed with HSE based on the detection of herpes simplex virus-1 in the cerebrospinal fluid by a polymerase chain reaction. The cerebral hemorrhage developed during acyclovir therapy; however, its diagnosis was delayed for 2 days. After the conservative treatment of the cerebral hemorrhage, the patient made a near-complete recovery. Cerebral hemorrhage should be considered as an acute-phase complication of HSE.
Mena, Othon J; Paul, Ian; Reichard, R Ross
We present the case of a 7-month-old female infant who was found crying and limp. She was transported to a hospital where a possible subarachnoid hemorrhage was diagnosed radiologically. Before further studies could be pursued, her condition worsened and she died. The autopsy demonstrated diffuse subarachnoid hemorrhage of the brain and along the spinal cord. The brain, spinal cord, and eyes were retained and examined postfixation. An aneurysm of the middle cerebral artery was identified. Examination of the eyes demonstrated bilateral optic nerve sheath hemorrhage and extensive retinal hemorrhages extending to the ora serrata. A rapid increase in intracranial pressure secondary to subarachnoid hemorrhage following rupture of an aneurysm can result in sequelae similar to those found in inflicted traumatic brain injury. In this case, the rise in intracranial pressure resulted in marked hemorrhage within the optic nerve sheaths as well as intra- and preretinal hemorrhages. Patients with subarachnoid hemorrhage, or other causes of rapidly increased intracranial pressure, may develop ocular hemorrhage (Terson syndrome). This case illustrates the importance of ruling out natural disease before attributing the autopsy findings to trauma, as well as the importance of postmortem fixation of pediatric brains and eyes prior to examination.
Walcott, Brian P; Berkhemer, Olvert A; Leslie-Mazwi, Thabele M; Chandra, Ronil V; Ogilvy, Christopher S; Yoo, Albert J
Vertebrovertebral fistulae are rare vascular malformations that uncommonly can rupture to present clinically as intracranial subarachnoid hemorrhage. We report a 69-year-old man presenting following spontaneous apoplectic collapse. Initial workup revealed diffuse, intracranial subarachnoid hemorrhage, intraventricular hemorrhage and hydrocephalus. However, the etiology was not apparent on CT angiography of the head. Catheter-based angiography was performed, demonstrating a single-hole, high-flow vertebrovertebral fistula, arising from the V2 segment and decompressing into both cervical and skull base venous structures. Definitive treatment consisted of endovascular fistula obliteration with a combination of coil and liquid embolic material. The patient made a full neurological recovery. High cervical and skull base fistulae are rare causes of intracranial hemorrhage; endovascular treatment is effective at disconnection of the arteriovenous shunt.
Lv, X.; Jiang, C.; Li, Y.; Yang, X.; Zhang, J.; Wu, Z.
Summary We report on report the clinical outcome obtained in treatment of giant intracranial aneurysms (GAs). Between 2005 and 2007, 51 patients with 51 GAs presented at our hospital. Twentynine were treated with primary parent vessel occlusion without distal bypass and ten underwent treatment preserving the parent artery. Twelve patients could not be treated endovascularly. Selective embolization (including two remodeling techniques and two stent-coil embolizations) resulted in only one cure. Two patients died as a result of subarachnoid hemorrhage periprocedurely. Twenty-nine patients treated primarily with parent vessel occlusion and three patients treated with covered stent were considered cured after their treatments. Only one patient treated with parent vessel occlusion experienced ischemia during follow-up, which resulted in a mild neurological deficit. Of the twelve patients who could not be treated endovascularly, one succumbed to surgery, four died while being treated conservatively, and three were lost to follow-up. Parent artery occlusion, covered stent and coil occlusion provide effective protection against bleeding. In treatment of paraclinoid GAs of the internal carotid artery, the use of a stent, and stent-assisted coil embolization may be a pitfall. PMID:20465907
Deguchi, Ichiro; Hayashi, Takeshi; Neki, Hiroaki; Yamane, Fumitaka; Ishihara, Shoichiro; Tanahashi, Norio; Takao, Masaki
We herein report three ischemic stroke patients who underwent emergency carotid artery stenting after receiving intravenous tissue plasminogen activator (t-PA) treatment. All patients received antiplatelet medications immediately before stent placement for loading as well as dual antiplatelet therapy after stenting. Under high-dose and dual antiplatelet therapy, none of the three patients showed symptomatic intracranial hemorrhaging. However, one case showed reocclusion of the placed stent after acute thrombosis. As a result, new treatment strategies for the use of antiplatelet agents during emergency stent placement must be developed, particularly for patients who have received intravenous t-PA therapy. PMID:27725550
Hayashi, M.; Kobayashi, H.; Kawano, H.; Handa, Y.; Kabuto, M.; Noguchi, Y.; Shirasaki, H.
Cerebrospinal fluid flow (CSF) was studied using isotope cisternography in 52 patients with increased intracranial pressure (ICP), all of whom showed acute transient rises of ICP, i.e., plateau waves, in their continuous ICP recordings. The patients were assigned to two groups. Group I was comprised of 23 patients without hydrocephalus and high ICP resulting from brain tumors, benign intracranial hypertension, and superior sagittal sinus thrombosis. Group II included 29 patients with either communicating hydrocephalus or high ICP resulting from rupture of intracranial aneurysm. Plateau waves were frequently observed in patients with baseline pressures ranging from 21 to 40 mmHg in both groups. The isotope cisternographic pattern in the Group I patients showed a large accumulation of radioactivity over the cerebral convexities, while that in the Group II patients revealed a complete obstruction of the subarachnoid space over both cerebral convexities. The isotope clearance from the intracranial CSF showed a marked delay in both groups of patients with one exception. The results suggest that, in the limited range of increased ICP caused by delayed CSF absorption, plateau waves are most evident regardless of the isotope cisternographic pattern.
Mallolas, Judith; Rodríguez, Rocío; Gubern, Carme; Camós, Susanna; Serena, Joaquín; Castellanos, Mar
Hemorrhagic transformation (HT) of cerebral infarction is a common and serious occurrence following acute ischemic stroke. The expression of survivin, a member of the inhibitor of apoptosis protein family, has been shown to increase after cerebral ischemia. This protein has been mainly located at the microvasculature within the infarcted and peri-infarcted area, so we aimed to investigate whether survivin gene polymorphisms, also known as BIRC5 gene, were associated with HT of cerebral infarction. Polymorphism screening of the BIRC5 gene was performed in 107 patients with a hemispheric ischemic stroke and 93 controls by polymerase chain reaction, single-strand conformation polymorphism and sequencing analysis. Genotype-phenotype correlation was performed in patients. MRI was carried out within 12 h of symptoms onset and at 72 ± 12 h. The presence of HT was determined on the second DWI sequence and classified according to ECASS II criteria. MMP-9 levels were analyzed at admission. Forty-nine patients (45.8%) had HT. The -241 C/T (rs17878467) polymorphism was identified in the promoter region of the survivin gene. The prevalence of the mutant allele (T) was similar in patients and controls (14 vs. 16%, respectively; P = 0.37). However, 9 (29%) patients with allele T had HT compared to 40 (52.6%) of wild-type (P = 0.021). Logistic regression analysis showed that the polymorphism was associated with a lower risk of HT (OR 0.16; 95% CI 0.04-0.65; P = 0.01). The -241 C/T polymorphism in the promoter region of the survivin gene is associated with a lower risk of HT in patients with ischemic stroke. It has recently been reported that the -241 C/T polymorphism increases survivin promoter activity, reinforcing the hypothesis that patients with the mutant allele may have increased survivin expression in the brain. Different mechanisms, including BBB protection by the inhibition or activation of different angiogenic growth factors and the inhibition of apoptosis during
Remirez, Juan M.; Sabet, Yasmin; Baca, Marshall; Maud, Alberto; Cruz-Flores, Salvador; Rodriguez, Gustavo J.; Mukherjee, Debabrata; Abbas, Aamer
Background Mycotic aneurysms are a complication of infective endocarditis. Infection of left ventricular assist devices (LVADs) may lead to bacteremia and fever causing complications similar to those seen in patients with prosthetic valve endocarditis. Intracranial mycotic aneurysms are rare, and their presence is signaled by the development of subarachnoid hemorrhage in the setting of bacteremia and aneurysms located distal to the circle of Willis. Case Presentation We present the case of a patient with a LVAD presenting with headache who is found to have an intracranial mycotic aneurysm through computed tomography angiography of the head. The patient was successfully treated with endovascular intervention. Conclusion In patients with LVADs, mycotic aneurysms have been reported, however not intracranially. To the best of our knowledge, this is the first intracranial mycotic aneurysm secondary to LVAD infection that was successfully treated with endovascular repair. Intracranial mycotic aneurysms associated with LVADs are a rare phenomenon. The diagnosis of mycotic aneurysms requires a high index of suspicion in patients who present with bacteremia with or without headache and other neurological symptoms. Disclosure None. PMID:28243347
Gazzeri, Roberto; Galarza, Marcelo; Costanzo, De Bonis; Carotenuto, Vincenzo; D'Angelo, Vincenzo
We report a patient with a large, pure intracranial vagal schwannoma, compressing the medulla who presented with essential hypertension. Based on this and on previous cases, we suggest that a differentiation of pure intracranial schwannomas (subtype A1) from intracranial schwannomas with some extension in the jugular foramen (type A) should be used.
Nogueira, Ariel B.; Esteves Veiga, José C.; Teixeira, Manoel J.
BACKGROUND: Stroke, including subarachnoid hemorrhage (SAH), is one of the leading causes of morbidity and mortality worldwide. The mortality rate of poor-grade SAH ranges from 34% to 52%. In an attempt to improve SAH outcomes, clinical research on multimodality monitoring has been performed, as has basic science research on inflammation and neuroregeneration (which can occur due to injury-induced neurogenesis). Nevertheless, the current literature does not focus on the integrated study of these fields. Multimodality monitoring corresponds to physiological data obtained during clinical management by both noninvasive and invasive methods. Regarding inflammation and neuroregeneration, evidence suggests that, in all types of stroke, a proinflammatory phase and an anti-inflammatory phase occur consecutively; these phases affect neurogenesis, which is also influenced by other pathophysiological features of stroke, such as ischemia, seizures, and spreading depression. OBJECTIVE: To assess whether injury-induced neurogenesis is a prognostic factor in poor-grade SAH that can be monitored and modulated. METHODS: We propose a protocol for multimodality monitoring-guided hypothermia in poor-grade SAH in which cellular and molecular markers of inflammation and neuroregeneration can be monitored in parallel with clinical and multimodal data. EXPECTED OUTCOMES: This study may reveal correlations between markers of inflammation and neurogenesis in blood and cerebrospinal fluid, based on clinical and multimodality monitoring parameters. DISCUSSION: This protocol has the potential to lead to new therapies for acute, diffuse, and severe brain diseases. ABBREVIATIONS: BBB, blood-brain barrier CPP, cerebral perfusion pressure EEG, electroencephalography ICP, intracranial pressure IL, interleukin MCA, middle cerebral artery SAH, subarachnoid hemorrhage SD, spreading depression SGZ, subgranular zone SVZ, subventricular zone TCD, transcranial Doppler PMID:25050583
Hill, Michael D.; Martin, Renee H.; Palesch, Yuko Y.; Moy, Claudia S.; Tamariz, Diego; Ryckborst, Karla J.; Jones, Elizabeth B.; Weisman, David; Pettigrew, Creed; Ginsberg, Myron D.
Background Albumin treatment of ischemic stroke was associated with cardiopulmonary adverse events in previous studies and a low incidence of intracranial hemorrhage. We sought to describe the neurological and cardiopulmonary adverse events in the ALIAS Part 2 Multicenter Trial. Methods Ischemic stroke patients, aged 18–83 and a baseline NIHSS ≥ 6, were randomized to treatment with ALB or saline control within 5 hours of stroke onset. Neurological adverse events included symptomatic intracranial hemorrhage, hemicraniectomy, neurological deterioration and neurological death. Cardiopulmonary adverse events included pulmonary edema/congestive heart failure, acute coronary syndromes, atrial fibrillation, pneumonia and pulmonary thromboembolism. Results Among 830 patients, neurological and cardiopulmonary adverse events were not differentially associated with poor outcome between ALB and saline control subjects. The rate of symptomatic intracranial hemorrhage in the first 24h was low overall (2.9%, 24/830) but more common in the ALB treated subjects (RR = 2.4, CI95 1.01–5.8). The rate of pulmonary edema/CHF in the first 48h was 7.9% (59/830) and was more common among ALB treated subjects (RR = 10.7, CI95 4.3–26.6); this complication was expected and was satisfactorily managed with mandated diuretic administration and intravenous fluid guidelines. Troponin elevations in the first 48h were common, occurring without ECG change or cardiac symptoms in 52 subjects (12.5%). Conclusions ALB therapy was associated with an increase in symptomatic ICH and pulmonary edema/congestive heart failure but this did not affect final outcomes. Troponin elevation occurs routinely in the first 48 hours after acute ischemic stroke. Trial Registration ClincalTrials.gov NCT00235495 PMID:26325387
Ni, Qian Qian; Tang, Chun Xiang; Zhao, Yan E; Zhou, Chang Sheng; Chen, Guo Zhong; Lu, Guang Ming; Zhang, Long Jiang
Aneurysmal subarachnoid hemorrhages have extremely high case fatality in clinic. Early and rapid identifications of ruptured intracranial aneurysms seem to be especially important. Here we evaluate clinical value of single phase contrast-enhanced dual-energy CT angiograph (DE-CTA) as a one-stop-shop tool in detecting aneurysmal subarachnoid hemorrhage. One hundred and five patients who underwent true non-enhanced CT (TNCT), contrast-enhanced DE-CTA and digital subtraction angiography (DSA) were included. Image quality and detectability of intracranial hemorrhage were evaluated and compared between virtual non-enhanced CT (VNCT) images reconstructed from DE-CTA and TNCT. There was no statistical difference in image quality (P > 0.05) between VNCT and TNCT. The agreement of VNCT and TNCT in detecting intracranial hemorrhage reached 98.1% on a per-patient basis. With DSA as reference standard, sensitivity and specificity on a per-patient were 98.3% and 97.9% for DE-CTA in intracranial aneurysm detection. Effective dose of DE-CTA was reduced by 75.0% compared to conventional digital subtraction CTA. Thus, single phase contrast-enhanced DE-CTA is optimal reliable one-stop-shop tool for detecting intracranial hemorrhage with VNCT and intracranial aneurysms with DE-CTA with substantial radiation dose reduction compared with conventional digital subtraction CTA.
Chaudhary, Neeraj; Pandey, Aditya S; Gemmete, Joseph J; Hua, Ya; Huang, Yining; Gu, Yuxiang; Xi, Guohua
Diffusion Tensor Imaging (DTI) has evolved considerably over the last decade to now be knocking on the doors of wider clinical applications. There have been several efforts over the last decade to seek valuable and reliable application of DTI in different neurological disorders. The role of DTI in predicting outcomes in patients with brain tumors has been extensively studied and has become a fairly established clinical tool in this scenario. More recently DTI has been applied in mild traumatic brain injury to predict clinical outcomes based on DTI of the white matter tracts. The resolution of white matter fiber tractography based on DTI has improved over the years with increased magnet strength and better tractography post processing. The role of DTI in hemorrhagic stroke has been studied preliminarily in the scientific literature. There is some evidence that DTI may be efficacious in predicting outcomes of motor function in animal models of intracranial hemorrhage. Only a handful of studies of DTI have been performed in subarachnoid hemorrhage or intraventricular hemorrhage scenarios. In this manuscript we will review the evolution of DTI, the existing evidence for its role in hemorrhagic stroke and discuss possible application of this non-invasive evaluation technique of human cerebral white matter tracts in the future. PMID:26015333
Claassen, Jan; Perotte, Adler; Albers, David; Kleinberg, Samantha; Schmidt, J. Michael; Tu, Bin; Badjatia, Neeraj; Lantigua, Hector; Hirsch, Lawrence J.; Mayer, Stephan A.; Connolly, E. Sander; Hripcsak, George
Objective Seizures have been implicated as a cause of secondary brain injury, but the systemic and cerebral physiologic effects of seizures after acute brain injury are poorly understood. Methods We analyzed intracortical EEG and multimodality physiological recordings in 48 comatose subarachnoid hemorrhage patients to better characterize the physiological response to seizures after acute brain injury. Results Intracortical seizures were seen in 38% of patients and 8% had surface seizures. Intracortical seizures were accompanied by elevated heart rate (P=0.001), blood pressure (P<0.001), and respiratory rate (P<0.001). There were trends for rising cerebral perfusion pressure (P=0.03) and intracranial pressure (P =0.06) seen after seizure onset. Intracortical seizure associated increases in global brain metabolism, partial brain tissue oxygenation, and regional cerebral blood flow (rCBF) did not reach significance, but a trend for a pronounced delayed rCBF rise was seen for surface seizures (P=0.08). Functional outcome was very poor for patients with severe background attenuation without seizures and best for those without severe attenuation or seizures (77% vs. 0% dead or severely disabled, respectively). Outcome was intermediate for those with seizures independent of the background EEG and worse for those with intracortical only seizures when compared to those with intracortical and scalp seizures (50% and 25% death or severe disability, respectively). Interpretation We replicated in humans complex physiologic processes associated with seizures after acute brain injury previously described in laboratory experiments and illustrated differences such as the delayed increase in regional cerebral blood flow. These real-world physiologic observations may permit more successful translation of laboratory research to the bedside. PMID:23813945
Ltaief, Z; Ben-Hamouda, N; Suys, T; Daniel, R T; Rossetti, A O; Oddo, M
Management of neurocritical care patients is focused on the prevention and treatment of secondary brain injury, i.e. the number of pathophysiological intracerebral (edema, ischemia, energy dysfunction, seizures) and systemic (hyperthermia, disorders of glucose homeostasis) events that occur following the initial insult (stroke, hemorrhage, head trauma, brain anoxia) that may aggravate patient outcome. The current therapeutic paradigm is based on multimodal neuromonitoring, including invasive (intracranial pressure, brain oxygen, cerebral microdialysis) and non-invasive (transcranial doppler, near-infrared spectroscopy, EEG) tools that allows targeted individualized management of acute coma in the early phase. The aim of this review is to describe the utility of multimodal neuromonitoring for the critical care management of acute coma.
Ledezma, Carlos J; Fiebach, Jochen B; Wintermark, Max
Thrombolysis has become an approved therapy for acute stroke. However, many stroke patients do not benefit from such treatment, since the presently used criteria are very restrictive, notably with respect to the accepted time window. Even so, a significant rate of intracranial hemorrhage still occurs. Conventional cerebral computed tomography (CT) without contrast has been proposed as a selection tool for acute stroke patients. However, more-modern MRI and CT techniques, referred to as diffusion- and perfusion-weighted imaging and perfusion-CT, have been introduced, which afford a comprehensive noninvasive survey of acute stroke patients as soon as their emergency admission, with accurate demonstration of the site of arterial occlusion and its hemodynamic and pathophysiological repercussions for the brain parenchyma. The objective of this article is to present the advantages and drawbacks of CT and MRI in the evaluation of acute stroke patients.
Wu, Xue-Mei; Zhang, Xu-Dong; Yun, Li-Bing; Liu, Min; Yi, Xu-Fu
Smothering and manual strangulation are not uncommon in domestic violence against women; however, no report on the combination of mechanical asphyxia and intracranial vascular malformations has been previously published. We report a middle-aged woman who was smothered and manually strangled by her husband and subsequently died from subarachnoid hemorrhage due to ruptured intracranial vascular malformations, rather than direct mechanical asphyxiation. Smothering and manual strangulation are considered provocative conditions for rupture and contributory causes of death. In this case study, we underline the importance of meticulous autopsy in cases of mechanical asphyxia and intracranial hemorrhage. Exclusion of underlying diseases that may have caused or contributed to death is also required, despite serious asphyxiation signs and neck injuries. Postmortem angiography is a valuable complement to autopsy to detect vascular pathology, with good prospects for further development in China.
Lv, X-F; Qiu, Y-W; Zhang, X-L; Han, L-J; Qiu, S-J; Xiong, W; Wen, G; Zhang, Y-Z; Zhang, J
PICCC is the rarest, most malignant primary intracranial GCT. The purpose of this study was to describe and characterize the MR imaging findings in a series of 7 patients (6 males and 1 female; mean age, 11.9 years) with pathologically proved PICCC in our institution from 2004 to 2009. All tumors were located within the pineal (n = 6) or suprasellar (n = 1) regions. On T2-weighted MR imaging, the lesions appeared markedly heterogeneous with areas of both hypointensity and hyperintensity reflecting the histologic heterogeneity, including hemorrhage, fibrosis, cysts, or necrosis. Heterogeneous (n = 7), ringlike (n = 4), and/or intratumoral nodular (n = 3) enhancement was noted on T1-weighted images with gadolinium. These MR imaging findings, combined with patient age and serum β-HCG levels, may prove helpful in distinguishing PICCC from the more common primary brain tumors, thereby avoiding biopsy of this highly vascular tumor.
Tiznado, E.G.; James, H.E.; Moore, S.
Experimental brain lesions were created over the left parietooccipital cortex of the albino rabbit through the intact dura mater with high radiating carbon dioxide laser energy. The brain water content was studied 2, 6, and 24 hours after the insult. Another two groups of animals received acute therapy with either dexamethasone (1 mg/kg) or furosemide (1 mg/kg). In all groups, Evans blue extravasation uniformly extended from the impact crater into the surrounding white matter. The brain water content in the gray matter was elevated from the control value by 2 hours after impact and remained elevated at 6 and 24 hours. The white matter brain water content did not increase until 6 hours after impact and remained elevated in the 24-hour group. After dexamethasone treatment, there was a significant decrease of water in the gray matter, but not in the white matter. With furosemide therapy, there was no reduction of gray or white matter brain water.
