Brainstem Hemorrhage Research Articles

Primary Hemorrhagic Neurovascular Diseases in Tibetans: A Retrospective Observational Study

Although there have been many studies on primary hemorrhagic neurovascular diseases (PHNVDs) in different populations, a study focusing on PHNVDs in Tibetan people was lacking. This study aimed to explore the notable characteristics of Tibetan PHNVDs by comparing the 3 most common PHNVDs (aneurysmal subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, and arteriovenous malformation) in our institution between Tibetan and Han patients. In this retrospective observational study, the hospital information system was used to access the records of patients with PHNVDs. A total of 249 Tibetan patients and 2093 corresponding contemporary Han patients were recruited from January 2012 to January 2016. Sociodemographic information and clinical data on each PHNVD subtype were collected and compared between the 2 races. For Tibetan patients, a significantly higher incidence (P < 0.05) of rebleeding and cerebral infarction was observed in all 3 PHNVD subtypes. In the aneurysmal subarachnoid hemorrhage group, Tibetan patients had significantly higher incidence of blood blisterlike aneurysms (BLAs) (19.6% [19/97] vs. 3.2% [34/1071]; P < 0.001). In the spontaneous intracerebral hemorrhage group, Tibetan patients had a significantly higher incidence of brainstem hemorrhage in the subtentorial area (10.8% vs. 5.1%; P= 0.035). For Tibetan PHNVDs, a high incidence of BLAs in aneurysmal subarachnoid hemorrhage, a tendency toward brainstem hemorrhage in subtentorial spontaneous intracerebral hemorrhage, and a high rate of infarction and rebleeding in all 3 subtypes were all recognized.

Methamphetamine-related brainstem haemorrhage

We report the case of an otherwise healthy 29-year-old woman who presented with a brainstem haemorrhage following intravenous methamphetamine use. Extensive investigation did not reveal an underlying pathology, and the development of symptoms was temporally related to methamphetamine injection. Although intracerebral haemorrhage secondary to methamphetamine use is well documented, this report describes a haemorrhage within the brainstem which is a rare location. While animal studies have demonstrated the potential of methamphetamines to produce brainstem haemorrhages, there has only been one previous report describing a haemorrhage in this location due to amphetamine use in humans. We conclude with a brief discussion of the clinical features and aetiology of methamphetamine-related stroke.

Atypical Brainstem Hemorrhage Clinical Presentation and Managed by Outpatient Clinic Follow-Up (P1.209)

Atypical Brainstem Hemorrhage Clinical Presentation and Managed by Outpatient Clinic Follow-Up (P1.209)

Dynamic Diffusion Tensor Imaging Reveals Structural Changes in the Bilateral Pyramidal Tracts after Brain Stem Hemorrhage in Rats.

Background and Purpose: Few studies have concentrated on pyramidal tract (PY) changes after brain stem hemorrhage (BSH). In this study, we used a diffusion tensor imaging (DTI) technique and histologic identification to investigate longitudinal PY changes on both the contralateral and ipsilateral sides after experimental BSH.Methods: BSH was induced in 61 Sprague-Dawley rats by infusing 30 μl of autogenous tail blood into each rat’s right pons. DTI and motor function examinations were performed repeatedly on days 1, 3, 7, 14, and 28 after surgery. Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity, and radial diffusivity were measured in the bilateral PYs. The axon and myelin injury in the PY were evaluated by histologic study.Results: As compared with normal controls, the bilateral PYs in rats with induced BSH showed an early decrease and a late increase in FA and an early increase and a late decrease in MD. A progressive decrease in axial diffusivity with dramatic axon loss from day 1 to day 28 after BSH was found bilaterally. The bilateral PYs showed an early increase and a late decrease in radial diffusivity. Early myelin injury and late repair were also detected pathologically in the bilateral PYs of rats with BSH. Thus, the early motor function deficits of rats with BSH began to improve on day 14 and had almost completely disappeared by day 28.Conclusions: DTI revealed dynamic changes in the bilateral PYs after BSH, which was confirmed by histologic findings and which correlated with motor function alteration. These findings support the idea that quantitative DTI can track structural changes in the bilateral PYs and that DTI may serve as a noninvasive tool to predict the prognoses of patients with BSH.

