Common Cause Of Intracerebral Hemorrhage Research Articles

The Neuropathological Correlates of White Matter Hyperintensities in Cerebral Amyloid Angiopathy

AbstractBackgroundCerebral amyloid angiopathy (CAA) is a common cause of intracerebral hemorrhage and cognitive impairment in older individuals. Hallmark manifestations of CAA on MRI include cortical hemorrhages, as well as perivascular spaces (PVS) in the white matter centrum semiovale and white matter hyperintensities (WMH) in a subcortical multi‐spot pattern. We performed an ex vivo MRI‐neuropathological study to: 1) determine the relationship between WMH volume and CAA severity, and 2) assess the histopathological substrate of confluent WMH, WMH in a multi‐spot pattern (WM_MS), and normal‐appearing white matter (NAWM).MethodNineteen autopsy cases with pathologically confirmed CAA (age 75±8y; 7F) and five non‐CAA controls (age 88±5y; 3F) were included. Formalin‐fixed hemispheres underwent 3T MRI, including a T2‐weighted (500µm isotropic resolution, to obtain manual WMH segmentations) and a T2*‐weighted sequence (1mm isotropic resolution, to automatically segment hemisphere volume using SynthSeg). After scanning, five pre‐defined standard areas were sampled from each brain, then processed to obtain manually assessed arteriolosclerosis scores and AI‐derived cortical and leptomeningeal CAA area measurements. In the CAA cases, specific areas with ex vivo MRI‐observed WM_MS (n = 7), confluent WMH (n = 9), and NAWM (n = 9) were sampled. Sections were stained with LH&E (to determine WM rarefaction, % PVS area, and degree of arteriolosclerosis), and CD68 (a marker of activated microglia, to assess density of CD68‐positive cells).ResultTotal normalized WMH volume did not differ between CAA cases (0.037±0.024) and non‐CAA controls (0.027±0.026) (Mann‐Whitney U test 36, p = 0.31). Within the CAA cases, a multivariable regression model corrected for age at death revealed that normalized WMH volume was associated with cortical CAA area (p = 0.010) and arteriolosclerosis (p = 0.066), but not leptomeningeal CAA area (p = 0.94). Targeted neuropathological assessment revealed that WM rarefaction, arteriolosclerosis score, and density of CD68‐positive cells were higher in areas with WMH compared to WM_MS and NAWM. In contrast, % PVS area was higher in WM_MS compared to WMH and NAWM.ConclusionThe observed differences in neuropathological correlates between WMH in a multi‐spot pattern and confluent WMH in CAA suggest different pathophysiological mechanisms. Future studies are needed to determine these mechanisms as well as the causal relationship between cortical CAA severity and WMH burden.

Abstract WP132: Cerebral Amyloid Angiopathy And Risk Of Ischemic And Hemorrhagic Stroke

Introduction: Cerebral amyloid angiopathy (CAA), a condition characterized by beta amyloid deposition in the cerebral vasculature, is a common cause of intracerebral hemorrhage (ICH) in elderly patients. Radiographic features of CAA such as white matter hyperintensities and cerebral microbleeds are also associated with an increased risk of ischemic stroke. However, there are limited population-based data regarding the risk of incident ischemic and hemorrhagic stroke associated with clinically diagnosed CAA. Methods: We performed a retrospective cohort study using inpatient and outpatient claims from 2016 to 2018 from a nationally representative 5% sample of Medicare beneficiaries. The study exposure was a diagnosis of CAA identified using ICD-10-CM code I68.0. Participants with prevalent stroke were excluded. The primary outcome was any stroke (ischemic or hemorrhagic), and secondary outcomes were ICH, subarachnoid hemorrhage (SAH), and ischemic stroke, assessed separately. These outcomes were identified using validated ICD-10-CM diagnosis codes. Cox proportional hazards regression was used to determine the association between CAA and outcomes after adjustment for demographics and vascular comorbidities. Results: Of the 1.3 million Medicare beneficiaries included, 436 had clinically documented CAA without a prior or concurrent stroke. During a median follow-up of 3.0 years (IQR, 2.3-3.0), incident ischemic stroke occurred in 29,545 patients (2.28%), SAH in 3,340 (0.26%), and ICH in 4,338 (0.34%). In adjusted Cox models, CAA was significantly associated with an increased risk of any stroke (HR, 3.4; 95% CI, 2.5-4.7), ICH (HR, 17.1; 95% CI, 11.1-26.3), and SAH (HR, 6.2; 95% CI, 2.7-13.9). There was a nonsignificant association with ischemic stroke (HR, 1.4; 95% CI, 0.8-2.4). Conclusions: In a nationally representative cohort of Medicare beneficiaries, CAA was associated with a significantly increased risk of future ICH and SAH, but was not significantly associated with an increased risk of future ischemic stroke.

