Bilateral Hemorrhage Research Articles

Widespread retinal hemorrhages after retinopathy of prematurity screening with scleral depression

We report a case of extensive bilateral intraretinal hemorrhages in a premature infant with active retinopathy of prematurity (ROP) after an examination with scleral depression. In the only other previously reported case, the retinal hemorrhages were limited to the posterior pole of an eye with preexisting vitreous hemorrhage, and the child had a history of severe necrotizing enterocolitis that required surgery. Investigators have hypothesized that the combination of ocular manipulation, abrupt intraocular pressure change, and fragile immature retinal vasculature with poor autoregulation may contribute to the pathogenesis of retinal hemorrhages. Physicians performing ROP examinations should be aware of this possibility and judiciously use scleral depression; however, examination-induced retinal hemorrhages in children have never been reported in the absence of active ROP.

Traumatic bilateral (mirror image) basal ganglia bleed

Bilateral traumatic hemorrhage of the basal ganglia is an extremely rare neuropathologic entity. Hematomas of the basal ganglia in head injury have long been recognized with an interest but their mechanism has not been revealed clearly. It is presumed to be secondary to rupture of the lenticulostriate or anterior choroidal artery by shearing as a result of acceleration/deceleration forces. Outcome of traumatic basal ganglia haemorrhage (TBGH) appears favourable unless it is large or associated with coagulation disorders or when it is associated with other intracranial injuries such as diffuse axonal injury, cerebral contusion etc. We present a rare case of 42 yrs old male with isolated bilateral (mirror-image) traumatic basal ganglia bleed. Mechanism, clinical features and management is discussed and available literature reviewed.

Bilateral bulbar subconjunctival hemorrhage associated with H1N1 vaccination

Subconjunctival hemorrhage (SCH) is a common eye disorder that is characterized by the sudden onset of a flat area of bleeding under the conjunctiva. Although SCH is a well-known and relatively common disease, the cause in a number of cases remains unknown. Here, we report an unusual ocular presentation of bulbar SCH in a patient who had received an influenza vaccine. Patients who present with SCH other than trauma episode should be evaluated with metabolic diseases or coagulopathy. Although there are rare cases of SCH related to vaccination, we should closely follow a patient if there is a risk of the SCH becoming bleeding disorder. To our knowledge, the features of SCH related to vaccination have not been reported.

Teaching Neuro Images : Remote cerebellar hemorrhage following resection of a supratentorial tumor

A 23-year-old man was admitted with blurred vision and headache. Ten years ago he was diagnosed with a left temporal pleomorphic xanthoastrocytoma; his last resection was 6 years ago. Current CT and MRI showed left temporal encephalomalacia; MRI also revealed incidental bilateral remote cerebellar hemorrhages (RCH) (figure). Called “remote” due to their distance from the surgical site, RCH are rare complications of supratentorial and spinal operations.1 Depending on extent, RCH may be symptomatic and diagnosed acutely on CT, or incidentally discovered as …

Recurrent, sequential, bilateral deep cerebellar hemorrhages: a case report

IntroductionHypertensive intra-cerebral hemorrhage is usually a one-time event and recurrences are rare. Most recurrences develop as part of long-term failure of blood pressure control. The site of the re-bleed is usually limited to the basal ganglia and thalami.Case presentationWe report the case of a 59-year-old hypertensive Caucasian woman who developed two sequential, right- and then left-sided, deep cerebellar hemorrhages. The second hemorrhage followed the first one by 57 days, at a time when her blood pressure was optimally controlled. In spite of these critical sites and short duration between the two bleeds, the patient achieved a relatively good functional recovery. Her brain magnetic resonance angiogram was unremarkable.ConclusionThe development of recurrent hypertensive hemorrhage is rare and usually occurs within two years of the first bleed. To the best of our knowledge, this is the first reported case of bilateral, sequential, right- and then left-sided deep cerebellar hemorrhages. These hemorrhages were separated by eight weeks and the patient had a relatively good functional recovery. We believe that hypertension was the etiology behind these hemorrhages.

