Cases Of Subarachnoid Hemorrhage Research Articles

7T magnetic resonance angiographic imaging of basilar artery perforator aneurysms - initial experience of a non-invasive alternative to DSA.

Perforator aneurysms of the basilar artery (PABA) are rare causes of subarachnoid haemorrhage (SAH) and challenging to diagnose. We present two cases of SAH caused by PABA diagnosed by cone beam computed tomography angiography (CBCTA) and a novel non-invasive method - 7T magnetic resonance imaging (7T MRI). Two patients with SAH, diagnosed with PABA, were imaged on day 9 and 13 after onset, respectively, with CBCTA and 7T MR angiography (MRA) performed on the day after and at follow-up at 3 months. All four 7T MRI examinations in the two patients were technically successful with fully diagnostic images. No endovascular treatment was performed and control with 7T MRA at 3 months showed no remaining aneurysms. PABA can be imaged with 7T MRI - a novel non-invasive method, allowing non-invasive follow-up to monitor this rare cause of SAH.

Sex and age effects on risk of non-traumatic subarachnoid hemorrhage: Retrospective cohort study of 124,234 cases using electronic health records

ObjectivesThe epidemiology of non-traumatic subarachnoid hemorrhage (SAH) is unclear. This study describes the antecedent characteristics of SAH patients, compares the risk of SAH between women and men, and explores if this changes with age. Materials and methodsRetrospective cohort study using an electronic health records network based in the USA (TriNetX). All patients aged 18-90y with at least one healthcare visit were included. Antecedent characteristics of SAH patients (ICD-10 code I60) were measured. The incidence proportion and the relative risk between women and men, were estimated overall, in the 55-90y age group, and in five-year age categories. ResultsOf 58.9 million eligible patients, with 190.8 million person-years of observations, 124,234 (0.21%; 63,467 female, 60,671 male) had a first SAH, with a mean age of 56.8 (S.D. 16.8) y (women: 58.2 [16.2] y, men 55.3 [17.2] y). 9,758 SAH cases (7.8%) occurred in people aged 18-30y. Prior to the SAH, an intracranial aneurysm had been diagnosed in 4.1% (women: 5.8% men: 2.5%), hypertension in 25.1% and nicotine dependence in 9.1%. Overall, women had a lower risk of SAH compared to men (RR 0.83, 95% CI 0.83-0.84), with a progressive increase in risk ratio across age groups: from RR 0.36 (0.35-0.37) in people aged 18-24y, to RR 1.07 (1.01-1.13) aged 85-90y. ConclusionsMen are at greater risk of SAH than women overall, driven by younger adult age groups. Women are at greater risk than men only in the over 75-year age groups. The excess of SAH in young men merits investigation.

Funnel Shaped Anterior Communicating Artery Fenestration Mistaken for an Aneurysm: A Cautionary Tale

This report portrays a case of a funnel shaped anterior communicating artery (ACoA) fenestration which was mistaken as a small A1 aneurysm in a subarachnoid hemorrhage case. Although tridimensional rotational digital subtraction angiography improves aneurysm diagnosis specially at the ACoA complex, current spatial resolution might leave behind a considerable percentage of ACoA fenestrations. This may lead to diagnostic errors and unnecessary treatments risking iatrogenic complications. Luckily for our patient, a concomitant aneurysm warranted clipping and subsequent surgical exploration of the ACoA complex revealed the pitfall, thus preventing further action. Interestingly, another group of authors who reported similar misdiagnosis with ACoA aneurysms were able to prevent a third error, thanks to the experience acquired with 2 prior cases. Therefore, this clinical image aims to raise wider awareness of the need for very cautious consideration of imaging depicting small and/or atypical aneurysms in the ACoA complex.

Sympathetic Nervous Hyperactivity Impairs Microcirculation Leading to Early Brain Injury After Subarachnoid Hemorrhage.