When less is more: Non-contrast head CT alone to work-up hypertensive intracerebral hemorrhage

Hypertension is a common cause of intracerebral hemorrhage (ICH). The work up typically involves neuroimaging of the brain and blood vessels to determine etiology. However, extensive testing may be unnecessary for presumed hypertensive hemorrhages, and instead prolong hospital stay and increase costs. This study evaluates the predictive utility of hemorrhage location on the non-contrast head CT in determining hypertensive ICH. Patients presenting with non-traumatic ICH between March 2014 and June 2019 were prospectively enrolled. Hemorrhage etiology was determined based on previously defined criteria. Chi square and Student’s t tests were used to determine the association between patient demographics, ICH severity, neuroimaging characteristics, and medical variables, with hypertensive etiology. Multivariable regression models and an ROC analysis determined utility of CT to accurately diagnose hypertensive ICH. Data on 380 patients with ICH were collected; 42% were determined to be hypertensive. Along with deep location on CT, black race, history of hypertension, renal disease, left ventricular hypertrophy, and higher admission blood pressure were significantly associated with hypertensive etiology, while atrial fibrillation and anticoagulation were associated with non-hypertensive etiologies. Deep location alone resulted in an area under the curve of 0.726. When history of hypertension was added, this improved to 0.771. Additional variables did not further improve the model’s predictability. Hypertensive ICH is associated with several predictive factors. Using deep location and history of hypertension alone correctly identifies the majority of hypertensive ICH without additional work-up. This model may result in more efficient diagnostic testing without sacrificing patient care.

MRI and CT imaging biomarkers of cerebral amyloid angiopathy in lobar intracerebral hemorrhage.

Cerebral amyloid angiopathy (CAA), a common cause of intracerebral hemorrhage (ICH), is diagnosed using the Boston criteria including magnetic resonance imaging (MRI) biomarkers (cerebral microbleeds (CMBs) and cortical superficial siderosis (cSS). The simplified Edinburgh criteria include computed tomography (CT) biomarkers (subarachnoid extension (SAE) and finger-like projections (FLPs)). The underlying mechanisms and diagnostic accuracy of CT compared to MRI biomarkers of CAA are unknown. We included 140 survivors of spontaneous lobar supratentorial ICH with both acute CT and MRI. We assessed associations between MRI and CT biomarkers and the diagnostic accuracy of CT- compared to MRI-based criteria. FLPs were more common in patients with strictly lobar CMB (44.7% vs 23.5%; p = 0.014) and SAE was more common in patients with cSS (61.3% vs 31.2%; p = 0.002). The high probability of the CAA category of the simplified Edinburgh criteria showed 87.2% (95% confidence interval (CI): 78.3-93.4) specificity, 29.6% (95% CI: 18.0-43.6) sensitivity, 59.3% (95% CI: 38.8-77.6) positive predictive value, and 66.4% (95%: CI 56.9-75.0) negative predictive value, 2.3 (95% CI: 1.2-4.6) positive likelihood ratio and 0.8 (95% CI 0.7-1.0) negative likelihood ratio for probable CAA (vs non-probable CAA), defined by the modified Boston criteria; the area under the receiver operating characteristic curve (AUROC) was 0.62 (95% CI: 0.54-0.71). In lobar ICH survivors, we found associations between putative biomarkers of parenchymal CAA (FLP and strictly lobar CMBs) and putative biomarkers of leptomeningeal CAA (SAE and cSS). In a hospital population, CT biomarkers might help rule-in probable CAA (diagnosed using the Boston criteria), but their absence is probably not as useful to rule it out, suggesting an important continued role for MRI in ICH survivors with suspected CAA.