A Novel Brainstem Hemorrhage Model by Autologous Blood Infusion in Rat: White Matter Injury, Magnetic Resonance Imaging, and Neurobehavioral Features

Primary brainstem hemorrhage (BSH) has the highest mortality and morbidity as a subtype of intracerebral hemorrhage. A major limitation of BSH research is the lack of a corresponding animal model. The purpose of this study was to establish a novel rat model of BSH and to characterize the resulting brain injury, especially focusing on white matter injury. BSH was produced by stereotactically injecting autologous whole blood into the pons. Time course of hematoma resolution was observed by 7-T magnetic resonance imaging. White matter injury was evaluated in detail by multiple parameters including diffuse tensor imaging (DTI), demyelination, axonal injury, oligodendrocyte degeneration, and oligodendrocyte precursor cell proliferation. Brain water content and neurobehavior were also evaluated. Blood infusion (30 µL) led to a stable, reproducible hematoma in the right basotegmental pons. The hematoma absorption started, became obvious, and was nearly completed at 7, 14, and 30 days, respectively. Hematoma caused obvious brain edema at 3 days. White mater injury was observed pathologically, which was in line with decreased fractional anisotropy (FA) in DTI in the pons. FA reduction was also noticed in the cerebral peduncle and medulla. Behavioral abnormality persisted for at least 14 days and neurofunction was recovered within 1 month. This novel model can produce a stable hematoma resulting in brain edema, white matter injury, and neurofunctional deficits, which could be useful for future investigation of pathophysiological mechanisms and new treatment evaluation after BSH.

ID 319 – Is the presence of late evoked potentials (N100 wave) a good predictor of survival in comatose patients?

Objective The persistence of both early cortical responses (N20, Pa) and late associative potentials (vertex potentials, N100) has been shown to improve the probability of return to consciousness of comatose patients. However, the prognostic value of late responses without early cortical potentials has not been documented. Methods We report results in 5 comatose patients in whom late N100 responses could be recorded in the absence of reproducible early cortical auditory and/or somatosensory potentials. The etiologies of coma were: anoxic–ischemic after cardiopulmonary arrest (3), brainstem hemorrhage (1) and ischeamic stroke (1). Results All patients showed reproducible N100 waves but absence of early cortical auditory and/or somatosensory responses. The EEG was non-reactive in 3 patients. All 5 patients had a poor clinical outcome, toward either death or vegetative state. Discussion The presence of N100 wave without previous recordable potentials may be explained either by alternative parallel pathways, or by re-synchronization of an altered ascending volley. Whatever the explanation, the presence of N100 wave may be associated with a good neurological outcome only if preceded by early cortical potentials (Pa and N20), but not if early responses are absent. Key message Caution should be exerted in interpreting the prognostic value of the N100 wave alone.

Endovascular treatment of popliteal artery aneurysm in a clinical analysis of 9 cases

To evaluate the efficacy of endovascular repair of popliteal artery aneurysm (PAA) and to summarize the clinical experience and lessons. A clinical data of 9 PAA cases (males 8, females 1, age range 55-84) undergoing endovascular repair from October 2006 to December 2014 at Zhongshan Hospital Fudan University were retrospectively analyzed. CT angiography was made in all of the 9 cases preoperatively, and 10 PAA were included in the analysis. Of the 9 cases, 6 cases were symptomatic. The mean diameter of PAA was 3.9 cm (range, 2.1-8.2). The technique successful rate of endovascular repair was 10/10. The preoperative complications were 2/10, including one case suffered hematoma in the arterial puncture site and 1 case with distal artery embolization. The mean follow-up was 33 months (range, 3-87). During the follow-up, 2 cases received the secondary intervention and drug thrombolysis because of the stent distal thrombosis. The stent-graft primary patency at 1 year was 78.8% (95% CI: 48%-91%). One case suffered stent fracture, and one case died of brainstem hemorrhage 15 months post endovascular repair of PAA. Endovascular treatment of PAA is safe and effective in perioperative and midterm follow-up. However, individual endovascular strategy and postoperative complications in the long-term follow-up should be payed more attention.