Pulling, T. Michael; Rosenberg, Jarrett; Marks, Michael P.; Steinberg, Gary K.; Zaharchuk, Greg
Background and Purpose Severe ischemic changes are a rare but devastating complication following direct superficial temporal artery to middle cerebral artery (STA MCA) bypass in Moyamoya patients. This study was undertaken to determine whether pre-operative MR imaging and/or cerebrovascular reserve (CVR) assessment using reference standard stable xenon enhanced computed tomography (xeCT) could predict such complications. Materials and Methods Among all adult patients receiving direct bypass at our institution between 2005 and 2010 who received a clinically interpretable xeCT examination, we identified index cases (patients with >15 ml post-operative infarcts) and control cases (patients without post-operative infarcts and without transient or permanent ischemic symptoms). Differences between groups were evaluated using the Mann Whitney test. Univariate and multivariate generalized linear model regression were employed to test predictors of post-operative infarct. Results Six index cases were identified and compared with 25 controls. Infarct size in the index cases was 95±55 ml. Four of six index cases (67%), but no control patients, had pre-operative acute infarcts. Baseline CBF was similar, but CVR was significantly lower in the index cases compared with control cases. For example, in the anterior circulation, median CVR was 0.4% (range: −38.0% to 16.6%) in index vs. 26.3% (range: −8.2% to 60.5%) in control patients (p=0.003). Multivariate analysis demonstrated that the presence of a small pre-operative infarct (regardless of location) and impaired CVR were independent, significant predictors of severe post-operative ischemic injury. Conclusion Acute infarcts and impaired CVR on pre operative imaging are independent risk factors for severe ischemic complications following STA MCA bypass in Moyamoya disease. PMID:26564435
Wagemans, Bart A. J. M.; van Zwam, Wim H.; Nelemans, Patricia J.; van Oostenbrugge, Robert J.; Postma, Alida A.
Introduction In acute ischemic stroke, imaging of the cranio-cervical vessels is essential for intra-arterial treatment selection. Fast, reliable and easy accessible imaging is necessary 24 hours a day, 7 days a week. Radiologists in training and non-expert readers often perform initial reviewing. In this pilot study, the potential benefit of adding 4Dimensional-CT Angiography (4D-CTA) to the patient selection protocol for intra-arterial therapy is investigated. Materials and methods Twenty-five datasets of prospectively recruited patients, eligible for intra-arterial treatment, were enrolled. Four radiologists-in-training consecutively reviewed CTA, CT-Perfusion and 4D-CTA (post-processed from CTP datasets) and scored: occlusion-presence and diagnostic certainty (scale 1–10). Time-to-diagnosis was registered. Results Arterial occlusion was present in 8 patients. Accuracy improved from 88–92% after CTA and CTP assessment to 96–100% after 4D-CTA assessment (P-values >0,05). Mean diagnostic certainty improved from 7,2–8,6 to 8,8–9,3 (P-values all < 0,05). Mean time to diagnosis increased from 3, 5, 5 and 4 minutes after CTA to 9, 14, 12, and 10 minutes after 4D-CTA. Conclusion 4D-CTA as an additive to regular CTA and CT-Perfusion in patients with acute ischemic stroke eligible for intra-arterial treatment shows a tendency to increase diagnostic accuracy and improves diagnostic certainty, when reviewed by radiologist in training, while only mildly prolonging time to diagnosis. PMID:28234928
Ulrich, Nicole D.; Lapeyre, Elizabeth R.; Moore, Robert C.
Background: Stroke in the pregnant patient is not a common occurrence. Despite its relative rarity, stroke during pregnancy is associated with high morbidity and mortality for both mother and infant. We report the case of a patient who experienced a hemorrhagic stroke during pregnancy because of venous cavernoma. Case Report: A 34-year-old patient, gravida 5 para 1-0-3-1, presented to labor and delivery triage at 21 weeks, 0 days' gestation with the concern of sudden-onset right-sided facial, arm, and leg numbness and weakness. Intracranial imaging via magnetic resonance imaging demonstrated a small left midbrain venous cavernoma in the periaqueductal region of the posterior lateral cerebral peduncle area with evidence of edema and focal hemorrhage. During a 3-day hospital admission, the patient's deficits slowly improved, and she was discharged home. She subsequently delivered vaginally without incident. Six days postpartum, the patient presented with symptoms that were similar to her initial presentation. She was correctly diagnosed with migraine with aura after the appropriate neuroimaging studies did not show an acute stroke. Conclusion: This case demonstrates the similarities between the perilous diagnosis of stroke and the more routine diagnosis of migraine. The case also highlights the need for caution and for a multidisciplinary treatment approach when the diagnosis of stroke is considered, particularly in the pregnant patient. PMID:27999514
Cerebral blood flow (CBF) was measured in 90 patients who underwent early aneurysmal clipping after subarachnoid hemorrhage (SAH). Measurements were made by a noninvasive, two-dimensional method involving intravenous injection of 133Xe. Patients of Hunt and Hess grades I and II exhibited normal to slightly subnormal CBF, without significant changes, during the study period. Grades III-V patients had almost normal CBF in the early postoperative period, but their CBF gradually decreased, becoming significantly low after day 31. It is noteworthy that in grades IV and V patients, CBF was abnormally high in the acute stage, relative to their poor neurological condition; these patients were considered to have the "global luxury perfusion syndrome." The syndrome was not uncommon in patients with severe SAH. Possible causative or contributory factors are attempts to surgically reduce intracranial pressure, which leads to increased cerebral perfusion pressure, and concomitant global dysautoregulation. In patients with this syndrome, maneuvers intended to increase CBF should be avoided, as they may aggravate brain swelling or cause hemorrhagic events. Positron emission tomographic studies will provide more accurate and useful information concerning the management of SAH patients.
Ambrosio, Ana; Saavedra, Maria; Mariani, Mauricio; Gamboa, Graciela; Maiza, Andrea
Argentine hemorrhagic fever (AHF), an acute disease caused by Junin virus (JUNV, Arenaviridae), has been an important issue to public health in Argentina since the early 1950s. The field rodent Calomys musculinus is JUNV natural reservoir and human disease is a consequence of contact with infected rodents. A steady extention of AHF endemic area is being observed since the first reports of the disease. Important achievements have been made in: (a) improvement of methods for the etiological diagnosis; (b) implementation and validation of therapeutical measures; (c) development of vaccines to protect against AHF. Reference is made to different research strategies used to obtain anti-AHF vaccines in the past and anti-arenaviral diseases in the present. Information is updated on features and field performance of Candid #1 vaccine, a live attenuted vaccine currently used to prevent AHF. This vaccine was developed through a joint international effort that envisioned it as an orphan drug. With transferred technology, Argentine government was committed to be Candid #1 manufacturer and to register this vaccine as a novel medical product under the Argentine regulatory authority. Candid #1 vaccine is the first one used to control an arenaviral hemorrhagic fever, the first live viral vaccine to be manufactured and registered in Argentina, reaching its target population through governmental effort.
Gazzeri, Roberto; Galarza, Marcelo; Callovini, Giorgio; Alfieri, Alex
Intraoperative hemostasis during neurosurgical procedures is one of the most important aspects of intracranial surgery. Hemostasis is mandatory to keep a clean operative field and to prevent blood loss and postoperative hemorrhage. In neurosurgical practice, biosurgical hemostatic agents have proved to be extremely useful to complete the more classic use of electrocoagulation. During recent years, many biosurgical topical hemostatic agents were created. Although routinely used during neurosurgical procedures, there is still a great deal of confusion concerning optimal use of these products, because of the wide range of products, as absorbable topical agents, antifibrinolytics agents, fibrin sealants and hemostatic matrix, which perform their hemostatic action in different ways. The choice of the hemostatic agent and the strategy for local hemostasis are correlated with the neurosurgical approach, the source of bleeding, and the neurosurgeon's practice. In this study, the authors review all the different sources of bleeding during intracranial surgical approaches and analyze how to best choose the right topical hemostatic agent to stop bleeding, from the beginning of the surgical approach to the end of the extradural hemostasis after dural closure, along all the steps of the neurosurgical procedure.
Intracranial trigeminal schwannomas are rare tumors. Patients usually present with symptoms of trigeminal nerve dysfunction, the most common symptom being facial pain. MRI is the imaging modality of choice and is usually diagnostic in the appropriate clinical setting. The thin T2-weighted CISS 3D axial sequence is important for proper assessment of the cisternal segment of the nerve. They are usually hypointense on T1, hyperintense on T2 with avid enhancement post gadolinium. CT scan is supplementary to MRI, particularly for tumors located in the skull base. Imaging plays a role in diagnosis and surgical planning. In this pictorial essay, we retrospectively reviewed imaging findings in nine patients with pathologically proven trigeminal schwannoma. Familiarity with the imaging findings of intracranial trigeminal schwannoma may help to diagnose this entity. PMID:25924170
Petrov, Andrey; Wynne, Karon E.; Prough, Donald S.; Dewitt, Douglas S.; Petrov, Yuriy; Petrov, Irene Y.; Parsley, Margaret A.; Esenaliev, Rinat O.
Patients with acute intracranial hematomas often require surgical drainage within the first four hours after traumatic brain injury (TBI) to avoid death or severe neurologic disability. CT and MRI permit rapid, noninvasive diagnosis of hematomas, but can be used only at a major health-care facility. At present, there is no device for noninvasive detection and characterization of hematomas in pre-hospital settings. We proposed to use an optoacoustic technique for rapid, noninvasive diagnosis and monitoring of hematomas, including intracranial hematomas. Unlike bulky CT and MR equipment, an optoacoustic system can be small and easily transported in an emergency vehicle. In this study we used a specially-designed blast device to inflict TBI in rats. A near-infrared OPO-based optoacoustic system developed for hematoma diagnosis and for blood oxygenation monitoring in the superior sagittal sinus (SSS) in small animals was used in the study. Optoacoustic signals recorded simultaneously from the SSS and hematomas allowed for measurements of their oxygenations. The presence of hematomas was confirmed after the experiment in gross pictures of the exposed brains. After blast the hematoma signal and oxygenation increased, while SSS oxygenation decreased due to the blastinduced TBI. The increase of the oxygenation in fresh hematomas may be explained by the leakage of blood from arteries which have higher blood pressure compared to that of veins. These results indicate that the optoacoustic technique can be used for early diagnosis of hematomas and may provide important information for improving outcomes in patients with TBI or stroke (both hemorrhagic and ischemic).
Mattle, H; Kohler, S; Huber, P; Rohner, M; Steinsiepe, K F
From January 1981 to June 1986 116 patients with anticoagulation-related intracranial haemorrhage were referred to hospital. Seventy six of these haemorrhages were extracerebral, 69 were in the subdural and seven in the subarachnoid space. No epidural haemorrhages were identified. Compared with non-anticoagulation-related haematomas, the risk of haemorrhage was calculated to be increased fourfold in men and thirteenfold in women. An acute subdural haematoma, mostly due to contusion, was more frequently accompanied by an additional intracerebral haematoma than a chronic subdural haematoma. Trauma was a more important factor in acute subdural haematomas than in chronic. Almost half of the patients (48%) had a history of hypertension, more than a third (35%) had heart disease and about one fifth (18%) were diabetic. Headache was the most frequent initial symptom. Later decreased level of consciousness and focal neurological signs exceeded the frequency of headache. Three patients with subarachnoid haemorrhage and nine patients with acute subdural haematomas died, while those with chronic subdural haematomas all survived and had at the most mild, non-disabling sequelae. Myocardial infarction (22%), pulmonary embolism (20%), and arterial disease (20%) were the most frequent reasons for anticoagulant treatment. Critical review based on established criteria for anticoagulation treatment suggests there was no medical reason to treat a third of these patients. The single most useful measure that could be taken to reduce the risk of anticoagulation-induced intracranial haemorrhage would be to identify patients who are being unnecessarily treated and to discontinue anticoagulants. PMID:2769275
automated real-time vital signs monitoring data” was funded by USAF (MSA); UM PI: Deborah Stein The project, titled “Noninvasive intracranial pressure ...scoring of cerebral perfusion pressure and intracranial pressure provides a Brain Trauma Index that predicts outcome in patients with severe TBI... intracranial pressure dose index: Dynamic 3-D scoring in the assessment of Traumatic Brain Injury Proceedings of American Association for the Surgery of
Maheshwari, Veena; Mehdi, Ghazala; Varshney, Manoranjan; Jain, Anshu; Vashishtha, Sonal; Gaur, Kavita; Srivastava, Vinod Kumar
Intracranial chondroma is a rare benign cartilaginous tumour with an incidence of less than 1% of all primary intracranial tumours. The authors are reporting here a case of intracranial chondroma in a 40-year-old man who presented with 5-month history of headache and gradual diminution of vision. A tentative diagnosis of chondroma was made on imprint cytology which was confirmed on histopathological examination.
Czosnyka, M; Pickard, J
Although there is no "Class I" evidence, ICP monitoring is useful, if not essential, in head injury, poor grade subarachnoid haemorrhage, stroke, intracerebral haematoma, meningitis, acute liver failure, hydrocephalus, benign intracranial hypertension, craniosynostosis etc. Information which can be derived from ICP and its waveforms includes cerebral perfusion pressure (CPP), regulation of cerebral blood flow and volume, CSF absorption capacity, brain compensatory reserve, and content of vasogenic events. Some of these parameters allow prediction of prognosis of survival following head injury and optimisation of "CPP-guided therapy". In hydrocephalus CSF dynamic tests aid diagnosis and subsequent monitoring of shunt function. PMID:15145991
Gulek, Bernice G; Rapport, Richard
Infectious intracranial aneurysms are a rare but serious potential complication of subacute endocarditis. Early diagnosis and treatment is essential to prevent devastating neurological deficits and mortality. Because nurse practitioners' roles expand into acute care as well as urgent care settings, they are frequently involved in the care of this population. Identifying the patients at risk, ordering appropriate studies, and initiating goal directed therapy are vital to outcomes. For nurse practitioners who are involved in care of neuroscience populations, it is important to be familiar with disease processes. This article provides a literature review of the topic, explores diagnostic methods, discusses management strategies, and presents an illustrative case.
Flores, Bruno C; Klinger, Daniel R; Rickert, Kim L; Barnett, Samuel L; Welch, Babu G; White, Jonathan A; Batjer, H Hunt; Samson, Duke S
Intracranial or brain arteriovenous malformations (BAVMs) are some of the most interesting and challenging lesions treated by the cerebrovascular neurosurgeon. It is generally believed that the combination of BAVMs and intracranial aneurysms (IAs) is associated with higher hemorrhage rates at presentation and higher rehemorrhage rates and thus with a more aggressive course and natural history. There is wide variation in the literature on the prevalence of BAVM-associated aneurysms (range 2.7%-58%), with 10%-20% being most often cited in the largest case series. The risk of intracranial hemorrhage in patients with unruptured BAVMs and coexisting IAs has been reported to be 7% annually, compared with 2%-4% annually for those with BAVM alone. Several different classification systems have been applied in an attempt to better understand the natural history of this combination of lesions and implications for treatment. Independent of the classification used, it is clear that a few subtypes of aneurysms have a direct hemodynamic correlation with the BAVM itself. This is exemplified by the fact that the presence of a distal flow-related or an intranidal aneurysm appears to be associated with an increased hemorrhage risk, when compared with an aneurysm located on a vessel with no direct supply to the BAVM nidus. Debate still exists regarding the etiology of the association between those two vascular lesions, the subsequent implications for patients' risk of hemorrhagic stroke, and finally the determination of which patients warrant treatment and when. The ultimate goals of the treatment of a BAVM associated with an IA are to prevent hemorrhage, avoid stepwise neurological deterioration, and eliminate the mortality risk associated with recurrent hemorrhagic events. The treatment is only justifiable if the risks associated with an intervention are lower than or equivalent to the long-term risks of disability or mortality caused by the lesion itself. When faced with this
Levin, T L; Morton, E
Huge dose ACTH therapy is used in some severely ill patients with inflammatory bowel disease. We report a teenage girl with Crohn's disease who developed an acute abdomen following ACTH therapy. CT revealed the mass to be a hemorrhagic adrenal gland; the opposite adrenal gland was hypertrophied but without signs of hemorrhage.
Kawoos, Usmah; McCarron, Richard M.; Auker, Charles R.; Chavko, Mikulas
Intracranial pressure (ICP) measurements are essential in evaluation and treatment of neurological disorders such as subarachnoid and intracerebral hemorrhage, ischemic stroke, hydrocephalus, meningitis/encephalitis, and traumatic brain injury (TBI). The techniques of ICP monitoring have evolved from invasive to non-invasive—with both limitations and advantages. Some limitations of the invasive methods include short-term monitoring, risk of infection, restricted mobility of the subject, etc. The invasiveness of a method limits the frequency of ICP evaluation in neurological conditions like hydrocephalus, thus hampering the long-term care of patients with compromised ICP. Thus, there has been substantial interest in developing noninvasive techniques for assessment of ICP. Several approaches were reported, although none seem to provide a complete solution due to inaccuracy. ICP measurements are fundamental for immediate care of TBI patients in the acute stages of severe TBI injury. In severe TBI, elevated ICP is associated with mortality or poor clinical outcome. ICP monitoring in conjunction with other neurological monitoring can aid in understanding the pathophysiology of brain damage. This review article presents: (a) the significance of ICP monitoring; (b) ICP monitoring methods (invasive and non-invasive); and (c) the role of ICP monitoring in the management of brain damage, especially TBI. PMID:26690122
Uchiyama, Shinichiro; Sakai, Nobuyuki; Toi, Sono; Ezura, Masayuki; Okada, Yasushi; Takagi, Makoto; Nagai, Yoji; Matsubara, Yoshihiro; Minematsu, Kazuo; Suzuki, Norihiro; Tanahashi, Norio; Taki, Waro; Nagata, Izumi; Matsumoto, Masayasu
Purpose To compare the effect of cilostazol plus aspirin versus aspirin alone on the progression of intracranial arterial stenosis (IAS), and to compare ischemic and hemorrhagic events in patients with symptomatic IAS, an investigator-driven, nationwide multicenter cooperative randomized controlled trial (CATHARSIS; ClinicalTrials.gov Identifier 00333164) was conducted. Methods 165 noncardioembolic ischemic stroke patients with >50% stenosis in the responsible intracranial artery after 2 weeks to 6 months from the onset were randomly allocated to receive either cilostazol 200 mg/day plus aspirin 100 mg/day (n = 83, CA group) or aspirin 100 mg/day alone (n = 82, A group). The primary endpoint was the progression of IAS on magnetic resonance angiography at 2 years after randomization. Secondary endpoints were any vascular events, any cause of death, serious adverse events, new silent brain infarcts, and worsening of the modified Rankin Scale score. Results Progression of IAS was observed in 9.6% of the CA group patients and in 5.6% of the A group patients, with no significant intergroup difference (p = 0.53). The incidence of the secondary endpoints tended to be lower in the CA group compared with the A group, although the differences were not significant. By using exploratory logistic regression analysis adjusted for patient background characteristics, it was shown that the risk for certain combinations of secondary endpoints was lower in the CA group than in the A group [all vascular events and silent brain infarcts: odds ratio (OR) = 0.37, p = 0.04; stroke and silent brain infarcts: OR = 0.34, p = 0.04; all vascular events, worsening of modified Rankin Scale scores and silent brain infracts: OR = 0.41, p = 0.03]. Major hemorrhage was observed in 4 patients of the CA group and in 3 of the A group. Conclusion Progression of IAS during the 2-year observation period appears to be less frequent than previously reported in stroke patients on antiplatelet agents after
Gliem, Michael; Lee, John-Ih; Barckhan, Aurica; Turowski, Bernd; Hartung, Hans-Peter; Jander, Sebastian
Background Endovascular therapy (EVT) with stent retrievers in addition to i.v. thrombolysis (IVT) has proven effective in acute stroke patients with middle cerebral artery (MCA, M1 segment) and distal internal carotid artery (ICA) occlusion. Limited data exist concerning acute cervical ICA occlusion, either alone or in combination with intracranial ICA occlusion (tandem occlusion). Therefore we analyzed outcome and treatment effects in stroke associated with cervical ICA occlusion, with specific focus on the impact of intracranial ICA or M1 patency. Methods Seventy-eight patients with cervical ICA occlusion from our local stroke unit registry were analyzed retrospectively. Thrombolysis in Cerebral Infarction (TICI) classification, infarct size, modified Rankin scale (mRS), symptomatic intracerebral hemorrhage (ICH), and death were assessed as outcome parameters. Results Forty-three patients had isolated cervical ICA occlusion whereas 35 patients presented with extra-/intracranial tandem occlusion. Patients underwent IVT alone (n = 23), combined IVT/EVT (n = 28) or no treatment (n = 27). Treated and untreated patients with tandem occlusion had a worse outcome after 90 days compared to isolated cervical occlusion (OR for moderate outcome 0.29, 0.27–0.88, p = 0.01). Additional EVT improved outcome in patients with tandem occlusion (OR for moderate outcome: 15.43, 1.60–148.90, p = 0.008) but not isolated cervical occlusion (OR 1.33, 0.38–11.60, NS). Conclusions In contrast to tandem occlusion, stroke outcome in patients with isolated cervical ICA occlusion was generally more benign and not improved by combined IVT/EVT compared to IVT alone. Intracranial vessel patency may be critical for treatment decision in acute cervical ICA occlusion. PMID:28081270
Walls, T J; Purohit, D P; Aji, W S; Schofield, I S; Barwick, D D
The case of a 40-year-old woman with increasing ataxia is described. Although the clinical presentation and evoked response studies raised the possibility of multiple sclerosis, further investigation revealed multiple cystic intracranial lesions. Surgical excision of one of the lesions relieved the patient's symptoms. Histological examination revealed that this was an enterogenous cyst. Although single cysts of this type have rarely been reported occurring in the posterior cranial fossa, the occurrence of multiple lesions, some in the supratentorial compartment, appears to be unique. Images PMID:3701354
Oursin, C; Wetzel, S G; Lyrer, P; Bächli, H; Stock, K W
Intradural dermoids are rare congenital tumors representing approximately 0.05% of all intracranial lesions. These benign tumors have a typical appearance on CT and MR due to their lipid components. The complication caused by rupture are the spillage of the fatty material into the cerebrospinal fluid. We report a case of a ruptured dermoid cyst showing fat/fluid levels in both side ventricles and fatty material in the subarachnoid space on CT and MR-imaging and the follow-up over four years after incomplete resection of the tumor.
