Bilateral Hemorrhage Research Articles

Trans-anal protrusion of the distal end of ventriculo-peritoneal (VP) shunt – The role of ommaya shunt

Transanal protrusion of the distal end of ventriculoperitoneal shunt is an extremely rare complication associated with this procedure. Such complication only reported once in Malaysia since 1987. Instead of usual external ventricular drain (EVD) insertion as temporary CSF diversion post VP shunt removal, does Ommaya shunt play a better role in this? This unfortunate boy had undergone a right VP shunt due to communicating hydrocephalus secondary to bilateral intraventricular haemorrhage at 7 months old. He then experienced transanal VP shunt protrusion five months following the surgery. Apart from a literature review on the diagnosis and treatment for this rare complication, we further discuss the role of ommaya shunt as compared to usual EVD insertion. Early detection and prompt management are warranted to prevent further devastating damage from such complication. Although this single Case showed a favourable result, more studies are required to confirm the role of the Ommaya shunt.

Diffuse Geometric Erosions on the Skin of a Premature Infant, Fraternal Twin Unaffected

Diffuse Geometric Erosions on the Skin of a Premature Infant, Fraternal Twin Unaffected

Why Me? To Be an Ultra-Responder to Antiplatelet Therapy: A Case Report

Background: Platelet function testing is a valid tool to investigate the clinical response to antiplatelet therapy in different clinical settings; in particular, it might supply helpful information in patients with cerebrovascular disease. Oral antiplatelet treatment, such as Aspirin (ASA) and Clopidogrel, is the gold standard in secondary stroke prevention of non-cardiogenic ischemic stroke; conversely, its application as a primary prevention therapy is not routinely recommended in patients with vascular risk factors. Multiple electrode platelet aggregometry (MEA) impedance aggregometer is a validated device to test platelet inhibition induced by ASA or Clopidogrel.Case Report: We report the case of a 78-year-old patient without relevant clinical history, taking ASA as primary prevention strategy, who was admitted for sudden onset of dysarthria and left facial hyposthenia during physical effort. Brain CT revealed two small subcortical bilateral spontaneous intracranial hemorrhages. Platelet aggregometry with MEA performed upon admission revealed a very strong platelet inhibition induced by ASA (result of the ASPI Test was 5 U, consistent with an ultra-responsiveness to ASA, and the cutoff value of correct responsiveness is <40 U). MRI at longitudinal follow-up revealed the presence of two small cavernous angioma underlying hemorrhagic spots.Conclusion: The evaluation of platelet reactivity in stroke patients undergoing antiplatelet therapies, not commonly performed in clinical practice, could be useful to optimize prevention strategies; the verification of the biological effectiveness of ASA or Clopidogrel could be a valid tool in the definition of each patient's risk profile, particularly in patients with cerebrovascular disease known to be at increased risk for both hemorrhagic and thrombotic complications.

Olfactory bulb SARS-CoV-2 infection is not paralleled by the presence of virus in other central nervous system areas.

Olfactory bulb SARS-CoV-2 infection is not paralleled by the presence of virus in other central nervous system areas.

28675 A case of systemic amyloidosis diagnosed by dermatologic consult

A 49-year-old male with PMH of hypertension and diabetes was admitted to the neurology ICU following thrombolytic therapy for left MCA occlusive thrombus. Dermatology was consulted for desquamation of the lower lip, lateral tongue, and bruising of the eyelid and cheeks. Patient originally presented to outside hospital with bilateral lower extremity swelling and shortness of breath. BNP and troponins were elevated, and ACS protocol was initiated. He had stroke-like symptoms while at the outside facility and CT showed MCA occlusive thrombus. He was transferred to our facility due to concern for stroke symptoms, where he had prompt thrombectomy with IR as well as right and left internal carotid artery intra-arterial TPA. After the procedure, bruising of the eyelids was noted. This was thought to be secondary to trauma from taping eyelids shut during the procedure. The next day, tongue swelling as well as lip swelling and desquamation were noted, so dermatology was consulted. On examination, bilateral periorbital hemorrhage was noted as well as hemorrhagic stomatitis and macroglossia. Differential at this time included systemic amyloidosis due to concern for the classic pinch purpura and skin fragility seen in systemic amyloidosis as well as macroglossia. Tongue and lip biopsies were performed. Echo was completed to work up heart failure and findings were suggestive of amyloidosis. Biopsy of the tongue and lip had amorphous pink, cracked material suggestive of amyloidosis. Congo Red stain was performed on lip biopsy and was markedly positive for amyloid deposits. Free light chains were markedly elevated.