Although early brain injury (EBI) is recognized as a critical step following subarachnoid hemorrhage (SAH), its pathophysiology and underlying mechanisms remain poorly understood. Herein, we investigated the role of cerebral circulation in the acute phase using patient data and a mouse SAH model and evaluated its regulation via the sympathetic nervous system. The cerebral circulation time and neurological outcomes in the human body were retrospectively examined in 34 SAH cases with ruptured anterior circulation aneurysms and 85 cases with unruptured anterior circulation cerebral aneurysms at Kanazawa University Hospital from January 2016 to December 2021. In a mouse study, a SAH model was created via endovascular perforation, and India-ink angiography was performed over time. Additionally, bilateral superior cervical ganglionectomy was performed immediately before surgery, and neurological scores and brain water content were evaluated after SAH. Cerebral circulation time was prolonged in the acute phase of SAH compared with that in the unruptured cerebral aneurysm group, especially in those with electrocardiographic changes. Furthermore, it was more prolonged in the poor prognosis group (modified Rankin Scale scores 3-6) than in the good prognosis group (modified Rankin Scale scores 0-2) at discharge. In mice, cerebral perfusion was significantly reduced at 1 and 3 hours after SAH and recovered at 6 hours. superior cervical ganglionectomy improved cerebral perfusion without altering the diameter of the middle cerebral artery at 1 hour and improved neurological outcomes at 48 hours after SAH. Consistently, brain edema, quantified by brain water content, was improved by superior cervical ganglionectomy 24 hours after SAH. Sympathetic hyperactivity may play a critical role in the development of EBI by impairing cerebral microcirculation and edema in the acute phase following SAH.

The value of ventricular measurements in the prediction of shunt dependency after aneurysmal subarachnoid hemorrhage

ObjectiveChronic hydrocephalus requiring shunt placement is a common complication of aneurysmal subarachnoid hemorrhage (SAH). Different risk factors and prediction scores for post-SAH shunt dependency have been evaluated so far. We analyzed the value of ventricle measurements for prediction of the need for shunt placement in SAH patients.MethodsEligible SAH cases treated between 01/2003 and 06/2016 were included. Initial computed tomography scans were reviewed to measure ventricle indices (bifrontal, bicaudate, Evans’, ventricular, Huckman’s, and third ventricle ratio). Previously introduced CHESS and SDASH scores for shunt dependency were calculated. Receiver operating characteristic analyses were performed for diagnostic accuracy of the ventricle indices and to identify the clinically relevant cut-offs.ResultsShunt placement followed in 221 (36.5%) of 606 patients. In univariate analyses, all ventricular indices were associated with shunting (all: p<0.0001). The area under the curve (AUC) ranged between 0.622 and 0.662. In multivariate analyses, only Huckman’s index was associated with shunt dependency (cut-off at ≥6.0cm, p<0.0001) independent of the CHESS score as baseline prediction model. A combined score (0–10 points) containing the CHESS score components (0–8 points) and Huckman’s index (+2 points) showed better diagnostic accuracy (AUC=0.751) than the CHESS (AUC=0.713) and SDASH (AUC=0.693) scores and the highest overall model quality (0.71 vs. 0.65 and 0.67), respectively.ConclusionsVentricle measurements are feasible for early prediction of shunt placement after SAH. The combined prediction model containing the CHESS score and Huckman’s index showed remarkable diagnostic accuracy regarding identification of SAH individuals requiring shunt placement. External validation of the presented combined CHESS-Huckman score is mandatory.

Letter to the Editor Regarding “Clinical Utility of Routine Postprocedural Computed Tomography of the Head Following Elective Neuroendovascular Interventions”

This report portrays a case of a funnel shaped anterior communicating artery (ACoA) fenestration which was mistaken as a small A1 aneurysm in a subarachnoid hemorrhage case. Although tridimensional rotational digital subtraction angiography improves aneurysm diagnosis specially at the ACoA complex, current spatial resolution might leave behind a considerable percentage of ACoA fenestrations. This may lead to diagnostic errors and unnecessary treatments risking iatrogenic complications. Luckily for our patient, a concomitant aneurysm warranted clipping and subsequent surgical exploration of the ACoA complex revealed the pitfall, thus preventing further action. Interestingly, another group of authors who reported similar misdiagnosis with ACoA aneurysms were able to prevent a third error, thanks to the experience acquired with 2 prior cases. Therefore, this clinical image aims to raise wider awareness of the need for very cautious consideration of imaging depicting small and/or atypical aneurysms in the ACoA complex.

Clinical features and prognosis of autosomal dominant polycystic kidney disease with cerebrovascular complications.

