Brainstem Hemorrhage Research Articles

Brainstem hemorrhage is uncommon and is associated with high morbidity, mortality, and prolonged hospitalization.

Objectives:To determine the frequency, risk factors, and outcomes of patients with brainstem hemorrhage in stroke center at King Abdulaziz Medical City, Riyadh.Methods:A retrospective, observational cohort study including all patients with brainstem hemorrhage from January 2014 to December 2017. The clinical presentation, location of hemorrhage, complications and clinical outcomes were analyzed.Results:Of 1921 stroke patients, 219 had hemorrhagic stroke (11.4%), of whom only 10 (4.6%) had brainstem hemorrhage, comprising 0.5% of all stroke patients. All patients were men; mean age was 58.5 years. Most frequent presenting symptoms were headache (70%), unilateral weakness (60%), and loss of consciousness (50%). All patients had hemorrhage in pons, 5 had concomitant cerebellar hemorrhage (50%), one had medullary hemorrhage, and one midbrain hemorrhage (10% each). Mean ICU stay was 17 days; mean hospital stay was 58 days. At the time of discharge, three (30%) had mRS of 0-2, 5 (50%) had mRS of 3-5, whereas 2 (20%) had died. Glasgow coma scale (GCS) of >8 at presentation was associated with a good outcome at three months (p=0.03). Presentation within six hours of symptom onset (p=0.233), hypertension on presentation (p=0.233), and age less than 60 years (p=0.065) did not affect discharge outcomes.Conclusion:Brainstem hemorrhage occurred in 0.5% of all stroke patients. It was associated with high morbidity and mortality. Low Glasgow Coma Scale at presentation was associated with poor outcomes.

Emergence of vanA-Type Vancomycin-Resistant Enterococcus faecium ST 78 Strain with a rep2-Type Plasmid Carrying a Tn1546-Like Element Isolated from a Urinary Tract Infection in China.

PurposeThe emergence of vancomycin-resistant enterococci (VRE) dramatically narrows therapeutic options. Although the prevalence of VRE in China has maintained a low level, VRE outbreaks have been reported in some tertiary hospitals in the developed areas of China. The clonal background of vanA-positive Enterococcus faecium strains has not been well characterized in China. Here, we report the whole-genome sequence of a vanA-type vancomycin-resistant E. faecium belonging to sequence type (ST) 78 isolated from a urinary tract infection in China.Patients and MethodsA vancomycin-resistant E. faecium was isolated from a 66-year-old male patient diagnosed with brainstem hemorrhage. Antibiotic susceptibility assays were performed according to the guidelines of the Clinical and Laboratory Standards Institute (CLSI). Complete genome sequencing was performed using both the HiSeqTM 4000 platform and the MinION platform. Plasmid, genomic and phylogenetic relationship analysis were further performed.ResultsE. faecium VRE1 was resistant to all antimicrobials tested except for tetracyclines and oxazolidinones. The whole genome of E. faecium VRE1 was composed of one chromosomal DNA and four plasmids. Two virulence genes and five antimicrobial resistance genes were identified. In silico multilocus sequence typing (MLST) showed that it belonged to ST78 (clonal complex CC17), a well-known epidemic clone that is widespread in Europe and the United States. Three antimicrobial resistance genes, including aminoglycoside resistance genes ant(6)-Ia and aph(3ʹ)-III; and glycopeptide resistance gene vanA, were located on a rep2-type plasmid carrying a Tn1546-like element that has not been reported. The most closely related strain harboring a similar plasmid backbone was recovered from fodder sample in China that differed by 178 cgMLST loci.ConclusionOur study characterizes the genomic feature of a vancomycin-resistant E. faecium ST78 strain harboring a vanA-carrying plasmid in China. The ST78 clonal group possessed the potential to emerge as a successful vanA-carrying epidemic lineage in China.