A Case of Neurosarcoid Presenting as Multiple Intraparenchymal Hemorrhages.

This report explores the case of a 49-year-old African American male with a six-month history of multifocal neurological deficits who presented to an outside hospital after a generalized seizure. Patient was transferred to our tertiary medical center after brain imaging showed multiple bilateral supratentorial intraparenchymal hemorrhages (IPH). A brain biopsy confirmed parenchymal and perivascular non-caseating granulomas with vasculitis. The patient was definitively diagnosed with neurosarcoidosis (NS) and his condition improved with high dose corticosteroids and additional immunosuppressive therapies. Intracranial hemorrhage in the setting of NS is extremely rare, with fewer than thirty documented cases; however, this is likely an underestimation of its true prevalence. This case illustrates the difficulty in diagnosis as many other etiologies of IPH must be considered. Additionally, the clinical course and manifestations of NS is often quite variable. The uniqueness of this case lies in the rapid progression from seemingly incidental microhemorrhages to multiple large IPHs over two months. While the cause of this progression is not immediately apparent, a possible cause may be inadequate initial treatment due to delayed diagnosis. Our case demonstrates the importance of early recognition and initiation of immunosuppressive therapy, potentially leading to dramatic clinical improvement, as seen in this patient.

Hemorrhagic Eye Involvement in Acute Myeloid Leukemia

Purpose: Through an observation, we focus on the ocular hemorrhagic manifestations during AML and the role of the ophthalmologist in the management of this condition. Methods: We report the case of a 14-year-old boy whose hemorrhagic ocular involvement was indicative of an AML. Results: This patient with no known history was sent for an ophthalmology consultation for a sudden decline in bilateral visual acuity associated with a bilateral periorbital ecchymosis. The interrogation found an effort of vomiting preceding the ocular symptoms and a notion of purpuric spots on the lower limbs 3 months ago. Distance visual acuity has been rated at 1/10 on the right and counts the fingers on the left. Examination of the anterior segment mainly revealed periorbital ecchymosis and diffuse bilateral subconjunctival hemorrhage. Fundus analysis revealed bilateral diffuse retinal hemorrhage, premacular retro-hyaloid hemorrhage on the right and macular hemorrhage on the left. An emergency blood count showed anemia with hemoglobin (Hb) level of 5.5g/dL and thrombocytopenia at 15,000/µL. Hyperleukocytosis at 126420/µL with monocytes at 84700/µL and neutrophils at 3312/µL. The patient was immediately referred to a hematologist and an oncologist. The investigations and the myelogram made it possible to make the diagnosis of acute myeloid leukemia. Conclusions: Although the ophthalmologist plays a secondary role in the treatment of leukemia, he must be able to recognize the eye symptoms indicative of systemic disease and collaborate with hematologists and oncologists in the follow-up and management of patients.

A Case Report of Putaminal Hemorrhage Due to Methanol Toxicity; is Hemodialysis the Offender?