Purtscher-like retinopathy following valsalva maneuver effect: case report

IntroductionPurtscher's retinopathy is a rare condition that is noted in cases related to various types of trauma. The characteristic finding in the fundus is the presence of multiple Purtscher flecken. Purtscher-like retinopathy has a similar presentation in the fundus, but without an association with trauma.Case presentationA 43-year old Malay man presented with a sudden onset of central foggy vision in the left eye after holding his breath for two minutes while catching a falling object. It was not associated with floaters, flashes of light, or head trauma. His vision in the right eye was 6/6, and in his left eye it was finger counting. He had bilateral temporal sub-conjunctival hemorrhages. An examination of his left fundus revealed multiple white cotton wool spots and dot-blot retinal hemorrhages with diffuse retinal edema at the posterior pole. His right fundus was noted to have only mild temporal peri-papillary edema associated with a few dot-blot hemorrhages. Fundus fluorescein angiography showed good arterial perfusion and no evidence of leaking or neo-vascularization. A diagnosis of Purtscher-like retinopathy was made, and the patient was treated with indomethacin tablets for six weeks. At his six-week follow-up examination, his left eye visual acuity had improved to 6/12. His bilateral sub-conjunctival hemorrhage had resolved. His left fundus showed residual multiple cotton wool spots and reduced retinal edema.ConclusionsTreatment with non-steroidal anti-inflammatory drugs seems to be effective in reducing edema in patients with Purtscher-like retinopathy.

Teaching Neuro Images : Postictal subconjunctival hemorrhages and skin petechiae

A 45-year-old man was evaluated for a seizure disorder of unknown cause characterized by secondarily generalized tonic-clonic seizures. He reported bilateral subconjunctival hemorrhages and facial petechiae immediately following most of his seizures …

Shaken Infants Die of Neck Trauma, Not of Brain Trauma

Shaken baby syndrome (SBS) is routinely diagnosed on the basis of a classic triad of autopsy findings, namely retinal hemorrhage, subdural hemorrhage, and anoxic encephalopathy. However, ongoing controversy exists regarding the specificity and potential causes of these signs, and hence their reliability as de facto markers of SBS, or of non-accidental head injury, where no external signs of trauma are evident.We investigated the deaths of 35 infants and young children, which fell into two broad groups: those with suspected hyperflexion/extension neck injuries, and those without. At autopsy, the entire cervical spinal column (spinal cord, vertebrae, intervertebral discs, neurovascular structures and adjacent soft tissues) was removed, formalin-fixed, decalcified, dissected, and microscopically evaluated.Of the 12 cases in which hyperflexion/extension was either suspected or confirmed, all had evidence of either bilateral or unilateral hemorrhages within or surrounding the C3, C4, and/or C5 cervical spinal nerve roots.We provide evidence that hyperflexion/extension forces as experienced by shaken and impacted infants and young children lead to injury of the cervical spinal nerve roots that innervate the diaphragm, with resulting asphyxia and hypoxic brain injury. Therefore, we propose that trauma to the third through fifth cervical spinal nerve roots induced by hyperflexion/extension of the neck is the cause of the anoxic encephalopathy of the classic SBS triad, and is therefore not only a more specific indicator of hyperflexion/extension injury than subdural hemorrhage alone, but is the mechanism of injury in these cases.

Role of Preoperative 3-Dimensional Computed Tomography Reconstruction in Depressed Skull Fractures Treated With Craniectomy

Patients affected by cranial trauma with depressed skull fractures and increased intracranial pressure generally undergo neurosurgical intervention. Because craniotomy and craniectomy remove skull fragments and generate new fracture lines, they complicate forensic examination and sometimes prevent a clear identification of skull fracture etiology. A 3-dimensional reconstruction based on preoperative computed tomography (CT) scans, giving a picture of the injuries before surgical intervention, can help the forensic examiner in identifying skull fracture origin and the means of production.We report the case of a 41-year-old-man presenting at the emergency department with a depressed skull fracture at the vertex and bilateral subdural hemorrhage. The patient underwent 2 neurosurgical interventions (craniotomy and craniectomy) but died after 40 days of hospitalization in an intensive care unit. At autopsy, the absence of various bone fragments did not allow us to establish if the skull had been stricken by a blunt object or had hit the ground with high kinetic energy. To analyze bone injuries before craniectomy, a 3-dimensional CT reconstruction based on preoperative scans was performed. A comparative analysis between autoptic and radiological data allowed us to differentiate surgical from traumatic injuries. Moreover, based on the shape and size of the depressed skull fracture (measured from the CT reformations), we inferred that the man had been stricken by a cylindric blunt object with a diameter of about 3 cm.