Imaging diagnosis of acute necrotizing encephalopathy of childhood

Objective To analyze the imaging features of acute necrotizing encephalopathy of childhood (ANEC), and try to investigate its potential clinical value. Methods The clinical and imaging findings of 22 children from Wuhan Children′s Hospital diagnosed with ANEC were retrospective analyzed, from January 2013 to October 2018. All children were presented with hyperpyrexia and rapidly developed into rapid neurological deterioration after prodromic infection. In the initial imaging examination, all patients underwent head MRI, and 6 cases underwent additional head CT. During MRI follow-up, 4 cases were lost, 6 cases were followed up only once ( 14 days).The presence of hemorrhage and encephalomalacia in thalamus, brainstem, white matter and basal ganglia was carefully investigated throughout the follow-up. Results For the imaging manifestations of ANEC, bilateral thalamus were involved in all children. Other symmetrical lesions included white matter (14 cases), basal ganglia (15 cases), brainstem (16 cases), cerebellum (9 cases), corpus callosum (2 cases) and hippocampus (1 case). There were 3 children with asymmetric lesions, which were found in white matter (2 cases) and cerebellum (1 case).In the acute phase, the most typical head MRI showed tricolor pattern(high signal intensity in the center with surrounding low-signal, and hyperintense signals in the periphery of thalamus) or bicolor pattern(low signal in the central thalamus with surrounding hyperintense signals) of the thalamus on the apparent diffusion coefficient (ADC) imaging. Hemorrhage and encephalomalacia on MRI may suggest poor clinical outcome. Conclusions ANEC is a rapid progressive encephalopathy with typical imaging features. Hemorrhage and encephalomalacia on MRI may be associated with poor prognosis. Key words: Brain diseases; Child; Magnetic resonance imaging; Thalamus

A novel surgical technique for spontaneous intracerebral hematoma evacuation.

Stereotactic removal of intracerebral hematoma is a routine procedure for treating hypertensive intracerebral hemorrhage, but the complex sequence of operations limits its adoption. We explored the application of a novel surgical technique for the removal of spontaneous intracerebral hematomas. The surgical technique based on computed tomography (CT) images was used in hematoma projection and surgical planning. Markers placed on the scalp based on an Android smartphone app allowed the installation of a stereotactic head frame to facilitate the selection of the best trajectory to the hematoma center for removing the hematoma. Forty-two patients with spontaneous intracerebral hemorrhage were included in the study, including 33 cases of supratentorial hemorrhage, 5 cases of cerebellum hemorrhage, and 4 cases of brain stem hemorrhage. The surgical technique combined with the stereotactic head frame helped the tip of the drainage tube achieve the desired position. The median surgical time was 45 (range 25-75)min. The actual head frame operating time was 10 (range 5-15)min. Target alignment performed by the surgical technique was accurate to ≤ 10.0mm in all 42 cases. No patient experienced postoperative rebleeding. In 33 cases of supratentorial intracerebral hemorrhage, an average evacuation rate of 77.5% was achieved at postoperative 3.1 ± 1.4days, and 29 (87.9%) cases had a residual hematoma of < 15ml. The novel surgical technique helped to quickly and effortlessly localize hematomas and achieve satisfactory hematoma removal. Clinical application of the stereotactic head frame was feasible for intracerebral hemorrhage in various locations.

Clinical Profile and Predictors of Outcome in Spontaneous Intracerebral Hemorrhage from a Tertiary Care Centre in South India.

Background. This article attempts to evaluate the clinical profile and outcome determinants following hypertensive SICH in a South Indian population. The study represents the largest series of SICH reported from a single centre in India. Materials and Methods. Prospective data collection and analysis of patients with SICH admitted to our centre between 1st January 2015 and 31st December 2018. The variables analysed include: age, sex, comorbidities, Glasgow coma score (GCS) on admission, radiological features, treatment modality, and outcome at three months. Modified Rankin score (mRS) was used to assess the outcome at discharge and three months. Results. Our study group of 905 patients included 638 males and 267 females and the mean age at presentation was 58.10 ± 12.76 years. The study group included 523 patients (57.8%) previously diagnosed hypertensive, of whom 36.3% (n = 190) were on irregular medication. The most frequent locations of hematoma were basal ganglia (478), thalamus (202), lobar (106), cerebellar (61), brainstem (31), and primary intraventricular haemorrhage (27). Secondary intraventricular extension was seen in 425 (47%) patients on admission. The mean volume of the clot on admission was 23.45 ± 19.79 ml, and clot progression was seen in only 46 (5.08%) cases. Surgical evacuation through craniotomy was done in 147 (16.8%) patients, and external ventricular drainage (EVD) was placed in 56 (6.2%) patients. Overall 3−month mortality was 30.1% (266 patients). On the last follow up a favorable outcome (mRS 0−3) was observed in 412 (45.53%) patients and a poor outcome (mRS 4−5) in 207 patients (22.87%). Independent predictors of mortality are Age >70 (p = <0.001, OR 4.806, 95% CI 3.064–7.54), admission GCS <8 (p = <0.001, OR7.684, 95% CI 5.055#x2013;11.68), and Hematoma volume >30 ml (p = <0.001, OR 2.45, 95% CI 1.626–3.691). Intraventricular haemorrhage was an additional poor outcome predictor (p < 0.015, CI 1.105–2.585). Surgical evacuation reduced mortality in the group, but morbidity rates remained the same. Conclusions. SICH predominantly affects a younger population in India in comparison to the Western society. Elderly age, poor GCS on admission, clot volume above 30 ml and intraventricular extension remain the most consistent predictors of death and poor outcome. Further studies are needed to assess the risk of SICH among hypertensive patients and to prognosticate the outcome after SICH using novel predictors, including biomarkers.