Excellent Outcome in Midbrain Contusion: An Uncommon Report

Traumatic brain injuries are an important cause of death for patients younger than 50 years of age. Brain stem hemorrhage after blunt head injury is a rare event. The relationship between the presence of brain stem injury and clinical outcome is unclear and has varied significantly. Our case highlights an uncommon case of good outcome after midbrain contusion after severe head injury.

Advances in minimally invasive treatment of hemorrhagic and ischemic stroke.

Advances in minimally invasive treatment of hemorrhagic and ischemic stroke.

Surgical treatment of hemorrhagic brainstem cavernous malformations.

Microsurgery is considered to be the optimal treatment for brainstem cavernous malformations (BCMs); however, the high surgery-related morbidity requires further assessment of therapeutic protocols. The surgical experience and the optimal surgical strategy for the management of brainstem cavernous malformations is discussed. From September 2007 to August 2014, a total of 120 patients with BCMs underwent surgical treatment in our hospital. The clinical features and neurological outcome of these patients were retrospectively analysed, and our institutional surgical strategy was discussed. The preoperative annual hemorrhage and rehemorrhage rates were 4.2% and 42.9%, respectively. Gross total resection was achieved in 116 patients (96.7%) and subtotal resection in 4 (3.3%). After a mean follow-up of 50.7 ± 26.5 months (range: 18-90 months), the neurological status showed improvement in 71 patients (67.0%) and remained stable in 24 (22.6%). The postoperative new-onset or worsened symptoms occurred in 53 cases. During the follow-up period, 58.5% of these symptoms improved and 32.1% remained stable. The mean modified Rankin score (mRS) score was 2.51 ± 0.90 preoperatively, 2.73 ± 0.83 postoperatively, and 1.71 ± 0.98 at the recent follow-up. The surgery-related mortality was 1.7% (n = 2), and two patients suffered from recurrence during the follow-up period. The preoperative mRS was considered to be an independent predictive factor of the neurological outcome (P = 0.003). Safe resection and a favourable outcome can be achieved via a standardized surgical strategy based on appropriate surgical indications, optimal selection of safe trajectories, and application of advanced supplementary techniques in the surgical treatment of BCMs.

Brainstem Hemorrhage after Evacuation of Chronic Subdural Hematoma: A Case Report and Review of Literature

Brainstem hemorrhage following evacuation of chronic subdural hematoma is extremely rare and its pathogenesis is unclear. In our case report, we present a rare case of brainstem hemorrhage following evacuation chronic subdural hematoma. Our patient was a 50-year-old man, with no comorbidities, presented with dorsal midbrain hemorrhage with ventricular extension and symptomatic progression of contralateral small chronic subdural hematoma following evacuation of chronic subdural hematoma. Contralateral subdural hematoma was evacuated and midbrain hemorrhage was managed conservatively. He was discharged with minimal neurologic deficit. Review of literature and pathogenesis of remote hemorrhage after evacuation of chronic subdural hematoma were discussed.

Endoscopic Endonasal Transclival Resection of a Brainstem Cavernoma: A Detailed Account of Our Technique and Comparison with the Literature

To report a technique of endoscopic transclival resection of a hemorrhagic brainstem cavernous malformation manifesting in the ventral pons. A 29-year-old woman presented with numbness and tingling of the right arm and leg and loss of fine motor control. Magnetic resonance imaging revealed a cavernoma in the ventromedial brainstem on the ventral surface. A purely endoscopic, endonasal, transclival approach was used to resect this cavernoma. Computed tomography/magnetic resonance imaging merged navigation (StealthStation, Medtronic) was used. The patient had no neurologic deficits postoperatively. The motor control loss and tingling disappeared. She did not experience any complications. Cerebrospinal fluid leakage appeared to result from using the very small opening of the skull base and dura mater and was the reason for the use of a lumbar drain for several days. At the 6-week follow-up examination, the patient was in excellent condition with no neurologic deficits and had returned to her full-time job. Successful endoscopic, endonasal, transclival resection of a brainstem cavernous malformation was described. This patient experienced improvement in neurologic symptoms after surgery without morbidity. Technologic advances in endoscopic skull base approaches provide access to lesions of the brainstem that previously required more invasive approaches. The endonasal transclival approach provides the most direct route to ventral pontine lesions. Early intervention in brainstem cavernous malformation is indicated and should be performed with an individualized approach taking into consideration the possible complications.

