Brainstem Hemorrhage Research Articles

Eye closure and oculopalatal tremor

A 59-year-old man with right tectal arteriovenous malformation complicated by brainstem hemorrhage was referred for unusual eye movements. He demonstrated rhythmic movements of face, larynx, and palate with horizontal saccadic intrusions and small amplitude, pendular oscillations of the left eye. Only active eye closure brought …

Brainstem hemorrhage presented as audiovestibular syndromes

Brainstem hemorrhage usually presented with acute multiple neurologic dysfunction, and the prognosis was poor. Rarely, it can manifest with audiovestibular symptoms only. Here, we report a case of brainstem hemorrhage involving the right middle cerebellar peduncle and dorsal lateral pons presented with constant nonpulsatile tinnitus and rotatory vertigo. We believed that rotatory nystagmus should be regarded as a central sign until proven otherwise even if the neurologic signs are subtle.

Clinical management and therapeutic strategy for patients with pseudobulbar paralysis post stroke

Objective To investigate the clinical management and therapeutic strategy for patients with pseudobulbar paralysis post stroke. Methods To retrospectively analyze the clinical data of 157 patients poststroke whom were in convalescence stage. Then patients with pseudobulbar paralysis were selected and whose epidemiology feature and treatment effect were analyzed. Results In 157 patients,55 patients(35.0%) were complicated with pseudobulbar paralysis,among whom,26 patients(26/55,47.3%) with hemorrhagic stroke,including basal ganglia hemorrhage 6(6/26,23. 0%) , cerebellar hemorrhage 12 (12/26,46. 2%) and brain stem hemorrhage 8 (8/26,30. 8%).29 patients suffered ischemic stroke(29/55,52.7%) ,including 9 cases with corticalis(9/29,31.0%),13 with brain stem infarction(13/29,44.8%) and 7 with cerebellar infarction(7/29,24. 2%). Among all the patients,32(32/55,58.2%) cases lesion were multiple and 23 cases(23/55,41. 8%) were simple. In the field of treatment effect of all patients,41 cases(42/55,76.4%) were with excellence, 11 with utility(11/55,20%) and 2 with inefficiency (2/55,3.6%). Conclusion The comprehensive management and compatible medical treatment should be the compatible clinical management and therapeutic strategy for patients with pseudobulbar paralysis post stroke. Key words: Stroke; Pseudobulbar paralysis; Therapeutic strategy

Influence of Antiplatelet Medications on Bleeding Events in Hemodialysis Patients

Although antiplatelet medication is used in various situations, including for the prevention of ischemic and thrombotic complications, long-term antiplatelet therapy in hemodialysis patients who are at high risk of bleeding may result in a harmful bleeding tendency. We investigated bleeding events that required the cessation of the use of heparin for hemodialysis in all the hemodialysis patients treated in our clinic. This analysis revealed 111 patients, of whom 52 had been treated with antiplatelet agents (female/male, 15/37; age, 70.4±11.3years; number of days of hemodialysis treatment in our clinic, 1073±696 [31-2144]days; diabetes mellitus [DM]/non-DM, 29/23), and 59 had not been treated with them (female/male, 17/42; age, 66.7±14.0 years; number of days of hemodialysis treatment in our clinic, 917±605 [26-2102]days; DM/non-DM, 21/38). During treatment in our clinic, 21 of the 52 patients undergoing antiplatelet therapy experienced a bleeding event (gastrointestinal bleeding 16, brain stem hemorrhage 2, others 3), while 7 of the 59 patients not receiving them had a bleeding event (gastrointestinal bleeding 7) (P<0.001). Of note, diabetic patients on antiplatelet therapy had the highest incidence of bleeding events (13 of 29 patients; 44.8%), followed by non-diabetic patients on antiplatelet therapy (7 of 23 patients; 30.4%), diabetic patients not receiving antiplatelets (3 of 21 patients; 14.3%), and finally non-diabetic patients not on antiplatelets (4 of 38 patients; 10.5%). Among the patients on antiplatelet therapy, no correlations were apparent between bleeding events and the duration of such therapy or the number of agents. In conclusion, antiplatelet medications can induce bleeding events more frequently in hemodialysis patients, especially in those with DM, than in non-hemodialysis patients, and such agents should be given only under prudent consideration of the associated risks and benefits.