Tripathy, L N; Singh, S N
The incidence of subarachnoid haemorrhage from intracranial aneurysms in the paediatric age group is extremely rare. Interestingly, occurrence of vasospasm has been reported to be less in comparison to the adults. Both coiling and clipping have been advocated in selected cases. Because of the thinness of the wall of the arteries, utmost care should be taken while handling these arteries during surgery. The overall results of surgery in children have been reported to be better than their adult counterparts. We present four such cases from our own experience. All these children were operated upon, where the solitary aneurysm in each case was clipped and all of them made a good recovery.
Merola, Joseph; Tipper, Geoffrey Adrian; Hussain, Zakier; Balakrishnan, Venkataraman; Gan, Peter
We present a case of intracranial abscess in a young female with Ectopia Cordis, an exceptionally rare cardiac condition. The neurosurgical implication is the predisposition to intracranial abscess formation. A heightened awareness of this association will aid diagnosis in similar clinical scenarios.
Matsushita, Hiroshi; Harada, Atsuko; Sato, Takashi; Kurabayashi, Takumi
The effects of airbag deployment in motor vehicle accidents (MVA) on the fetus are poorly understood. A 22-year-old woman at 24 weeks of gestation collided with a telephone pole while driving. She was restrained and an airbag deployed. Although she had no major injuries, she experienced decreased fetal movements. Fetal heart rate (FHR) monitoring revealed loss of variability without any evidence of abruptio placentae, and 4 days later, the variability spontaneously recovered. Two weeks after the MVA, ultrasonography showed unilateral ventricular dilatation suggestive of fetal brain injury. Magnetic resonance imaging revealed subdural hematoma, intraventricular hemorrhage and cystic lesions, interpreted as indirect (hypoxic-ischemic) and direct (hemorrhagic) intracranial injuries. After MVA with airbag deployment, FHR monitoring can show a transient loss of variability, which may precede the appearance of fetal brain injury.
Jiang, Hanqiang; Ni, Wei; Lei, Yu; Li, Yanjiang; Gu, Yuxiang
A ruptured wide-necked basilar trunk aneurysm is uncommon in patients with moyamoya disease. The optimal treatment is unclear. We report a safe and beneficial treatment modality for moyamoya disease with aneurysms located in the posterior circulation. A 37-year-old man presenting with subarachnoid hemorrhage was admitted to our hospital. Emergent cerebral angiography demonstrated moyamoya disease associated with a wide-necked basilar trunk aneurysm. We performed bilateral extracranial-intracranial bypass surgeries prior to stent-assisted coil embolization of the aneurysm after the acute phase. No complication occurred and the patient was discharged with no neurological deficit. Follow-up digital subtraction angiography (DSA) performed 6 months after the surgery showed that all the anastomosises were patent and bilateral collateral vascular compensation was fully established with no recanalization of the basilar trunk aneurysm post embolization.We also found that high-flow bypass did not contribute to cerebral revascularization as imagined despite the good patency. Combined extracranial-intracranial bypass surgery with endovascular treatment proved to be an efficient therapeutic modality for moyamoya disease with aneurysms located in the posterior circulation. High-flow bypass surgery was not essential due to the inefficiency and the high risk of postoperative cerebral hyperperfusion syndrome.
Mansencal, Nicolas; N'Guetta, Roland; Desperramons, Julien; Dubourg, Olivier
We present the case of an 89-year-old woman with no previous cardiovascular disease who presented a stress cardiomyopathy secondary to acute hemorrhagic stroke. Contrast and two-dimensional speckle tracking echocardiography was helpful to perform the diagnosis and the follow-up.
Diogo, Cláudia; Baltazar, José; Fernandes, Mário
The association between intracranial and visceral aneurysms is very rare, with a bad prognosis. The rupture usually appears in the Emergency Room, and it implies an immediate treatment. We describe the case of a woman with rupture of an anterior communicant artery aneurysm and rupture of a pancreatic duodenal artery aneurysm. The actuation of all specialties allowed the direct surgical treatment of the visceral aneurysm, without the aggravation of the cerebral hemorrhage that the eventual Aorta Artery clamping could provoke. The maintenance of the hemodynamic stability was essential for the posterior treatment of the intracranial aneurysm.
Kim, Tackeun; Lee, Heeyoung; Ahn, Soyeon; Kwon, O-Ki; Bang, Jae Seung; Hwang, Gyojun; Kim, Jeong Eun; Kang, Hyun-Seung; Son, Young-Je; Cho, Won-Sang; Oh, Chang Wan
Background Estimations of the intracranial aneurysm incidence require long-term follow-up of a relatively large at-risk population; as a result, the incidence remains largely unknown. Aims To investigate the national incidence of intracranial aneurysm in a Korean population. Methods After excluding 18,604 potential subjects with a previous history of stroke (I6x.x), 998,216 subjects were included in this observational cohort. The primary endpoint was the earliest date of diagnosis of either unruptured intracranial aneurysm (UIA; I67.1) or subarachnoid hemorrhage (SAH; I60.x). We collected anthropometric data, blood pressure measurements, laboratory data, and smoking, drinking, and physical exercise habits of 132,355 subjects for whom healthcare screening data were available. Factors influencing intracranial aneurysm were evaluated via multivariate Cox regression. Results The overall observation size was 8,792,214 person-years. During follow-up, 4346 subjects were diagnosed with intracranial aneurysm (SAH, 1960; UIA, 2386). The crude incidence of intracranial aneurysm was 49.4/100,000 person-years. The hazard ratio for women was 1.56 ( p < 0.01), and older subjects had an increased hazard ratio. Subjects with hypertension had an approximately 1.5-fold higher risk of intracranial aneurysm. A history of heart disease and family history of stroke were associated with respective hazard ratios of 2.08 and 1.77. Conclusions In this Korean population study, the standardized incidence of intracranial aneurysm was 52.2/100,000 person-years. Older age, female sex, hypertension, history of heart disease, and family history of stroke were independent risk factors for intracranial aneurysm.
trauma, or as secondary, relating to intracranial pressure elevations, hemorrhage and edema , cortical spreading depolarization waves, temperature...Hextend use, and may also indicate worsened pulmonary and cardiac damage and contribute to early mortality. iii) Oxidative Stress and Pulmonary Edema ...ongoing for over 40 years. Currently none have successfully translated. 3.0% saline has shown to be effective in reducing edema and intracranial pressure
Moreno-Aranda, Jorge; Wingartz-Plata, Hugo F; Maldonado-Arce, Boris; Vega-Espinosa, J Juvenal; Maldonado-Alcaraz, Efraín
Adrenal cysts are rare entities, and hemorrhagic pseudocysts are even less frequent. Generally, they are unsuspected during first patient evaluation and can suggest acute abdomen. We present the case of a hemorrhagic pseudocyst with sudden onset of abdominal pain and features compatible with acute appendicitis.
Valentino, Alden K; Nau, Karen M; Miller, David A; Hanel, Ricardo A; Freeman, WD
Background: Hypertonic saline (HTS) at a concentration of 23.4% is an emerging therapy for intracranial hypertension. Compared to mannitol which can be given as a single bolus or as repeated bolus dosing, little data exists regarding safety or efficacy of repeated dosing of 23.4% HTS. We report the first case of 16 doses of 23.4% HTS over a 5 day period in a patient with refractory intracranial hypertension. Case Report: A 43-year-old woman with Fisher 3 subarachnoid hemorrhage and hydrocephalus requiring an external ventricular drain developed global cerebral edema on computed tomography. Medically refractory intracranial hypertension ensued which required repeated dosing of 23.4% HTS. Reductions in intracranial pressure (ICP) occurred after each dose of 23.4% HTS. No central nervous system complications occurred. Anasarca was the only observed complication, which responded to furosemide diuresis. Conclusion: Repeated dosing of 23.4% HTS was effective in reducing ICP in a case of medically refractory intracranial hypertension without major systemic complications. Prospective studies should address the safety and efficacy of repeat dose 23.4% HTS on serum sodium, intracranial pressure, and complications. PMID:22518235
Kim, Helen; Nelson, Jeffrey; Krings, Timo; terBrugge, Karel G.; McCulloch, Charles E.; Lawton, Michael T.; Young, William L.; Faughnan, Marie E.
Background and Purpose Hereditary hemorrhagic telangiectasia (HHT) is a systemic disease characterized by mucocutaneous telangiectasias, epistaxis, and arteriovenous malformations (AVM). Intracranial hemorrhage (ICH) rates in this population are not well described. We report ICH rates and characteristics in HHT patients with brain arteriovenous malformations (HHT-BAVM). Methods We studied the first 153 HHT-BAVM patients with follow-up data enrolled in the Brain Vascular Malformation Consortium HHT Project. We estimated ICH rates after BAVM diagnosis. Results The majority of patients were female (58%) and Caucasian (98%). The mean age at BAVM diagnosis was 31±19 years (range: 0–70), with 61% of cases diagnosed upon asymptomatic screening. Overall, 14% presented with ICH; among symptomatic cases, 37% presented ruptured. During 493 patient-years of follow-up, 5 ICH events occurred yielding a rate of 1.02% per-year (95% CI: 0.42–2.44%). ICH-free survival differed significantly by ICH presentation (P=0.003); ruptured cases had a higher ICH rate (10.07%, 95% CI: 3.25–31.21%) than unruptured cases (0.43%, 95% CI: 0.11–1.73%). Conclusions HHT-BAVM patients who present with hemorrhage are at a higher risk for re-hemorrhage compared to BAVMs detected pre-symptomatically. PMID:25858236
Liu, Ann; Huang, Judy
Intracranial aneurysms (IAs) have an estimated incidence of up to 10 % and can lead to serious morbidity and mortality. Because of this, the natural history of IAs has been studied extensively, with rupture rates ranging from 0.5 to 7 %, depending on aneurysm characteristics. The spectrum of presentation of IAs ranges from incidental detection to devastating subarachnoid hemorrhage. Although the gold standard imaging technique is intra-arterial digital subtraction angiography, other modalities such as computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are being increasingly used for screening and treatment planning. Management of these patients depends upon a number of factors including aneurysmal, patient, institutional, and operator factors. The ultimate goal of treating patients with IAs is complete and permanent occlusion of the aneurysm sac in order to eliminate future hemorrhagic risk, while preserving or restoring the patient's neurological function. The most common treatment approaches include microsurgical clipping and endovascular coiling, and multiple studies have compared these two techniques. To date, three large prospective, randomized studies have been done: a study from Finland, International Subarachnoid Aneurysm Trial (ISAT), and the Barrow Ruptured Aneurysm Trial (BRAT). Despite differences in methodology, the results were similar: in patients undergoing coiling, although rates of rebleeding and retreatment are higher, the overall rate of poor outcomes at 12 months was significantly lower. As minimally invasive procedures and devices continue to be refined, endovascular strategies are likely to increase in popularity. However, as long-term outcome studies become available, it is increasingly apparent that they are complementary treatment strategies, with patient selection of critical importance.
Hammar, Samuel P
We describe a 64-year-old man with extensive diffuse acute lung hemorrhage, presumably as a result of anticoagulation therapy. We evaluated reports in the literature concerning acute exacerbation (acute lung injury of unknown cause) in UIP and other forms of fibrotic interstitial pneumonias. We also evaluated autopsy tissue in this case in order to determine the cause of death in this 64-year-old man, who was initially thought to have an asbestos-related disease. Based on the autopsy findings, this man died as a result of anticoagulation therapy; specifically, the use of Xarelto(®) (rivaroxaban).
Hammar, Samuel P.
We describe a 64-year-old man with extensive diffuse acute lung hemorrhage, presumably as a result of anticoagulation therapy. We evaluated reports in the literature concerning acute exacerbation (acute lung injury of unknown cause) in UIP and other forms of fibrotic interstitial pneumonias. We also evaluated autopsy tissue in this case in order to determine the cause of death in this 64-year-old man, who was initially thought to have an asbestos-related disease. Based on the autopsy findings, this man died as a result of anticoagulation therapy; specifically, the use of Xarelto® (rivaroxaban). PMID:26236607
Huai, Jiaping; Chen, Yanping
Background. Cyanoacrylate injection (GVO) and band ligation (GVL) are effective treatments for gastric variceal hemorrhage. However, data on the optimal treatment are still controversial. Methods. For our overall analysis, relevant studies were identified from several databases. For each outcome, data were pooled using a fixed-effect or random-effects model according to the result of a heterogeneity test. Results. Seven studies were included. Compared with GVL, GVO was associated with increased likelihood of hemostasis of active bleeding (odds ratio [OR] = 2.32; 95% confidence interval [CI] = 1.19–4.51) and a longer gastric variceal rebleeding-free period (hazard ratio = 0.37; 95% CI = 0.24–0.56). No significant differences were observed between GVL and GVO for mortality (hazard ratio = 0.66; 95% CI = 0.43–1.02), likelihood of variceal obliteration (OR = 0.89; 95% CI = 0.52–1.54), number of treatment sessions required for complete variceal eradication (weighted mean difference = −0.45; 95% CI = −1.14–0.23), or complications (OR = 1.02; 95% CI = 0.48–2.19). Conclusion. GVO may be superior to GVL for achieving hemostasis and preventing recurrence of gastric variceal rebleeding but has no advantage over GVL for mortality and complications. Additional studies are warranted to enable definitive conclusions. PMID:24868204
Wong, George K C; Kwan, Marco C L; Ng, Rebecca Y T; Yu, Simon C H; Poon, W S
The ultimate treatment goal for intracranial aneurysms is to reconstruct the vessel wall and correct the hemodynamic disturbance. A flow diverter is a stent placed in the parent artery to reduce blood flow in the aneurysm sac to the point of stagnation, gradual thrombosis, and neointimal remodeling to maintain outflow in the side branches and perforators. Here, we review the two commercially available flow diverters, the Pipeline Embolization Device (PED) and the SILK flow diverter (SFD). The rates of severe hemorrhagic complications have been reported to be 2% for the PED and 0.8% for the SFD. The results of studies completed thus far show that endovascular reconstruction with flow diverters is an effective treatment of wide-necked, fusiform, large, and giant unruptured intracranial aneurysms, with 5% to 10% of patients experiencing permanent major morbidity and mortality. The results of ongoing studies may resolve whether flow diverters can replace coil embolization for the treatment of all, or selected, intracranial aneurysms.
Jun, Chung-Hwan; Park, Chang-Hwan; Lee, Wan-Sik; Joo, Young-Eun; Kim, Hyun-Soo; Choi, Sung-Kyu; Rew, Jong-Sun; Kim, Sei-Jong
Bacterial infection may be a critical trigger for variceal bleeding. Antibiotic prophylaxis can prevent rebleeding in patients with acute gastroesophageal variceal bleeding (GEVB). The aim of the study was to compare prophylactic third generation cephalosporins with on-demand antibiotics for the prevention of gastroesophageal variceal rebleeding. In a prospective trial, patients with the first acute GEVB were randomly assigned to receive prophylactic antibiotics (intravenous cefotaxime 2 g q 8 hr for 7 days, prophylactic antibiotics group) or to receive the same antibiotics only when infection became evident (on-demand group). Sixty-two patients in the prophylactic group and 58 patients in the on-demand group were included for analysis. Antibiotic prophylaxis decreased infection (3.2% vs. 15.5%, p=0.026). The actuarial rebleeding rate in the prophylactic group was significantly lower than that in the ondemand group (33.9% vs. 62.1%, p=0.004). The difference of rebleeding rate was mostly due to early rebleeding within 6 weeks (4.8% vs. 20.7%, p=0.012). On multivariate analysis, antibiotic prophylaxis (relative hazard: 0.248, 95% confidence interval (CI): 0.067-0.919, p=0.037) and bacterial infection (relative hazard: 3.901, 95% CI: 1.053-14.448, p=0.042) were two independent determinants of early rebleeding. In conclusion, antibiotic prophylaxis using third generation cephalosporins can prevent bacterial infection and early rebleeding in patients with the first acute GEVB. PMID:17043424
Nidaira, Minoru; Kuba, Yumani; Saitoh, Mika; Taira, Katsuya; Maeshiro, Noriyuki; Mahoe, Yoko; Kyan, Hisako; Takara, Taketoshi; Okano, Sho; Kudaka, Jun; Yoshida, Hiromu; Oishi, Kazunori; Kimura, Hirokazu
A large acute hemorrhagic conjunctivitis (AHC) outbreak occurred in 2011 in Okinawa Prefecture in Japan. Ten strains of coxsackievirus group A type 24 variant (CA24v) were isolated from patients with AHC and full sequence analysis of the VP3, VP1, 3C(pro) and 3D(pol) coding regions performed. To assess time-scale evolution, phylogenetic analysis was performed using the Bayesian Markov chain Monte Carlo method. In addition, similarity plots were constructed and pairwise distance (p-distance) and positive pressure analyses performed. A phylogenetic tree based on the VP1 coding region showed that the present strains belong to genotype 4 (G4). In addition, the present strains could have divided in about 2010 from the same lineages detected in other countries such as China, India and Australia. The mean rates of molecular evolution of four coding regions were estimated at about 6.15 to 7.86 × 10(-3) substitutions/site/year. Similarity plot analyses suggested that nucleotide similarities between the present strains and a prototype strain (EH24/70 strain) were 0.77-0.94. The p-distance of the present strains was relatively short (<0.01). Only one positive selected site (L25H) was identified in the VP1 protein. These findings suggest that the present CA24v strains causing AHC are genetically related to other AHC strains with rapid evolution and emerged in around 2010.
Maleki, Maryam; Nematbakhsh, Mehdi
Background. Angiotensin 1-7 (Ang1-7) plays an important role in renal circulation. Hemorrhagic shock (HS) may cause kidney circulation disturbance, and this study was designed to investigate the renal blood flow (RBF) response to Ang1-7 after HS. Methods. 27 male Wistar rats were subjected to blood withdrawal to reduce mean arterial pressure (MAP) to 45 mmHg for 45 min. The animals were treated with saline (group 1), Ang1-7 (300 ng·kg−1 min−1), Ang1-7 in hypertonic sodium chloride 7.5% (group 3), and hypertonic solution alone (group 4). Results. MAP was increased in a time-related fashion (Ptime < 0.0001) in all groups; however, there was a tendency for the increase in MAP in response to hypertonic solution (P = 0.09). Ang1-7, hypertonic solution, or combination of both increased RBF in groups 2-4, and these were significantly different from saline group (P = 0.05); that is, Ang1-7 leads to a significant increase in RBF to 1.35 ± 0.25 mL/min compared with 0.55 ± 0.12 mL/min in saline group (P < 0.05). Conclusion. Although Ang1-7 administration unlike hypertonic solution could not elevate MAP after HS, it potentially could increase RBF similar to hypertonic solution. This suggested that Ang1-7 recovers RBF after HS when therapeutic opportunities of hypertonic solution are limited. PMID:27073699
Manjón, José V.; Eskildsen, Simon F.; Coupé, Pierrick; Romero, José E.; Collins, D. Louis; Robles, Montserrat
Automatic and accurate methods to estimate normalized regional brain volumes from MRI data are valuable tools which may help to obtain an objective diagnosis and followup of many neurological diseases. To estimate such regional brain volumes, the intracranial cavity volume (ICV) is often used for normalization. However, the high variability of brain shape and size due to normal intersubject variability, normal changes occurring over the lifespan, and abnormal changes due to disease makes the ICV estimation problem challenging. In this paper, we present a new approach to perform ICV extraction based on the use of a library of prelabeled brain images to capture the large variability of brain shapes. To this end, an improved nonlocal label fusion scheme based on BEaST technique is proposed to increase the accuracy of the ICV estimation. The proposed method is compared with recent state-of-the-art methods and the results demonstrate an improved performance both in terms of accuracy and reproducibility while maintaining a reduced computational burden. PMID:25328511
Derdeyn, Colin P; Fiorella, David; Lynn, Michael J; Rumboldt, Zoran; Cloft, Harry J.; Gibson, Daniel; Turan, Tanya N.; Lane, Bethany F.; Janis, L. Scott; Chimowitz, Marc I.
Background Enrollment in the Stenting and Aggressive Medical Management for the Prevention of stroke in Intracranial Stenosis (SAMMPRIS) trial was halted owing to higher than expected 30-day stroke rates in the stenting arm. Improvement in peri-procedural stroke rates from angioplasty and stenting for intracranial atherosclerotic disease (ICAD) requires an understanding of the mechanisms of these events. Objective To identify the types and mechanisms of peri-procedural stroke after angioplasty and stenting for ICAD. Methods Patients that suffered a hemorrhagic or ischemic stroke or a cerebral infarct with temporary signs (CITS) within 30 days of attempted angioplasty and stenting in SAMMPRIS were identified. Study records, including case report forms, procedure notes, and imaging were reviewed. Strokes were categorized as ischemic or hemorrhagic. Ischemic strokes were categorized as perforator territory, distal embolic, or delayed stent thrombosis. Hemorrhagic strokes were categorized as subarachnoid or intraparenchymal. Causes of hemorrhage (wire perforation, vessel rupture) were recorded. Results Three patients suffered an ischemic stroke after diagnostic angiography. Two were unrelated to the procedure. Twenty-one patients suffered an ischemic stroke (n= 19) or CITS (n=2) within 30 days of angioplasty and stenting. Most (n=15) were perforator territory and many of these occurred after angiographically successful angioplasty and stenting of the basilar artery (n = 8). Six patients suffered subarachnoid hemorrhage (three from wire perforation) and seven a delayed intraparenchymal hemorrhage. Conclusion Efforts at reducing complications from angioplasty and stenting for ICAD must focus on reducing the risks of regional perforator infarction, delayed intraparenchymal hemorrhage, and wire perforation. PMID:23328689
Lee, V K; Kimbrough, D J; Jarquin-Valdivia, A A
Acute bacterial parotitis (ABP) is a relatively uncommon condition that tends to occur in debilitated older patients. We report a case of an older woman that presented with an acute intracerebral hemorrhage who developed ABP. This morbidity led to endotracheal intubation, mechanical ventilation, tracheostomy and gastrostomy, all of which were not initially needed. We discuss the proposed physiopathology and etiopathogenesis of ABP in adults.