Clinical and Radiological Profile in Non Hypertensive Intracerebral HaemorrhageA Prospective Observational Study

Introduction: Intracerebral Haemorrhage (ICH) is less frequent than ischemic stroke, but has higher mortality and morbidity, it being one of the first causes of severe disability. Hypertension is the most common cause of ICH but Non Hypertensive Intracerebral Haemorrhages (NHICH) are not rare. Hence, the importance of recognizing these conditions and need for urgent specific therapy which may play a vital role in therapeutic planning and prevention of ICH. Hence this study was performed to study. Aim: To study the clinical and radiological profile in NHICH, to identify risk factors, and to determine whether clinical/neuronradiological parameters would predict the prognosis of ICH. Materials and Methods: The present prospective observational study was conducted in the Department of General Medicine Mahadevappa Rampure Medical College Gulbarga, Karnataka, India, from January 2016-January 2017. It involved 50 subjects with NHICH. Demographic details, clinical and radiological data were collected in patients presenting with signs and symptoms of stroke and confirmed by Computed Tomography (CT) scan/ Magnetic Resonance Imaging (MRI) brain as ICH, who were non hypertensive and with age more than 18 years. Clinical outcome of the patients was measured based on Glasgow Coma Scale (GCS), site and volume of haemorrhage. Descriptive statistics of the explanatory and outcome variables were calculated by mean, Standard Deviation (SD) and Chi-square test was applied for qualitative variables. Results: In the present study 31 (62%) were males, and 19 (38%) were females. The age of patients ranged from 18-85 years. The most common risk factor associated with intracerebral haemorrhage was alcohol consumption 16 (32.0%), followed by smoking 13 (26%), and anticoagulant intake 13 (26%). Most common clinical presentation were hemiplegia/hemiparesis, speech defect, vomiting, convulsion, pupillary defect and cranial nerve involvement, in decreasing frequency. High ICH score and low GCS were poor prognostic factors for outcome of intracerebral haemorrhage patient in the present study. In hospital mortality rate was 28%. During 30 days follow-up, there was 22.2% mortality among the discharged patient. Conclusion: Although hypertension remains as a most common risk factor for intracerebral bleed, other risk factors such as significant alcohol consumption, coagulopathy should also be kept in mind especially in young. Non hypertensive haemorrhage usually occurs at sites not typical for hypertensive bleed. All efforts should be directed to establish the aetiological factors for intracerebral bleed, so that appropriate timely therapy can be provided to prevent further morbidity and mortality