Early tracheostomy is associated with better prognosis in patients with brainstem hemorrhage.

Brainstem hemorrhage is presumed to be invariably associated with a poor prognosis in people with spontaneous hypertensive cerebral hemorrhage. The optimal timing of tracheostomy placement in brainstem hemorrhage patients, who generally require endotracheal intubation for airway protection, remains uncertain. Our research aim was to analyze the impact of early tracheostomy versus late tracheostomy on brainstem hemorrhage patients related outcomes and prognostic factors at 30 days. We identified early tracheostomy and how it could benefit the patients with brainstem hemorrhage and ameliorate the predictors of functional recovery at 30 days. Data on 136 patients with brainstem hemorrhage and Glasgow Coma Scale score ≤ 8, were retrospectively collected from 2012 to 2019. Patients were divided into the early tracheostomy group and the late tracheostomy group. Patients in the early tracheostomy group had a significantly lower neurosurgical intensive care unit stay (both overall and survival) compared with the late tracheostomy group (15.6 days vs. 19.0 days, P = 0.041, overall and 14.5 vs. 19.5 days, P = 0.023, survival). Also, the good outcomes (modified Rankin Score ≤ 3) were higher in the early tracheostomy group (P = 0.036). Multivariate analysis demonstrated that less hemorrhagic volume, high Glasgow Coma Scale score on admission, young age, and early tracheostomy were significantly associated with a better 30-day functional outcome. In conclusion, an early tracheostomy in patients with brainstem hemorrhage can reduce neurosurgical intensive care unit stay, and in addition to improvements in prognosis at 30 days.

Computed Tomography-Guided Virtual Stereotactic Puncture and Catheter Drainage for a Brainstem Pontine Hemorrhage: A Case Report

Background: Patients with severe hypertensive brainstem hemorrhages have poor prognoses if they only receive conservative medical management. In contrast, aggressive operative interventions may decrease the morbidity and mortality in such patients. These operative treatments include craniotomy for evacuation of the hematoma, stereotactic positioning, and neuronavigational-guided hemorrhage puncture and drainage. Here, we report a novel and relatively simple procedure to achieve satisfactory outcomes in a patient with a brainstem pontine hemorrhage. Case Presentation: A 53-year-old man who was diagnosed with brainstem pontine hemorrhage. On hospital day 6, he underwent CT-guided, virtual stereotactic puncture and catheter drainage of this brainstem pontine hemorrhage. Medical treatments were continued after this procedure. On postoperative day 16 (hospital day 22), the patient was discharged from the hospital, awake and able to answer questions appropriately. Muscle strengths were grades V and IV for the left and right extremities, respectively. The patient was continued with active rehabilitation and achieved a Barthel index of 85 points at one month after the percutaneous drainage procedure. Conclusion: CT-guided, virtual stereotactic percutaneous transcranial puncture and catheter drainage for brainstem pontine hemorrhages has obvious potential advantages and offers a possible alternative to achieve the best outcomes with minimal operative trauma compared to open microcraniotomy.

Intracerebral Hemorrhage of Brainstem in triple pregnancy after in vitro fertilization by receiving Ovum Donation: A case report and review

Deliveries prior to 28 weeks’ gestation (extreme preterm birth) pose a global health concern, according to the World Health Organization (WHO). Extreme preterm birth is associated with several complications in the newborn and management in neonatal intensive care unit would incur high expenses.

