Infratentorial Hemorrhage Research Articles

PO-0476 Brain-injury After Neonatal Surgery For Non-cardiac Congenital Anomalies

<h3>Background</h3> Increasing concerns have been raised about the incidence of perioperative brain injury in neonates with non-cardiac congenital anomalies (NCCA). <h3>Aims</h3> To evaluate brain-injury following neonatal surgery for NCCA using magnetic resonance imaging (MRI). <h3>Methods</h3> Since January 2013 MRI became clinical routine after neonatal surgery for NCCA at our hospital. T1, T2, and DWI were performed to evaluate acute hypoxic-ischaemic injury. Brain injury was assessed on MRI after surgery. <h3>Results</h3> Surgery and MRI were performed respectively at a median postnatal age of 2 days [0–29] and 8 days [3–44] after surgery in 38/45 infants. Thirteen (34%) neonates had a normal MRI-scan (GA 39.0[35.86–40.57], BW 2930, z-score -1.38). Among 14 preterm infants the following lesions (79%) were found: IVH grade II (1), punctate cerebellar haemorrhages (4), punctate white matter lesions (9, PWML) and lenticulostriate-infarction (1). For 24 full-term infants, 58% had brain lesions: punctate cerebellar haemorrhages (2), PWML (5), supra- and infratentorial subdural haemorrhages (mild, 7) and sinus thrombosis (1, superior sagittal sinus). Several infants had a combination of lesions (n = 8). <h3>Conclusion</h3> This cohort shows a wide range of mild to moderate brain lesions in infants with NCCA. Brain injury was more prevalent in preterm infants. Additional research is needed to gain better insight into clinical and surgical risk factors and underlying NCCA, timing of onset and aetiology of brain injury. Neurodevelopmental follow-up should be conducted to evaluate the clinical implications of these findings.

Surgical treatment of intraparenchymal hemorrhage during mechanical circulatory support for heart-failure--a single-centre experience.

Cranial intraparenchymal hemorrhage represents a critical complication of mechanical circulatory support requiring constant antithrombotic treatment. Surgery of intraparenchymal hemorrhage under anticoagulation represents a challenge and imposes significant risks for patients. It was the aim to analyse surgical and clinical outcome of patients requiring surgical treatment due to intraparenchymal hemorrhage. Patients with mechanical circulatory support requiring surgical therapy due to space-occupying lobar supratentorial or infratentorial hemorrhage from January 1, 2009 to January 1, 2014 were included in our study. Baseline parameters are preoperative International Normalized Ratio (INR) values, postoperative anticoagulation regiment, bleeding size and localization. Co-primary outcome parameters were the extent of hematoma evacuation and the Modified Rankin Scale at discharge from hospital. Secondary outcome parameters included rate of recurrent hemorrhage, rate of revision surgery and in-hospital mortality. Twelve patients (mean age 44 ± 18 years, nine supratentorial-/three infratentorial hemorrhages, 11 left ventricular assist devices, and one extracorporeal membrane oxygenation) were included. Surgical hematoma evacuation was performed in 11 patients, one patient received decompressive hemicraniectomy. Hematoma evacuation was complete in no patients, and partial in 11 patients. Initial INR was 2,7 ± 1,6. Rate of recurrent hemorrhage was 75 %. Revision surgery was performed in three patients achieving partial hematoma evacuation in two patients and complete evacuation in one patient. Modified Rankin Scale at discharge from hospital was six in nine patients (in-hospital mortality of 75 %), five in two patients and four in one patient. Surgical treatment of life threatening, space-occupying intraparenchymal hemorrhage under mechanical circulation support is of limited efficacy with high rates of recurrent hemorrhage and in-hospital mortality. We provide additional data that postponing anticoagulation is feasible and may lead to improved clinical outcome and survival.

Neuromonitoring of Neonatal Extracorporeal Membrane Oxygenation Patients Using Serial Cranial Ultrasounds*

Neuromonitoring of Neonatal Extracorporeal Membrane Oxygenation Patients Using Serial Cranial Ultrasounds*

Warfarin-associated intracerebral hemorrhage: Volume, anticoagulation intensity and location