This retrospective study was used to evaluate the clinical and imaging characteristics and the prognosis of autosomal dominant polycystic kidney disease (ADPKD) with cerebrovascular complications. We retrospectively analyzed 30 patients with ADPKD complicated with intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), unruptured intracranial aneurysms (UIAs), or Moyamoya disease (MMD) who were admitted to Jinling Hospital from January 2001 to January 2022. We analyzed the clinical manifestations and imaging characteristics of ADPKD patients with cerebrovascular complications and followed up on their long-term outcomes. 30 patients, 17 men and 13 women, with an average age of 47.5 (40.0, 54.0) years were included in this study, including 12 cases of ICH, 12 cases of SAH, 5 cases of UIA, and 1 case of MMD. The 8 patients who died during follow-up had a lower Glasgow Coma Scale (GCS) on admission (p=0.024) and a significantly higher serum creatinine (p=0.004) and blood urea nitrogen (p=0.006) than the 22 patients with long-term survival. Intracranial aneurysms, SAH, and ICH are the most common cerebrovascular diseases in ADPKD. Patients with low GCS score or worse renal function have a poor prognosis, which can lead to disability and even death.

Pathogenesis of cerebral amyloid angiopathy caused by chaotic glymphatics-Mini-review.

Cerebral amyloid angiopathy (CAA) is a common cause of lobar intracerebral hemorrhage in the elderly. It is also associated pathologically with Alzheimer's disease (AD). Both CAA and AD share similar pathology of deposition amyloid beta fibrils (Aβ). Aβ is deposited mainly in the neurites in AD and vascular walls in CAA. Aβ is formed inside the brain parenchyma from the amyloid precursor protein. It is easier to understand how Aβ is deposited in the cerebral neurites in AD. However, the pathogenesis of CAA is still largely unknown. It is difficult to understand or visualize how Aβ fibrils formed inside the brain can be deposited against the cerebral perfusion pressure to be deposited in the cerebral and meningeal arterial walls. We encountered an unusual clinical case of acute aneurysmal subarachnoid hemorrhage which was followed after a few years with localized CAA involving mainly the sites of the subarachnoid hemorrhage. We reviewed the formation of Aβ and postulated how the Aβ fibrils are transported retrogradely toward the cerebral arteries and deposited in the arterial walls resulting in the final pathology of CAA. There is a clear disturbance of the glymphatic system, the aquaporin-4 channel, and the parenchymal border macrophages.

Will improved neuroradiology facilities debunk the reported rarity of intracranial aneurysms in Sub-Saharan Africa?

Intracranial aneurysms (IAN) are rare in the Sub-Saharan Africa unlike other parts of the world. The debate is whether the low frequency might be apparent because of the scarcity of advanced neuroimaging services, or real. This study investigated if improved imaging facilities would debunk the rarity of IAN in our subregion. This is a retrospective cohort study of prospectively recorded data of patients with subarachnoid hemorrhage (SAH) and IAN managed over 19 years (2003-2021), at the study center with a catchment population of over 47 million. The center witnessed progressive improvements in neuroimaging facilities: 2-Slice, 8-slice, and 64-slice computed tomography (CT) and 0.35T, 1.5T magnetic resonance imaging (MRI) during the period. There were 241 cases of SAH, but only 166 aneurysms were confirmed in 158 patients. Between 2003 and 2008, only 27 IAN patients (4.5 IAN/year) were diagnosed. After introduction of CT angiography/magnetic resonance angiography MRA using 8-slice CT/0.35T magnetic resonance imaging (MRI), between 2009 and 2014, the frequency of IAN increased to 8/year. Between 2015 and 2018 after installation of a 64-slice CT in 2014, the IAN remained the same (8/year). MRI 1.5T was added in 2018, the frequency doubled to 17 cases/year. The females were more (67.7%), the mean age was 46.3 years, but peak incidence was the sixth decade. Internal carotid artery aneurysms including posterior communicating artery were the most common (43%) followed by ACA with anterior communicating artery (24%) and middle cerebral artery (20%). Multiple aneurysms were seen in ten patients. Improved neuroimaging between 2003 and 2021 did not debunk the rarity of IAN in our region.