Efficiency and influence factors of stereotactic precision aspiration in the treatment of primary brain stem hemorrhage

Objective To investigate the efficiency and influence factors of stereotactic precise aspiration in treatment of primary brainstem hemorrhage. Methods A total of 47 patients with primary brainstem hemorrhage who underwent stereotactic precision aspiration from March 2014 to September 2018 at Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine were enrolled and their clinical data were collected. Surgical approach was chosen according to the location of the pons where the hematoma was located. Meanwhile, patients with postoperative hydrocephalus underwent external ventricular drainage. Intracranial residual hematoma volume was evaluated by CT scan on the first day post operation. Further follow-up at 30 days post surgery by phone or clinic was conducted to confirm the status of all patients. Univariate analysis and logistic regression analysis were performed to investigate the clinical factors associated with survival of patients.(ROC) curvecurve was further drawn to judge its predictive value. Results Among 47 patients, no death was reported during the operation. CT scan at day 1 post surgery showed that the average of intracranial residual hematoma volume in 47 patients was (2.7±0.9) ml (0-15.5 ml), and the clearance rate of hematoma was (75.0±24.2)%. In this series, 7 cases died and 40 survived within 30 days. The mortality rate was 14.9%. Univariate analysis revealed that classification of hematoma was the factor influencing postoperative mortality (χ2=13.689, P=0.033), which was confirmed by multiple logistic regression analysis (OR=0.053, 95% CI: 0.744-0.992, P=0.004). Further ROC curve results showed that the sensitivity and specificity of hematoma classification in predicting the prognosis of patients were 85.7% and 82.5%, respectively. Conclusions The new classification of brainstem hematoma is suitable for surgical planning and beneficial for prediction of the 30-day mortality. Key words: Cerebral hemorrhage; Brain stem; Treatment outcome; Factor analysis, statistical

Operative versus non-operative treatment of traumatic brain injuries in patients 80years of age or older.

Traumatic brain injury (TBI) in older adults is an increasing issue in modern medicine. Nevertheless, it remains unclear which patients presenting with TBI and 80years of age or older benefit from an operative treatment. The aim of this study was to explore the effect of an operative treatment in isolated TBI patients ≥ 80years of age. Data were derived from the TraumaRegister DGU® from 2002 to 2016. Inclusion criteria were ≥ 80years of age, an Abbreviated Injury ScaleHead (AIS) ≥ 3, and an AISNon-Head ≤ 1. The cohort was split in operatively and non-operatively treated patients, and outcome was assessed at discharge using the Glasgow Outcome Scale (GOS). A favorable outcome was defined as a GOS of 4 or 5. A total of 1.693 patients (431 operatively and 1.262 non-operatively treated patients) were analyzed. Mortality rate was 54.4% (687 patients) in the non-operative group and 49.4% in the operative group. Simultaneously, there were more patients discharged with a GOS 2 (persistent vegetative state) in the operative group (7.9%, 34 patients) than in the non-operative group (1.0%, 13 patients). An analysis of the operatively treated patients showed an association between a higher mortality risk and brainstem hemorrhage (p = 0.04), fixed pupils (p = 0.001), initial intubation (p = 0.03), and an AISHead of 5/6 (p = 0.03). Patients 80years of age or older seem to benefit from an operative treatment regarding mortality rate. However, there has been a higher rate of a poor neurological outcome particularly with regard to persistent vegetative state in the operative treatment group at discharge.

Application of a 3D-Printed Navigation Mold in Puncture Drainage for Brainstem Hemorrhage

BackgroundBrainstem hemorrhage is an acute and severe neurosurgical disease. Cerebral hemorrhage is surgically treated via hematoma puncture drainage because of its minimally invasive nature. However, the placement of puncture must be extremely accurate due to the special anatomical location of the brainstem and its physiological functions. The present study aimed to evaluate whether the application of a three-dimensional (3D)-printed navigation mold achieved good outcomes in the surgical treatment of brainstem hemorrhage. Material and methodsThe present study included seven patients (three men and four women aged 40-56 y) who underwent 3D print–assisted hematoma puncture drainage between June 2016 and March 2018 at Binzhou Medical University Hospital. The amount of brainstem hemorrhage was 15-47 mL. We analyzed the basic surgical conditions, deviation distance, and postoperative clinical improvement. ResultsIn all cases, the operation was completed successfully; no patient died or contracted an infection intraoperatively. The end of the puncture tube was located in the hematoma cavity in all cases. The deviation distance ranged from 2.5 to 7.2, and this distance gradually reduced with improvements in the technique. The hematoma drainage achieved satisfactory postoperative outcomes, with improvements in symptoms such as respiratory failure and hyperthermia. ConclusionsUse of a 3D-printed navigation mold for puncture drainage of brainstem hemorrhage realized the purpose of individualized and precision medicine, which is important in maintaining the vital signs of patients with severe brainstem hemorrhage.