Fatal brainstem haemorrhage after intracranial stenting: how much anti-platelet medication should we give?

Fatal brainstem haemorrhage after intracranial stenting: how much anti-platelet medication should we give?

Brainstem hemorrhage after neural therapy for decreased libido in a 31-year-old woman

In September 2010, a 31-year-old otherwise healthy, female Caucasian consulted a dermatologist with additional qualifications in neural therapy because of decreased libido resistant to treatment. Following unproblematic procaine 1% injections at multiple gynecological and thyroidal sites, per os epipharyngeal injection was performed intending to infiltrate a neural therapy trigger point close to the pharyngeal tonsil at the anterior aspect of the sphenoid bone. This target point is assumed to represent remnants of the craniopharyngeal duct and Rathke’s pouch and is considered the source of various hormone imbalances [1]. Immediately after injection of 1 ml procaine, the patient developed right-sided brachiocrural hemiparesis, numbness of all limbs, nausea, vomiting, and rotatory vertigo. Approximately 30 min later, sensorimotor deficits gradually subsided, the vertiginous patient was reassured and sent home with an appointment set for the next day. Since the patient still complained about vertigo, nausea, and repeated vomitus on the following day, she was admitted to the emergency department of our hospital. At initial presentation, the patient was fully alert and orientated. The clinical examination was notable for positional vertigo in right lateral position and gaze-provoked upbeat nystagmus. Furthermore, a slight deficit in sensibility on the anterior aspect of the right lower leg was detected. The remainder of the clinical examination and all laboratory results were normal. Magnetic resonance imaging revealed a hemorrhagic lesion of 3 mm in diameter in the left paramedian medulla oblongata with slight perifocal edema (Fig. 1). Contrast-enhanced magnetic resonance angiography showed no evidence of any vertebral or intracranial artery dissection. Hereafter the patient was transferred to the intermediate care unit for further observation and was started on ceftriaxone and metronidazole to cover for possible contamination of the cerebrospinal fluid and brain by enoral microflora. She made an uneventful recovery, which allowed transfer to the neurology ward on the following day. Six days after admission, the patient was discharged from the hospital without a neurological deficit or subjective discomfort. To what extent the primordial desire was influenced by this experience was not ascertainable. Neural therapy was first described by Walter and Ferdinand Huneke in 1925 [1]. Although lacking scientific evidence, it is a widely used complementary medical method in Europe to treat acute and chronic pain syndromes, circulatory, autoimmune, and vegetative dysregulations [1]. Neural therapy uses injections of local anesthetics into or close to pathologically altered body regions such as scars, peripheral nerves, autonomic ganglia, glands, or other trigger points. Numerous adverse events have been reported following neural therapy, particularly when deep structures or internal organs were targeted [2–4]. So far, only one case of central nervous system hemorrhage has been reported. In 1979, Heyll and C. A. Schmittinger M. W. Dunser Department of Intensive Care Medicine, Inselspital, Bern Medical University, Bern, Switzerland

脳幹出血患者の予後予測

We evaluated the prognosis of patients 6 months after a brain-stem hemorrhage, based on clinical findings obtained at admission and 1 month after commencement of rehabilitation. Seventeen patients who were admitted to our hospital during the past 2 years with a brain-stem hemorrhage were evaluated at admission and 1 month later, based on the National Institute of Health Stroke Scale (NIHSS), Functional Independence Measure (FIM), modified Rankin Scale (mRS), motor paralysis, sensory disturbance, ataxia, blood pressure, and swallowing. To retrospectively examine these evaluation items, the patients were divided into 2 groups: patients who became ambulatory within 6 months (Group A) and patients who did not become ambulatory (Group B). Significant differences were confirmed between groups regarding NIHSS, FIM points, motor paralysis, sensory disturbance, and ataxia at admission and regarding motion capability and mRS at 1 month. At admission, Group A had NIHSS of ≤8.5 (lower limit: 16), FIM of ≥60.7 points (24 points), motor paralysis of Stage IV or higher, and normal to mild sensory disturbance. Moreover, they could retain the sitting position within 1 month, with mRS of Grade 3 or higher (Grade 4 or higher), which indicates their motion capability. Many patients with severe ataxia became ambulatory. Based on these findings, 6-month recovery of patients with brain-stem hemorrhage could be determined based on their achievements at 1 month.