Diagnosis and treatment approaches for simultaneous onset of subarachnoid hemorrhage and thyroid storm: a case report

BackgroundSubarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital.Case presentationThe patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient’s symptoms improved, and she became lucid.In this case, we believe that in the presence of untreated hyperthyroidism, the onset of subarachnoid hemorrhage induced thyroid storm. Tachycardia of 130 bpm or higher, which is the diagnostic criterion for thyroid storm, rarely occurs with subarachnoid hemorrhage. Therefore, we believe it is an important factor for recognizing the presence of the thyroid storm. In this case, clipping surgery was prioritized which resulted in a favorable outcome. However, it is possible that invasive surgery may have exacerbated thyroid storm, suggesting that treatment should be tailored as per patient’s condition.ConclusionIf a pulse rate of 130 bpm or higher is observed alongside subarachnoid hemorrhage, we recommend considering the possibility of concomitant thyroid storm and testing for thyroid hormone. If concomitant thyroid storm is present, we believe that a treatment plan tailored to the patient’s condition is critical, and early diagnosis will lead to a favorable outcome for the patient.

Racial differences in time to blood pressure control of aneurysmal subarachnoid hemorrhage patients: A single-institution study.

Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 patients annually in the United States. Uncontrolled blood pressure is a major risk factor for aneurysmal subarachnoid hemorrhage. Clinical guidelines recommend maintaining blood pressure control until definitive aneurysm securement occurs. It is unknown whether racial differences exist regarding blood pressure control and outcomes (HLOS, discharge disposition) in aneurysmal subarachnoid hemorrhage. Here, we aim to assess whether racial differences exist in 1) presentation, 2) clinical course, and 3) outcomes, including time to blood pressure stabilization, for aSAH patients at a large tertiary care medical center. We conducted a retrospective review of adult aneurysmal subarachnoid hemorrhage cases from 2013 to 2019 at a single large tertiary medical center. Data extracted from the medical record included sex, age, race, insurance status, aneurysm location, aneurysm treatment, initial systolic and diastolic blood pressure, Hunt Hess grade, modified Fisher score, time to blood pressure control (defined as time in minutes from first blood pressure measurement to the first of three consecutive systolic blood pressure measurements under 140mmHg), hospital length of stay, and final discharge disposition. 194 patients met inclusion criteria; 140 (72%) White and 54 (28%) Black. While White patients were more likely than Black patients to be privately insured (62.1% versus 33.3%, p < 0.001), Black patients were more likely than White patients to have Medicaid (55.6% versus 15.0%, p < 0.001). Compared to White patients, Black patients presented with a higher median systolic (165 mmHg versus 148 mmHg, p = 0.004) and diastolic (93 mmHg versus 84 mmHg, p = 0.02) blood pressure. Black patients had a longer median time to blood pressure control than White patients (200 minutes versus 90 minutes, p = 0.001). Black patients had a shorter median hospital length of stay than White patients (15 days versus 18 days, p < 0.031). There was a small but statistically significant difference in modified Fisher score between black and white patients (3.48 versus 3.17, p = 0.04).There were no significant racial differences present in sex, Hunt Hess grade, discharge disposition, complications, or need for further interventions. Black race was associated with higher blood pressure at presentation, longer time to blood pressure control, but shorter hospital length of stay. No racial differences were present in aneurysmal subarachnoid hemorrhage associated complications or interventions.

Subarachnoid hemorrhage: New insights on pathogenesis

Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke characterized by high morbidity and mortality. Saccular intracranial aneurysms account for most cases of SAH. While the role of hemodynamic stress and inflammation have been extensively studied in SAH, little is known about the role of the microbiome in SAH despite recent studies uncovering new insights on the effects of microbiome alteration in ischemic stroke. This review presents the current knowledge around the role of the microbiome in intracranial aneurysm formation and rupture. We also highlight the influence of diet on intracranial aneurysm formation and provide evidence that corroborates the targeting of inflammatory pathways as a potential strategy to curb SAH-associated neurological dysfunction.

Development and External Validation of a Deep Learning Algorithm to Identify and Localize Subarachnoid Hemorrhage on CT Scans.