Kahlke, Volker; Brossmann, Joachim; Klomp, Hans-Juergen
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.
Godoy, Daniel Agustin; Piñero, Gustavo Rene; Koller, Patricia; Masotti, Luca; Di Napoli, Mario
Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurological-neurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it’s important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery. PMID:26261773
Lv, Xianli; Ge, Huijian; He, Hongwei; Jiang, Chuhan; Li, Youxiang
The experience with respect to the treatment of giant intracranial aneurysms with flow-diversion devices is limited. The aim of the present systematic review was to evaluate the effect of the pipeline embolization device (PED) on giant intracranial aneurysms. Eligible related articles were identified by searching the PubMed, Web of Science, Springer, ScienceDirect, and OVID databases using "giant aneurysm" and "pipeline" as the search items. The date of the last search was November 20, 2015. This systematic review adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In a total of 9 eligible studies with 200 patients and 215 aneurysms, 40 (18.6%) giant (aneurysm diameter >25mm) intracranial aneurysms treated with PED were analyzed. During a 6 to 34 month follow-up, complete occlusion was achieved in 23 (57.5%) cases. Seven patients (17.5%) developed intracranial hemorrhage, 5 developed ischemic attack (12.5%), and 13 (32.5%) developed a mass effect after PED treatment. The complication rate was 77.8% in PED for giant vertebrobasilar artery aneurysms. The cumulative mortality rate for giant paraclinoid carotid artery and middle cerebral artery aneurysms was 13.3% and increased up to 50% for giant vertebrobasilar artery aneurysms. The complete obliteration rate of PED for giant intracranial aneurysms was approximately 60%. Mass effect is the most mechanism of complications. Complication and mortality rates associated with PED for giant vertebrobasilar artery aneurysms are still extremely high.
Moster, Stephen J.; Moster, Mark L.
Abstract A 56-year-old woman developed progressive headache, mental status changes, and diplopia after trauma. She was diagnosed with alternating skew deviation caused by intracranial hypotension. This is the first case of alternating skew deviation reported from intracranial hypotension and perhaps a differential pressure between intracranial and intraspinal spaces plays a role in the development of these findings. PMID:27928294
Al-Kandari, Salwa Ramadan; Pandey, Tarun; Badawi, Mona H
Intracranial calcification is a known but extremely rare complication of diabetes insipidus. To date, only 16 patients have been reported and all had the peripheral (nephrogenic) type of diabetes insipidus. We report a child with intracranial calcification complicating central diabetes insipidus. We also report a child with nephrogenic diabetes insipidus, and compare the patterns of intracranial calcification.
A literature and institutional review of fetal intracranial teratomas yielded 90 tumors. The mean age at ultrasound diagnosis was 32 weeks, ranging from 21 to 41 weeks. Males and females were equally affected. The average, maximum tumor size was 10 cm, varying between 3.5 and 23 cm. Forty-two percent of patients died within the first week of life. Death rate was exceptionally high before 30 weeks gestation where almost half the affected fetuses expired. The overall survival rate for 90 fetuses with intracranial teratoma was only 7.8%.
Pigott, David C
This article reviews the epidemiology, pathophysiology, and clinical management of patients with suspected or confirmed viral hemorrhagic fever infection. The focus is on clinical management based on case series from naturally occuring outbreaks of viral hemorrhagic fever infection as well as imported cases of viral hemorrhagic fever encountered in industrialized nations. The potential risk of bioterrorism involving these agents is discussed as well as emergency department and critical care management of isolated cases or larger outbreaks. Important aspects of management, including recognition of infected patients, isolation and decontamination procedures, as well as available vaccines and therapies are emphasized.
Brant-Zawadzki, M.; Anderson, M.; DeArmond, S.J.; conley, F.K.; Jahnke, R.W.
Two patients who developed large intracranial vessel occlusion after standard radiation therapy for brain tumor are described. This form of vascular occlusion is usually seen in patients who have previously been treated by radiotherapy for intracranial tumor who then develop a relatively acute change in neurologic status. Histology of the lesion mimics accelerated focal arteriosclerosis. The clinical and radiographic manifestations of one case were highly atypical. The vasculopathy became evident shortly after termination of radiation therapy for a fourth ventricular ependymoma, and the angiographic picture stimulated a diffuse arteritis. The second patient was more typical, with clinical symptoms developing 12 years after radiation therapy for an oligodendroglioma. Occlusion of a proximal vessel that had been included in the radiation port was demonstrated radiographically and confirmed by pathologic examination. The clinical, angiographic, and histologic features of these two cases are discussed and previously reported cases are reviewed.
Haddad, Waleed S.; Trebes, James E.
The microwave hemorrhagic stroke detector includes a low power pulsed microwave transmitter with a broad-band antenna for producing a directional beam of microwaves, an index of refraction matching cap placed over the patients head, and an array of broad-band microwave receivers with collection antennae. The system of microwave transmitter and receivers are scanned around, and can also be positioned up and down the axis of the patients head. The microwave hemorrhagic stroke detector is a completely non-invasive device designed to detect and localize blood pooling and clots or to measure blood flow within the head or body. The device is based on low power pulsed microwave technology combined with specialized antennas and tomographic methods. The system can be used for rapid, non-invasive detection of blood pooling such as occurs with hemorrhagic stroke in human or animal patients as well as for the detection of hemorrhage within a patient's body.
Haddad, Waleed S.; Trebes, James E.
The microwave hemorrhagic stroke detector includes a low power pulsed microwave transmitter with a broad-band antenna for producing a directional beam of microwaves, an index of refraction matching cap placed over the patients head, and an array of broad-band microwave receivers with collection antennae. The system of microwave transmitter and receivers are scanned around, and can also be positioned up and down the axis of the patients head. The microwave hemorrhagic stroke detector is a completely non-invasive device designed to detect and localize blood pooling and clots or to measure blood flow within the head or body. The device is based on low power pulsed microwave technology combined with specialized antennas and tomographic methods. The system can be used for rapid, non-invasive detection of blood pooling such as occurs with hemorrhagic stoke in human or animal patients as well as for the detection of hemorrhage within a patient's body.
This book chapter describes the taxonomic classification of Simian hemorrhagic fever virus (SHFV). Included are: host, genome, classification, morphology, physicochemical and physical properties, nucleic acid, proteins, lipids, carbohydrates, geographic range, phylogenetic properties, biological pro...
Liebeskind, David S; Caplan, Louis R
Anatomy, physiology, and pathophysiology are inextricably linked in patients with intracranial atherosclerosis. Knowledge of abnormal or pathological conditions such as intracranial atherosclerosis stems from detailed recognition of the normal pattern of vascular anatomy. The vascular anatomy of the intracranial arteries, both at the level of the vessel wall and as a larger structure or conduit, is a reflection of physiology over time, from in utero stages through adult life. The unique characteristics of arteries at the base of the brain may help our understanding of atherosclerotic lesions that tend to afflict specific arterial segments. Although much of the knowledge regarding intracranial arteries originates from pathology and angiography series over several centuries, evolving noninvasive techniques have rapidly expanded our perspective. As each imaging modality provides a depiction that combines anatomy and flow physiology, it is important to interpret each image with a solid understanding of typical arterial anatomy and corresponding collateral routes. Compensatory collateral perfusion and downstream flow status have recently emerged as pivotal variables in the clinical management of patients with atherosclerosis. Ongoing studies that illustrate the anatomy and pathophysiology of these proximal arterial segments across modalities will help refine our knowledge of the interplay between vascular anatomy and cerebral blood flow. Future studies may help elucidate pivotal arterial factors far beyond the degree of stenosis, examining downstream influences on cerebral perfusion, artery-to-artery thromboembolic potential, amenability to endovascular therapies and stent conformation, and the propensity for restenosis due to biophysical factors.
Buxton, N; McConachie, N S
Amphetamines taken by any route can cause cerebral vasculitis and intracranial haemorrhage. 8 cases were seen in a neurosurgical unit over 3.5 years. The published work indicates that those who experience these complications, mainly young adults, have poor outcomes. PMID:11089483
Salaskar, Abhijit L; Hassaneen, Wael; Keenan, Cheryl H; Suki, Dima
To our knowledge, this is the first report of an intracranial tuberculoma in an immunocompetent patient with a solid primary tumor outside the central nervous system. This case is important because the patient underwent treatment for a presumed brain metastasis, based on the knowledge that a solid extracranial primary tumor was present, but before the brain lesion pathology was determined.
Kanai, Ryuichi; Shinoda, Jun; Irie, Seiichiro; Inoue, Koji; Sato, Teiko; Tsutsumi, Yutaka
Early detection followed by treatment with antibiotics in conjunction with direct or endovascular surgery is integral in the management of patients with intracranial infectious aneurysms. These aneurysms often manifest as massive intracranial hemorrhages, which severely deteriorate the outcome. It is very important to detect infectious aneurysms before they rupture. Although usually associated with infective endocarditis, these aneurysms can occur in a variety of clinical settings. We present a case of α-Streptococcus-provoked infectious aneurysm in a patient without infective endocarditis, initially presenting as atherothrombotic-like brain infarction, before massive intracranial hemorrhage. The present case alerts clinicians to keep in mind possible development of infectious aneurysms, even in patients who appear to be suffering from atherothrombotic stoke, especially in patients presenting with signs of infection.
Burnett, Mark W
Ebola hemorrhagic fever is an often-fatal disease caused by a virus of the Filoviridae family, genus Ebolavirus. Initial signs and symptoms of the disease are nonspecific, often progressing on to a severe hemorrhagic illness. Special Operations Forces Medical Providers should be aware of this disease, which occurs in sporadic outbreaks throughout Africa. Treatment at the present time is mainly supportive. Special care should be taken to prevent contact with bodily fluids of those infected, which can transmit the virus to caregivers.
Thunderclap headache is a sudden and severe headache that can occur after an aneurysmal subarachnoid hemorrhage (SAH). Subarachnoid hemorrhage is a medical emergency that requires prompt attention and hospitalization. Patients with thunderclap headache often undergo a noncontrast head computed tomography (CT) scan to ascertain SAH bleeding and, if the scan is negative, then undergo a lumbar puncture to look for cerebrospinal fluid (CSF) red blood cells (RBCs), which would be consistent with an aneurysmal leak. If the initial CT is negative and CSF is positive for RBCs, patients are usually admitted to the hospital for evaluation of intracranial aneurysm. We encountered a patient with thunderclap headache whose initial head CT was negative for SAH and whose CSF tested positive for RBCs. The patient was referred to our center for evaluation and management of aneurysmal SAH. However, on careful review of the patient’s medical history, serum laboratory values, and spinal fluid values, the patient was diagnosed with Ehrlichia chaffeensis meningitis. While Ehrlichia meningitis is rare, it is important to recognize the clinical clues that could help avoid formal cerebral angiography, a costly and potentially unnecessary procedure. We present how this case represented a cognitive framing bias and anchoring heuristic as well as steps that medical providers can use to prevent such cognitive errors in diagnosis. PMID:27053985
Guppy, Kern H; Silverthorn, James W; Akins, Paul T
Intrathecal spinal catheters (lumbar drains) are indicated for several medical and surgical conditions. In neurosurgical procedures, they are used to reduce intracranial and intrathecal pressures by diverting CSF. They have also been placed for therapeutic access to administer drugs, and more recently, vascular surgeons have used them to improve spinal cord perfusion during the treatment of thoracic aortic aneurysms. Insertion of these lumbar drains is not without attendant complications. One complication is the shearing of the distal end of the catheter with a resultant retained fragment. The authors report the case of a 65-year-old man who presented with a subarachnoid hemorrhage due to the migration of a retained lumbar drain that sheared off during its removal. To the best of the authors' knowledge, this is the first case of rostral migration of a retained intrathecal catheter causing subarachnoid hemorrhage. The authors review the literature on retained intrathecal spinal catheters, and their findings support either early removal of easily accessible catheters or close monitoring with serial imaging.
Chowdhury, Forhad Hossain; Haque, Mohammod Raziul; Sarker, Mainul Haque
Objectives: An intracranial epidermoid tumor is relatively a rare tumor, accounting for approximately 0.1% of all intracranial space occupying lesions. These are also known as pearly tumor due to their pearl like appearance. In this series, the localization of the tumor, presenting age and symptoms, imaging criteria for diagnosis, surgical management strategy with completeness of excision and overall outcome were studied prospectively. Here, we report our short experience of intracranial epidermoid as a whole. Materials and Methods: Between January 2006 to December 2010, 23 cases of intracranial epidermoid were diagnosed preoperatively with almost certainty by computed tomography (CT) and magnetic resonance imaging (MRI) of brain in plain, contrast and other relevant studies. All of them underwent operation in Dhaka Medical College Hospital and in some Private Hospital in Dhaka, Bangladesh. All patients were followed-up routinely by clinical examination and neuroimaging. Average follow-up was 39 (range-71-11months) months. Patients of the series were prospectively studied. Results: Supratentorial epidermoids were 04 cases and infratemporal epidermoids were 19 cases. Clinical features and surgical strategy varies according to the location and extension of the tumors. Age range was 19-71 years (37.46 years). Common clinical features were headache, cerebellar features, seizure, vertigo, hearing impairment and features of raised intracranial pressure (ICP). Investigation was CT scan or/+ MRI of brain in all cases. Pre-operative complete excision was 20 cases, but post-operative images showed complete excision in 17 cases. Content of tumor was pearly white/white material in all cases except one, where content was putty material. Re-operation for residual/recurrent tumor was nil. Complications included pre-operative mortality one case, persisted sixth nerve palsy in one case, transient memory disturbance one case, and extra dural hematoma one case. One senior patient
Kim, S.-R.; Vora, N.; Jovin, T.G.; Gupta, R.; Thomas, A.; Kassam, A.; Lee, K.; Gologorsky, Y.; Jankowitz, B.; Panapitiya, N.; Aleu, A.; Sandhu, E.; Crago, E.; Hricik, A.; Gallek, M.; Horowitz, M.B.
Summary The purpose of this study was to evaluate and report our anatomic results and complications associated with stent-assisted coil embolization of intracranial aneurysms using the Neuroform stent. From September 2003 to August 2007, 127 consecutive patients (ruptured 50, 39.4%; unruptured 77, 60.6%) underwent 129 stent-assisted coil embolization procedures to treat 136 aneurysms at our institution. Anatomic results at follow-up, procedure-related complications, and morbidity/mortality were retrospectively reviewed. Stent deployment was successful in 128 out of 129 procedures (99.2%). Forty-seven patients presented with 53 procedure-related complications (37.0%, 47/127). Thromboembolic events (n=17, 13.4%) were the most common complications, followed by intraoperative rupture (n=8, 6.3%), coil herniation (n=5, 3.9%), and postoperative rupture (n=4, 3.1%). For thromboembolic events, acute intra-procedural in-stent thromboses were observed in two patients and subacute or delayed in-stent thromboses in three patients. Overall mortality rate was 16.5% (21/127) and procedure-related morbidity and mortality rates were 5.5% (7/127) and 8.7% (11/127) retrospectively. Patients with poor grade subarachnoid hemorrhage (Hunt and Hess grade IV or V; 25/127, 19.7%) exhibited 56% (14/25) overall mortality rate and 24% (6/25) procedure-related mortality rate. Immediate angiographic results showed complete occlusion in 31.7% of aneurysms, near-complete occlusion in 45.5%, and partial occlusion in 22.8%. Sixty nine patients in 70 procedures with 77 aneurysms underwent angiographic follow-up at six months or later. Mean follow-up period was 13.7 months (6 to 45 months). Complete occlusion was observed in 57 aneurysms (74.0%) and significant in-stent stenosis was not found. Thromboembolism and intra/postoperative aneurysm ruptures were the most common complications and the main causes of procedure-related morbidity and mortality. Patients with poor grade subarachnoid hemorrhage
Fujita, Keishi; Komatsu, Yoji; Sato, Naoaki; Higuchi, Osamu; Kujiraoka, Yuji; Kamezaki, Takao; Suzuki, Kensuke; Matsumura, Akira
Progressive stroke is a serious problem due to the associated morbidity and mortality. Aspirin is recommended for acute ischemic stroke, but does not reduce the frequency of stroke progression. No standard treatment has been approved for the prevention of stroke progression. Cilostazol, which reduces platelet aggregation about 3 hours after single administration, does not increase the frequency of bleeding events when compared with aspirin or a placebo. Moreover, the combination of 100 mg aspirin and 200 mg cilostazol does not increase the frequency of bleeding events compared with only 100 mg aspirin, and thus is expected to prevent stroke progression with a high degree of safety. The present study investigated the safety of this combination of two drugs administered at the above concentrations in 54 patients with acute ischemic stroke within 48 hours of stroke onset. Modified National Institutes of Health Stroke Scale (NIHSS) measurements were performed at baseline and again on day 4 to 7. Progressive stroke was defined as an increase greater than or equal to 1 point on NIHSS. Patient scores on the modified Rankin Scale (mRS) were evaluated at baseline and 3 months after enrollment. Stroke progression occurred in 11.1% of the patients. The percentages of patients with mRS score from 0 to 2 were 42.6% and 75% at baseline and 3 months, respectively. No symptomatic intracranial hemorrhage or major extracranial hemorrhage occurred. These results suggest that administration of aspirin and cilostazol is safe for acute ischemic stroke.
Zieliński, Rafał; Zakrzewska, Anna
The most frequent primary infections causing purulent meningitis in older children are both acute and chronic otitis media and sinusitis or upper and lower airways infections. In these cases sometimes purulent meningitis is accompanied with other intracranial complications. Pharmacological treatment of intracranial complications without surgical intervention concerning primary source of infection increases risk of complications including death of a patient and also recurrences of bacterial meningitis. In the paper authors present two uncommon cases of children with purulent meningitis and other intracranial complications of otitis media and sinusitis diagnosed by pediatricians.
Teo, Mario; Johnson, Jeremiah N; Bell-Stephens, Teresa E; Marks, Michael P; Do, Huy M; Dodd, Robert L; Bober, Michael B; Steinberg, Gary K
OBJECTIVE Majewski osteodysplastic primordial dwarfism Type II (MOPD II) is a rare genetic disorder. Features of it include extremely small stature, severe microcephaly, and normal or near-normal intelligence. Previous studies have found that more than 50% of patients with MOPD II have intracranial vascular anomalies, but few successful surgical revascularization or aneurysm-clipping cases have been reported because of the diminutive arteries and narrow surgical corridors in these patients. Here, the authors report on a large series of patients with MOPD II who underwent surgery for an intracranial vascular anomaly. METHODS In conjunction with an approved prospective registry of patients with MOPD II, a prospectively collected institutional surgical database of children with MOPD II and intracranial vascular anomalies who underwent surgery was analyzed retrospectively to establish long-term outcomes. RESULTS Ten patients with MOPD II underwent surgery between 2005 and 2012; 5 patients had moyamoya disease (MMD), 2 had intracranial aneurysms, and 3 had both MMD and aneurysms. Patients presented with transient ischemic attack (TIA) (n = 2), ischemic stroke (n = 2), intraparenchymal hemorrhage from MMD (n = 1), and aneurysmal subarachnoid hemorrhage (n = 1), and 4 were diagnosed on screening. The mean age of the 8 patients with MMD, all of whom underwent extracranial-intracranial revascularization (14 indirect, 1 direct) was 9 years (range 1-17 years). The mean age of the 5 patients with aneurysms was 15.5 years (range 9-18 years). Two patients experienced postoperative complications (1 transient weakness after clipping, 1 femoral thrombosis that required surgical repair). During a mean follow-up of 5.9 years (range 3-10 years), 3 patients died (1 of subarachnoid hemorrhage, 1 of myocardial infarct, and 1 of respiratory failure), and 1 patient had continued TIAs. All of the surviving patients recovered to their neurological baseline. CONCLUSIONS Patients with MMD
Tonglet, Martin L
Early prediction of ongoing hemorrhage may reduce mortality via the earlier delivery of blood products, adequate orientation of the patient in a dedicated highly specialized and trained infrastructure, and by earlier correction of acute traumatic coagulopathy. We identified 14 scores or algorithms developed for the prediction of ongoing hemorrhage and the need for massive transfusion in severe trauma patients. PMID:28144603
Moon, Alaina Burkard; Heller, Heidi Barnes; Forrest, Lisa
The purpose of this study was to describe the use, and side effects, of a novel stereotactic radiotherapy protocol using TomoTherapy(®) in 4 dogs with confirmed or suspected primary extra-axial intracranial neoplasia. Three fractions of 8 Gy were prescribed. Acute side effects were noted in 1 dog; no late effects were noted.