Bilateral Spontaneous Subperiosteal Orbital Hemorrhages Following Endoscopic Retrograde Cholangiopancreatography

Spontaneous subperiosteal orbital hemorrhage is rare. The authors describe a case of acute bilateral eyelid swelling, eyelid ptosis, and double vision in a patient immediately following endoscopic retrograde cholangiopancreatography. CT revealed bilateral subperiosteal orbital hemorrhages. The patient demonstrated no signs of optic nerve compromise, and the hemorrhages resolved spontaneously without sequela. Previous reports in the literature have documented subperiosteal hemorrhages following increased intracranial venous pressure, coagulopathies, and prone positioning during procedures. To the authors' knowledge, subperiosteal orbital hemorrhages have not been previously described following endoscopic retrograde cholangiopancreatography. Ophthalmologists and gastroenterologists should be aware of this potential complication associated with this procedure.

Bilateral Orbital Subperiosteal Hemorrhage Following Labor

A 27-year-old woman presented with 13 days of bilateral periorbital swelling, discomfort, and visual loss, which developed immediately after labor. She had significant blood loss requiring blood transfusion. There was bilateral proptosis, left optic neuropathy, and a superior visual hemifield defect in the left eye. MRI of the orbits showed bilateral superior subperiosteal hematomas. She underwent bilateral orbitotomy and drainage of subperiosteal hematomas. Six months later, complete resolution of proptosis with normal ocular motility and visual acuity was observed; however, there was persistence of a left relative afferent pupillary defect with superior visual field loss. This case report highlights the need for a high index of diagnostic suspicion of subperiosteal hematoma arising in a nontraumatic setting, such as in the peripartum period, and consideration for emergent surgical management of optic neuropathy.

Diabetic papillopathy: an uncommon cause of bilateral optic disc swelling

A 60-year-old lady with type 2 diabetes mellitus was admitted with apparent bilateral papilloedema, detected by her optician. Fundoscopic findings on admission are shown in Figure 1A and B. Figure 1. ( A and B ) Optic discs showing bilateral marked swelling and superficial flame haemorrhages in the left eye. Note absence of significant diabetic retinopathy. ( C and D ) Swelling gradually resolving without atrophy 3 months later. She was diagnosed with type 2 diabetes mellitus in 1992 and treated with metformin, acarbose and gliclazide. She had no …

Challenging cases discussed by experts: retinal vasculitis following coinfection with HIV and syphilis

A patient with HIV and syphilis presents with bilateral retinal vasculitis and recurrent vitreous hemorrhage. Diagnostic and treatment strategies are discussed.

Rapidly Progressive Cognitive Impairment, Ataxia, and Myoclonus: An Unusual Presentation of a Dural Arteriovenous Fistula

Dural arteriovenous fistulas (DAVFs) have a wide range of clinical presentations, including dementia associated with white matter changes (WMCs). We report a case of DAVF presenting as a rapid progressive dementia and myoclonus without WMCs. A 64-year-old hypertensive and diabetic man was admitted because of a 3-month history of progressive cognitive decline, extrapyramidal and cerebellar signs, and myoclonus. Magnetic resonance imaging (MRI) scans of the brain showed dilated cerebellar veins and T2WI hypersignal in the basal ganglia without WMCs. After admission, he suffered sequential bilateral deep intracerebral hemorrhages. A repeated angioMRI disclosed thrombosis of the distal sagittal and the proximal lateral sinuses. Angiography revealed a torcullar region DAVF. Embolization of the dural fistula was performed. On follow-up, the patients' cognitive deficits improved and myoclonus disappeared. The clinical picture may be explained by venous hypertension in the deep venous system, producing bilateral basal ganglia/thalamic dysfunction and in the posterior fossa. This case shows that DAVFs can produce subcortical dementia without involvement of the deep white matter.