Use of CT-Scan for Predicting Mortality of Acute Intracerebral Haemorrhagic Stroke within 7 and 28 Days

Background: Recognition of factors affecting morbidity and mortality of a disease helps in the proper management of a disease. CT scan of Brain is an essential investigation for all stroke patients. Identifying different characteristics of the CT findings of stroke patients which affect morbidity and mortality will help in the specific management of stroke patients. Thus this study was done to identify such factors from CT scan of Brain which will help in the proper management of stroke patients.&#x0D; Objectives: The aim of this present study was to determine the 7th and 28th days’ mortality rate of acute intracerebral hemorrhagic stroke and to determine the predictors of mortality.&#x0D; Methodology: Consecutive CT scan proven stroke patients following ICH were studied in the department of Radiology &amp; Imaging at Rajshahi Medical College, Rajshahi, Bangladesh in collaboration with the Department of Neurology of Rajshahi Medical College, Rajshahi from January 2012 to December 2013. Site, size and volume of haematoma, midline shift, pineal gland displacement, hydrocephalus and intraventricular extension of haemorrhage were correlated with the mortality within 7th and 28th days of acute stroke. Risk factors like hypertension, smoking, diabetes and alcoholism were also recorded.&#x0D; Result: Ninety-nine consecutive CT scan proven stroke patients following ICH were studied. The 28-day mortality of intracerebral hemorrhage was 44.44% and it was 29.30% within the first 7 days of onset. Maximum number of death occurred in brainstem haemorrhage (75%), initial haematoma volume 61 to 80 ml (89.47%), &gt;80 ml (91.7%), pineal gland displacement &gt;3mm (79.5%), septum pellucidum displacement &gt;5 mm (72.4%), ventricular extension (88.57%), and hydrocephalus (76.74%).&#x0D; Conclusion: The present study shows that deaths within 7th and 28th day of acute haemorrhagic stroke are correlated with the initial CT findings which could be regarded as a good predictor of mortality.&#x0D; Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 42-46

Resection of brainstem cavernous malformation via perifacial zone through retrosigmoid supracondylar approach.

Hemorrhagic brainstem cavernous malformations carry a high risk of progressive neurological deficits owing to recurrent hemorrhages and hence require complete surgical resection while minimizing damage to the dense concentration of nuclei and fibers inside the brainstem. To access lesions inside the lower pons, the senior author (H.B.) has preferred to approach the lesions via the “perifacial zone” through the pontomedullary sulcus from the inferior surface of the pontine bulge for more than 20 years.1,2 This video demonstrates a case of a cavernous malformation inside the lower pons, which was surgically treated via the pontomedullary junction through the retrosigmoid supracondylar approach in a half-sitting position. The lesion was completely removed in piecemeal fashion through a tiny incision on the sulcus, which did not cause any new neurological deficits. The modified Rankin Scale improved from 4 before the surgery to 1, and the patient had no recurrence during the 2 years of follow-up. The advantage of this access and the dissection techniques for this challenging lesion are introduced, based on our experience with more than 230 surgeries of brainstem cavernoma.The video can be found here: https://youtu.be/0H_XqkQgQ9I.