Toward an In Vivo Neuroimaging Template of Human Brainstem Nuclei of the Ascending Arousal, Autonomic, and Motor Systems.

Brainstem nuclei (Bn) in humans play a crucial role in vital functions, such as arousal, autonomic homeostasis, sensory and motor relay, nociception, sleep, and cranial nerve function, and they have been implicated in a vast array of brain pathologies. However, an in vivo delineation of most human Bn has been elusive because of limited sensitivity and contrast for detecting these small regions using standard neuroimaging methods. To precisely identify several human Bn in vivo, we employed a 7 Tesla scanner equipped with multi-channel receive-coil array, which provided high magnetic resonance imaging sensitivity, and a multi-contrast (diffusion fractional anisotropy and T2-weighted) echo-planar-imaging approach, which provided complementary contrasts for Bn anatomy with matched geometric distortions and resolution. Through a combined examination of 1.3 mm(3) multi-contrast anatomical images acquired in healthy human adults, we semi-automatically generated in vivo probabilistic Bn labels of the ascending arousal (median and dorsal raphe), autonomic (raphe magnus, periaqueductal gray), and motor (inferior olivary nuclei, two subregions of the substantia nigra compatible with pars compacta and pars reticulata, two subregions of the red nucleus, and, in the diencephalon, two subregions of the subthalamic nucleus) systems. These labels constitute a first step toward the development of an in vivo neuroimaging template of Bn in standard space to facilitate future clinical and research investigations of human brainstem function and pathology. Proof-of-concept clinical use of this template is demonstrated in a minimally conscious patient with traumatic brainstem hemorrhages precisely localized to the raphe Bn involved in arousal.

Surgical management of spontaneous hypertensive brainstem hemorrhage

Abstract Spontaneous hypertensive brainstem hemorrhage is the spontaneous brainstem hemorrhage associated with long term hypertension but not having definite focal or objective lesion. It is a catastrophic event which has a poor prognosis and usually managed conservatively. It is not uncommon, especially in eastern Asian populations, accounting approximately for 10% of the intracerebral hemorrhage. Before the advent of computed tomography, the diagnosis of brainstem hemorrhage was usually based on the clinical picture or by autopsy and believed to be untreatable via surgery. The introduction of computed tomography permitted to categorize the subtypes of brainstem hemorrhage with more predicted outcome. Continuous ongoing developments in the stereotactic surgery and microsurgery have added more specific surgical management in these patients. However, whether to manage conservatively or promptly with surgical evacuation of hematoma is still a controversy. Studies have shown that an accurate prognostic assessment based on clinical and radiological features on admission is critical for establishing a reasonable therapeutic approach. Some authors have advocate conservative management, whereas others have suggested the efficacy of surgical treatment in brainstem hemorrhage. With the widening knowledge in microsurgical techniques as well as neuroimaging technology, there seems to have more optimistic hope of surgical management of spontaneous hypertensive brainstem hemorrhage for better prognosis. Here we present five cases of severe spontaneous hypertensive brainstem hemorrhage patients who had undergone surgery; and explore the possibilities of surgical management in patients with the spontaneous hypertensive brainstem hemorrhage.