Introduction: Methanol toxicity is a life-threatening condition which is rare in developed countries but common in developing countries. Bilateral putaminal necrosis and hemorrhage are potentially two lethal consequences of methanol toxicity which may be due to direct neurotoxicity of methanol metabolites, especially formic acid, or the consequences of acidosis and hypoxemia in the course of poisoning. Hemodialysis is an important part of the treatment of methanol toxicity and some researchers believe that heparin which is administrated during the hemodialysis may be the cause of putaminal hemorrhage Case report: We report a-32-year old man who presented with acute symptoms of methanol toxicity. A day after hemodialysis he suffered from seizure and Parkinsonism, and the neuroimaging revealed bilateral putaminal hemorrhage. Treatment with Levodopa-carbidopa was introduced for the management of Parkinsonism and finally the patient was discharged with marked improvement of symptoms and relative independency in daily activities Discussion and Conclusion: Our patient suffered from a late manifestation of methanol intoxication, bilateral putaminal hemorrhage, and necrosis. This appearance along with subcortical white matter involvement are the most common abnormalities of methanol toxicity in the brain imaging which can be associated with peripheral enhancement. Based on the reported case and review of present evidences, it is suggested that putaminal hemorrhage in methanol toxicity can be due to anticoagulant agents used in hemodialysis

Retinal manifestations in patients following COVID-19 infection: A consecutive case series.

Purpose:To describe retinal manifestations seen in patients associated with COVID-19 infection at a multi-specialty tertiary care hospital in Southern India.Methods:In this retrospective chart review, all consecutive cases presenting to the Retina-Uveitis service from May 2020 to January 2021 with retinal manifestations associated with COVID-19 infection or its sequelae or as a result of treatment given for COVID-19 were included.Results:Of the 7 patients, 3 were female, and 4 were male. Four patients had onset of symptoms during the active phase of COVID-19 infection. Four had bilateral and three had unilateral involvement. The manifestations ranged from mild to vision threatening. Vision threatening manifestations included infections: endogenous endophthalmitis, candida retinitis and tubercular choroidal abscess and bilateral pre-foveal hemorrhages. Milder manifestations included paracentral acute middle maculopathy, central serous chorio-retinopathy and voriconazole induced visual symptoms. Final visual acuity was 6/36 or better in the four severe cases and 6/9 or better in the mild cases.Conclusion:This study highlights the retinal manifestations associated with COVID-19 infection and its sequelae. As these patients presented with an association with COVID-19 (either during or after recovery), ophthalmologists should be vigilant and screen for such entities in case of complaints of visual symptoms or in the presence of systemic sepsis. The outcomes can be good with prompt and aggressive management.

An Unusual Cause of Concordance in the Setting of Left Bundle Branch Block

A 73-year-old female with a past medical history of atrial fibrillation, mechanical mitral valve replacement on warfarin, hypertension and hypothyroidism presented to the emergency department with a fall. She fell and hit her head upon standing up from a seated position. She reported a constant posteriorly located headache along with episodes of nausea and vomiting. She denied chest pain, shortness of breath, syncope and fever. The initial examination showed blood pressure of 107/64mmHg, respiratory rate of 13/Min, pulse of 76/Min, oxygen saturation of 96% and Glascow Coma Scale (GCS) of 13, verbal response 4, motor response 6 and eye response 3. Pupils were round and reactive to light. No focal weakness or sensory loss were noted. The patient’s mental status and GCS progressively worsened for which she eventually was intubated. The patient had a mild leukocytosis of 14.11×109 (4.0-10.0). Her sodium, calcium, magnesium, phosphorus and potassium were normal. International Normalized Ratio (INR) was 2.9. The troponin upon presentation was 0.69ng/ml and trended down throughout the hospitalization. Her EKG showed normal sinus rhythm with a left bundle branch block with ST segment elevation in leads V3 - V5 and concordant ST elevation &gt;1mm in V5. Sgarbossa criteria for acute myocardial infarction in the presence of LBBB was 5 points. Computed tomography (CT) scan of the head without contrast showed large bilateral cerebellar hemorrhages with mild inferior herniation of the cerebellar tonsils. Echocardiogram showed ejection fraction of 55-60% with no wall motion abnormalities. Immediate supportive treatment, including fluids and reversal of anticoagulation with prothrombin complex concentrate and vitamin K were administered. The patient underwent a successful suboccipital decompressive craniotomy.