Kompheak, Heng; Kim, Dong-Sung; Shin, Dong-Sung; Kim, Bum-Tae
Objective Management guidelines for single intracranial hematomas have been established, but the optimal management of multiple hematomas has little known. We present bilateral traumatic supratentorial hematomas that each has enough volume to be evacuated and discuss how to operate effectively it in a single anesthesia. Methods In total, 203 patients underwent evacuation and/or decompressive craniectomies for acute intracranial hematomas over 5 years. Among them, only eight cases (3.9%) underwent operations for bilateral intracranial hematomas in a single session. Injury mechanism, initial Glasgow Coma Scale score, types of intracranial lesions, surgical methods, and Glasgow outcome scale were evaluated. Results The most common injury mechanism was a fall (four cases). The types of intracranial lesions were epidural hematoma (EDH)/intracerebral hematoma (ICH) in five, EDH/EDH in one, EDH/subdural hematoma (SDH) in one, and ICH/SDH in one. All cases except one had an EDH. The EDH was addressed first in all cases. Then, the evacuation of the ICH was performed through a small craniotomy or burr hole. All patients except one survived. Conclusion Bilateral intracranial hematomas that should be removed in a single-session operation are rare. Epidural hematomas almost always occur in these cases and should be removed first to prevent the hematoma from growing during the surgery. Then, the other hematoma, contralateral to the EDH, can be evacuated with a small craniotomy. PMID:25237431
McLaughlin, Nancy; Berthelet, France; Bojanowski, Michel W
Schwannomas are slow-growing tumors with symptoms manifesting progressively. We report the case of a patient who manifested a sudden loss of consciousness as clinical presentation of an intracranial schwannoma with no acute hemorrhage or hydrocephalus. A 30-year-old male presented comatose and posturing. Cerebral CT revealed an extra-axial lesion with a heterogeneous enhancement and a cystic component located on the right cerebellopontine angle (CPA), displacing the brain stem. No acute hemorrhage or hydrocephalus was documented. Through a retrosigmoid suboccipital craniotomy, an extended subtotal tumor resection was performed. The patient experienced no functional hearing impairment and resumed his daily-life activities 3 months after surgery. Histopathological examination was compatible with a benign schwannoma. An exuberant lymphoplasmacytic infiltrate was found in many areas, signing the presence of an unusual inflammatory reaction with adjacent important intratumoral edema. We propose that the exuberant inflammatory infiltrate and the associated intratumoral edema acted as determining elements in the increase of mass effect and sudden clinical deterioration.
Weiss, Miriam; Clusmann, Hans; Fuest, Matthias; Mueller, Marguerite; Brockmann, Marc Alexander; Vilser, Walthard; Schmidt-Trucksäss, Arno; Hoellig, Anke; Seiz, Marcel; Thomé, Claudius; Kotliar, Konstantin; Schubert, Gerrit Alexander
Background Timely detection of impending delayed cerebral ischemia after subarachnoid hemorrhage (SAH) is essential to improve outcome, but poses a diagnostic challenge. Retinal vessels as an embryological part of the intracranial vasculature are easily accessible for analysis and may hold the key to a new and non-invasive monitoring technique. This investigation aims to determine the feasibility of standardized retinal vessel analysis (RVA) in the context of SAH. Methods In a prospective pilot study, we performed RVA in six patients awake and cooperative with SAH in the acute phase (day 2–14) and eight patients at the time of follow-up (mean 4.6±1.7months after SAH), and included 33 age-matched healthy controls. Data was acquired using a manoeuvrable Dynamic Vessel Analyzer (Imedos Systems UG, Jena) for examination of retinal vessel dimension and neurovascular coupling. Results Image quality was satisfactory in the majority of cases (93.3%). In the acute phase after SAH, retinal arteries were significantly dilated when compared to the control group (124.2±4.3MU vs 110.9±11.4MU, p<0.01), a difference that persisted to a lesser extent in the later stage of the disease (122.7±17.2MU, p<0.05). Testing for neurovascular coupling showed a trend towards impaired primary vasodilation and secondary vasoconstriction (p = 0.08, p = 0.09 resp.) initially and partial recovery at the time of follow-up, indicating a relative improvement in a time-dependent fashion. Conclusion RVA is technically feasible in patients with SAH and can detect fluctuations in vessel diameter and autoregulation even in less severely affected patients. Preliminary data suggests potential for RVA as a new and non-invasive tool for advanced SAH monitoring, but clinical relevance and prognostic value will have to be determined in a larger cohort. PMID:27388619
Abla, Adib A.; Nelson, Jeffrey; Kim, Helen; Hess, Christopher P.; Tihan, Tarik; Lawton, Michael T.
BACKGROUND Arteriovenous malformation (AVM) patients present in 4 ways relative to hemorrhage: (1) unruptured, without a history or radiographic evidence of old hemorrhage (EOOH); (2) silent hemorrhage, without a bleeding history but with EOOH; (3) ruptured, with acute bleeding but without EOOH; and (4) reruptured, with acute bleeding and EOOH. OBJECTIVE We hypothesized that characteristics and outcomes in the unrecognized group of silent hemorrhage patients may differ from those of unruptured patients. METHODS Two hundred forty-two patients operated-on since 1997 were categorized by hemorrhage status and hemosiderin positivity in this cohort study: unruptured (group 1), silent hemorrhage (group 2), and ruptured/reruptured (group 3/4). Group 3/4 was combined because hemosiderin cannot distinguish acute hemorrhage from older silent hemorrhage. RESULTS Hemosiderin was found in 45% of specimens. Seventy-five patients (31.0%) had unruptured AVMs, 30 (12.4%) had silent hemorrhage, and 137 (56.6%) had ruptured/ reruptured AVMs. Deep drainage, posterior fossa location, preoperative modified Rankin Scale (mRS) score, outcome, and macrophage score were different across groups. Only the macrophage score was different between the groups without clinical hemorrhage. Outcomes were better in silent hemorrhage patients than in those with frank rupture (mean mRS scores of 1.2 and 1.7, respectively). CONCLUSION One-third of patients present with silent AVM hemorrhage. No clinical or anatomic features differentiate these patients from unruptured patients, except the presence of hemosiderin and macrophages. Silent hemorrhage can be diagnosed using magnetic resonance imaging with iron-sensitive imaging. Silent hemorrhage portends an aggressive natural history, and surgery halts progression to rerupture. Good final mRS outcomes and better outcomes than in those with frank rupture support surgery for silent hemorrhage patients, despite the findings of ARUBA. PMID:25714514
Batts, William N.; Winton, James R.
Viral hemorrhagic septicemia (VHS) is one of the most important viral diseases of finfish worldwide. In the past, VHS was thought to affect mainly rainbow trout Oncorhynchus mykiss reared at freshwater facilities in Western Europe where it was known by various names including Egtved disease and infectious kidney swelling and liver degeneration (Wolf 1988). Today, VHS is known as an important source of mortality for cultured and wild fish in freshwater and marine environments in several regions of the northern hemisphere (Dixon 1999; Gagné et al. 2007; Kim and Faisal 2011; Lumsden et al. 2007; Marty et al. 1998, 2003; Meyers and Winton 1995; Skall et al. 2005b; Smail 1999; Takano et al. 2001). Viral hemorrhagic septicemia is caused by the fish rhabdovirus, viral hemorrhagic septicemia virus (VHSV), a member of the genus Novirhabdovirus of the family Rhabdoviridae
Chen, S F; Kato, Y; Kumar, A; Tan, G W; Oguri, D; Oda, J; Watabe, T; Imizu, S; Sano, H; Wang, Z X
Intraoperative rerupture (IOR) during clipping of cerebral aneurysms is a difficult complication of microneurosurgery. The aim of this study was to evaluate the incidence of IOR and analyze the strategies for controlling profound hemorrhage. A total of 165 patients with unruptured intracranial aneurysms and 46 patients with subarachnoid hemorrhage (SAH) treated surgically between April 2010 and March 2011, were reviewed. The data were collected with regard to age, sex, presence of symptoms, confounding factors and strategy for controlling intraoperative hemorrhage was analyzed in terms of location of aneurysms, timing of rupture and severity of IOR. 211 patients with 228 aneurysms were treated in this series. There were a total of six IORs which represented an IOR rate of 2.84% per patient and 2.63% per aneurysm. The highest ruptures rates occurred in patients with internal carotid artery aneurysms (25%). Surgeries in the group with ruptured aneurysms had a much higher rate of IOR compared with surgeries in the group with unruptured aneurysms. Of the six IOR aneurysms, one occurred during predissection, four during microdissection and one during clipping. One was major IOR, three were moderate and two were minor. Intraoperative rupture of an intracranial aneurysm can be potentially devastating in vascular neurosurgery. Aneurysm location, presence of SAH and surgical experience of the operating surgeon seem to be important factors affecting the incidence of IOR.
... VHFs) are caused by several families of enveloped RNA viruses: filoviruses (Ebola and Marburg hemorrhagic fever), arenaviruses ( ... in hemorrhagic fever with high death rates. Old World (Eastern Hemisphere) and New World (Western Hemisphere) viruses ...
AD-A<m 761 KOREA UNIV SEOUL COLL OF MEDICINE KOREAN HEM0RRHA6IC FEVER.(U) MAR 80 H W LEE UNCLASSIFIED ICFI F/6 6/5 DAM017-79-6-9<*55 NL...I» > I,,iu. •Uli ••-. SUMMARY There were 364 hospitalized cases of Korean hemorrhagic fever (KHF) in 1979 in Korea . Lee et al...STANDARDS-1963-A ?H "LEVEtf® AD <o KOREAN HEMORRHAGIC F EVER A D A 09 47 Final Report HO WANG LEE, M. D. March 1980 i MIL. IIB«I . Mm k iw
Hayreh, Sohan Singh
Optic disc edema in raised intracranial pressure was first described in 1853. Ever since, there has been a plethora of controversial hypotheses to explain its pathogenesis. I have explored the subject comprehensively by doing basic, experimental and clinical studies. My objective was to investigate the fundamentals of the subject, to test the validity of the previous theories, and finally, based on all these studies, to find a logical explanation for the pathogenesis. My studies included the following issues pertinent to the pathogenesis of optic disc edema in raised intracranial pressure: the anatomy and blood supply of the optic nerve, the roles of the sheath of the optic nerve, of the centripetal flow of fluids along the optic nerve, of compression of the central retinal vein, and of acute intracranial hypertension and its associated effects. I found that, contrary to some previous claims, an acute rise of intracranial pressure was not quickly followed by production of optic disc edema. Then, in rhesus monkeys, I produced experimentally chronic intracranial hypertension by slowly increasing in size space-occupying lesions, in different parts of the brain. Those produced raised cerebrospinal fluid pressure (CSFP) and optic disc edema, identical to those seen in patients with elevated CSFP. Having achieved that, I investigated various aspects of optic disc edema by ophthalmoscopy, stereoscopic color fundus photography and fluorescein fundus angiography, and light microscopic, electron microscopic, horseradish peroxidase and axoplasmic transport studies, and evaluated the effect of opening the sheath of the optic nerve on the optic disc edema. This latter study showed that opening the sheath resulted in resolution of optic disc edema on the side of the sheath fenestration, in spite of high intracranial CSFP, proving that a rise of CSFP in the sheath was the essential pre-requisite for the development of optic disc edema. I also investigated optic disc edema with
Hayreh, Sohan Singh
Optic disc edema in raised intracranial pressure was first described in 1853. Ever since, there has been a plethora of controversial hypotheses to explain its pathogenesis. I have explored the subject comprehensively by doing basic, experimental and clinical studies. My objective was to investigate the fundamentals of the subject, to test the validity of the previous theories, and finally, based on all these studies, to find a logical explanation for the pathogenesis. My studies included the following issues pertinent to the pathogenesis of optic disc edema in raised intracranial pressure: the anatomy and blood supply of the optic nerve, the roles of the sheath of the optic nerve, of the centripetal flow of fluids along the optic nerve, of compression of the central retinal vein, and of acute intracranial hypertension and its associated effects. I found that, contrary to some previous claims, an acute rise of intracranial pressure was not quickly followed by production of optic disc edema. Then, in rhesus monkeys, I produced experimentally chronic intracranial hypertension by slowly increasing in size space-occupying lesions, in different parts of the brain. Those produced raised cerebrospinal fluid pressure (CSFP) and optic disc edema, identical to those seen in patients with elevated CSFP. Having achieved that, I investigated various aspects of optic disc edema by ophthalmoscopy, stereoscopic color fundus photography and fluorescein fundus angiography, and light microscopic, electron microscopic, horseradish peroxidase and axoplasmic transport studies, and evaluated the effect of opening the sheath of the optic nerve on the optic disc edema. This latter study showed that opening the sheath resulted in resolution of optic disc edema on the side of the sheath fenestration, in spite of high intracranial CSFP, proving that a rise of CSFP in the sheath was the essential pre-requisite for the development of optic disc edema. I also investigated optic disc edema with
Franco, D; Deporte, A; Darragon, T; Bismuth, H
The cause of upper gastrointestinal bleeding was studied in 85 cirrhotic patients by emergency endoscopy. In every patient, one or several lesions were observed and the site of bleeding was ascertained in 59. The two main causes were oesophago-gastric varices (46 p.cent) and acute mucosal lesions(42 p.cent). The source of bleeding appeared to be related to the degree of liver function impairment. In patients with no or moderate liver function impariment, bleeding usually originated from varices or from drug-associated mucosal erosions. Patients with severe impairment of liver function most often bled from spontaneous acute oeso-gastro-duodenal ulcerations. These ulcerations resembled what has been described in "stress" hemorrhage. Because of the relationship between liver function and the cause of hemorrhage, mortality was lower in variceal bleeders (29 p.cent) than in patients with spontaneous ulcerations (83 p.cent). In patients with severely impaired liver function, portacaval shunt was rarely indicated since hemorrhage was generally due to acute mucosal ulcerations.
Zaidat, Osama O
Clinical outcome in endovascular therapy of intracranial atherosclerosis with stenting and angioplasty or angioplasty alone is dependent on multiple other factors beside the procedure itself. Preprocedure combined antiplatelet administration of aspirin and clopidogrel and its duration is critical. Preferably, this should be administered 5-7 days prior to the intended procedure and 90 days after the stent placement is preferred. Anticoagulation during the procedure is implemented routinely in the neurointerventional labs during intracranial intervention, with a goal of activated clotting time between 250 to 300 seconds. The preferred agent is unfractionated heparin as an intravenous bolus of 70-80 units/kg, without postprocedure reversal in most cases. Control of blood pressure intraprocedure and in the neurointensive care unit to avoid intracranial hemorrhage and hyperperfusion injury is of paramount significance. The preferred blood pressure is not well known, but lowering the blood pressure below the baseline after luminal gain with stenting would be recommended to prevent secondary injury. The use of general anesthesia versus local and monitored awake anesthesia is controversial and there are no data to support one method over another in cases of intracranial atherosclerosis interventional and endovascular therapy. If the patient is cooperative and would be able to tolerate the procedure under awake anesthesia, the latter would provide an immediate assessment of the neurological outcome and feedback from the patient. However, general anesthesia would provide the interventionalist with less movement artifact and less road mapping need and immediate and accurate assessment of the location of the microwire, catheter, and stent.
for the protocol with pigs and will be submitting to ACURO in the near future. Preliminary experiments performed with human cerebrospinal fluid ...impact traumatic brain injury plus hemorrhagic shock has been successfully developed. • Preliminary experiments performed with human cerebrospinal fluid ...Kreutzer, J. S., Kolakowsky-Hayner, S. A., Marwitz, J. H., & Englander, J. (2003). The relationship between therapy intensity and rehabilitative
RD-RI55 255 KOREAN HEMORRHAGIC FEVER (HEMORRHAGIC FEVER WITH RENAL 11 SYNDROME (HFRS))(U) KOREA UNIV SEOUL DEPT OF MICROBIOLOGY H U LEE RUG 83 DRMDi...the first time in Korea (4,13). WHO has recently adapted to call Korean hemorrhagic fever and clinically similar diseases with a different name, HFRS...AD_______ I •. KOREAN HEMORRHAGIC FEVER • (HEMORRHAGIC FEVER WITH RENAL SYNDROME (HFRS)) I Final Report 0 In HO WANG LEE, M.D. August 1983 Supported by U.S
Kirmani, Altaf Rehman; Sarmast, Arif Hussain; Bhat, Abdul Rashid
Background: External ventricular drainage (EVD) is the procedure of choice for the treatment of acute hydrocephalus and increased intracranial pressure in patients of subarachnoid hemorrhage (SAH) and intracerebral hemorrhage with hydrocephalus and its sequelae. We evaluated the use of EVD in patients of SAHs (spontaneous/posttraumatic with/without hydrocephalus), hypertensive intracerebral bleeds with interventricular extensions, along with evaluation of the frequency of occurrence of complications of the procedure, infectious and noninfectious, and their management. Methods: During the period of 2½ years, between September 2012 and February 2015, 130 patients were subjected to external drainage procedure and were prospectively enrolled in this study. Information was collected on each patient regarding age, sex, diagnosis, underlying illness, secondary complications, other coexisting infections, use of systemic steroids, antibiotic treatment (systemic and intraventricular), and whether any other neurosurgical procedures were performed within 2 weeks of EVD insertion or any time the duration of ventriculostomy. Results: The study population of 130 patients underwent a total of 193 ventriculostomies. Thirty-six patients had ventriculostomy infection (27.6%). Evaluation of the use of EVD was done by comparing preoperative and postoperative grading scores. Forty-nine patients survived and improved their score from Grade 3–5 to Grade 2–4. Twenty-nine patients were moderately disable, 16 were severely disable, and 5 were left in the vegetative state. Evaluation of outcome of patients revealed that there was an overall mortality of 61 (46.9%) patients both in the acute phase and later. 33 of the 39 patients having Glasgow Coma Score (GCS) 3–5 at the time of EVD insertion expired, as against 20 of the 51 patients in GCS 6–8. Patients in GCS 9–12 had an even better outcome, with 8 of the 35 patients in this group expiring. Conclusions: The use of EVD should be
Pereira, Vitor M; Gralla, Jan; Davalos, Antoni; Bonafé, Alain; Castaño, Carlos; Chapot, Rene; Liebeskind, David S; Nogueira, Raul G; Arnold, Marcel; Sztajzel, Roman; Liebig, Thomas; Goyal, Mayank; Besselmann, Michael; Moreno, Alfredo; Schroth, Gerhard
Background and Purpose Mechanical thrombectomy using stent retriever devices have been advocated to increase revascularization in intracranial vessel occlusion. We present the results of a large prospective study on the use of the Solitaire FR in patients with acute ischemic stroke. Methods STAR was an international, multicenter, prospective, single-arm study of Solitaire FR thrombectomy in patients with large vessel anterior circulation strokes treated within 8 hours of symptom onset. Strict criteria for site selection were applied. The primary endpoint was the revascularization rate (3TICI 2b) of the occluded vessel as determined by an independent core lab. The secondary endpoint was the rate of good functional outcome (defined as 90-day modified Rankin scale (mRS) 0–2). Results A total of 202 patients were enrolled across 14 comprehensive stroke centers in Europe, Canada and Australia. The median age was 72 years, 60% were female patients. The median National Institute of Health Stroke Scale (NIHSS) was 17. Most proximal intracranial occlusion was the internal carotid artery in 18%, the middle cerebral artery in 82%. Successful revascularization was achieved in 79.2% of patients. Device and/or procedure related severe adverse events were found in 7.4%. Favorable neurological outcome was found in 57.9%. The mortality rate was 6.9%. Any intracranial hemorrhagic transformation was found in 18.8% of patients, 1.5% were symptomatic. Conclusions In this single arm study, treatment with the Solitaire™ FR device in intracranial anterior circulation occlusions results in high rates of revascularization, low risk of clinically relevant procedural complications, and good clinical outcomes in combination with low mortality at 90 days. Clinical Trial Registration This study is registered with ClinicalTrials.gov, number NCT01327989. PMID:23908066
Casas Parera, I; Abruzzi, M; Lehkuniec, E; Schuster, G; Muchnik, S
Dolichoectasia of intracranial arteries is an infrequent disease with an incidence less than 0.05% in general population. It represents 7% of all intracranial aneurysms. Commonly seen in middle age patients with severe atherosclerosis and hypertension, the affected arteries include the basilar artery, supraclinoid segment of the internal carotid artery, middle, anterior and posterior cerebral arteries; males are more frequently affected. The clinical features of these fusiform aneurysms are divided in three categories: ische-mic, cranial nerve compression and signs from mass effect. Hemorrhage may also occur. Nine patients with symptomatic cerebral blood vessel dolichoectasias are presented. Six of them were males with moderate or severe hypertension. Lesions were confined to the basilar artery in 3 cases, carotid arteries and the middle cerebral artery in 1 case, and both systems were affected in 4 patients. Middle cerebral arteries were affected in 5 cases and the anterior cerebral artery in one. An isolated fusiform aneurysm of the posterior cerebral artery is also presented (case 8) (Table 3). Motor or sensory deficits, ataxia, dementia, hemifacial spasm and parkinsonism were observed. One patient died from cerebro-meningeal hemorrhage (Table 2). All patients were studied with computerized axial tomography of the brain, 5 cases with four vessel cerebral angiography, 4 cases with magnetic resonance imaging (MRI) and case 5 with MRI angiography. Clinical symptoms depend on the affected vascular territory, size of the aneurysm and compression of adjacent structures. The histopathologic findings are atheromatous lesions, disruption of the internal elastic membrane and fibrosis of the muscular wall. The resultant is a diffuse deficiency of the muscular wall and the internal elastic membrane. Recent advances in neuroimaging such as better resolution of CT scan, magnetic resonance images (MRI) and MRI angiography increased the diagnosis of this pathology showing
Waldron, James S; Hetts, Steven W; Armstrong-Wells, Jennifer; Dowd, Christopher F; Fullerton, Heather J; Gupta, Nalin; Lawton, Michael T
Microcephalic osteodysplastic primordial dwarfism type II (MOPD II) is a rare genetic syndrome characterized by extremely small stature and microcephaly, and is associated in 25% of patients with intracranial aneurysms and moyamoya disease. Although aneurysmal subarachnoid hemorrhage and stroke are leading causes of morbidity and death in these patients, MOPD II is rarely examined in the neurosurgical literature. The authors report their experience with 3 patients who presented with MOPD II, which includes a patient with 8 aneurysms (the most aneurysms reported in the literature), and the first report of a patient with both moyamoya disease and multiple aneurysms. The poor natural history of these lesions indicates aggressive microsurgical and/or endovascular therapy. Microsurgery, whether for aneurysm clip placement or extracranial-intracranial bypass, is challenging due to tight surgical corridors and diminutive arteries in these patients, but is technically feasible and strongly indicated when multiple aneurysms must be treated or cerebral revascularization is needed.