Abstract W P321: Predicting Mortality in ICH: Redefining the ICH Score

Introduction: The stated 30-day mortality rate for the original ICH score is 0%, 13%, 26%, 72%, 97%, and 99% for scores of 0-5, respectively. Although the score has been externally validated and widely used, recently proposed updates to the model have failed to improve its mortality prognostication. We hypothesized that precise quantification of ICH and IVH volumes more accurately reflect the severity of the disease and enhance its prognostic value. Materials and Methods: A modified ICH score was developed to quantify ICH volume, IVH volume (with the modified Graeb score), GCS at admission, and hemorrhage location. The modified score was as follows: GCS 11-15: 0 points, 6-10: 1 point, 3-5: 2 points; ICH volume &lt;20 cm3: 0 points, 20-34 cm3: 1 point, 35-44 cm3: 2 points, &gt;45 cm3: 3 points; mGraeb score 0: 0 points, 1-9: 1 point, &gt;10: 2 points; cerebellar hemorrhage: 1 point; brainstem hemorrhage: 1 point. Possible scores ranged from 0-9 and were designed to provide a more accurate stratified prognostic reflection for 30-day mortality. Results: The modified score was tested in 362 patients previously evaluated with the original ICH score. Thirty -day mortality rates per group were 0%, 5%, 33%, 61%, 70%, and 91%, for ICH scores of 0-5, respectively. Median time to death in those that died within 30 days was 15.5, 3, 4, 1.5, and 1 day(s) for ICH scores of 1-5, respectively. Application of the proposed modified ICH score resulted in 30-day mortality rates of 0: 0%, 1: 5%, 2: 11%, 3: 4%, 4: 51%, 5: 73%, 6: 74%, 7: 90%, 8/9: 100%. Median time to death was 6, 13, 4, 4, 2, 2, 1, and 0 day(s), in scores of 1-8, respectively. In our patient population, 99% of patients who died within a 30-day period did so within 18 days. Furthermore, 75% died within the first week and 50% within the first 72 hours. Predicted 30-day mortality in the original ICH score had an area under the receiver-operating curve (AUROC) of 0.88, while the proposed new model showed a higher AUROC of 0.91. Conclusions: Improved outcomes in ICH therapy require better assessment and prognostic tools. By accurately determining hemorrhage volumes and increasing anatomical localization, stratification of ICH patients can result in better predictors of 30-day mortality. Further validation of this model is needed in larger patient populations.

Abstract T MP66: The Ich Score: A Self-fulfilling Prophecy?

Introduction: Spontaneous intracerebral hemorrhage (ICH) remains one of the most disabling forms of stroke. Of the prognostication models developed to aid in treatment decisions, the ICH score remains the most widely used. We hypothesize that patients with higher scores that carry a poor prognosis receive less aggressive treatment based on their expected mortality and that actual mortality rates are lower than those predicted by the ICH score. Materials and Methods: A retrospective analysis of 362 patients with spontaneous ICH from 2010-2013 was reviewed. ICH was due to hypertension, amyloid angiopathy, or was coagulopathy-induced. Surgical intervention was at the discretion of the treating neurosurgeon. Aggressive medical management was provided regardless of surgical intervention. 30-day mortality rates are reported. Results: Of the 362 patients, mortality rates based on the original ICH score were 0%, 5%, 33%, 61%, 70%, and 91%, for ICH scores of 0-5, respectively. EVD placement rates amongst groups were 3%, 18%, 46%, 58%, 21%, and 9% in scores of 0-5, respectively and significantly different between scores of 3 and 4 (p&lt;0.001). Median modified Graeb scores, used to estimate IVH volume, were 0, 1, 5, 14, 11, and 17 in the same groups, with no difference between scores of 3 and 4. When comparing patients with ICH scores of 3 and 4, the percentages of patients with IVH were 86% and 98% (p=0.048), rates of cerebellar hemorrhage were 3% vs. 26% (p&lt;0.001), ICH volumes were 44 cm3 vs. 49 cm3 (p=0.030), and median GCS scores were 7 vs. 4 (p&lt;0.001), respectively. Between both groups, there was no difference in age, rate of brainstem hemorrhages, rate of surgical intervention, 30-day mortality, or time to death in patients in whom care was withdrawn vs. those who progressed to natural death. Conclusion: Our observed mortality rate in patients with poor prognosis ICH scores was lower than the historically quoted 97% and 99%, respectively. Higher IVH scores, ICH volumes, and cerebellar hemorrhage were not associated with increased rates of surgical intervention suggesting less aggressive treatment goals based on historical mortality rates. Scoring systems must be updated to allow for accurate prognostication and more aggressive treatment strategies.

脳幹出血を来したS状静脈洞部硬膜動静脈瘻の1例

要旨：【目的】橋出血で発症したS 状静脈洞部硬膜動静脈瘻に対して経静脈的塞栓術を行った1 例を報告する．【症例】症例は77 歳女性．突然の右片麻痺で発症し，当初は高血圧性橋出血と診断されていた．5 カ月後も脳幹部の浮腫が改善せず，脳血管撮影を行うとS 状静脈洞部に硬膜動静脈瘻が確認された．静脈洞閉塞を伴っていたため短絡血は上錐体静脈洞を経由しさらに脳幹，小脳の静脈に逆流していた．これが出血源と判断し，経静脈的コイル塞栓術を施行した．【結論】橋出血で発症したS 状静脈洞部硬膜動静脈瘻を経験し塞栓術で治癒しえた．脳幹出血の原因として硬膜動静脈瘻も鑑別疾患の一つとして認識すべきである．