Factors affecting outcome of intracerebral hemorrhage in patients undergoing chronic hemodialysis

To date, despite a markedly high incidence of intracerebral hemorrhage (ICH) in patients with end-stage renal disease, only few studies have focused on factors that affect patient's prognosis. To elucidate these factors, we retrospectively investigated 22 consecutive patients who had chronic renal failure, were maintained by hemodialysis (HD), had suffered from ICH, and were hospitalized and treated in our institute from 2006 to 2008. Hematoma volume, blood pressure on admission, blood pressure 3 days after ICH onset, and neurological deterioration significantly affected patient mortality. Progression of neurological symptoms during HD was observed often in patients with hematoma of more than 60 mL or in patients with pontine hemorrhages. Age, gender, duration of HD, anti-platelet or anticoagulant therapies, or maximal dose of nicardipine did not affect patient's prognosis. Based on this study we conclude that controlling blood pressure on admission and within 3 days after onset of ICH may be the most important factor that would improve patient's prognosis. Further, special care might be required for patients with large hematomas (more than 60 mL) or those with brainstem hemorrhages, because progression of neurological symptoms occurs often in such patients.

Reversible sensorineural hearing loss with normal brainstem auditory evoked potentials in pontine hemorrhage due to capillary telangiectasia

Capillary telangiectasias are vascular malformations most commonly found in the pons that are rarely associated with hemorrhage. We describe a unique case of pontine capillary telangiectasia causing central brainstem hemorrhage leading to reversible sensorineural deafness associated with a normal brainstem auditory evoked response.

Cognitive dysfunction in a patient with brainstem hemorrhage

A 54-year-old, right-handed male suffered sudden onset of vertigo and vomiting. He was diagnosed with brainstem hemorrhage, and treatment was administered. After the vertigo improved, he showed disturbance of attention and anterograde amnesia. Magnetic resonance imaging revealed a hematoma across the pons on both sides, but no lesions were obvious in the cerebellum or the cerebrum. Single photon emission tomography showed decreased perfusion not only in the brainstem but also in the bilateral frontal and temporal lobes. Amnesia and executive dysfunction decreased in the 8 months following the stroke onset, with improvement in regional cerebral blood flow to the frontal and temporal lobes. These findings suggest that a hemorrhage in the pons caused diaschisis resulting in a secondary reduction of activity in the cerebral cortex and the occurrence of cortical symptoms.

Hirnstammblutungen

Brainstem hemorrhage is a neurological emergency. Early and correct recognition, appropriate emergency treatment considering typical complications and the allocation to appropriate diagnostics and treatment are crucial for the functional outcome. Etiology, symptoms, typical complications and initial diagnostics of brainstem hemorrhage will be discussed. Erroneously prognosis is thought to be poor, but good functional recovery is possible as illustrated by 2 case histories. Possible reasons for this negative prognostic estimation will be discussed as well as the hereby resulting consequences on communication with relatives and on preclinical and clinical emergency therapy.