POCUS OBTAINED OPTIC NERVE SHEATH DIAMETER IN PATIENTS PRESENTING WITH INTRACEREBRAL HEMORRHAGE

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Intracerebral hemorrhage (ICH) results in spontaneous bleeding into the brain. This accounts for 10-15% of all strokes in the United States and has poor outcomes due to death or disability. An ICH can result in increased intracranial pressure due to blood occupying extra space. Optic nerve ultrasonography has emerged as a quick noninvasive procedure to detect increased intracranial pressure. A question that has not been answered is whether there is a specific correlation between the size of hematoma in the brain and the optic nerve sheath diameter (ONSD). The optic nerve is wrapped by a sheath derived from the meninges. Cerebrospinal fluid (CSF) can transfer freely between the intracranial and intraorbital spaces. METHODS: 23 patients were recruited into this study. Each of these patient’s received the diagnosis of ICH and admitted to the neuro intensive care unit (NICU). Ultrasound of the optic nerve was performed using a Sonosite machine and the high frequency probe. The exam was performed upon admission to the NICU. Both eyes were scanned in two planes, longitudinal and transverse. Once the ONSD measurements were recorded, the volume of the ICH was noted on initial head CT. RESULTS: The average ICH score was 1.35 and the average APACHE IV score was 27.35. In addition, the average GCS on admission was 13. The most common cause of ICH was hypertension. The most common location for the ICH was lobar hemorrhage. 8 out of 23 patients had midline shift on their initial head CT. 4 out of 23 patients underwent some sort of surgical intervention. The smallest average combined ONSD was 4.43cm. The longest average combined ONSD was 8.03cm. The minimum hemorrhage volume was 0.20cm3. The maximum was 60.0cm3. A moderate, positive correlation was detected between average optic nerve size and hemorrhage volume (correlation=0.5262; p-value=0.0099). A weak positive correlation was detected between APACHE IV and average ONSD (correlation=0.2052; p-value=0.3476). A weak-moderate positive correlation was detected between ICH score and average ONSD. (correlation=0.3622; p-value=0.0895). Those who experienced a midline shift had significantly higher averaged ONSD compared to those who did not. CONCLUSIONS: This study determined there was a moderate positive correlation between the ONSD and volume of hematoma. From a pathophysiological standpoint, conditions like ICH lead to cerebral parenchyma swelling which is transmitted to the optic nerves through the meninges. Additionally, our study revealed a significant difference in average ONSD and midline shift observed on CT scan. In settings where no invasive monitoring is available, ONSD enlargement may be a useful technique for monitoring midline shift. CLINICAL IMPLICATIONS: There are already established prognostic indicators for ICH including an ICH volume of 60cm3or greater on initial CT along with a GCS of 9 or less which predict a 30 day mortality of 19%. ONSD has a role in prognostication. Growth of the hematoma in the first 24 hours is an independent predictor of mortality and poor outcome. Serial exams of a patients ONSD can be applied to indirectly monitor any expanding hematoma. Given the positive correlation between ONSD and hematoma volume, I would be interested in ONSD and the degree of disability scores such as the modified rankin scale. DISCLOSURES: No relevant relationships by Braden Anderson, source=Web Response No relevant relationships by Shekhar Ghamande, source=Web Response No relevant relationships by Sarita Kambhampati, source=Web Response No relevant relationships by Matthew Lohse, source=Web Response No relevant relationships by Alireza Nathani, source=Web Response

Interventions for treating brain arteriovenous malformations in adults.

Brain arteriovenous malformations (AVMs) are the single most common cause of intracerebral haemorrhage in young adults. Brain AVMs also cause seizure(s) and focal neurological deficits (in the absence of haemorrhage, migraine or an epileptic seizure); approximately one-fifth are incidental discoveries. Various interventions are used in an attempt to eradicate brain AVMs: neurosurgical excision, stereotactic radiosurgery, endovascular embolization, and staged combinations of these interventions. This is an update of a Cochrane Review first published in 2006, and last updated in 2009. To determine the effectiveness and safety of the different interventions, alone or in combination, for treating brain AVMs in adults compared against either each other, or conservative management, in randomized controlled trials (RCTs). The Cochrane Stroke Group Information Specialist searched the Cochrane Stroke Group Trials Register (last searched 7 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library, MEDLINE Ovid (1980 to 14 January 2019), and Embase OVID (1980 to 14 January 2019). We searched international registers of clinical trials, the contents pages of relevant journals, and bibliographies of relevant articles (November 2009). We also contacted manufacturers of interventional treatments for brain AVMs (March 2005). We sought RCTs of any intervention for brain AVMs (used alone or in combination), compared against each other or against conservative management, with relevant clinical outcome measures. One author screened the results of the updated searches for potentially eligible RCTs for this updated review. Both authors independently read the potentially eligible RCTs in full and confirmed their inclusion according to the inclusion criteria. We resolved disagreement by discussion. We assessed the risk of bias in included studies and applied GRADE. We included one trial with 226 participants: A Randomized trial of Unruptured Brain Arteriovenous Malformations (ARUBA), comparing intervention versus conservative management for unruptured brain AVMs (that had never bled). The quality of evidence was moderate because we found just one trial that was at low risk of bias other than a high risk of performance bias due to participants and treating physicians not being blinded to allocated treatment. Data on functional outcome and death at a follow-up of 12 months were provided for 218 (96%) of the participants in ARUBA. In this randomized controlled trial (RCT), intervention compared to conservative management increased death or dependency (modified Rankin Scale score ≥ 2, risk ratio (RR) 2.53, 95% confidence interval (CI) 1.28 to 4.98; 1 trial, 226 participants; moderate-quality evidence) and the proportion of participants with symptomatic intracranial haemorrhage (RR 6.75, 95% CI 2.07 to 21.96; 1 trial, 226 participants; moderate-quality evidence), but there was no difference in the frequency of epileptic seizures (RR 1.14, 95% CI 0.63 to 2.06; 1 trial, 226 participants; moderate-quality evidence). Three RCTs are ongoing. We found moderate-quality evidence from one RCT including adults with unruptured brain AVMs that conservative management was superior to intervention with respect to functional outcome and symptomatic intracranial haemorrhage over one year after randomization. More RCTs will help to confirm or refute these findings.