When doom is vincible but imperceptible

An eighty-year-old gentleman without any comorbidity or significant medical illness had presented with headache of recent onset. A detail clinical evaluation and imaging (MRI of brain) ruled out secondary cause of headache. A month later, he presented to emergency with altered sensorium and quadriparesis. Repeat brain imaging revealed bilateral subdural hemorrhage requiring emergent surgery. He was back to normalcy within few days postoperatively. A confession was obtained about his daily habit of induced vomiting after drinking large amount of water (kunjala kriya). The repeated habit of induced vomiting might have been responsible for the slowly evolving subdural hemorrhage. Interestingly, though he had significant clinical symptoms at the initial presentation, he had normal initial MRI of brain (the more sensitive imaging modality). Our case highlights the interesting neurophysiology of subdural hemorrhage and the importance of close monitoring of elderly patients of recent onset headache.

Neonatal risk Factors and their Correlation with Severity and Stages of Retinopathy of Prematurity A Five Year Retrospective Study in a District General Hospital

Introduction: Retinopathy of prematurity is a largely preventable condition with appropriate screening and early intervention. A comprehensive study of risk factors and knowledge on the pathophysiology is of great importance to help clinicians predict high-risk patients. This paper aims to further identify risk factors of ROP and correlate them with different stages (severity) of ROP. Methods: A retrospective review of all preterm infants admitted to neonatal intensive care unit (NICU) in ELHT from January 2015 to December 2019. All infants screened and included were based on the screening criteria set out by the Royal College of Ophthalmologists. Results: Among 415 infants included, 199(48.0%) were male with gestational age of 28.90±2.72 weeks and mean birth weight of 1214.42±350.81g. The incidence of bilateral intraventricular haemorrhage (IVH) is higher in infants with stage 3 ROP (34.8%, P=0.002). Neonates who were Asian in ethnicity were more likely to have stage 3 ROP requiring laser treatment (60.9%, P=0.008; 66.7%, P=0.040). Units of blood transfusion and duration of ventilation were highly associated with severe ROP (5.26 ± 3.22, P&lt;0.001; 31.13 ± 24.59, P&lt;0.001) and ROP that required treatment (6.89 ± 6.17, P&lt;0.001; 41.56 ± 37.02, P&lt;0.001). Logistic regression analysis also revealed significant association between Asian ethnicity (OR: 0.289, CI:0.101-0.823), bilateral IVH (OR:1.895, CI:1.035-3.471), unit of blood transfusion (OR: 1.205, CI:1.028-1.413) with severe ROP and ROP requiring treatment. Conclusion: Bilateral IVH, units of blood transfusion, bronchopulmonary dysplasia, and Asian ethnicity are associated with severe ROP and ROP requiring treatment.

Application of veno-venous extracorporeal membrane oxygenation in lymphoma patients with severe acute respiratory distress syndrome

Aim: To report the clinical courses of two patients, one with Hodgkin’s lymphoma (HL) and one with Non-Hodgkin’s lymphoma (NHL), who developed severe refractory acute respiratory distress syndrome (ARDS) and were treated with veno-venous extracorporeal membrane oxygenation (VV ECMO). Case report: Both patients developed chemotherapy-associated febrile neutropenia followed by pneumonia and ARDS, after which they were transferred to the intensive care unit. Their respiratory failure deteriorated despite endotracheal intubation with protective mechanical ventilation, at which point a decision for VV ECMO initiation was made. Both patients had complicated treatment courses and developed severe ECMO-associated complications. The most important complications of ECMO support in our HL patient were cardiac arrest; right atrial laceration with pericardial tamponade which needed surgical treatment; right leg ischemia which required transfemoral amputation; thrombosis within the membrane oxygenator; several septic episodes with severe hemodynamic instability; and right sided tension pneumothorax. Despite all difficulties, the patient was successfully weaned from ECMO. Unfortunately, he died prior to hospital discharge as a result of sepsis with multiple organ failure. The most significant ECMO-induced complications in our NHL patient were severe bleeding incidents, most notably diffuse oropharyngeal and continuous bilateral pulmonary hemorrhage; superimposed bacterial pneumonia; extensive pneumomediastinum and subcutaneous emphysema. Despite all therapeutic efforts, the patient died during ECMO treatment because of respiratory decompensation. Conclusions: The patients with hematologic malignancies (HMs) undergoing ECMO support have poor outcomes, with high rates of severe ECMO-induced complications. Further studies focusing on patient selection and issues concerning prevention, diagnosis and treatment of ECMO-associated complications are needed.