Secondary (Duret) brainstem haemorrhage may not always represent a fatal event

Background. Secondary brainstem haemorrhage (eponymously called Duret haemorrhage) is a well-known complication of transtentorial brain herniation or of rapid decompression of intracranial space. It is considered to be a consequence of arterial rupture, venous infarction or ischemia-reperfusion injury and it is regarded as a harbinger of an unfavourable outcome for the patient. Despite this, several case reports describing good outcome after Duret haemorrhage preceded by evacuation of an expansive traumatic intracranial mass lesion, an episode of intracranial hypotension or lumbar drainage have been published.Case description. We present four cases of patients with secondary brainstem haemorrhage linked to an episode of intracranial hypertension due to various reasons who were treated at our clinic. The first patient suffered a small brainstem haemorrhage that was described on his initial CT scan presumably as a result of massive intracranial expansion caused by an acute subdural haematoma and this Duret haemorrhage markedly expanded after the subdural haematoma was evacuated by means of a decompressive craniectomy. The next two patients developed Duret haemorrhage after the evacuation of intracranial haematomas. The fourth patient presented with posttraumatic cerebral oedema complicated by a subtle Duret haemorrhage displayed on his initial CT scan and this bleeding remained stable even after a bilateral decompressive craniectomy. One patient passed away, one remained in a persistent coma and two survived with a light neurological deficit.Conclusions. However ominous a newly discovered Duret haemorrhage may be, it alone should not discourage us from the further intensive treatment of our patients as their outcome may considerably vary. The extent of this bleeding, type and severity of underlying brain injury and complete clinical status and history of our patients should all be taken into account when deciding about patients’ prognosis.

Deferoxamine Alleviates Iron Overload and Brain Injury in a Rat Model of Brainstem Hemorrhage

Brainstem hemorrhage (BSH) is the most dangerous and devastating subtype of intracerebral hemorrhage and is associated with high morbidity and mortality. However, to date, no effective prevention methods or specific therapies have been available to improve its clinical outcomes. We preliminarily explored the efficacy of deferoxamine (DFO), a clinical chelator known for its iron-scavenging activities, in a rat model of BSH induced with collagenase infusion. DFO or saline was administrated 6 hours after BSH induction and then every 12 hours for ≤7 days. The survival curve of the rats was created, and the neurological scores were examined on days 1, 3, and 7 after BSH. The rats were sacrificed after 1, 3, and 7 days of DFO treatment for histological examination and immunohistochemistry. The results showed that administration of DFO delayed erythrocytes lysis, reduced iron deposition, reduced reactive oxygen species generation, reduced heme oxygenase-1 expression, and alleviated brain injury such as neuron degeneration and myelin sheath injury. However, DFO did not improve the survival rate and neurobehavioral outcomes in this model. Administration of DFO had limited therapeutic effects on collagenase-induced brainstem hemorrhage in rats. Some potential explanations were proposed, and more preclinical work is required to clarify the controversial curative effect of DFO in ICH.

Management of brainstem haemorrhages.

Among spontaneous intracranial haemorrhages, primary non-traumatic brainstem haemorrhages are associated with the highest mortality rate. Patients classically present with rapid neurological deterioration. Previous studies have found that the severity of initial neurological symptoms and hydrocephalus are predictors of poor outcomes. In addition, radiological parameters aim to classify brainstem haematomas according to volume, extension and impact on prognosis. However, previous studies have failed to agree on a differentiated radiological classification for outcome and functional recovery. Electrophysiology, including motor, auditory and somatosensory evoked potentials, is used to estimate the extent of the initial injury and predict functional recovery. The current management of brainstem haematomas remains conservative, focusing on initial close neurocritical care monitoring. Surgical treatment concepts exist, but similarly to general intracranial haemorrhage management, they continue to be controversial and have not been sufficiently investigated. This is especially the case for haematomas in the posterior fossa, as these are excluded from most current clinical trials. Existing studies were mostly carried out before the present millennium began, and limitations are evident in the adaptation of those results and recommendations to current management, with today&rsquo;s technological and diagnostic possibilities. We therefore recommend the re-evaluation of brainstem haemorrhages in the modern neurosurgical and intensive care environment.

Association between Non-Alcoholic Fatty Liver Disease and Intracerebral Hemorrhage