Intracerebral Hemorrhage in a Young Urban Population: Etiologies and Outcomes in Patients 50 and Younger

Goal: There is limited research on intracerebral hemorrhage in young urban populations. There is reduced access to healthcare and a high prevalence of multiple comorbidities in this vulnerable population. We studied the etiologies and outcomes of spontaneous intracerebral hemorrhage in an urban North Philadelphia cohort aged 50 years old and younger. Materials and methods: A retrospective chart review of subjects 50 years old and younger who presented with spontaneous intracerebral hemorrhage at Temple University Hospital was conducted. A novel scoring system was used to classify the cause of each intracerebral hemorrhage. This system was used to assign a degree of likelihood that hypertension, amyloid angiopathy, tumor, oral anticoagulants, vascular malformations, infrequent causes, or cryptogenic etiologies were present. Aneurysmal subarachnoid hemorrhage was excluded. The prevalence of each risk factor and outcomes were analyzed. Findings: Of the 110 patients in the study, the most common etiology was hypertension (82.7%). There was no statistically significant difference in mortality between patients with multiple possible etiologies for their hemorrhage. Vascular malformations and cavernomas were rare (5.5%). Conclusions: Hypertension was the most common cause of intracerebral hemorrhage in a young urban population. The presence of multiple possible etiologies does not correlate with a worse prognosis of mortality. There is a need for further research into hemorrhagic stroke in young populations.

Abstract WP440: Pre-existing Cerebral Atrophy is Associated With Diminished Intracerebral Hemorrhage Severity

Background and Objective: Cerebral small vessel disease (CSVD) is a chronic, cumulative cerebrovascular disease and is the most common cause of intracerebral hemorrhage (ICH). The effects of pre-existing CSVD on the severity of acute ICH are incompletely understood. We aim to clarify associations between computed tomography (CT) markers of CSVD and 1) acute ICH volume and 2) presence and severity of concomitant intraventricular hemorrhage (IVH). Methods: Baseline CT scans of patients from the Ethnic and Racial Variations of Intracerebral Hemorrhage (ERICH) study were evaluated for the extent of leukoaraiosis and cerebral atrophy using visual rating scales and for the Graeb Score, as a measure of IVH severity. ICH volume was measured on baseline CT scans using semi-automated software. The associations of leukoaraiosis and atrophy and ICH volume, IVH presence and the Graeb Score were tested using multivariable linear, ordinal and binary logistic regression models. Secondary analyses were stratified by hemorrhage location (lobar versus non-lobar). Bonferroni correction was applied. Results: The study included 2579 patients, 774 (30.0%) with a lobar ICH and 1805 (70.0%) with a non-lobar ICH. Median ICH volume was higher for lobar ICH and non-lobar ICH was more frequently associated with IVH. Increasing grades of central, cortical and total atrophy were inversely and dose-dependently associated with baseline ICH volume (P for trend <0.001). Leukoaraiosis was not significantly associated with ICH volume in multivariable analysis. Leukoaraiosis was associated with increased risk of IVH in a dose-dependent manner (P for trend <0.001), while global atrophy was inversely associated with IVH presence and severity (both P for trend <0.001). Analyses stratified by ICH location revealed largely similar associations for non-lobar and lobar ICH. Conclusions: In this study, increasing grades of cerebral atrophy were associated with smaller ICH volume and decreased risk of IVH presence and severity, while increasing extent of leukoaraiosis was associated with higher risk of IVH. These findings suggest that cerebral atrophy might be protective in the setting of acute ICH. Future studies are needed to confirm our findings and identify the underlying mechanisms.