Lactococcus garvieae Isolates from Rainbow Trout (Oncorhynchus mykiss, W.) Compared by PLG and SA1B10 PCR Primer Pairs

The aim of this study was to identify and compare Lactococcus garvieae strains using the PLG primer pair and SA1B10 primer pair. Also, the antibiotic resistance of the strains was investigated in the study. For this aim, commercial trout farms at Kemer, Korkuteli, and Manavgat, Antalya Province, Turkey were visited every month from June to September 2018. Thirty sick fish were sampled in the study. Lethargy, anorexia, darkening of skin color, unilateral or bilateral exophthalmos, opacification and hemorrhages in the eyes of the sick fish, and abdominal dropsy were observed. At necropsy, hemorrhages in the internal organs, splenomegaly, and darkening of the spleen and ascites were present. Seventy-five strains from sick fish samples verified on the basis of the biochemical characterization and PCR studies. The strains showed homogeneity in terms of phenotypic characteristics and all strains were identified as Lactococcus garvieae. The PCR technique was applied to 50 of 75 strains using PLG primer pair. While 47 of 50 strains gave positive results, amplification was not observed in 3 strains. When the PCR technique using SA1B10 primer pair was applied to a total of 25 strains, 3 of which were negative, 22 of which gave positive amplification, and 25 strains gave positive results. Resistance was determined by the disk diffusion method. All seventy-five strains were resistant to ampicillin and all strains were susceptible to bacitracin and tetracycline. It was found that the resistance and susceptibility of the strains showed variation to other antibiotics used in the study.Keywords: Lactococcus garvieae; Rainbow Trout; PCR; Antibiotic

Unusual eye injury related to abusive head trauma

AbstractOphthalmological examination is an essential component in clinically diagnosing abusive head trauma (AHT). Typical of AHT injuries is retinal bleeding, with other parts of the eye sometimes also being affected. Visual impairment and blindness are long-term complications in this context. We present a case with unusual eye injuries after a diagnostically confirmed AHT.The ophthalmological findings on admission day showed a massive subhyaloid hemorrhage at the posterior pole and extensive flame-shaped intraretinal hemorrhages accented on the right side., A centrally localized vitreous hemorrhage appeared on both sides 3 weeks later, obscuring the optic disc and macula most probably due to a breakthrough of a sub-internal limiting membrane (ILM) hemorrhage into the vitreous cavity. Follow-up 4 weeks later revealed a dense and organized vitreous hemorrhage occupying the optic disc and macula so that a pars plana vitrectomy was performed on both eyes.The bilateral bleeding in different retinal layers, the vitreous hemorrhage and the proliferative vitreoretinal reaction (PVR) indicated massive damage caused by a significant acceleration-deceleration trauma. A two-phase vitreous hemorrhage in a child with AHT does not yet appear to have been described in the literature.

Case 1: A Term Neonate with Conjunctival Hemorrhage, Ecchymoses, and Umbilical Hematoma

A term male neonate with a birthweight of 3,350 g is born via emergency cesarean delivery for the indication of abruptio placenta. The mother is a booked and immunized, gravida 4, para 3 woman with normal platelet counts and an uneventful antenatal course. The neonate was conceived spontaneously in a nonconsanguineous marriage and the family history is nonsignificant. The neonate has a normal transition after birth, is given a 1-mg intramuscular injection of vitamin K in the right thigh; he rooms in with the mother and is exclusively breastfed. Around 48 hours after birth, the neonate is noted to have bilateral conjunctival hemorrhages, ecchymoses on the face and trunk/back, boggy swelling over the scalp, and umbilical cord hematoma (Figs 1, 2 and 3). The neonate is noted to have pallor, but his vital sign parameters are normal (heart rate 140 beats/min, respiratory rate 40 breaths/min, temperature 98.6oF [37oC], capillary refill time <2 seconds, and oxygen saturation 96% in room air). There is no history of hematemesis, hematuria, or bleeding per rectum. Figure 1. Conjunctival hemorrhage. Figure 2. Ecchymoses on the face. Figure 3. Umbilical hematoma. ### Progression With a provisional clinical diagnosis of vitamin K deficiency bleeding (VKDB), the neonate is given a repeat 1-mg intramuscular injection of vitamin K and evaluated for the cause of the bleeding manifestations. Laboratory investigations reveal a hemoglobin of 6.4 …