Brainstem Haemorrhage due to Autonomic Dysreflexia in a Person with C6 Tetraplegia

Abstract Autonomic dysreflexia is an important clinical complication occurring in patients with high levels of spinal cord injury. If untreated, the acute rise in blood pressure can cause end organ damage, including intracerebral haemorrhage. Though unusual, it can be fatal with large haemorrhages causing brain herniation syndromes. Here we report the case of a patient with C6 complete tetraplegia patient who developed brainstem haemorrhage during an episode of autonomic dysreflexia. The pathophysiology and treatment methods of this condition are discussed, highlighting the importance of preventive measures to avoid the same.

Inpatient stroke rehabilitation outcomes in Korea derived from the Korean Brain Rehabilitation Centers' online database system for the years 2007 to 2011.

The purpose of this report was to provide information for patients receiving inpatient rehabilitation after stroke and to identify the possible factors influencing functional outcome after inpatient rehabilitation. Stroke patients (n = 5,212) who were discharged from the Departments of Rehabilitation Medicine (RM) of university hospitals and rehabilitation hospitals from 2007 through 2011 were participants. Prevalence, age, transfer time after onset, length of stay (LOS), functional status at admission and discharge were analyzed. In all stroke subjects, cerebral infarctions (67%) were more common than hemorrhages. Cerebral infarctions in the middle cerebral artery territory were most common, while the basal ganglia and cerebral cortex were the most common areas for hemorrhagic stroke. The LOS decreased from 45 to 28 days. Transfer time after onset decreased from 44 to 30 days. Shorter transfer time after onset was correlated with better discharge functional status and shorter LOS. Initial functional status was correlated with discharge functional status. In ischemic stroke subtypes, cerebellar and brainstem strokes predicted better outcomes, while strokes with more than one territory predicted poorer outcomes with more disabilities. In hemorrhagic stroke subtypes, initial and discharge functional status was the lowest for cortical hemorrhages and highest for brainstem hemorrhages. This report shows that LOS and transfer time after onset has been decreased over time and initial functional status and shorter transfer after onset are predictors of better functional outcome at discharge.

Catheter-directed thrombolysis for acute limb ischaemia: An audit.

Acute limb ischaemia (ALI) is commonly managed with surgical intervention but catheter-directed thrombolysis (CDT) is a proven treatment alternative. CDT as a treatment for ALI is not common and is dependent on local practice. All patients receiving urokinase infusions at our institution currently require a bed in the high-dependency unit (HDU). Administering the infusion requires significant nursing time and this can be accommodated in HDU where the nurse-to-patient ratio is higher than it is on general wards. To report the outcomes of the initial admission of patients who received CDT to manage ALI, and to give a cost estimate of their care. A retrospective audit was undertaken of all patients who received CDT with urokinase for the management of ALI over a four-year period. Success of thrombolysis was defined as a patient's survival with no need for any surgical intervention prior to discharge. Outcome measures included the requirement for further vascular procedures in the same admission, the complication rate, and the median urokinase dose and duration. Cost estimates were based on hospital pharmacy and administration data. Seventy-three patients (median age 66 years, range 27-93 years) were included in the audit. The median urokinase dose was 2.3 million units (range 0.9-5.0 million units) with a median duration of treatment of 26 hours (range 3-96 hours). Fifty-seven patients did not require any further intervention prior to discharge, 14 had further intervention, and two died (one from a brainstem haemorrhage and one who deteriorated despite thrombolysis). The total cost per CDT case at our institution is currently approximately AUD $4,500 and AUD $6,700 for a patient being treated in HDU for one and two days, respectively. If patients were treated on a general ward, the cost would be approximately AUD $2,600 and AUD $3,000, respectively. Rates of clinically acceptable clot lysis were high for patients treated with urokinase for ALI. Complication rates were comparable with published studies. Infusions can be required for prolonged periods of time and given the low complication rate, managing patients on a general ward rather than in the HDU is a feasible alternative and would reduce costs substantially.