Cerebral amyloid angiopathy mimicking central nervous system metastases: a case report

BackgroundThis case describes an unusual presentation of an intracranial hemorrhage first thought to be metastatic disease on computed tomography and magnetic resonance imaging. The healthcare team completed an exhaustive search for a primary malignancy that was negative. Final diagnosis on brain biopsy showed intercranial hemorrhage secondary to cerebral amyloid angiopathy. With an increasing number of elderly patients and the rising cost of health care, this case can serve as a reminder to clinicians about their own responsibilities in limiting the cost of health care.Case presentationThis is a case report about a 72-year-old white woman with an intracranial hemorrhage secondary to cerebral amyloid angiopathy. The brain lesions on computed tomography/magnetic resonance imaging mimicked a metastatic process until a brain biopsy could give a definitive diagnosis that was completely unexpected. Cerebral amyloid angiopathy is a rare cause of intracerebral hemorrhage and this diagnosis is important to consider in older patients on anticoagulation.ConclusionsCerebral amyloid angiopathy is a rare diagnosis but should be considered in elderly patients on anticoagulation presenting with imaging findings consistent with intracerebral hemorrhage. While metastatic disease is a more common cause of intracerebral hemorrhage, cerebral amyloid angiopathy should remain in the differential diagnosis. This case report serves as a teaching point to clinicians in cases involving an older patient on anticoagulation.

Spontaneous intracerebral hemorrhage: A pediatric case of undetermined etiology and review of literature

Cerebrovascular disorders, particularly intracerebral hemorrhage (ICH), rarely occur in children. The most common underlying cause for ICH in the pediatric population is arteriovenous malformation (AVM). The best approach to diagnostic evaluation of pediatric ICH is unknown due to its low incidence (2-3/100,000 children). In recent years, early discovery of underlying cause of pediatric ICH has been possible due to a more widespread use of imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). We report a case of a 5-year-old boy with a ICH of unknown etiology. He presented with left hemiparesis and left facial droop for one hour. Non- contrast CT scan demonstrated right periventricular hematoma extending to all ventricles. Follow-up MRI, CT angiography and DSA were unremarkable. Laboratory findings including liver function tests, hematologic studies were normal. Screening for hemoglobinopathies was negative. Transthoracic echocardiography was unremarkable. Surgery for ventricular drain place- ment and intense physical therapy were performed. During the follow ups at 1 and 6 mo of initial admission, repeat brain MRI and magnetic resonance angiography were unremarkable. The complete diagnostic evaluation in children presenting with ICH of undetermined origin is critically important,but stillthe etiol- ogy may not be identified in some cases. As AVMs are the most common cause of ICH in children and may rarely regress following hemorrhage, our patient's normal follow-up imaging may be related to such a spontaneous thrombosis of an underlying AVM.

Underlying effect of age on outcome differences in arteriovenous malformation-associated intracerebral hemorrhage

Brain arteriovenous malformations (AVM) are the most common cause of intracerebral hemorrhage (ICH) in young adults. Although previous studies have found that the mortality and morbidity of ICH due to AVM (AVM-ICH) is lower than in spontaneous ICH, it is unclear whether the more favorable prognosis is directly related to the presence of the vascular malformation. We included 34 patients with AVM-ICH and 187 with spontaneous intracerebral hemorrhage (sICH) due to either hypertension or cerebral amyloid angiopathy. Patient data were obtained from the prospective Intracerebral Hemorrhage Outcomes Project, which enrolls ICH patients admitted to Columbia University Medical Center. Using ICH etiology (AVM-ICH or sICH) and previously verified predictors of ICH outcome, two multivariate analyses were performed with and without age to compare the odds of death at 3months and the functional outcome. Although mortality in AVM-ICH group was lower than the sICH group (20.6% versus 43.3%, respectively), this value was only significant when age was excluded (p=0.017) and lost its significance when we controlled for age (p=0.157). There was an analogous loss of significance with functional outcome using the modified Rankin Scale. In conclusion, our data suggests that the previously observed lower case fatality rate and more favorable functional outcomes in the AVM-ICH group compared to the sICH group may largely be the result of age.