In medical imaging, a limited number of trained deep learning algorithms have been externally validated and released publicly. We hypothesized that a deep learning algorithm can be trained to identify and localize subarachnoid hemorrhage (SAH) on head computed tomography (CT) scans and that the trained model performs satisfactorily when tested using external and real-world data. We used noncontrast head CT images of patients admitted to Helsinki University Hospital between 2012 and 2017. We manually segmented (i.e., delineated) SAH on 90 head CT scans and used the segmented CT scans together with 22 negative (no SAH) control CT scans in training an open-source convolutional neural network (U-Net) to identify and localize SAH. We then tested the performance of the trained algorithm by using external data sets (137 SAH and 1,242 control cases) collected in 2 foreign countries and also by creating a data set of consecutive emergency head CT scans (8 SAH and 511 control cases) performed during on-call hours in 5 different domestic hospitals in September 2021. We assessed the algorithm's capability to identify SAH by calculating patient- and slice-level performance metrics, such as sensitivity and specificity. In the external validation set of 1,379 cases, the algorithm identified 136 of 137 SAH cases correctly (sensitivity 99.3% and specificity 63.2%). Of the 49,064 axial head CT slices, the algorithm identified and localized SAH in 1845 of 2,110 slices with SAH (sensitivity 87.4% and specificity 95.3%). Of 519 consecutive emergency head CT scans imaged in September 2021, the algorithm identified all 8 SAH cases correctly (sensitivity 100.0% and specificity 75.3%). The slice-level (27,167 axial slices in total) sensitivity and specificity were 87.3% and 98.8%, respectively, as the algorithm identified and localized SAH in 58 of 77 slices with SAH. The performance of the algorithm can be tested on through a web service. We show that the shared algorithm identifies SAH cases with a high sensitivity and that the slice-level specificity is high. In addition to openly sharing a high-performing deep learning algorithm, our work presents infrequently used approaches in designing, training, testing, and reporting deep learning algorithms developed for medical imaging diagnostics. This study provides Class III evidence that a deep learning algorithm correctly identifies the presence of subarachnoid hemorrhage on CT scan.

Characterizing the individual course of health-related quality of life after subarachnoid haemorrhage: Latent growth mixture modelling

BackgroundSurvivors of aneurysmal subarachnoid haemorrhage (SAH) show heterogeneous profiles of health-related quality of life (HrQoL). The aim of this study was to characterize individual differences in the course of HrQoL following SAH using latent growth mixture modelling (LGMM). MethodsA longitudinal study with 113 incident cases of aneurysmal SAH was performed in order to evaluate clinical outcome (Hunt and Hess scale, Barthel-Index, Beck Depression Inventory) and HrQoL data (EQ-5D) at baseline, 6 and 12 months. The heterogeneity in HrQoL courses after SAH was analysed using LGMM. ResultsFour subgroups (classes) of different patterns of HrQoL course after SAH were identified. Two of these classes (1 and 3) comprised patients with considerably reduced initial HrQoL, which was associated with more severe symptoms of SAH. Class 1 showing the worst EQ5D-index values during the entire study period. Class 3 experiencing a considerable improvement in HrQoL values. In comparison to classes 1 and 3, class 2 and 4 were characterized by less severe SAH and better functional outcome. An important difference in the disease course between classes 2 and 4 was a temporary increase in depression scores at the 6-month time point in class 4, which was associated with a considerable reduction in HrQoL.The specific clinical parameters characterizing differences between classes, such as severity of SAH, functional outcome, cognitive impairment and post-stroke depression, were identified and the influence of their potential improvement on HrQoL was estimated. ConclusionBy means of LGMM we could classify the course of HrQoL after SAH in four different patterns, which are relevant for the clinical decisions. Clinical parameters, which can be modified in order to improve the course of HrQoL were identified and could help to develop individual therapeutic strategies for the rehabilitation after SAH.

The Association Between Adult Height and Stroke Incidence in Japanese Men and Women: A Population-based Case-Control Study.

No studies have examined the associations between adult height and ischemic stroke subtypes. We conducted a population-based case-control study that included 2,451 thrombotic and 687 embolic stroke cases, as well as 1,623 intracerebral and 768 subarachnoid hemorrhage cases without history of stroke aged 40-79 years, and the same number of sex- and age-matched controls. Cases and controls were grouped according to the quintile cut-off values of height in controls, and the third quintile, which was approximately the average height group, was used as the reference group. Height divided by one standard deviation of height in controls was also examined as a continuous variable. The analyses were carried out separately for participants aged 40-59 years and 60-79 years. In both younger and older men, height was linearly inversely associated with total and thrombotic strokes, and the shortest quintile compared to the reference group was associated with increased risks of these strokes. Although height was linearly inversely associated with embolic stroke and intracerebral hemorrhage in younger men, the shortest quintile did not show increased risks of these strokes. Height did not seem to be associated with total stroke and any stroke subtypes in younger women. In contrast, the tallest quintile was significantly associated with increased risks of total stroke and intracerebral hemorrhage, and height tended to be positively associated with these strokes in older women. We reported the associations between adult height and ischemic stroke subtypes for the first time, which differed according to sex and age group.