Maramattom, Boby Varkey
Cerebral hyperperfusion syndrome (CHS) is a rare complication following cerebral revascularization. It presents with ipsilateral headache, seizures, and intracerebral hemorrhage. It has mostly been described following extracranial carotid endarterectomy and stenting and it is very unusual after intracranial stenting. A 71-year-old man with a stuttering stroke was taken up for a cerebral angiogram (digital subtraction angiography), which showed a dissection of the distal left middle cerebral artery. This was recanalized with a solitaire AB stent. After 12 h, the patient developed a right hemiplegia and aphasia. Computed tomography brain showed two discrete intracerebral hematomas in the left hemisphere. This is the first reported case of CHS following intracranial stenting from India. PMID:27829722
Levy, R.P.; Fabrikant, J.I.; Phillips, M.H.; Frankel, K.A.; Steinberg, G.K.; Marks, M.P.; DeLaPaz, R.L.; Chuang, F.Y.S.; Lyman, J.T.
Angiographically occult vascular malformations (AOVMs) of the brain have been recognized for many years to cause neurologic morbidity and mortality. They generally become symptomatic due to intracranial hemorrhage, focal mass effect, seizures or headaches. The true incidence of AOVMs is unknown, but autopsy studies suggest that they are more common than high-flow angiographically demonstrable arteriovenous malformations (AVMs). We have developed stereotactic heavy-charged-particle Bragg peak radiosurgery for the treatment of inoperable intracranial vascular malformations, using the helium ion beams at the Lawrence Berkeley Laboratory 184-inch Synchrocyclotron and Bevatron. This report describes the protocol for patient selection, radiosurgical treatment planning method, clinical and neuroradiologic results and complications encountered, and discusses the strengths and limitations of the method. 10 refs., 1 fig.
EROL, Fatih Serhat; ÖZTÜRK, Sait; ÇAKIN, Hakan; AKIN, Mehmet Mustafa
We discussed the case of a 14-year-old patient with acute onset of psychiatric symptoms for two months who had been examined and different antipsychotic drugs had been prescribed by several psychiatrists without any neuroradiological imaging. Because of unresponsiveness to the antipsychotic drugs, computed tomography and magnetic resonance imaging were performed which revealed a ruptured intracranial dermoid cyst. The patient underwent surgery and antipsychotic medications were withdrawn in short time. The emphasis of this case is that intracranial lesions can present with neuropsychiatric symptoms and findings only without any neurological deficit or signs.
Gutierrez, Guillermo; Reines, H David; Wulf-Gutierrez, Marian E
This review addresses the pathophysiology and treatment of hemorrhagic shock – a condition produced by rapid and significant loss of intravascular volume, which may lead sequentially to hemodynamic instability, decreases in oxygen delivery, decreased tissue perfusion, cellular hypoxia, organ damage, and death. Hemorrhagic shock can be rapidly fatal. The primary goals are to stop the bleeding and to restore circulating blood volume. Resuscitation may well depend on the estimated severity of hemorrhage. It now appears that patients with moderate hypotension from bleeding may benefit by delaying massive fluid resuscitation until they reach a definitive care facility. On the other hand, the use of intravenous fluids, crystalloids or colloids, and blood products can be life saving in those patients who are in severe hemorrhagic shock. The optimal method of resuscitation has not been clearly established. A hemoglobin level of 7–8 g/dl appears to be an appropriate threshold for transfusion in critically ill patients with no evidence of tissue hypoxia. However, maintaining a higher hemoglobin level of 10 g/dl is a reasonable goal in actively bleeding patients, the elderly, or individuals who are at risk for myocardial infarction. Moreover, hemoglobin concentration should not be the only therapeutic guide in actively bleeding patients. Instead, therapy should be aimed at restoring intravascular volume and adequate hemodynamic parameters. PMID:15469601
Korean hemorrhagic fever (KHF) occurred for the first time in Korea , 1951, although it had previously been known to both the Japanese and Russians...After Korean war, the disease has been fixed in the areas of DMZ as an endemic one, and from 100 to 400 cases have been being reportee every year
Frontera, Jennifer A
Introduction. Elevated intracranial pressure that occurs at the time of cerebral aneurysm rupture can lead to inadequate cerebral blood flow, which may mimic the brain injury cascade that occurs after cardiac arrest. Insights from clinical trials in cardiac arrest may provide direction for future early brain injury research after subarachnoid hemorrhage (SAH). Methods. A search of PubMed from 1980 to 2012 and clinicaltrials.gov was conducted to identify published and ongoing randomized clinical trials in aneurysmal SAH and cardiac arrest patients. Only English, adult, human studies with primary or secondary mortality or neurological outcomes were included. Results. A total of 142 trials (82 SAH, 60 cardiac arrest) met the review criteria (103 published, 39 ongoing). The majority of both published and ongoing SAH trials focus on delayed secondary insults after SAH (70%), while 100% of cardiac arrest trials tested interventions within the first few hours of ictus. No SAH trials addressing treatment of early brain injury were identified. Twenty-nine percent of SAH and 13% of cardiac arrest trials showed outcome benefit, though there is no overlap mechanistically. Conclusions. Clinical trials in SAH assessing acute brain injury are warranted and successful interventions identified by the cardiac arrest literature may be reasonable targets of the study.
Nakagawa, K; Hirai, K; Aoyagi, M; Yamamoto, K; Hirakawa, K; Katayama, Y
Endothelial cell dysfunction may contribute to cerebral vasospasm and aggravation of ischemic brain damage following subarachnoid hemorrhage (SAH). It has been suggested that oxyhemoglobin derived from subarachnoid blood clots might be a prime candidate for cerebral vasospasm. In this study, cisternal bloody cerebrospinal fluid (bCSF) was collected from SAH patients four and seven days after aneurysmal rupture, and the effects of bCSF on the cell growth and intracellular calcium ion ([Ca2+]i) dynamics were investigated in cultured human umbilical vein endothelial cells. CSF collected from patients undergoing other intracranial surgeries was used as a control. Pre-treatment with bCSF4 significantly facilitated cell proliferation and DNA synthesis in the cultured endothelial cells, and significantly enhanced histamine-induced [Ca2+]i increase, while acute treatment of the bCSF elicited no [Ca2+]i change. Pre-treatment with interleukin-1 beta showed a similar significant enhancement of the histamine-induced [Ca2+]i response, while pre-treatment with high concentrations of serum or interleukin-6 did not change the [Ca2+]i response. It is concluded that bCSF collected from SAH patients contains some substances which enhance endothelial cell proliferation and sensitivity to inflammatory mediator.
Kamper, Lars; Mansour, Michael; Winkler, Sven B.; Kempkes, Udo; Haage, Patrick
Acute vertebrobasilar occlusion (VBO) is associated with a high risk of stroke and death. Although local thrombolysis may achieve recanalization and improve outcome, mortality is still between 35% and 75%. However, without recanalization the chance of a good outcome is extremely poor, with mortality rates of 80-90%. Early treatment is a fundamental factor, but detailed studies of the exact time management of the diagnostic and interventional workflow are still lacking. Data on 18 patients were retrospectively evaluated. Time periods between symptom onset, admission to hospital, time of diagnosis, and beginning of intervention were correlated with postinterventional neurological status. The Glasgow Coma Scale and National Institute of Health Stroke Scale (NIHSS) were used to examine patients before and after local thrombolysis. Additionally, multivariate statistics were applied to reveal similarities between patients with neurological improvement. Primary recanalization was achieved in 77% of patients. The overall mortality was 55%. Major complications were intracranial hemorrhage and peripheral embolism. The time period from symptom onset to intervention showed a strong correlation with the postinterventional NIHSS as well as the patient's age, with the best results in a 4-h interval. Multivariate statistics revealed similarities among the patients. Evaluation of time management in acute VBO by multivariate statistics is a helpful tool for definition of similarities in this patient group. Similarly to the door-to-balloon time for acute coronary interventions, the chances for a good outcome depend on a short time interval between symptom onset and intervention. While the only manipulable time period starts with hospital admission, our results emphasize the necessity of efficient intrahospital workflow.
Geokas, Michael C.
For many decades two types of acute pancreatitis have been recognized: the edematous or interstitial and the hemorrhagic or necrotic. In most cases acute pancreatitis is associated with alcoholism or biliary tract disease. Elevated serum or urinary α-amylase is the most important finding in diagnosis. The presence of methemalbumin in serum and in peritoneal or pleural fluid supports the diagnosis of the hemorrhagic form of the disease in patients with a history and enzyme studies suggestive of pancreatitis. There is no characteristic clinical picture in acute pancreatitis, and its complications are legion. Pancreatic pseudocyst is probably the most common and pancreatic abscess is the most serious complication. The pathogenetic principle is autodigestion, but the precise sequence of biochemical events is unclear, especially the mode of trypsinogen activation and the role of lysosomal hydrolases. A host of metabolic derangements have been identified in acute pancreatitis, involving lipid, glucose, calcium and magnesium metabolism and changes of the blood clotting mechanism, to name but a few. Medical treatment includes intestinal decompression, analgesics, correction of hypovolemia and other supportive and protective measures. Surgical exploration is advisable in selected cases, when the diagnosis is in doubt, and is considered imperative in the presence of certain complications, especially pancreatic abscess. PMID:4559467
Kitano, A; Shimomura, T; Okada, A; Takahashi, K
A 29-year-old woman with a 4-year history of multifocal fibrosclerosis showed unique neurologic complications. Episcleritis, orbital pseudotumor, and eosinophilic phlegmon preceded intracranial inflammatory pachymeningitis. The pachymeningitis was associated with disturbance of the visual field, incomplete Gerstmann's syndrome, and pseudotumor cerebri. T2-weighted magnetic resonance images revealed a high signal intensity lesion in the left temporal and occipital lobes, and gadolinium-enhanced T1-weighted images revealed the enhancement of the thickened left tentorial leaf. The laboratory data suggested that the etiology might be autoimmunological. The disease and MRI abnormalities improved following administration of corticosteroids.
Freije, J E; Donegan, J O
The transnasal approach to the ethmoid and sphenoid sinuses is a well-established technique for treating nasal polyposis and chronic sinusitis. The literature supports the effectiveness and safety of this procedure when performed by experienced surgeons. Although various authors allude to catastrophic complications of intranasal ethmoidectomy, there are few case reports of complications involving significant morbidity or mortality. The potential for serious intracranial trauma is present during ethmoid surgery, especially during an intranasal approach due to limited exposure and difficulty in identifying surgical landmarks, but with renewed interest in this approach utilizing endoscopic instrumentation, the risks may be reduced.
Lapchak, Paul A; Araujo, Dalia M
Treatments for spontaneous intracerebral, thrombolytic-induced and intraventricular hemorrhages (IVH) are still at the preclinical or early clinical investigational stages. There has been some renewed interest in the use of surgical evacuation surgery or thrombolytics to remove hematomas, but these techniques can be used only for specific types of brain bleeding. The STICH (Surgical Trial in Intracerebral Haemorrhage) clinical trials should provide some insight into the potential for such techniques to counteract hematoma-induced damage and subsequently, morbidity and mortality. More recently, clinical trials (ATACH [Antihypertensive Treatment in Acute Cerebral Hemorrhage] and INTERACT [Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial]) have begun testing whether or not regulating blood pressure affects the well-being of hemorrhage patients, but the findings thus far have not conclusively demonstrated a positive result. More promising trials, such as the early stage CHANT (Cerebral Hemorrhagic And NXY-059 Treatment) and the late stage FAST (Factor VIIa for Acute Hemorrhagic Stroke Treatment), have addressed whether or not manipulating oxidative stress and components of the blood coagulation cascade can achieve an improved prognosis following spontaneous hemorrhages. However, CHANT was halted prematurely because although it showed that the spin trap agent NXY-059 was safe, it also demonstrated that the drug was ineffective in treating acute ischemic stroke. In addition, the recombinant activated factor VII FAST trial recently concluded with only modestly positive results. Despite a beneficial effect on the primary end point of reducing hemorrhage volume, controlling the coagulation cascade with recombinant factor VIIa did not decrease the mortality rate. Consequently, Novo Nordisk has abandoned further development of the drug for the treatment of intracerebral hemorrhaging. Even though progress in hemorrhage therapy that successfully reduces the
Kiyosue, Hiro Okahara, Mika; Yamashita, Masanori; Nagatomi, Hirofumi; Nakamura, Natsuki; Mori, Hiromu
Percutaneous transluminal balloon angioplasty (PTA) has been used in the treatment of critical stenosis of the intracranial vertebrobasilar artery (VBA). PTA of the intracranial VBA carries the risk of fatal complications such as arterial dissection or acute occlusion as well as postoperative restenosis. The estimated risk of periprocedural complications and restenosis were approximately 20% and 27%. The use of recently developed stents could prevent these problems of PTA. We present two cases of restenosis of the intracranial VBA after PTA which stenoses were successfully retreated with endovascular stenting using flexible coronary stents without any complications. Neither restenosis nor other recurrent symptoms were observed during the 4- and 6-month follow-up period. Reviewing the literature of 33 cases and our 2 cases, the overall complication rates related to stenting and restenosis were 5.6% and 7.8%. Endovascular stenting for the treatment of intracranial VBA can reduce the risk of arterial dissection and restenosis.
Vakil, P.; Elmokadem, A.H.; Syed, F.H.; Cantrell, C.G.; Dehkordi, F.H.; Carroll, T.J.; Ansari, S.A.
BACKGROUND AND PURPOSE Intracranial atherosclerotic disease plaque hyperintensity and/or gadolinium contrast enhancement have been studied as imaging biomarkers of acutely symptomatic ischemic presentations using single static MR imaging measurements. However, the value in modeling the dynamics of intracranial plaque permeability has yet to be evaluated. The purpose of this study was to use dynamic contrast-enhanced MR imaging to quantify the contrast permeability of intracranial atherosclerotic disease plaques in symptomatic patients and to compare these parameters against existing markers of plaque volatility using black-blood MR imaging pulse sequences. MATERIALS AND METHODS We performed a prospective study of contrast uptake dynamics in the major intracranial vessels proximal and immediately distal to the circle of Willis using dynamic contrast-enhanced MR imaging, specifically in patients with symptomatic intracranial atherosclerotic disease. Using the Modified Tofts model, we extracted the volume transfer constant (Ktrans) and fractional plasma volume (Vp) parameters from plaque-enhancement curves. Using regression analyses, we compared these parameters against time from symptom onset as well as intraplaque hyperintensity and postcontrast enhancement derived from T1 SPACE, a black-blood MR vessel wall imaging sequence. RESULTS We completed analysis in 10 patients presenting with symptomatic intracranial atherosclerotic disease. Ktrans and Vp measurements were higher in plaques versus healthy white matter and similar or less than values in the choroid plexus. Only Ktrans correlated significantly with time from symptom onset (P = .02). Dynamic contrast-enhanced MR imaging parameters were not found to correlate significantly with intraplaque enhancement or intraplaque hyperintensity (P = .4 and P = .17, respectively). CONCLUSIONS Elevated Ktrans and Vp values found in intracranial atherosclerotic disease plaques versus healthy white matter suggest that dynamic
Singla, Navneet; Aggarwal, Ashish; Vyas, Sameer; Sanghvi, Ankur; Salunke, Pravin; Garg, Ravi
Background A sudden onset of neurological symptoms in patients is conventionally thought to be due to vascular phenomenon, with one common differential diagnosis being subarachnoid hemorrhage. Another important differential diagnosis is ischemic stroke. An uncommon cause of such acute symptoms can be hemorrhage in a pre-existing tumor, that is, intratumoral hemorrhage (ITH). Purpose ITH is an important, though uncommon differential diagnosis in cases of sudden onset of neurological deterioration. Methods and Result A 60-year-old male presented with seizures and loss of consciousness 12 h prior to admission. The episode was sudden in onset. After detailed clinical and radiological investigations, the patient was diagnosed with glioma with bleed and was successfully operated upon. Conclusion The combination of hemorrhage and ischemic stroke pointed more towards an aneurysm rather than a tumor bleed. There were pointers both in favor of and against both the diagnosis. Therefore, a complex hemorrhagic cerebral tumor with acute presentation and discordant finding on CT or CT angiography should be characterized preoperatively. A large thrombosed aneurysm remains an important differential diagnosis. PMID:27780994
We have been able to create a reproducible experimental model of nonexpulsive massive suprachoroidal hemorrhage in a rabbit eye. Massive suprachoroidal hemorrhage was demonstrated on echography and confirmed on histopathologic examination in all eyes. The natural course of the disease suggests that there is very little change in the size of the choroidal detachment in the first 7 days. Maximum liquefaction of the suprachoroidal hemorrhage clot was seen to occur between 7 and 14 days. However, increased retinal and ciliary body atrophy was also noted at 14 days. Therefore, the optimum time to drain massive suprachoroidal hemorrhage appears to be between 7 and 14 days. Immediate sclerotomy during the acute formation of massive suprachoroidal hemorrhage resulted in further increase in the suprachoroidal hemorrhage, with marked extension of the hemorrhage into the retina and vitreous. Therefore, in our opinion, immediate sclerotomy during massive suprachoroidal hemorrhage is detrimental to the eye. Our clinical data have shown that eyes with massive suprachoroidal hemorrhage can be treated successfully by secondary surgery, and the majority of the eyes can be salvaged with good visual results. No serious complications of this surgery were encountered in our cases. We advocate early surgical intervention between 7 and 14 days. Aggressive anterior and posterior segment reconstruction by anterior and posterior vitrectomy after sclerotomy drainage of the suprachoroidal hemorrhage is essential for better anatomic and visual results. Our animal data and clinical experience suggest that the optimum time of drainage of massive suprachoroidal hemorrhage is between 7 and 14 days. The results of our animal experiments in relation to human clinical application should be taken with caution. Furthermore, we had a small number of animals to study the various groups. In addition, longer follow-up may be needed for comparing controls with the treatment groups. Our animal model may help
Radian, A B; Corşatea, L; Alupei, L
The paper presents the evolution at ten eyes (nine patients) that presented expulsive hemorrhage during surgical act of extracapsular extraction with implant of crystalline lens. There are several cases of extracapsular extraction than intracapsular extraction which were more short like duration. The frequency of female was 90% from cases. The good results show the efficiency of associated treatment: closing of the eyeball with scleral punctura and internal tamponing. Only one eye was lost functionally.
Medicine Seoul, Korea * S 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SUM ARY Urban rats captured in Seoul and four nearby Korean cities were found to have...rattus, urban Korean cities, 1980. . . . 15 Table 2. Isolation of Hantaan virus from antigen-positive wild house rats, Korea , 1980 .... ........... .. 16...Figures Figure 1. Map of Seoul City, South Korea and metropolitan area showing locations of urban Korean hemorrhagic fever cases, andRattu s positive
Babi, Marc-Alain; James, Michael L.
Spontaneous intracerebral hemorrhage (SICH) is the most lethal type of stroke. Half of these deaths occur within the acute phase. Frequently observed deterioration during the acute phase is often due to rebleeding or peri-hematomal expansion. The exact pathogenesis that leads to rebleeding or peri-hemorrhagic edema remains under much controversy. Numerous trials have investigated potential predictor of peri-hemorrhagic edema formation or rebleeding but have yet to come with consistent results. Unfortunately, almost all of the “classical” approaches have failed to show a significant impact in regard of significant clinical outcome in randomized clinical trials. Current treatment strategies may remain “double-edged swords,” for inherent reasons to the pathophysiology of sICH. Therefore, the right balance and possibly the combination of current accepted strategies as well as the evaluation of future approaches seem urgent. This article reviews the role of disturbed autoregulation following SICH, surgical and non-surgical approaches in management of SICH, peri-hematoma edema, peri-hematoma expansion, and future therapeutic trends. PMID:28154550
Yılmaz, Baran; Işık, Semra; Ekşi, Murat Şakir; Ekşi, Emel Ece Özcan; Akakın, Akın; Toktaş, Zafer Orkun; Konya, Deniz
Remote cerebellar hemorrhage after cranial and spinal surgeries is a well-documented entity, so far concomitant supra- and infra-tentorial hemorrhage after spine surgery has rarely been reported in the literature. A 57-year-old woman presented with intractable low back pain and severely impaired mobility. One year ago, she underwent lumbar laminectomy and fusion with posterior spinal instrumentation between L2 and S1. She developed adjacent segment disease at the upper level of the instrumented vertebra. She had a revision surgery and underwent posterior laminectomy and fusion with bilateral transpedicular instrumentation between T10 and S1. She had severe headache, somnolence, and left hemiparesia 48 h after the surgery. Her emergent head computed tomography depicted intra-parenchymal hemorrhage in the right parietal lobe accompanying with subarachnoid hemorrhage, bilateral symmetrical cerebellar hemorrhages and pneumocephalus. She was treated nonsurgically and she got better despite some residual deficits. Symptoms including constant headache, nausea, vomiting, impaired consciousness, new onset seizure, and focal neurological deficit after spine surgeries should raise suspicion for intracranial intra-parenchymal hemorrhage. PMID:26692705
Yılmaz, Baran; Işık, Semra; Ekşi, Murat Şakir; Ekşi, Emel Ece Özcan; Akakın, Akın; Toktaş, Zafer Orkun; Konya, Deniz
Remote cerebellar hemorrhage after cranial and spinal surgeries is a well-documented entity, so far concomitant supra- and infra-tentorial hemorrhage after spine surgery has rarely been reported in the literature. A 57-year-old woman presented with intractable low back pain and severely impaired mobility. One year ago, she underwent lumbar laminectomy and fusion with posterior spinal instrumentation between L2 and S1. She developed adjacent segment disease at the upper level of the instrumented vertebra. She had a revision surgery and underwent posterior laminectomy and fusion with bilateral transpedicular instrumentation between T10 and S1. She had severe headache, somnolence, and left hemiparesia 48 h after the surgery. Her emergent head computed tomography depicted intra-parenchymal hemorrhage in the right parietal lobe accompanying with subarachnoid hemorrhage, bilateral symmetrical cerebellar hemorrhages and pneumocephalus. She was treated nonsurgically and she got better despite some residual deficits. Symptoms including constant headache, nausea, vomiting, impaired consciousness, new onset seizure, and focal neurological deficit after spine surgeries should raise suspicion for intracranial intra-parenchymal hemorrhage.