Angiopathie amyloïde cérébrale : un diagnostic difficile en réanimation

Cerebral amyloid angiopathy is a common cause of intracerebral haemorrhage in elderly patients. The diagnosis of cerebral amyloid angiopathy is based on the Boston criteria combining clinical and radiological criteria with no other cause of intracerebral haemorrhage. We describe the case of a 60-year-old female admitted to the intensive care unit for agitation and spatial disorientation. She had multiple intracerebral haematomas on brain CT scan. Typical cerebral microbleeds using MRI and the absence of other cause of intracerebral haemorrhage argued in favour of the diagnosis of cerebral amyloid angiopathy. The patient outcome was favourable with a discharge from the intensive care unit on day 16.

Low Avidity and Level of Serum Anti-Aβ Antibodies in Patients With Cerebral Amyloid Angiopathy-Related Cerebral Hemorrhage

ABSTRACTCerebral amyloid angiopathy (CAA) is characterized by the deposition of the beta-amyloid protein (Aβ) in small cerebral vessels, which is considered a common cause of intracerebral hemorrhage (CAAH) in elderly people. Little is known about the properties of serum naturally occurring anti-Aβ antibodies in patients with CAAH. We investigated the avidity and levels of anti-Aβ antibodies in 20 patients and 20 age-matched healthy controls by an enzyme-linked immunosorbent assay with thiocyanate elution. Our study revealed that both the levels and the avidity of these endogenous anti-Aβ antibodies were lower in patients with CAAH than in controls, which may be a new mechanism for the impaired clearance of cerebral Aβ and have important implications for the development of immune-based therapeutic strategies for CAA.

Interventions for treating brain arteriovenous malformations in adults.

Brain arteriovenous malformations (AVMs) are the single most common cause of intracerebral haemorrhage in young adults. Brain AVMs also cause seizure(s) and focal neurological deficits (in the absence of haemorrhage, migraine or an epileptic seizure); approximately one fifth are incidental discoveries. Various interventions are used in an attempt to eradicate brain AVMs: neurosurgical excision, stereotactic radiotherapy/'radiosurgery' (using gamma knife, linear accelerator, proton beam, or 'Cyber Knife'), endovascular embolisation (using glues, particles, fibres, coils, or balloons), and staged combinations of these interventions. This is an update of a Cochrane review first published in 2006. To assess the clinical effects of interventions to treat brain AVMs in adults (with the aim of either partial obliteration or total eradication), using data published in randomised controlled trials (RCTs). We searched the Cochrane Stroke Group Trials Register (last searched November 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2009), MEDLINE (1966 to November 2009) and EMBASE (1980 to November 2009). We searched international registers of clinical trials, the contents pages of relevant journals, and bibliographies of relevant articles (November 2009). We also contacted manufacturers of interventional treatments for brain AVMs (March 2005). We sought randomised trials of any or all of the interventions for brain AVMs, compared against each other or against usual medical therapy, with relevant clinical outcome measures. Two authors independently applied the inclusion criteria and reviewed the relevant studies. One ongoing RCT fulfils the selection criteria for this review: A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA, www.arubastudy.org), comparing interventional treatment versus medical management for brain AVMs that have never bled. We also found two RCTs which tested the equivalence of two embolic agents for the pre-operative embolisation of brain AVMs (one published, one unpublished), but none of the primary or secondary outcome measures in these trials met our desired criteria. We also excluded a third RCT which studied three different blood pressure lowering treatments to induce deliberate hypotension during surgical resection of brain AVMs because the intervention was not the focus of this review. There is no evidence from randomised trials with clear clinical outcomes comparing different interventional treatments for brain AVMs against each other or against usual medical therapy to guide the interventional treatment of brain AVMs in adults. One such trial (ARUBA) is ongoing.

Surgical management of pediatric cerebral arteriovenous malformations

Arteriovenous malformations (AVMs) are the most common cause of intracerebral hemorrhage in children. Different options exist for their successful management consisting of surgery, endovascular embolization, stereotactic radiosurgery, or a combination of these treatments. In this paper, we discuss the different treatment modalities in the treatment of pediatric cerebral AVMs emphasizing the role of surgery and endovascular embolization as a preoperative strategy.