Aneurysmal subarachnoid haemorrhage in the pituitary fossa of a patient with acromegaly - a rare phenomenon.

The anatomy of the pituitary fossa is complex. The wall of the fossa can vary, resulting in inconsistencies in the nature and integrity of the sella barrier. Cerebrospinal fluid is generally confined to the subarachnoid space and does not circulate freely in the pituitary fossa. Spontaneous haemorrhage in the fossa typically occurs in the context of pre-existing intrasellar pathology such as a pituitary adenoma. Extravasation of blood into the subarachnoid space can rarely be observed following pituitary apoplexy. We describe the unique occurrence of subarachnoid haemorrhage in a largely empty pituitary fossa after the rupture of a cerebral aneurysm. Pituitary apoplexy and subarachnoid haemorrhage (SAH) are both high in the differential diagnosis of sudden onset severe headaches. Haemorrhagic pituitary apoplexy may result in extravasation into the subarachnoid space, resulting in typical SAH symptoms and signs. This is the first reported case of primary SAH resulting in blood pooling in an empty sella arising from previous surgical resection of a large macroadenoma.

Ruptured giant fusiform aneurysm in an infant: Case report and review of the literature.

Background: Intracranial aneurysms are exceedingly rare in neonates, accounting for less than 2% of all relevant cases that occur during the first decade of life. More precisely, intracranial aneurysms in children (less than 18 years old) are rarely been recorded, and their epidemiology is poorly investigated. Details about this pathology in this specific population are lacking. Because of the scarcity of this entity along with the peculiar characteristics of this patient group, the treatment of aneurysms of the cerebral circulation of these patients is challenging. The prevalence of Intracranial aneurysms in children is much lower than in adults· apart from that, several differences exist, centered on their etiology, demographic variables, aneurysm location, aneurysm morphological characteristics, clinical presentation, and outcome in pediatric and adult intracranial aneurysms. We describe the case of aneurysmal subarachnoid hemorrhage and extra-axial hemorrhage in an infant, as well as the review of the relevant current literature. Case description: We report the case of a three months old infant who was admitted to our hospital due to episodes of vomiting, associated with loss of consciousness and an epileptic ictus. An MRI-MRA scan and a digital subtraction angiography were immediately performed, which revealed the presence of a giant fusiform aneurysm near the origin of the right anterior cerebral artery. Because of the location and shape of the aneurysmal sac, the ipsilateral internal carotid artery was totally occluded with detachable coils. At follow-up, the child experienced normal psychomotor development with no motor deficit. Conclusions: Intracranial aneurysms should be considered in the differential diagnosis of infants and neonates who present with acute raised intracranial pressure. Even though rupture of an intracranial aneurysm in this age group is rare, subarachnoid hemorrhage is the most common mode of presentation. Intracranial aneurysms are frequently larger than 10 mm and located on the middle cerebral artery. The treatment could be surgical or endovascular, depending on the characteristics of the aneurysm. Seizures and cranial nerve involvement are the most common presenting features in children. The most commonly encountered sites of origin for such aneurysms are the posterior circulation, along with the internal carotid artery bifurcation. Current literature and case series suggest that there is increased incidence of giant, posttraumatic, and mycotic aneurysms in children. Based on the most recently published data, the treatment of ruptured and unruptured pediatric aneurysms is related with an increased incidence of an uneventful outcome, which reaches 95% in the current series. Pediatric intracranial aneurysms are more commonly encountered in male patients and have a predilection for the terminal ICA bifurcation.

A quantitative model to differentiate nonaneurysmal perimesencephalic subarachnoid hemorrhage from aneurysmal etiology.