53 INTRODUCTION During the Korean War more than 3,200 United Nations troops in Korea devel6ped a rare hemorrhagic fever which attracted...patients in the Republic of Korea . Year Korean Korean US Total civilian soldiers soldiers 1951 ...... 627 827 1952 .... 833 833 1953 ... ... 455 455...0 RI m HEMORRHAGIC FEVER WITH RENAL SYNDROME ( KOREAN HEMORRHAGIC FEVER) ANNUAL SUMMARY REPORT HO WANG LEE, M.D. June 30, 1988 Door., Supported by U.S
Zhang, Jifang; Wang, Donghai; Li, Xingang
Recent advances in neuroradiological techniques have increasingly improved the diagnosis rate for very small aneurysms, particularly with the widespread use of three-dimensional cerebral angiography. However, the treatment of very small aneurysms remains a considerable challenge for neurosurgeons. Endovascular coiling has emerged as a potential treatment option for intracranial aneurysms. The aim of the present study was to evaluate the safety and efficacy of Solitaire AB stent-assisted coiling embolization for the treatment of ruptured very small intracranial aneurysms. This retrospective study included nine consecutive patients with ruptured very small intracranial aneurysms (≤3 mm) that underwent Solitaire AB stent-assisted coiling embolization. The aneurysms were located in the ophthalmic branch of the internal carotid artery (n=2), the posterior communicating branch of the internal carotid artery (n=4), the top of the basilar artery (n=1) and the middle cerebral artery (n=2). Solitaire AB stents were successfully implanted in all nine patients. Of the nice individuals, six patients exhibited complete occlusion at Raymond grade I and three patients exhibited occlusion at Raymond grade II. No aneurysm rupture was observed during the surgery. During the follow-up period of 8-13 months, no intracranial hemorrhage occurred. A total of seven patients underwent follow-up digital subtraction angiography at 5-10 months post-intervention. No recurrence of the aneurysms and no stenosis or occlusion of the parent arteries was observed. Therefore, Solitaire AB stent-assisted coil embolization was demonstrated to be a safe and effective treatment for ruptured very small intracranial aneurysms. The long-term efficacy of this technique may be improved by increasing the packing density around the aneurysmal neck and improving the hemodynamics.
de Holanda, Bruna A.; Barreto, Isabela G. Menna; de Araujo, Isadora S. Gomes
Alveolar hemorrhage (AH) is a rare syndrome that can often occur in autoimmune diseases, blood clotting disorders, infection or by acute inhalation injury, presenting rapid evolution and high mortality, especially with late diagnosis and treatment. Among the autoimmune diseases, there are reported cases in patients with primary antiphospholipid syndrome (PAPS), vasculitis and systemic lupus erythematosus (SLE). An early diagnosis is an essential tool in the successful management of this complication, requiring aggressive treatment based on vigorous immunosuppression and broad-spectrum antibiotic. We describe here a case of alveolar hemorrhage associated with glomerulonephritis as the open presentation in a patient with SLE. PMID:27994272
de Holanda, Bruna A; Barreto, Isabela G Menna; de Araujo, Isadora S Gomes; de Araujo, Daniel B
Alveolar hemorrhage (AH) is a rare syndrome that can often occur in autoimmune diseases, blood clotting disorders, infection or by acute inhalation injury, presenting rapid evolution and high mortality, especially with late diagnosis and treatment. Among the autoimmune diseases, there are reported cases in patients with primary antiphospholipid syndrome (PAPS), vasculitis and systemic lupus erythematosus (SLE). An early diagnosis is an essential tool in the successful management of this complication, requiring aggressive treatment based on vigorous immunosuppression and broad-spectrum antibiotic. We describe here a case of alveolar hemorrhage associated with glomerulonephritis as the open presentation in a patient with SLE.
Agito, Katrina; Krug, Esther I.
Bilateral adrenal hemorrhage (BAH) is a rare complication typically seen in critically ill patients, which can lead to acute adrenal insufficiency and death unless it is recognized promptly and treated appropriately. We describe the case of a 64-year-old man with polycythemia vera found to be unresponsive with fever, hypotension, tachycardia, and hypoglycemia. Electrocardiogram showed ST-elevation with elevated troponin, hemoglobin, prothrombin time, and partial thromboplastin time. He required aggressive ventilator and vasopressor support. Despite primary coronary intervention, he remained hypotensive. Random cortisol level was low. He received stress dose hydrocortisone with immediate hemodynamic stability. BAH was highly suspected and was confirmed by non-contrast abdominal computed tomography. Prompt recognition and timely initiated treatment remain crucial to impact the mortality associated with acute adrenal insufficiency. PMID:27609733
Gunasekaran, Kulothungan; Rudd, Kelly M.; Murthi, Swetha; Kaatz, Scott; Lone, Nazir
Even though highly vascularized, the thyroid gland rarely has spontaneous bleeding. Bleeding into the thyroid gland can result in potentially lethal acute airway compromise. This case report describes an elderly patient on warfarin for atrial fibrillation, who presented with swelling on the right side of her neck causing acute airway obstruction. An urgent computed tomography of the neck showed an enlarging hemorrhage into the right lobe of the thyroid gland. She was initially intubated for airway protection and her anticoagulation was reversed to stop the bleeding. She was closely monitored in the intensive care unit. After an uncomplicated tracheal extubation and recovery, she was discharged and scheduled for an elective total thyroidectomy. We desire that physicians be aware of this rare, potentially lethal bleeding complication. PMID:28243434
Desai, Jay; Mitchell, Wendy G
Acute cerebellar ataxia and acute cerebellitis represent a process characterized by parainfectious, postinfectious, or postvaccination cerebellar inflammation. There is considerable overlap between these entities. The mildest cases of acute cerebellar ataxia represent a benign condition that is characterized by acute truncal and gait ataxia, variably with appendicular ataxia, nystagmus, dysarthria, and hypotonia. It occurs mostly in young children, presents abruptly, and recovers over weeks. Neuroimaging is normal. Severe cases of cerebellitis represent the other end of the spectrum, presenting with acute cerebellar signs often overshadowed by alteration of consciousness, focal neurological deficits, raised intracranial pressure, hydrocephalus, and even herniation. Neuroimaging is abnormal and the prognosis is less favorable than in acute cerebellar ataxia. Acute disseminated encephalomyelitis may be confused with acute cerebellitis when the clinical findings are predominantly cerebellar, but lesions on neuroimaging are usually widespread. Paraneoplastic opsoclonus-myoclonus syndrome is often initially misdiagnosed as acute cerebellar ataxia, but has very specific features, course, and etiopathogensis.
Darlington, Daniel N.; Chew, Gordon; Ha, Taryn; Keil, Lanny C.; Dallman, Mary F.
Fed adrenalectomized rats survive the stress of hemorrhage and hypovolemia, whereas fasted adrenalectomized rats become hypotensive and hypoglycemic after the first 90 min and die within 4 hours (h). We have studied the effects of glucose and corticosterone (B) infusions after hemorrhage as well as treatment with B at the time of adrenalectomy on the capacity of chronically prepared, conscious, fasted, adrenalectomized rats to survive hemorrhage. We have also measured the magnitudes of vasoactive hormone responses to hemorrhage. Maintenance of plasma glucose concentrations did not sustain life; however, treatment of rats at the time of adrenalectomy with B allowed 100 percent survival, and acute treatment of adrenalectomized rats at the time of hemorrhage allowed about 50 percent survival during the 5-h posthemorrhage observation period. Rats in the acute B infusion group that died exhibited significantly increased plasma B and significantly decreased plasma glucose concentrations by 2 h compared to the rats that lived. Plasma vasopressin, renin, and norepinephrine responses to hemorrhage were markedly augmented in the adrenalectomized rats not treated with B, and plasma vasopressin concentrations were significantly elevated at 1 and 2 h in all of the rats that subsequently died compared to values in those that lived. We conclude that: 1) death after hemorrhage in fasted adrenalectomized rats is not a result of lack of glucose; 2) chronic and, to an extent, acute treatment of fasted adrenalectomized rats with B enables survival; 3) fasted adrenalectomized rats exhibit strong evidence of hepatic insufficiency which is not apparent in either fed adrenalectomized rats or B-treated fasted adrenalectomized rats; 4) death after hemorrhage in fasted adrenalectomized rats may result from hepatic failure as a consequence of marked splanchnic vasoconstriction mediated bv the actions of extraordinarily high levels of vasoactive hormones after hemorrhage; and 5) B appears to
Imamura, Hiroshi; Yashio, Akihiro; Kashima, Satoko; Mochizuki, Katsunori
Introduction. The main adverse effect of anticoagulant therapy is bleeding, and major bleeding, including intracranial, gastrointestinal, and retroperitoneal bleeding, has been reported as an adverse effect of edoxaban, a direct oral anticoagulant (DOAC). Bleeding during systemic anticoagulation with edoxaban presents a therapeutic conundrum, because there is currently no safe or efficacious reversal agent to stop major bleeding. Case Report. A 51-year-old woman had multiple traumatic injuries, including lower limb fractures. On day 8, she developed deep venous thrombosis, and edoxaban was administered orally. On day 38, she developed fungemia, which was treated with an antifungal drug. On day 43, she presented with dyspnea. Chest computed tomography scan showed bilateral diffuse ground-glass opacities in the whole lung fields. The results of the subsequent workup (i.e., serum levels of the antineutrophil cytoplasmic antibody, antinuclear antibody, and antiglomerular basement membrane antibody) and microbiological study were unremarkable. Based on these findings, her condition was diagnosed as diffuse alveolar hemorrhage (DAH) associated with edoxaban therapy. The lung opacities disappeared spontaneously after edoxaban therapy was discontinued. Conclusion. DAH is a dangerous complication associated with edoxaban therapy. DOACs, including edoxaban, should be prescribed with caution, especially for patients in a critical condition. PMID:27872767
Johnson, Elizabeth L; Knight, Robert T
Recent work involving intracranial recording during human memory performance provides superb spatiotemporal resolution on mnemonic processes. These data demonstrate that the cortical regions identified in neuroimaging studies of memory fall into temporally distinct networks and the hippocampal theta activity reported in animal memory literature also plays a central role in human memory. Memory is linked to activity at multiple interacting frequencies, ranging from 1 to 500Hz. High-frequency responses and coupling between different frequencies suggest that frontal cortex activity is critical to human memory processes, as well as a potential key role for the thalamus in neocortical oscillations. Future research will inform unresolved questions in the neuroscience of human memory and guide creation of stimulation protocols to facilitate function in the damaged brain.
Delannes, M; Latorzeff, I; Chand, M E; Huchet, A; Dupin, C; Colin, P
Most of the benign intracranial tumors are meningiomas, vestibular schwannomas, pituitary adenomas, craniopharyngiomas, and glomus tumors. Some of them grow very slowly, and can be observed without specific treatment, especially if they are asymptomatic. Symptomatic or growing tumors are treated by surgery, which is the reference treatment. When surgery is not possible, due to the location of the lesion, or general conditions, radiotherapy can be applied, as it is if there is a postoperative growing residual tumor, or a local relapse. Indications have to be discussed in polydisciplinary meetings, with precise evaluation of the benefit and risks of the treatments. The techniques to be used are the most modern ones, as multimodal imaging and image-guided radiation therapy. Stereotactic treatments, using fractionated or single doses depending on the size or the location of the tumors, are commonly realized, to avoid as much a possible the occurrence of late side effects.
Shenkar, R; Coulson, W F; Abraham, E
Acute lung injury, characterized as the adult respiratory distress syndrome (ARDS), is a common clinical occurrence following blood loss and injury. We previously found increased levels of transforming growth factor (TGF)-beta 1 mRNA in murine intraparenchymal mononuclear cells and in alveolar macrophages within 1 h after hemorrhage. Because TGF-beta has potent proinflammatory and immunoregulatory properties, we investigated the effect of blocking TGF-beta with mAb on hemorrhage-induced pathology, cytokine mRNA levels in lungs, as well as survival from pneumonia. Mice treated with anti-TGF-beta mAb showed normal pulmonary histology 3 days after hemorrhage and resuscitation in contrast to the mononuclear and neutrophil infiltrates, intraalveolar hemorrhage, and interstitial edema found in hemorrhaged mice either treated with control antibody or not treated with any antibody. Decreased mRNA levels for IL-1 beta, TNF-alpha, IL-6, IL-10, and IFN-gamma as compared with untreated, hemorrhaged controls were present in intraparenchymal pulmonary mononuclear cells following therapy with anti-TGF-beta. In contrast, therapy with anti-TGF-beta increased mRNA levels for IL-1 beta and TNF-alpha in alveolar macrophages and for TGF-beta in peripheral blood mononuclear cells collected 3 days after hemorrhage. Administration of anti-TGF-beta to hemorrhaged mice did not correct the enhanced susceptibility to Pseudomonas aeruginosa pneumonia that exists after hemorrhage. These results suggest that TGF-beta has an important role in hemorrhage-induced acute lung injury, but does not contribute to the post-hemorrhage depression in pulmonary antibacterial response.
Semyachkina-Glushkovskaya, Oxana; Pavlov, Alexey; Kurths, Jürgen; Borisova, Ekaterina; Gisbrecht, Alexander; Sindeeva, Olga; Abdurashitov, Arkady; Shirokov, Alexander; Navolokin, Nikita; Zinchenko, Ekaterina; Gekalyuk, Artem; Ulanova, Maria; Zhu, Dan; Luo, Qingming; Tuchin, Valery
Stress is a major factor for a risk of cerebrovascular catastrophes. Studying of mechanisms underlying stress-related brain-injures in neonates is crucial for development of strategy to prevent of neonatal stroke. Here, using a model of sound-stress-induced intracranial hemorrhages in newborn rats and optical methods, we found that cerebral veins are more sensitive to the deleterious effect of stress than arteries and microvessels. The development of venous insufficiency with decreased blood outflow from the brain accompanied by hypoxia, reduction of complexity of venous blood flow and high production of beta-arrestin-1 are possible mechanisms responsible for a risk of neonatal hemorrhagic stroke.
Semyachkina-Glushkovskaya, Oxana; Pavlov, Alexey; Kurths, Jürgen; Borisova, Ekaterina; Gisbrecht, Alexander; Sindeeva, Olga; Abdurashitov, Arkady; Shirokov, Alexander; Navolokin, Nikita; Zinchenko, Ekaterina; Gekalyuk, Artem; Ulanova, Maria; Zhu, Dan; Luo, Qingming; Tuchin, Valery
Stress is a major factor for a risk of cerebrovascular catastrophes. Studying of mechanisms underlying stress-related brain-injures in neonates is crucial for development of strategy to prevent of neonatal stroke. Here, using a model of sound-stress-induced intracranial hemorrhages in newborn rats and optical methods, we found that cerebral veins are more sensitive to the deleterious effect of stress than arteries and microvessels. The development of venous insufficiency with decreased blood outflow from the brain accompanied by hypoxia, reduction of complexity of venous blood flow and high production of beta-arrestin-1 are possible mechanisms responsible for a risk of neonatal hemorrhagic stroke. PMID:26504656
Kaleel, Mohammed; Schramm, Craig; Pascal, Melanie; O’Louglin, Michael; Collins, Melanie Sue
Serial lung magnetic resonance imaging (MRI) was performed in a child with diffuse alveolar hemorrhage (DAH). To minimize radiation exposure with conventional serial chest computerized tomography (CT), serial MRIs of the lungs were used. This effectively monitored her disease process as well as detected acute hemorrhage after 5 years remission. PMID:25699125
Lambrinos, Anna; Schaink, Alexis K; Dhalla, Irfan; Krings, Timo; Casaubon, Leanne K; Sikich, Nancy; Lum, Cheemun; Bharatha, Aditya; Pereira, Vitor Mendes; Stotts, Grant; Saposnik, Gustavo; Kelloway, Linda; Xie, Xuanqian; Hill, Michael D
Although intravenous thrombolysis increases the probability of a good functional outcome in carefully selected patients with acute ischemic stroke, a substantial proportion of patients who receive thrombolysis do not have a good outcome. Several recent trials of mechanical thrombectomy appear to indicate that this treatment may be superior to thrombolysis. We therefore conducted a systematic review and meta-analysis to evaluate the clinical effectiveness and safety of new-generation mechanical thrombectomy devices with intravenous thrombolysis (if eligible) compared with intravenous thrombolysis (if eligible) in patients with acute ischemic stroke caused by a proximal intracranial occlusion. We systematically searched seven databases for randomized controlled trials published between January 2005 and March 2015 comparing stent retrievers or thromboaspiration devices with best medical therapy (with or without intravenous thrombolysis) in adults with acute ischemic stroke. We assessed risk of bias and overall quality of the included trials. We combined the data using a fixed or random effects meta-analysis, where appropriate. We identified 1579 studies; of these, we evaluated 122 full-text papers and included five randomized control trials (n=1287). Compared with patients treated medically, patients who received mechanical thrombectomy were more likely to be functionally independent as measured by a modified Rankin score of 0-2 (odds ratio, 2.39; 95% confidence interval, 1.88-3.04; I2=0%). This finding was robust to subgroup analysis. Mortality and symptomatic intracerebral hemorrhage were not significantly different between the two groups. Mechanical thrombectomy significantly improves functional independence in appropriately selected patients with acute ischemic stroke.
Saarinen, Jukka T; Sillanpää, Niko; Kantola, Ilkka
The use of intravenous thrombolytic therapy for acute ischemic stroke is associated with improved outcomes. Fabry disease is an X-linked glycosphingolipid storage disease with vascular endothelial deposits. Affected males with the classic phenotype develop renal, cardiac, and cerebrovascular disease and die prematurely. However, Fabry disease is rare in young men with first ischemic stroke of undetermined cause. We report a 38-year-old man with acute aphasia and a left M2 segment of the middle cerebral artery thrombus with no recanalization who was finally diagnosed with Fabry disease after left ventricular hypertrophy of undetermined cause had been identified. A gene test revealed a R227X mutation typical of Fabry disease with the classical phenotype. To our knowledge our patient is the first reported male Fabry patient who was given intravenous thrombolytic therapy and the first reported Fabry patient who received intravenous thrombolytic therapy between 3 and 4.5 hours of the symptom onset. Despite favorable prognostic indicators on admission imaging, our patient suffered a significant stroke and had an unfavorable clinical outcome. Fortunately, the episode was not complicated by intracranial hemorrhage. Further studies are needed to evaluate the efficacy and safety of intravenous thrombolytic therapy in treating patients with Fabry disease and acute ischemic stroke.
KARIBE, Hiroshi; KAMEYAMA, Motonobu; HAYASHI, Toshiaki; NARISAWA, Ayumi; TOMINAGA, Teiji
The number of cases with child abuse is increasing in Japan, and abusive head trauma (AHT) is a major cause of death in abused children. Child abuse has been recognized by the late 19th century, and widely accepted as battered child syndrome in the middle of the 20th century. As terms, there had been considerable mechanistic controversies between shaken-baby and -impact syndrome until the beginning of the 21st century. In recent years, AHT has been utilized as a less mechanistic term. Most of the characteristics of AHT in Japan have been similar to those in the United States as follows: infant is the most common victim, acute subdural hematoma (SDH) is the most common intracranial lesion, and retinal hemorrhage is often complicated. On the other hand, several characteristics have been different as follows: mother is the most common perpetrators, impact is a more common mechanism of trauma than shaking, and external trauma is more common reflecting the existence of impact. Since AHT as well as child abuse is a social pathological phenomenon influenced by victims, perpetrators, socioeconomic circumstances, and so on, various aspects of AHT as well as child abuse can be changed with times. Actually, a recent paper suggests such changes in infants with acute SDH due to AHT. In this review article, AHT, abusive infantile acute SDH in particular, are reviewed from the aspect of neurosurgical perspectives, including its mechanisms of trauma, biomechanics, clinical features, management, and prognosis, to update the trend in Japan. PMID:26960448
Karanth, Suman S; Gupta, Anurag; Prabhu, Mukhyaprana
Dengue hemorrhagic fever is a more serious form of disease characterised by plasma leakage syndrome, thrombocytopenia and disseminated intravascular coagulation. We present a 51 year old male who presented with fever, petechiae and acute onset of breathlessness. Emergency chest rhoentogram showed a massive right sided pleural effusion. On insertion of intercostal drain, there was a sudden gush of blood tinged fluid suggestive of hemothorax. There was no history of trauma or bleeding tendencies. Laboratory investigations revealed a raised hematocrit and severe thrombocytopenia. Dengue IgM was surprisingly positive. After aggressive supportive management the patient gradually improved and was discharged. While bilateral pleural effusion is a known occurrence in dengue hemorrhagic fever, massive hemothorax is unheard of. We report the first case in literature of dengue hemorrhagic fever presenting as unilateral massive hemothorax. A suspicion of dengue must also be borne in mind in cases of non-traumatic hemothorax especially in endemic areas.