Cerebral immunoglobulin light chain amyloid angiopathy-related hemorrhages

Introduction Cerebral amyloid angiopathy (CAA) is a common cause of intracerebral hemorrhage (ICH) particularly in elderly patients. In CAA-related hemorrhages, amyloid deposits in the brain vessel walls mainly contain amyloid beta-protein (A-beta). Rarely other forms of amyloid substances have been reported in sporadic CAA-related hemorrhages. Methods We report the case of a 44-year-old patient with recurrent ICH who had surgical evacuation of a large frontal hematoma. Following surgery, samples from the hematoma and adjacent cerebral cortex were obtained for histopathological examination. Results Within the recent hemorrhage, a few arteriolar walls were thickened with an amyloid deposit that was immunostained for immunoglobulin (Ig) M and light chain lambda. In the wall of some vessels, around the amyloid deposits, as well as in the adjacent cerebral cortex, there was an infiltration by monotypic lymphocytes and plasma cells expressing IgM and light chain lambda. No amyloid deposition was found outside the hemorrhage. There was no evidence of multiple myeloma, B-cell malignancy, or systemic amyloidosis. Conclusions Recurrent ICH may be due to amyloid deposition of IgM lambda produced by monotypic proliferation of lymphocytes and plasma cells purely localized to the brain.

History of surgery for cerebrovascular disease in children. Part III. Arteriovenous malformations

Arteriovenous malformations (AVMs) are the most common cause of intracerebral hemorrhage in children. In this paper the authors trace the historical evolution of the recognition, diagnosis, and treatment of pediatric intracerebral AVMs, and they summarize the contemporary approach and current controversies surrounding treatment of these lesions. Important distinctions between adult and pediatric AVMs are emphasized.

Cerebral Amyloid Angiopathy: A Common Cause of Intracerebral Hemorrhage in the Elderly - A casereport

Cerebral amyloid angiopathy, defined as deposition of amyloid in the walls of brain vessels, is belived to be a common cause of intracerebral hemorrhage in the elderly. It differentiates from the intracerebral hemorrhage of hypertension by its specific location of bleeding. The hematoma from cerebral amyloid angiopathy, sometimes multilobar, is always located in the brain cortices and the white matter beneath them. In the previous reports, the presence of cerebral amyloid angiopathy accounts for 5-10% of non-traumatic cerebral hemorrhage. However, it has been overlooked or misdiagnosed all the time because of the lack of tissue proof. Recurrent bleeding occurs so often, as it is rare in hypertensive intracerebral hemorrhage, that we should know how to detect cerebral amyloid angiopathy and prevent rebleeding. We report a case of intracerebral hemorrhage which was misdiagnosed as tumor bleeding. The patient underwent craniotomy for evacuation of hematoma and tumor excision. There was no tumor tissue in the specimen but it showed amyloid angiopathy. We presented her clinical course and discussed the differential diagnosis of intracerebral hemorrhage. We remind all the physiatrists that cerebral amyloid angiopathy is a possible cause of intracerebral hemorrhage, and not rare.

Delayed Posttraumatic Hemorrhage

Delayed posttraumatic hemorrhage (DPTH) is one of the causes of intracerebral hemorrhage (ICH). Most of the published series were reported before the advent of CT. Clinical characteristics and CT findings are described. Ten cases of CT-proven DPTH from a series of 216 patients (age range, 15 to 50 years) with ICH were evaluated. Previous CT scans performed in the first 6 hours after head injury were normal in all patients. Cerebral angiography showed no evidence of vascular disorders in any patient. DPTH was the fourth most common cause of ICH in our series. The symptom-free interval after head injury ranged from 1 to 15 days. Most hematomas were located deep in the hemisphere and were of small or medium size. Clinical course was good in the majority of cases; none of the patients died, and there was no recurrence. DPTH is a relatively frequent cause of ICH in young adults. There is no relationship with intensity of the previous head injury. The more frequent location deep in the hemisphere may be related to the younger age of our patients compared with those of other published series. The good outcome in our patients may be related to their youth and the absence of complications such as skull fracture, need for neurosurgery, or coagulation disorders.