Aneurysmatic Subdural Haemorrhage: Brief Review

Acute subdural hemorrhage caused by a ruptured intracranial aneurysm is a well-known association but usually linked to dismal outcome. We briefly reviewed the clinical and imaging features, surgical management and outcome of 45 patients with subdural bleeding related to intracranial aneurysm. Forty-two reports were encountered in the literature between 1981-2015 and three additional patients were identified in the author personal archives. A total of three patients had bilateral acute subdural hemorrhage, and the epidural hematoma was not present in any of the 45 reports. Coma was identified in 32/45 (71%) patients at admission. Only seven of 45 cases reported were managed by endovascular approach. A good clinical outcome was observed in 23/45 (51%) and early mortality occurred in 10/45 (22%) of the patients analysed. Neurosurgical management has evolved tremendously in recent years leading to more comprehensive understanding about this association. Factors leading to natural history, mechanisms, imaging aspects and improvement of clinical results of aneurysmatic subdural bleeding merit further studies.

Recurrent Spontaneous Bilateral Subdural Hemorrhage as a Consequence of High-Cervical Spontaneous CSF Leak—Lessons for Neurosurgeons

AbstractSpontaneous intracranial hypotension (SIH) is rare. It presents as intractable posture headache and is identified by radiological findings. It is confirmed by cerebrospinal fluid (CSF) manometry and myelography, and treatment is carried out with the help of epidural blood patch (EBP) therapy. SIH presenting with spontaneous bilateral recurrent subdural bleeds is uncommon. The cause being a high-spinal CSF leak is even more uncommon! Our patient had recurrent bilateral spontaneous chronic subdural hematomas. Myelographic examination of the spine showed a C1–C2 level leak of CSF. He was taken up for open microsurgery, and the leak was identified and closed with fibrin glue. The patient however deteriorated the next day. An EBP was applied in the lumbar region to cover the myelogram lumbar puncture site. We present a review of literature and an algorithm to detect the elusive CSF leak and effect definitive treatment, either open or EBP, to treat the source of the problem.

Glasses-shaped petechiae and bilateral subconjunctival hemorrhage following a Valsalva maneuver in the setting of iron poisoning

Introduction: Acute iron salt poisonings are potentially serious poisonings that can be life threatening. The toxicity is mainly digestive, cardiovascular, and hepatic. To make a first assessment of the potential seriousness of the poisoning, it is necessary to calculate (in mg/kg) the dose assumed to be ingested in elemental iron. The Valsalva maneuver during the vomiting effort may be responsible for retinal or subconjunctival hemorrhage. Case Report: We report the case of glasses-shaped petechiae and bilateral subconjunctival hemorrhage following a Valsalva maneuver in the setting of iron poisoning in an 18-year-old female patient whose outcome was favorable. Conclusion: In our case, the dose of iron ingested was not accompanied by symptoms related to intoxication, but rather periorbital petechiae and subconjunctival hemorrhage following the Valsalva maneuver associated with the efforts to vomit.

Periorbital ecchymosis and subconjunctival hemorrhage due to leech therapy for headache

A 62-year-old woman was admitted to our clinic with the complaints of periorbital ecchymosis and subconjunctival hemorrhage that are visible, especially on the right eye. We noted that her complaints began the day after she underwent leech therapy on the glabella area for headache. On the glabella, 2 leech bites were observed close to the right side. Examination revealed ecchymosis on the bilateral eyelids and subconjunctival hemorrhage on the inferolateral and medial limbus on the right eye. No treatment was initiated, rather control measures were recommended. The follow-up after 1 month revealed that the patient's complaints had disappeared.