To determine whether non-alcoholic fatty liver disease (NAFLD) and intracerebral hemorrhage (ICH) are connected, and assess the role played by NAFLD in ICH development. A retrospective study evaluated inpatients treated at the First Affiliated Hospital of Zhejiang University. We divided the patients into Group A (ICH with NAFLD) and Group B (ICH alone). Moreover, univariate and multivariate logistic regression analyses were performed to identify the risk factors for unfavorable outcomes. A total of 128 patients were included: 34 ICH with NAFLD (group A) and 94 ICH (group B). Sixteen patients exhibited an unfavorable outcome. There was no significant difference among the two groups on the underlying diseases hypertension and heart disease. Group A had more diabetes mellitus cases (35.29% vs 12.76%, p = 0.004). Levels of alanine aminotransferase and triglyceride were higher in group A than in group B (all p < 0.05), while differences in other blood biochemistry tests were statistically insignificant (all p > 0.05). There was a similarity in bleeding sites except for brainstem hemorrhage, which was higher in group B patients (p = 0.036). Multivariate logistic regression analysis revealed that low-density lipoprotein (OR, 0.278; 95% CI (0.107–0.702), p = 0.008) was a protective factor for ICH patients with NAFLD. The National Institute of Health Stroke Scale (NIHSS) score at discharge (OR, 3.152; 95% CI (1.532–6.486), p = 0.002) was independent of risk factors for unfavorable outcomes. Serum levels of LDL was a protective factor. NAFLD did not increase the unfavorable outcome of ICH patients in our study.

Evaluating the effects of causes of death on postmortem interval estimation by ATR-FTIR spectroscopy.

Estimating postmortem interval (PMI) is one of the most challenging tasks in forensic practice due to the effects of many factors. Here, attenuated total reflection Fourier transform infrared (ATR-FTIR) spectroscopy combined with chemometrics was utilized to evaluate the effects of causes of death when estimating PMI and to establish a partial least square (PLS) regression model, which can precisely predict PMI under different causes of death. First, the sensitivities to causes of death (brainstem injury, mechanical asphyxia, and hemorrhage shock) of seven kinds of organs were evaluated based on their degrees of cohesion and separation. Then, the liver was selected as the most sensitive organ to establish a PMI estimation model to compare the predicted deviations from different causes of death. It turns out that the cause of death has no significant effect on estimating PMI. Next, a PLS regression model was built with kidney tissues, which have the lowest sensitivity, and this model showed a satisfactory predictive ability and wide applicability. This study demonstrates the feasibility of using ATR-FTIR spectroscopy in conjunction with chemometrics as a powerful alternative for detecting changes in biochemistry and estimating PMI. A new perspective was also provided for evaluating the effect of causes of death when predicting PMI.

The Origin of Intracranial Pressure Causing Brainstem Hemorrhages.

The origin of secondary brainstem hemorrhages following an acute expansive hemispheric lesion has been attributed to Henri Duret, who proposed that hemorrhaging was caused by a shock wave through the cerebral spinal fluid. However, other experiments have shown important findings correlating brainstem hemorrhages to arterial hemorrhages. Animal studies found that the rapidity of expansion of a lesion would be crucial in producing these lesions, but there was no consistent correlation with paratentorial grooving so commonly seen with increased intracranial pressure. This historical perspective studies the different experimentalists who paved the way for the discovery of these secondary brainstem hemorrhages-often named after Duret-and now known not to be invariably associated with poor outcome.

Spontaneous hypertensive brainstem hemorrhage: Does surgery benefit the severe cases?

Abstract Background Treatment of hypertensive brainstem hemorrhage (HBSH) is still controversial, especially for severe cases (GCS ≤ 8). With the improvement in neuroimaging and microsurgical techniques, severe HBSH is no longer considered inoperable. We analyzed comatose patients in whom radiology revealed severe HBSH. We further analyzed the outcome of cases we successfully operated on and compared surgical intervention with conservative management. Methods We retrospectively analyzed data obtained from patients with HBSH who represented at our facility from 2005 to 2015. We evaluated their demographics data, lesion characteristics, surgical approaches, as well as outcomes. We further assessed their outcomes with the Glasgow Outcome Scale (GOS). We also compared the outcome of surgical hematoma evacuation with conservative treatment. Results A total of 286 adult patients with severe HBSH was included in the study. Forty-six (46) patients were treated via craniotomy and the evacuation of the hematoma within 3 h to 2 days on admission at the emergency department. Ultra-early surgery (within 6 h of ictus) was performed in twenty (20) cases (43.5%). 240 patients were managed conservatively. The mortality rate for surgical group was 14/46 (30.4%) while the conservative group was 169/240(70.4%). The timing of surgical intervention was one of the strongest factors affecting outcome GOS (p = 0.02). The volume of the hematoma, GCS score on admission and the presence of acute hydrocephalus also affected the outcome (p = 0.03 respectively). Conclusions Our data suggest that early surgical intervention is very crucial in achieving successful outcomes in patients with severe HBSH.