BackgroundWarfarin use increases mortality in patients with intracerebral hemorrhage (ICH). Larger hematoma volume and infratentorial location are both major determinants of poor outcome in ICH. Although warfarin-associated intracerebral hemorrhages have greater volumes, there is uncertainty about the effects of location. We aimed to investigate the influence of warfarin on hematoma volume and location. MethodsWe conducted a retrospective study of all patients hospitalized for ICH at a large stroke center from October 2007 to January 2012. Initial CT scans were used to quantify hematoma volumes using the computer-assisted planimetric analysis. Univariate and multivariable analyses determined the influence of warfarin on hemorrhage location. Median regression analysis was performed to estimate the effects of INR on hematoma volumes. ResultsWe included 404 consecutive patients with ICH of whom 69 were on warfarin. Patients on warfarin had larger hematoma volumes (median 23.9mL vs. 14.2mL; P=0.046). In patients excessively anticoagulated with warfarin (defined as INR>3.0), compared with those in the therapeutic range, brainstem ICH was more frequent (24.0% vs. 6.1%; P=0.005). Patients with INR>3.0 had increased odds of infratentorial hemorrhage (OR 3.63; 95% CI 1.52–8.64; P=0.004) when compared to non-warfarin ICH patients. After adjustment for hematoma location, there was no significant association between INR and hematoma volume. ConclusionsPatients with warfarin-associated ICH have a predilection for brainstem ICH. After adjustment for ICH location, no relationship between admission INR and hematoma volume was found.

Warfarin and Statins are Associated with Hematoma Volume in Primary Infratentorial Intracerebral Hemorrhage

Despite extensive studies of supratentorial intracerebral hemorrhage (ICH), limited data are available on determinants of hematoma volume in infratentorial ICH. We therefore aimed to identify predictors of infratentorial ICH volume and to evaluate whether location specificity exists when comparing cerebellar to brainstem ICH. We undertook a retrospective analysis of 139 consecutive infratentorial ICH cases (95 cerebellar and 44 brainstem ICH) prospectively enrolled in a single-center study of ICH. ICH volume was measured on the CT scan obtained upon presentation to the Emergency Department using an established computer-assisted method. We used linear regression to identify determinants of log-transformed ICH volume and logistic regression to evaluate their role in surgical evacuation. Median ICH volumes for all infratentorial, cerebellar, and brainstem ICH were nine [interquartile range (IQR), 3-23], ten (IQR, 3-25), and eight (IQR, 3-19) milliliters, respectively. Thirty-six patients were on warfarin treatment, 31 underwent surgical evacuation, and 65 died within 90 days. Warfarin was associated with an increase in ICH volume of 86 % [β = 0.86, standard error (SE) = 0.29, p = 0.003] and statin treatment with a decrease of 69 % (β = -69, SE = 0.26, p = 0.008). Among cerebellar ICH subjects, those on warfarin were five times more likely to undergo surgical evacuation (OR = 4.80, 95 % confidence interval 1.63-14.16, p = 0.005). Warfarin exposure increases ICH volume in infratentorial ICH. Further studies will be necessary to confirm the inverse relation observed between statins and ICH volume.

Concurrent supra and infra-tentorial traumatic parenchymal hematomas: Which one needs to be evacuated first?

Traumatic intra-cerebellar hematoma although uncommon, yet increasing recognized lesions accounting for 6–0.82% of the total hematomas. We discuss a case of 19-year-old male multiple simultaneous traumatic supratentorial and infra-tentorial hemorrhages. In present case presence of significant size hematomas in both supra and infra-tentorial compartment posed a difficult challenge as which one needs to be evacuated first? This was a concern in present case as evacuation of the infra-tentorial hematoma can lead to downward herniation and evacuation of the supratentorial hematoma can lead to upward herniation. The difficulties and approach for an uncommon case of delayed and multiple traumatic supra and infra-tentorial hematomas are discussed.

Volume Quantification of Acute Infratentorial Hemorrhage with Computed Tomography: Validation of the Formula 1/2ABC and 2/3SH

ObjectiveTo compare the accuracy of formula 1/2ABC with 2/3SH on volume estimation for hypertensive infratentorial hematoma.MethodsOne hundred and forty-seven CT scans diagnosed as hypertensive infratentorial hemorrhage were reviewed. Based on the shape, hematomas were categorized as regular or irregular. Multilobular was defined as a special shape of irregular. Hematoma volume was calculated employing computer-assisted volumetric analysis (CAVA), 1/2ABC and 2/3SH, respectively.ResultsThe correlation coefficients between 1/2ABC (or 2/3SH) and CAVA were greater than 0.900 in all subgroups. There were neither significant differences in absolute values of volume deviation nor percentage deviation between 1/2ABC and 2/3SH for regular hemorrhage (P>0.05). While for cerebellar, brainstem and irregular hemorrhages, the absolute values of volume deviation and percentage deviation by formula 1/2ABC were greater than 2/3SH (P<0.05). 1/2ABC and 2/3SH underestimated hematoma volume each by 10% and 5% for cerebellar hemorrhage, 14% and 9% for brainstem hemorrhage, 19% and 16% for regular hemorrhage, 9% and 3% for irregular hemorrhage, respectively. In addition, for the multilobular hemorrhage, 1/2ABC underestimated the volume by 9% while 2/3SH overestimated it by 2%.ConclusionsFor regular hemorrhage volume calculation, the accuracy of 2/3SH is similar to 1/2ABC. While for cerebellar, brainstem or irregular hemorrhages (including multilobular), 2/3SH is more accurate than 1/2ABC.