The current situation and issues of the surgical treatments result for brain hemorrhage

The aim of this study to evaluate treatment results for brain hemorrhage at Kyorin University Faculty of Medicine. We treated consecutive 152 cases of brain hemorrhage. We studied to examine their treatment contents and mRS (modified Rankin scale) at the time of their discharge.The surgeries were performed for 53 cases. Outcome of cerebellar and subcortical hemorrhage was relatively satisfactory compared to other bleeding sites and mRS: 0–2 was recognized in about 40% of the cases. In contrast, outcome of brain-stem hemorrhage was poor, and it caused 30% of overall mortality.There has been no specific evidence regarding surgical intervention for brain hemorrhage. As for putaminal hemorrhage which is likely to develop pyramidal tract disorder, the functional prognosis tends to deteriorate easily compared to cerebellar and subcortical hemorrhage, and it was considered to be the limit for judging prognostic evaluation based on functional assessment. Decisions for surgical indication for severe cases and significance of lifesaving effects include important life ethical issues, which are to be worked on in order to establish decision making methods which can be effective with limited time and manpower and to combine them with the development and application of regenerative medicine in future.

Central Alveolar Hypoventilation and Failure to Wean from the Ventilator

A 66-year-old woman was transferred to our respiratory care unit for “failure to wean” from the mechanical ventilator. Initially admitted to another hospital for worsening headaches and nausea, she awoke with dysphagia, dysphonia, hypothermia (body temperature 93°F), and sinus bradycardia (heart rate ∼40); she was later found to be apneic and required intubation for hypercapnic respiratory failure. Personnel at the other hospital attempted twice to extubate the patient, but she was unable to clear her secretions and developed hypercapnia, leading to transfer to our facility for further management. Medical history included smoldering myeloma, migraine headaches, and hypothyroidism. Her thyrotropin stimulating hormone (TSH) level was normal. Arterial blood gas (ABG) drawn while the patient was awake revealed a mildly elevated PCO2 of 45, but, during sleep, the level increased to the mid-60s. Of note, the patient was able to normalize her daytime PCO2 by voluntarily increasing her ventilation. She also had periodic apneas while sleeping, triggering ventilatory alarms while she was on pressure-support mode and, therefore, requiring a back-up rate. She also had significant bradyarrhythmias during sleep, with sinus pauses of approximately 4 seconds. The patient had a tracheostomy tube, through which she was ventilated during the night and that was corked during the day. Except for dysphonia and bilateral Babinski signs, the neurologic examination, including the cranial nerves and cerebellar exam, revealed no abnormalities. The findings of the chest radiograph and maximal respiratory pressures performed at the bedside were normal. Electromyogram of the diaphragm and phrenic nerves revealed no evidence of a neuromuscular disorder. A central cause for hypoventilation was suspected; a brain magnetic resonance imaging scan revealed abnormal, bilateral, symmetric T-2 hyperintensities within the lateral medulla (Figure 1) with no clear cause. Figure 1 Presence of abnormal, symmetrical, bilateral lesions in the lateral medulla (white arrow). What is the diagnosis? Answer: Acquired central alveolar hypoventilation due to bilateral medullary lesions Congenital central alveolar hypoventilation is a rare but severe condition that usually affects infants. The syndrome is characterized by hypoventilation that is worse during sleep than wakefulness and is unexplained by primary pulmonary, neurologic, or metabolic disease.1–3 The hypoventilation is often worse during non-rapid eye movement (NREM) sleep than during rapid eye movement (REM) sleep because the control of breathing is entirely metabolic during NREM sleep.4 Patients with congenital central hypoventilation syndrome also have abnormalities of autonomic nervous system function, such as Hirschsprung disease. A suspected diagnosis of congenital central hypoventilation syndrome is confirmed by genetic testing for mutations in the PHOX2b gene.5,6 Acquired central alveolar hypoventilation has similar clinical features and reportedly results from lesions affecting the medullary centers that specifically control respiration.7, 8 The acquired form has been reported to occur secondary to brainstem infarction, hemorrhage, encephalitis, demyelinating diseases, and nonspecific anoxic insult.7 Ventilatory support at night may correct the hypoventilation; however, patients with severe manifestations may require ventilatory support during the day as well. Medications such as acetazolamide, levothyroxine, and clomipramine have been tried with minimal clinical benefit. Due to the precarious position of the medullary lesions in our patient, biopsies were not performed. She developed pancytopenia and was treated with cyclophosphamide and intravenously administered methylprednisolone after the diagnosis of multiple myeloma was confirmed. The bilateral medullary lesions were assumed to be related to myeloma and improved with chemotherapy. Though the symptoms of dysphagia and dysphonia improved, the hypoventilation and sinus bradycardia persisted while the patient was asleep. Central sleep apnea was documented by a split-night overnight polysomnogram with the tracheostomy tube corked. The apnea-hypopnea index (AHI) was 83 per hour. The very high AHI appeared to be due to repetitive short central apneas (Figure 2A). This was treated with a bilevel positive pressure airway device with a spontaneous timed (BPAP-ST) mode (Figure 2B). Because the patient's symptoms responded very well to BPAP-ST (Figure 2B) with a back-up rate of 14 breaths per minute, the tracheostomy tube was removed before the patient was transferred to a skilled nursing facility for further care and rehabilitation. Figure 2 (A) Compressed diagnostic portion of the polysomnogram focusing on the respiratory and electrocardiogram (ECG) channels (120-s epoch) showing repetitive short central apneas associated with bradyarrhythmias. A breathing pattern of closely grouped series ...