Nonaneurysmal perimesencephalic subarachnoid hemorrhage (pmSAH) is considered to have a lower-risk pattern than other types of subarachnoid hemorrhage (SAH). However, a minority of patients with pmSAH may harbor a causative posterior circulation aneurysm. To exclude this possibility, many institutions pursue exhaustive imaging. In this study the authors aimed to develop a novel predictive model based on initial noncontrast head CT (NCHCT) features to differentiate pmSAH from aneurysmal causes. The authors retrospectively reviewed patients admitted to an academic center for treatment of a suspected aneurysmal SAH (aSAH) during the period from 2016 to 2021. Patients with a final diagnosis of pmSAH or posterior circulation aSAH were included. Using NCHCT, the thickness (continuous variable) and location of blood in basal cisterns and sylvian fissures (categorical variables) were compared between groups. A scoring system was created using features that were significantly different between groups. Receiver operating characteristic curve analysis was used to measure the accuracy of this model in predicting aneurysmal etiology. A separate patient cohort was used for external validation of this model. Of 420 SAH cases, 48 patients with pmSAH and 37 with posterior circulation aSAH were identified. Blood thickness measurements in the crural and ambient cisterns and interhemispheric and sylvian fissures and degree of extension into the sylvian fissure were all significantly different between groups (all p < 0.001). The authors developed a 10-point scoring model to predict aneurysmal causes with high accuracy (area under the curve [AUC] 0.99; 95% CI 0.98-1.00; OR per point increase 10; 95% CI 2.18-46.4). External validation resulted in persistently high accuracy (AUC 0.97; 95% CI 0.92-1.00) of this model. A risk stratification score using initial blood clot burden may accurately differentiate between aneurysmal and nonaneurysmal pmSAH. Larger prospective studies are encouraged to further validate this quantitative tool.

A Case of Subarachnoid Haemorrhage and Postop Cerebral Vasospasm Successfully Healed Using Yoga Prana Vidya Energy Healing Techniques as Complementary Therapy

Introduction: Subarachnoid haemorrhage (SAH) refers to the bleeding in the space surrounding the brain and its membrane and occurs usually due to the bulging or ruptures in the blood vessels of the brain. Following SAH, cerebral vasospasm can occur which can lead to sudden death or brain damage if not treated correctly and immediately. This paper presents a case of a 35 years old male patient with SAH &amp; cerebral vasospasm, who completely recovered after a successful surgery, and using Yoga Prana Vidya Healing techniques as complementary therapy. Method: This paper uses case study method going through patient medical records, YPV healers’ records and patient feedback. Results: The patient recovered within 4 hours from a complicated 7+ hours of SAH surgery, was able to recognize people and respond to body movements and also use the washroom comfort ability by himself. Within 14 days of YPV healing, the patient was discharged from the hospital and within 2 months of the surgery the patient resumed office and started leading normal life. Conclusion: It is observed that with Yoga Prana Vidya, which is a no-touch no-drug and distant healing modality, faster and complete recovery of patients takes place when used complementarily to medical and surgical treatments such as this case. YPV Healing techniques have been known to increase the life energy or prana in the energy body of a person thereby helping them with a speedy recovery. There is a great scope for further research on this topic using appropriate methodology and sample size.

Methamphetamine-related forensic autopsy cases in a Japanese prefecture over a 7-year period: Characteristics of deaths and blood concentrations

Understanding the actual conditions of methamphetamine (MA)-related death is important from the perspectives of criminal justice and public health. In this report, we review 104 cases of MA-related death handled by our departments between January 2014 and December 2020. Based on information from police and autopsy examinations, we classified the cases into the following categories: “accidental intoxication” (“MA only” and “multiple drugs or alcohol”), “fatal disease” (“definitively MA-related,” “possibly MA-related,” and “unlikely MA-related”), “accident,” “suicide,” “homicide,” and “undetermined.” The total number and annual trends for each category and their respective femoral blood concentrations were investigated. “Fatal disease” was the most common category (48 cases), followed by “suicide” (25 cases), “accidental intoxication” (14 cases), and “accident” (11 cases). “Definitively MA-related” in which MA may have played a role in their onset or exacerbation accounted for the majority of “fatal disease”: 12 cases of heart disease, 4 cases of aortic dissection, 12 cases of cerebral hemorrhage, and 4 cases of subarachnoid hemorrhage. Cases classified as “definitively MA-related” died with lower femoral blood concentrations of MA compared with “MA only.” Cases with “fatal disease” might have been misdiagnosed as “death by natural causes” if a proper autopsy and toxicology examinations were not performed. In death investigations, it is necessary to keep in mind that there are some MA-related deaths, and efforts should be made to increase awareness about the risk of death in using this drug.