Krohmer, Steven J. Hoffer, Eric K.; Burchard, Kenneth W.
Although the exact benefit of adjunctive splenic artery embolization (SAE) in the nonoperative management (NOM) of patients with blunt splenic trauma has been debated, the role of transcatheter embolization in delayed splenic hemorrhage is rarely addressed. The purpose of this study was to evaluate the effectiveness of SAE in the management of patients who presented at least 3 days after initial splenic trauma with delayed hemorrhage. During a 24-month period 4 patients (all male; ages 19-49 years) presented with acute onset of pain 5-70 days after blunt trauma to the left upper quadrant. Two had known splenic injuries that had been managed nonoperatively. All had computed axial tomography evidence of active splenic hemorrhage or false aneurysm on representation. All underwent successful SAE. Follow-up ranged from 28 to 370 days. These cases and a review of the literature indicate that SAE is safe and effective for NOM failure caused by delayed manifestations of splenic arterial injury.
Herzig, R; Bogousslavsky, J; Maeder, P; Maeder-Ingvar, M; Reichhart, M; Urbano, L A; Leemann, B
Cerebral aneurysms and arteriovenous malformations (AVMs) are well-known sources of intracranial hemorrhage, but can also manifest as other clinical symptoms or remain clinically asymptomatic. The aim was to document and analyze cases of aneurysm or AVM with brain infarction. Survey on 4804 stroke patients treated at the Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland between 1978 and 2000 using the Lausanne Stroke Registry. Twenty patients presented with cerebral aneurysm and 21 with cerebral AVM. Hemorrhage was present in 100% of the AVM and in 75% of the aneurysm patients; in one (5%) of the remaining aneurysm patients, aneurysm and infarction were located in different territories. Infarction associated with Sylvian artery aneurysm was found in three (15%), vertebrobasilar ischemia because of fusiform left vertebral artery aneurysm in one (5%), and dural fistula draining to the distal transversal and left sigmoid sinus associated with a stroke in the territory of the left anterior inferior cerebellar artery in one patient. Ischemic stroke is infrequent, but important, complication in unruptured intracranial aneurysms and AVMs. The early recognition and therapy of these vascular malformations in selected patients can avoid a major neurological deficit or death caused by their rupture.
Korean hemorrhagic fever (KHF) occurred for the first time in Korea , 1951, although it had previously been known to both the Japanese and Russians...After Korean war, the disease has been fixed in the areas of DMZ as an endemic one, and from 100 to 300 cases have been reported every year. The aims...but in 1971 affected the middle districts and in 1972 invaded the southern parts of South Korea . The number of patients and the areas of KHF in 1972
Fryer, T. B.
Implantable RF powered monitor uses capacitive transducer and stiff metal diaphragm that gives high stability for long term intracranial pressure monitoring. Design of monitor reduces risk of infection while improving patient comfort and mobility.
Ding, Dale; Starke, Robert M; Kano, Hideyuki; Mathieu, David; Huang, Paul P; Feliciano, Caleb; Rodriguez-Mercado, Rafael; Almodovar, Luis; Grills, Inga S; Silva, Danilo; Abbassy, Mahmoud; Missios, Symeon; Kondziolka, Douglas; Barnett, Gene H; Dade Lunsford, L; Sheehan, Jason P
OBJECTIVE Brain arteriovenous malformations (AVMs) are the most common cause of spontaneous intracranial hemorrhage in pediatric patients (age < 18 years). Since the cumulative lifetime risk of AVM hemorrhage is considerable in children, an improved understanding of the risk factors influencing hemorrhagic presentation may aid in the management of pediatric AVMs. The aims of this first of a 2-part multicenter, retrospective cohort study are to evaluate the incidence and determine the predictors of hemorrhagic presentation in pediatric AVM patients. METHODS The authors analyzed pooled AVM radiosurgery data from 7 institutions participating in the International Gamma Knife Research Foundation (IGKRF). Patients younger than 18 years at the time of radiosurgery and who had at least 12 months of follow-up were included in the study cohort. Patient and AVM characteristics were compared between unruptured and ruptured pediatric AVMs. RESULTS A total of 357 pediatric patients were eligible for analysis, including 112 patients in the unruptured and 245 patients in the ruptured AVM cohorts (69% incidence of hemorrhagic presentation). The annual hemorrhage rate prior to radiosurgery was 6.3%. Hemorrhagic presentation was significantly more common in deep locations (basal ganglia, thalamus, and brainstem) than in cortical locations (frontal, temporal, parietal, and occipital lobes) (76% vs 62%, p = 0.006). Among the factors found to be significantly associated with hemorrhagic presentation in the multivariate logistic regression analysis, deep venous drainage (OR 3.2, p < 0.001) was the strongest independent predictor, followed by female sex (OR 1.7, p = 0.042) and smaller AVM volume (OR 1.1, p < 0.001). CONCLUSIONS Unruptured and ruptured pediatric AVMs have significantly different patient and nidal features. Pediatric AVM patients who possess 1 or more of these high-risk features may be candidates for relatively more aggressive management strategies.
difference between the systemic arterial blood pressure and the intracranial pressure , CPP = ABP − ICP. 2Ischemia is a decrease in blood supply...and the average arterial blood pressure , µABP, were consistently higher. Our results seem to be inconsistent with the observations of previous studies...1 PRECURSORS TO RAPID ELEVATIONS IN INTRACRANIAL PRESSURE James McNames1, Cristina Crespo1, Mateo Aboy1, Miles Ellenby2, Susanna Lai2, Robert
Yasuno, Katsuhito; Bilguvar, Kaya; Bijlenga, Philippe; Low, Siew-Kee; Krischek, Boris; Auburger, Georg; Simon, Matthias; Krex, Dietmar; Arlier, Zulfikar; Nayak, Nikhil; Ruigrok, Ynte M; Niemelä, Mika; Tajima, Atsushi; von und zu Fraunberg, Mikael; Dóczi, Tamás; Wirjatijasa, Florentina; Hata, Akira; Blasco, Jordi; Oszvald, Agi; Kasuya, Hidetoshi; Zilani, Gulam; Schoch, Beate; Singh, Pankaj; Stüer, Carsten; Risselada, Roelof; Beck, Jürgen; Sola, Teresa; Ricciardi, Filomena; Aromaa, Arpo; Illig, Thomas; Schreiber, Stefan; van Duijn, Cornelia M; van den Berg, Leonard H; Perret, Claire; Proust, Carole; Roder, Constantin; Ozturk, Ali K; Gaál, Emília; Berg, Daniela; Geisen, Christof; Friedrich, Christoph M; Summers, Paul; Frangi, Alejandro F; State, Matthew W; Wichmann, H Erich; Breteler, Monique M B; Wijmenga, Cisca; Mane, Shrikant; Peltonen, Leena; Elio, Vivas; Sturkenboom, Miriam C J M; Lawford, Patricia; Byrne, James; Macho, Juan; Sandalcioglu, Erol I; Meyer, Bernhard; Raabe, Andreas; Steinmetz, Helmuth; Rüfenacht, Daniel; Jääskeläinen, Juha E; Hernesniemi, Juha; Rinkel, Gabriel J E; Zembutsu, Hitoshi; Inoue, Ituro; Palotie, Aarno; Cambien, François; Nakamura, Yusuke; Lifton, Richard P; Günel, Murat
Saccular intracranial aneurysms are balloon-like dilations of the intracranial arterial wall; their hemorrhage commonly results in severe neurologic impairment and death. We report a second genome-wide association study with discovery and replication cohorts from Europe and Japan comprising 5,891 cases and 14,181 controls with approximately 832,000 genotyped and imputed SNPs across discovery cohorts. We identified three new loci showing strong evidence for association with intracranial aneurysms in the combined dataset, including intervals near RBBP8 on 18q11.2 (odds ratio (OR) = 1.22, P = 1.1 x 10(-12)), STARD13-KL on 13q13.1 (OR = 1.20, P = 2.5 x 10(-9)) and a gene-rich region on 10q24.32 (OR = 1.29, P = 1.2 x 10(-9)). We also confirmed prior associations near SOX17 (8q11.23-q12.1; OR = 1.28, P = 1.3 x 10(-12)) and CDKN2A-CDKN2B (9p21.3; OR = 1.31, P = 1.5 x 10(-22)). It is noteworthy that several putative risk genes play a role in cell-cycle progression, potentially affecting the proliferation and senescence of progenitor-cell populations that are responsible for vascular formation and repair.
Alaraj, Ali; Behbahani, Mandana; Valyi-Nagy, Tibor; Aardsma, Nathan; Aletich, Victor A
A middle-aged patient presented with a rapidly growing right dural-based extra-axial posterior clinoid mass extending to the right cavernous sinus that was surgically resected. Histological examination showed solid growth of primitive neuroectodermal tumor arising from the third nerve. Following surgical resection, the patient was further managed by radiation and chemotherapy. Two years later the patient developed new intracranial hemorrhage in the area adjacent to the previous surgical cavity. A cerebral angiogram showed contrast extravasation at the junction of the posterior communicating artery (Pcom) and the right posterior cerebral artery (PCA), with an expanding pseudoaneurysm. This was managed with N-butyl cyanoacrylate embolization. Autopsy showed microscopic recurrence of tumor into the PCA/PCom region with invasion of the wall of the Pcom. This case report illustrates the concept of vascular blowout in intracranial cerebral vasculature. It appears that, in the presence of risk factors that contribute to weakening of vessel walls (surgery, radiation, tumor recurrence), a blowout can occur intracranially. PMID:24748141
Zou, Xiang; Zhou, Liangfu; Zhu, Wei; Mao, Ying; Chen, Liang
OBJECT Intracranial dural arteriovenous fistulas (DAVFs) are complex intracranial vascular malformations that can lead to hemorrhage. The authors recently found that chronic local hypoperfusion seems to be the main cause of angiogenesis in the dura mater, which leads to the formation of DAVFs. As a natural derivative of estradiol, 2-methoxyestradiol (2-ME) has an antiangiogenic effect and can be used safely in patients with advanced carcinoid tumors. This study was conducted to examine the antiangiogenic effects of 2-ME on a rat DAVF model. METHODS Male Sprague-Dawley rats (n = 72) were used in the experiments. Intracranial venous hypertension was induced for modeling, and 2-ME was used in the early or late stage for treatment. The effects were examined by immunohistochemistry, Western blot analysis, and quantitative real-time polymerase chain reaction assays. RESULTS 2-Methoxyestradiol significantly reduced angiogenesis in the dura in early- and late-intervention treatment groups, as proven by the results of immunohistochemical staining, Western blotting, real-time polymerase chain reaction assays, and microvessel density counts. The antiangiogenic effect even lasted for up to 2 weeks after 2-ME cessation. CONCLUSIONS These data collectively suggest that 2-ME can reduce the angiogenic effect caused by venous hypertension in a rat DAVF model, mainly by suppressing the inhibitor of differentiation 1 (ID-1) and hypoxia-inducible factor 1α (HIF-1α) pathways.
Zheng, Mei; Lei, Hongyan; Cui, Yansen; Yang, Daiqun; Wang, Liquang; Wang, Ziran
Objective: This study aims to observe the clinical efficacies of hyper-early low-dose alteplase thrombolysis in treating acute ischemic stroke (AIS). Methods: Two hundred twenty AIS patients were randomly divided into group A (90 cases), group B (90 cases), and group C (40 cases). The National Institutes of Health Stroke Scale (NIHSS) scores, mRS score-evaluated prognosis, intracranial hemorrhage, and mortality of the three groups were observed before and after the treatment. Results: The NIHSS scores of the three groups were significantly reduced after the treatment (P<0.05), among which the NIHSS score of group A was the lowest (P<0.05); and the difference between group B and C was not significant (P>0.05). The incidence of such complications as cerebral hemorrhage in the three groups was low, and there was no significant difference among the groups (P>0.05). The modified Rankin Scale (mRS)scores of the three groups showed that group A had much better prognosis than group B and C, while the difference between group B and group C was not significant. Conclusions: The hyper-early low-dose alteplase thrombolysis was safe and effective in Acute ischemic stroke (AIS). PMID:27648019
Cardim, Danilo Augusto; do Val da Silva, Raquel Araújo; Cardim, Ana Carolina; Cabella, Brenno Caetano Troca; Frigieri, Gustavo Henrique; de Sousa Torres, Cecília Vidal; Wang, Charles Chenwei; de Pacheco Andrade, Rodrigo Albuquerque; Scandiuzzi, Renata Caldo; Rizzatti, Ana Carolina Segato; Mascarenhas, Yvonne Maria; Leite, João Pereira; Mascarenhas, Sérgio
Intracranial pressure (ICP) monitoring is sometimes required in clinical pictures of stroke, as extensive intraparenchymal hematomas and intracranial bleeding may severely increase ICP, which can lead to irreversible conditions, such as dementia and cognitive derangement. ICP monitoring has been accepted as a procedure for the safe diagnosis of increased ICP, and for the treatment of intracranial hypertension in some diseases. In this work, we evaluated ICP behavior during the induction of an experimental model of autologous blood injection in rats, simulating a hemorrhagic stroke. Rats were subjected to stereotactic surgery for the implantation of a unilateral cannula into the left striatal region of the brain. Autologous blood was infused into the left striatal region with an automatic microinfusion pump. ICP monitoring was performed throughout the procedure of hemorrhagic stroke induction. Analyses consisted of short-time Fourier transform for ICP before and after stroke induction and the histological processing of the animals' brains. Short-time Fourier transform analysis demonstrated oscillations in the ICP frequency components throughout time after the microinjections compared with data before them. Histological analysis revealed neuropathological changes in the striatum in all microinjected animals.
Bao, Xin-Jie; Li, Xue-Yuan; Wang, Qi-Pu; Ren, Xin-Yu; Liang, Zhi-Yong; Ma, Wen-Bin; Wang, Ren-Zhi; Wei, Jun-Ji
Abstract Background: Endodermal cysts (EC) are rare but well-known congenial lesions of the central nervous system mainly located in the spinal subdural space. Intracranial ECs are rare and commonly encountered in the posterior cranial fossa as extra-axial lesions; an intraparenchymal location is exceedingly rare. A complete removal is the best surgical strategy and any residue can cause recurrence. It is necessary to exclude EC in patients with intracranial cystic lesions. We present a case of intraparenchymal EC with spontaneous intracystic hemorrhage in the temporal lobe of an adult. Methods: A 43-year-old man presented with headache and memory deterioration. Brain computed tomography and magnetic resonance imaging showed a slightly enhanced temporal lobe cystic lesion, which was homogenously hyperintense on T1-and T2-weighted images. There was a suspicion of brain abscess at admission. The lesion was totally removed with a left subtemporal craniotomy. Histological examination revealed an EC with intracystic hemorrhage. Results: The preoperative symptoms were relieved after surgery and 3-month follow-up magnetic resonance imaging found no cystic signs. Conclusion: This case suggests that EC should be considered in the differential diagnosis of intracranial cystic lesions and a complete removal is the best strategy of choice. PMID:27861331
Ye, Xianwang; Wang, Haifeng; Huang, Yi; Zhou, Shengjun; Gao, Xiang
The rupture of dural arteriovenous fistula (DAVF) is a serious complication endangering the lives of patients. It is difficult to treat such ruptured DAVF with large intracranial hematoma since lacking of early diagnostic methods. Meanwhile, there was no consensus of how to surgically treat these patients in early stage. In this study, we tried to use 4D-CTA to diagnose DAVF and guide surgical treatment. Based on the result of 4D-CTA, we attempted to eliminate DAVF at the same time we removed hematoma. The result was encouraging. 7 patients with ruptured DAVF presented as large spontaneous intracranial hemorrhage were included in this research between May, 2010 and August, 2012 in our hospital. 4D-CTA was performed in all cases. All results of 4D-CTA inspections were studied by both neurosurgeon and neuroradiologist. The therapeutic options were evaluated based on the clinical and angiographic results. All fistulas of seven patients were eliminated at the same time the hematoma being evacuated. 4D-CTA was sufficient for detecting and recognizing basic vessel angioarchitecture of DAVF to guide surgical treatment. Main arterial supplies, fistula location and CVDs found during surgery are consistent with the results 4D-CTA. All seven cases achieved completely fistula occlusion in operation without new neurological complication. We favor one stage surgical treatment for ruptured DAVF with large intracranial hemorrhage. 4D-CTA plays an important role in preoperative emergent inspection for its safety, rapidity and accuracy. However, it still needs further and larger investigations to optimize such treatment methods and to find out other potential risks. PMID:25664027
Strahle, Jennifer; Garton, Hugh J.L.; Maher, Cormac O.; Muraszko, Karin M.; Keep, Richard F.; Xi, Guohua
Intraventricular hemorrhage (IVH) is a cause of significant morbidity and mortality and is an independent predictor of a worse outcome in intracerebral hemorrhage (ICH) and germinal matrix hemorrhage (GMH). IVH may result in both injuries to the brain as well as hydrocephalus. This paper reviews evidence on the mechanisms and potential treatments for IVH-induced hydrocephalus. One frequently cited theory to explain hydrocephalus after IVH involves obliteration of the arachnoid villi by microthrombi with subsequent inflammation and fibrosis causing CSF outflow obstruction. Although there is some evidence to support this theory, there may be other mechanisms involved, which contribute to the development of hydrocephalus. It is also unclear whether the causes of acute and chronic hydrocephalus after hemorrhage occur via different mechanisms; mechanical obstruction by blood in the former, and inflammation and fibrosis in the latter. Management of IVH and strategies for prevention of brain injury and hydrocephalus are areas requiring further study. A better understanding of the pathogenesis of hydrocephalus after IVH, may lead to improved strategies to prevent and treat post-hemorrhagic hydrocephalus. PMID:23976902
Iaroshenko, K O
There were examined 113 patients, suffering pyloroduodenal zone ulcers, complicated by an acute hemorrhage. H. pylori was revealed in 108 (96%) patients. To escape a false-negative results a serological method was applied, which was used to determine a content of IgG antibodies to H. pylori with the help of diagnostic panel GastroPanel (Biohit PLc firm, Finland). The H. pylori presence in patients must be considered as a risk factor for the early recurrent hemorrhage occurrence. A timely conducted examination, determination of H. pylori and timely prescription of antihelicobacter therapy promote the improvement of the treatment results in patients, suffering gastroduodenal ulcers, complicated by an acute hemorrhage due to reduction of the occurrence rate of early recurrence of hemorrhage.
Ikeya, Yoshimori; Fukuyama, Naoto; Mori, Hidezo
N-3 fatty acids, including eicosapentaenoic acid (EPA), prevent ischemic stroke. The preventive effect has been attributed to an antithrombic effect induced by elevated EPA and reduced arachidonic acid (AA) levels. However, the relationship between intracranial hemorrhage and N-3 fatty acids has not yet been elucidated. In this cross-sectional study, we compared common clinical and lifestyle parameters between 70 patients with intracranial hemorrhages and 66 control subjects. The parameters included blood chemistry data, smoking, alcohol intake, fish consumption, and the incidences of underlying diseases. The comparisons were performed using the Mann-Whitney U test followed by multiple logistic regression analysis. Nonparametric tests revealed that the 70 patients with intracerebral hemorrhages exhibited significantly higher diastolic blood pressures and alcohol intakes and lower body mass indices, high-density lipoprotein (HDL) cholesterol levels, EPA concentrations, EPA/AA ratios, and vegetable consumption compared with the 66 control subjects. A multiple logistic regression analysis revealed that higher diastolic blood pressure and alcohol intake and lower body mass index, HDL cholesterol, EPA/AA ratio, and vegetable consumption were relative risk factors for intracerebral hemorrhage. High HDL cholesterol was a common risk factor in both of the sex-segregated subgroups and the <65-year-old subgroup. However, neither EPA nor the EPA/AA ratio was a risk factor in these subgroups. Eicosapentaenoic acid was relative risk factor only in the ≥65-year-old subgroup. Rather than higher EPA levels, lower EPA concentrations and EPA/AA ratios were found to be risk factors for intracerebral hemorrhage in addition to previously known risk factors such as blood pressure, alcohol consumption, and lifestyle.
Sabageh, Donatus; Odujoko, Oluwole Olaniyi; Komolafe, Akinwumi Oluwole
Right atrial myxomas are rare primary tumors of the heart. They may remain asymptomatic or eventually cause constitutional signs and symptoms. Less frequently, obstruction of the tricuspid valve occurs, resulting in exertional dyspnea, syncope, or sudden death. Neurological manifestation as initial presentation of atrial myxomas is rarely, if ever, associated with right atrial myxomas and may be secondary to cerebral infarction, cerebral hemorrhage and, more rarely subarachnoid hemorrhage. We review the case of a previously unknown, middle-aged Nigerian man who presented to hospital with severe headache and sudden loss of consciousness. A clinical diagnosis of hypertensive hemorrhagic cerebrovascular accident was made. The patient died suddenly a few hours after presentation. Post-mortem examination revealed a small intracerebral hemorrhage in the left superior temporal lobe as well as a large right atrial myxoma, a ventricular septal defect in the muscular septum, and right ventricular hypertrophy. The liver showed fatty change while the kidneys showed evidence of benign nephrosclerosis. Right atrial myxomas may, therefore, be remotely considered as a cause of intracranial hemorrhage, especially in the presence of predisposing cardiac anomalies such as a ventricular septal defect. Similarly, being a known cause of right heart failure, sudden death, and other constitutional derangements, it may contribute significantly to disease outcome. Hence, it should be given due consideration in the differential diagnosis of cerebrovascular accidents.