Iron-Oxide Nanoparticles as Magnetic Resonance Contrast Agents: Expanding Their Potential Beyond Iron Replacement Therapy.

Abstract 1998Poster Board I-1020Ferumoxytol (Feraheme™), an iron oxide nanoparticle, was approved as an iron replacement product for the treatment of iron deficiency anemia in adult patients with chronic kidney disease (CKD) (United States Food and Drug Administration, June 2009). Potential uses of ferumoxytol extend beyond the treatment of iron deficiency anemia and may have important implications for hematology-oncology. Following administration, iron oxide nanoparticles initially serve as blood pool agents which is an ideal characteristic for assessing blood volume and blood flow. Subsequently, because of their long plasma half-life and ability to target inflammatory cells in the central nervous system (CNS), these compounds serve as excellent anatomic imaging agents. We have given adult patients with malignant CNS tumors and other CNS inflammatory lesions, ferumoxytol (n = 68) and ferumoxytran-10 [Combidex™' (n = 97) as magnetic resonance (MR) contrast agents, on Institutional Review Board approved protocols. We hypothesize that iron oxide nanoparticles provide additional MR imaging information which may be beneficial in the differential diagnosis and in monitoring therapy in patients with CNS lesions. This report focuses on our experience with 16 patients with central nervous system lymphoma (CNSL). The patients underwent brain MR with gadolinium followed in 10 ± 9 days (mean ± SD) by MR with ferumoxytran-10 (2.6 mg/kg, intravenous [IV' over 30 min) (n = 11) or ferumoxytol (510 mg, IV bolus) (n = 5). Findings of interest include: 1) in 3 patients, MR with iron oxide nanoparticles showed additional areas of CNS enhancement when compared with MR with gadolinium; 2) in 2 patients, increased enhancement patterns with iron oxide nanoparticles were diagnostically useful in distinguishing lymphoma from non-lymphomatous inflammatory conditions; and 3) in 2 patients with histories of CKD and post-renal transplant lymphoproliferative disorder confined to the CNS, MR with ferumoxytol was used to monitor therapy, as this agent appears to avoid the risk of nephrogenic systemic fibrosis (NSF), which is associated with exposure to gadolinium-containing contrast agents. Of note, in 1 patient with thromboembolic complications during therapy, brain MR enhancement was seen approximately 5 weeks after ferumoxytol infusion. The enhancement was initially interpreted as a hemorrhagic brainstem event and led to insertion of a superior vena cava filter rather than anticoagulation. This is an example of MR alteration which generally resolves in 3 to 5 days following ferumoxytol, however in rare instances may persist for up to 3 months. In summary, in addition to their use as iron replacement agents in iron deficiency anemia, the use of iron oxide compounds as MR contrast agents compliment the use of gadolinium. These agents offer exciting potential in the differential diagnosis of CNS inflammatory lesions versus CNSL, in monitoring CNS therapy, and may provide dual benefit in patients with CKD by possibly eliminating the gadolinium-associated risk of NSF. Disclosures:Off Label Use: Feraheme is an iron replacement product indicated for the treatment of iron deficiency in adult patients with chronic kidney disease (CKD).