Posterior Reversible Encephalopathy Syndrome in the Context of Phentermine Use Resulting in Intracranial Hemorrhage

Posterior reversible encephalopathy syndrome (PRES) is a brain disorder characterized by clinical symptoms of headache, visual changes, altered mentation, and seizures. On neuroimaging, focal regions of symmetrical hemispheric edema are most commonly seen in the occipital lobes. It has been suggested that associated intracranial hemorrhage is present in approximately 5% to 17% of cases. We report a case of PRES with large bilateral parieto-occipital hemorrhages in the context of phentermine use. To our knowledge, this is the first reported case of phentermine use associated with PRES. A 35-year-old woman taking phentermine for weight loss presented with altered mental status and 2 witnessed generalized seizures. She was found to have large bilateral parieto-occipital hemorrhages. The radiographic imaging was consistent with PRES with hemorrhagic conversion. After treatment with anti-epileptic medication, normalization of blood pressure, and discontinuation of phentermine, the patient improved clinically. Five months after the event, the patient had a repeat brain magnetic resonance imaging that showed resolution of the diffuse edema and hemorrhage. This case of PRES with hemorrhagic conversation is distinctive in the bilateral and extensive nature of the hemorrhage, and, to our knowledge, is the first reported case of phentermine use likely resulting in PRES. Physicians should be aware of the cerebrovascular risks associated with phentermine use.

Ocular Findings in Raised Intracranial Pressure

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.

Perioperative spontaneous bilateral suprachoroidal hemorrhage

Suprachoroidal hemorrhage is a rare condition, occurring most commonly in the perioperative period, although cases of unilateral spontaneous hemorrhages have been reported. We report a case of bilateral spontaneous suprachoroidal hemorrhage and discuss the potential causative factors.

Agenesia de la vena cava inferior infrarrenal con trombosis de la vena renal fetal: a propósito de un caso

Agenesis of the inferior vena cava, especially of the infrarenal segment, is exceptional. This condition is thought to result from thrombosis during gestation rather than from a true congenital malformation. Agenesis of the inferior vena cava can be associated with renal vein thrombosis, which in turn is related to suprarenal hemorrhage in the fetus.We present a case of agenesis of the inferior vena cava with preservation of the hepatic segment, thrombosis of the left renal vein, and secondary bilateral suprarenal hemorrhage diagnosed prenatally using sonography and magnetic resonance imaging.

Microsangrados cerebrales múltiples en paciente con hipertensión mal controlada. Un nuevo marcador de vasculopatía hipertensiva

Brain microbleeds are small dot-like lesions appearing as hyposignal on gradient echo T2* MR sequences. They represent microscopic areas of old hemosiderin deposits. They are frequent in the setting of symptomatic cerebrovascular disease and also in older healthy people, which suggests a link with arterial hypertension. Their use as diagnostic or prognostic biomarkers remains uncertain. The appearance of these microbleedings and increasing use of Magnetic resonance imaging (MRI) in the clinical practice causes many clinical dilemmas. We report the case of a woman with difficult to control hypertension, who was admitted with bilateral simultaneous cerebral hemorrhage, multiple microbleedings being observed in the cerebral magnetic resonance. We discuss the identification and meaning of these hemorrhagic lesions.

Neonatal rat model of intraventricular haemorrhage and post-haemorrhagic ventricular dilatation with long-term survival into adulthood

post-haemorrhagic ventricular dilatation (PHVD) is a significant problem in neonatal care, with sequelae extending beyond childhood. Its management is important in determining outcome. Although rodent hydrocephalus models have been developed, PHVD, as a specific entity with a distinct pathophysiology, has not been studied in a small animal model surviving to adulthood. Our objective is to evaluate survival, to adulthood, in our immature (7-day-old, P7) neonatal rat model, and to analyse early motor reflexes and fine motor and cognitive function, and neuropathology, at 8-12 weeks. sixty-six rats underwent sequential bilateral stereotactic intraventricular haemorrhage (IVH); 36 more acted as controls. Staircase and radial maze evaluations were carried out at 7-11 weeks; animals were sacrificed at 12 weeks. Post mortem ventricular size and corpus callosum thickness were determined. seventy-six per cent of IVH animals developed PHVD; median (interquartile range) composite ventricular area was 3.46 mm(2) (2.32-5.24). Sixteen (24%) animals demonstrated severe ventricular dilatation (area > 5 mm(2) ). IVH animals failed to improve on the negative geotaxis test at 2 weeks. The staircase test did not identify any significant difference. On the radial maze, animals with severe PHVD made more reference errors. Histopathology confirmed PHVD, ependymal disruption and periventricular white matter injury. Median anterior corpus callosum thickness was significantly lower in IVH animals (0.35 mm) than in those not undergoing IVH (0.43 mm). our P7 neonatal rat IVH model is suitable for long-term survival and replicates many of the morphological and some of the behavioural features seen in human PHVD.