Atypical Acute Hemorrhagic Leukoencephalitis (Hurst’s disease) Presenting with Focal Hemorrhagic Brainstem Lesion

Acute hemorrhagic leukoencephalitis (AHL; Hurst's disease) is a rare, severe, inflammatory CNS disease that is typically diffuse, multifocal and associated with petechial hemorrhage. The objective of this study is to report the clinical, radiologic, and pathologic findings in a fatal AHL case with focal brainstem involvement and gross hemorrhage. Patient evaluation in a tertiary neurointensive care unit with serial brain magnetic resonance imaging (MRI) and neuropathological examination on autopsy were performed. The patient presented with mild, then rapidly worsening, brainstem impairment to a locked-in syndrome. Brain MRI demonstrated an isolated gadolinium enhancing brainstem lesion that enlarged dramatically over weeks and was associated with gross hemorrhage and necrosis. The patient died despite aggressive treatment with intravenous corticosteroids and plasma exchange. Autopsy demonstrated the isolated severe necrotic lesion consistent with AHL. AHL may present as a solitary brainstem lesion with gross hemorrhage and should be considered in patients with isolated enhancing brainstem lesions. AHL may be fatal even despite early, aggressive immunomodulatory therapy.

Three-Year Survival and Stroke Recurrence Rates in Patients With Primary Intracerebral Hemorrhage

There are few studies on the prognosis after primary intracerebral hemorrhages, and they reported big differences in mortality rates. Our aim was to evaluate mortality and stroke recurrence rates in relation to hemorrhage characteristics, demographic and clinical factors, in a large unselected patient cohort. We analyzed consecutive cases of first-ever primary intracerebral hemorrhages from 1993 to 2000 in a prospective stroke register covering the Malmö region, Sweden (population approximately 250 000). Mortality rates during 28 days and 3 years of follow-up and recurrence rates were analyzed. A total of 474 cases were identified (46% women). In patients <75 years of age, 20% of the women and 23% of the men died within 28 days (P=0.38). The corresponding figures in patients >or=75 years were 26% and 41%, respectively (P=0.02). Male sex was an independent risk factor both for 28-day (OR, 1.5; 95% CI, 1.008 to 2.2) and 3-year mortality (OR, 1.7; 95% CI, 1.3 to 2.3). Other independent predictors of death were high age, central and brain stem hemorrhage location, intraventricular hemorrhage, increased volume, and decreased consciousness level. The recurrence rate was 5.1 per 100 person-years, 2.3 per 100 person-years for intracerebral hemorrhage and 2.8 per 100 person-years for cerebral infarction. Only age >65 years was significantly related to recurrent stroke. Women had better survival than men after primary intracerebral hemorrhages. The difference is largely explained by a higher 28-day mortality in male patients >75 years. However, the underlying reasons are yet to be explored.

Histopathological changes of the hippocampus neurons in brain injury.

The glial fibrillary acidic protein (GFAP) is known as a peculiar marker of mature astrocytes of the central nervous system (CNS). However, we found distinct immunopositivity to a monoclonal anti-GFAP reagent in the hippocampus neurons in head injury fatalities. The present study investigated the neuronal and neuroglial GFAP-immunopositivity in the hippocampus in a series of head injury cases, which included acute and subacute/delayed deaths (n=17 and n=73, respectively), and acute cardiac death (n=13), delayed death due to multiple organ failure from non-head injury (n=6), and pneumonia (n=9) cases were examined as controls. GFAP-immunopositivity in the neurons was frequently observed in CA4, CA3 and CA2 regions in cases of subacute/delayed head injury death that showed marked brain swelling accompanied by secondary brain stem hemorrhages, showing an inverse relationship to that in astrocytes. These findings suggest possible induction of GFAP or a related protein in hippocampus neurons depending on the severity of brain swelling following head injury.

Central Hyperthermia in Acute Stroke

Background: Central hyperthermia is an unresolved riddle; this study tries to define its characteristics. Methods: Seventy-four previously healthy patients who developed hyperthermia (≥39°C) within 24 h after stroke onset were enrolled. The lesion sites, nature of stroke, and clinical features were studied. Results: Brainstem hemorrhage was the most common cause of hyperthermia (64%), followed by putamino-thalamus hemorrhage (24%), cerebellum hemorrhage (4%), large cortical infarct (4%), basilar artery occlusion (3%), and intraventricular hemorrhage (1%). Whatever the site of the lesion, all patients had brainstem involvement either by direct destruction or indirect compression. Three fourths of the patients reached 39°C within 12 h of stroke, and 82% arrived at the maximum within 24 h. A peculiar finding of central hyperthermia was the marked fluctuation in body temperature within a short period, which was more severe initially then decreased gradually. Leukocytosis was seen in 60%, but shift to the left was rare (1%). The prognosis was grave, nearly 70% of the patients expired within 1 month, especially those with a temperature of >41°C or those who reached 39°C within 6 h after onset of stroke, or those who had severe fluctuations in temperature. Conclusions: Central hyperthermia is characterized by rapid onset of high fever, marked temperature fluctuation and high mortality. It is likely associated with brainstem (mainly pons) damage by direct destruction or indirect compression.

Prediction of fatal intracranial hemorrhage in patients with acute myeloid leukemia

Background: Intracranial hemorrhage (ICH) is the second leading cause of mortality in patients with acute myeloid leukemia (AML). However, the prognostic factors for ICH in AML patients are still under investigation.Patients and methods: A total of 841 AML patients admitted to the Department of Internal Medicine from January 1995 to December 2007 were enrolled in this study.Results: There were 51 patients with ICH, median age of 51 (range 17–86), including 12 patients diagnosed as acute promyelocytic leukemia. Forty-three patients were refractory/relapsed status. ICH was localized in the supratentorium (44 cases), basal ganglion (9), cerebellum (5), and brainstem (4). Twenty-one patients had multiple sites. Thirty-eight patients had intraparenchymal hemorrhage, 16 subarachnoid hemorrhage (SAH), 10 subdural hemorrhage, and one epidural hemorrhage (EDH). Hemorrhage ruptured into the ventricles in 13 patients. Thirty-four patients (67%) died of ICH within 30 days of diagnosis. Multivariate analysis revealed four independent prognostic factors, prolonged prothrombin time international normalized ratio >1.5 (P<0.001), brainstem hemorrhage (P=0.001), SAH (P=0.017), and EDH (P=0.014). Other clinico-laboratory data had no impact on 30-day survival.Conclusions: ICH has high morbidity and mortality in AML. Early detection and aggressive correction coagulopathy may prevent the catastrophic event. Prompt image study for locations and types of ICH can predict outcomes.

Survival with good outcome after cerebral herniation and Duret hemorrhage caused by traumatic brain injury

Brainstem hemorrhage can occur as a primary or secondary event in traumatic brain injury (TBI). Secondary brainstem hemorrhage that evolves from raised intracranial pressure and transtentorial herniation is referred to as Duret hemorrhage. Duret hemorrhage following TBI has been considered an irreversible and terminal event. The authors report on the case of a young adult patient with TBI who presented with a low Glasgow Coma Scale score and advanced signs of cerebral herniation. She underwent an urgent decompressive hemicraniectomy for evacuation of an acute epidural hematoma and developed a Duret hemorrhage postoperatively. In accordance with the family's wishes, aggressive TBI monitoring and treatment in the intensive care unit was continued even though the anticipated outcome was poor. After a lengthy hospital course, the patient improved dramatically and was discharged ambulatory, with good cognitive functioning and a Glasgow Outcome Scale score of 4. Duret hemorrhage secondary to raised intracranial pressure is not always a terminal event, and by itself should not trigger a decision to withdraw care. Aggressive intracranial monitoring and treatment of a Duret hemorrhage arising secondary to cerebral herniation may enable a good recovery in selected patients after severe TBI.