Abstract WP302: Racial Differences in Imaging Characteristics and Risk Factors for Primary Intracerebral Hemorrhage: Final Results from the DECIPHER Study

Background: Previous studies have reported racial differences in the incidence, location and risk factors for primary intracerebral hemorrhage (ICH). We now report differences in imaging characteristics and risk factors for ICH from the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) study. Methods: DECIPHER is a longitudinal, multicenter, MRI-based, natural history study of racial differences in primary ICH. Inclusion criteria were: primary ICH, age ≥ 18, baseline and 1 year MRI scan obtained. Clinical and demographic data were collected on all subjects. Results: A total of 193 subjects of black or white race were enrolled. Subject characteristics overall and by race are provided in the table. Black subjects were younger, had a higher rate of hypertension, cocaine use, and were more frequently smokers. White subjects had a higher rate of hyperlipidemia. A lobar ICH location was more frequent in the white subjects, while infratentorial hemorrhages were more common in blacks. 60% of blacks had 1 or more microbleeds compared to 52% of whites (NS), and blacks tended to have more severe white matter disease. Conclusions: In the DECIPHER study, there were significant racial differences both in the risk factors for primary ICH and in the imaging characteristics. Compared to whites, blacks have a greater rate of hypertension, as well as cocaine and tobacco use. Imaging findings are indicative of a more severe underlying small vessel vasculopathy in the black cohort. The risk factor information may be used to enhance prevention programs tailored for black communities at risk of ICH, while imaging data may provide a useful biomarker to assess the impact of these interventions.

Paratrigonal choroid plexus papilloma presenting with satellite multiple supra- and infratentorial hemorrhages. Neuroanatomical basis and pathological hypothesis

INTRODUCTIONChoroid plexus papillomas (CPP) are rare tumors arising from the neuroepithelium of the choroid plexus. PRESENTATION OF CASEWe report a case of a patient operated for a paratrigonal hemorrhagic WHO class I CPP presenting with multiple satellite supra- and infratentorial hemorrhages. Clinical presentation was characterized by sudden hemiparesis, speech impairment and consciousness deterioration; neuroradiological imaging showed a huge contrast-enhanced solid hemorrhagic left paratrigonal lesion along with others multifocal right occipital and vermian hemorrhages. The patient underwent urgent intervention for excision of the paratrigonal lesion, whose histological analysis led to the diagnosis of CPP. A few days later due to failure of conservative treatment of the satellite hemorrhages the patient underwent a second-time surgery for their evacuation; interestingly histological examination of the tissue probe did not reveal any neoplastic features confirming their sole hemorrhagic nature. Patient's conditions slowly improved despite severe neurological deficits, without any further tumor recurrence. DISCUSSIONA thorough revision of the literature is provided including previous reported cases of spontaneous bleeding CPPs and other underlying causes that could lead to multifocal hemorrhages. CONCLUSIONDue to the rarity of these events, this case remains still open to speculative hypotheses drawn to explain the neuroanatomical and pathogenetic basis behind this case report.

Multiple simultaneous hypertensive supratentorial and infratentorial hemorrhages: A rare kind of hypertensive bleed

Multiple simultaneous intracranial hemorrhages are very uncommon and both supra- and infratentorial hemorrhages are even more rare. Here we report a case of 56 year old hypertensive male with no other significant medical history who presented with a hypertensive emergency. Emergency head computed tomography showed bilateral basal ganglia and midbrain hemorrhages extending to right cerebellar peduncle. The patient made a progressive recovery and finally achieved functional independence. This report shows that hypertension may cause multiple simultaneous supra- and infratentorial hemorrhages and have good prognosis. Journal of College of Medical Sciences-Nepal,2011,Vol-6,No-4, 53-56 DOI: http://dx.doi.org/10.3126/jcmsn.v6i4.6728

Characteristics and Sequelae of Intracranial Hypertension After Intracerebral Hemorrhage

The characteristics and sequelae of intracranial hypertension after ICH are unclear. In a cohort of patients with spontaneous ICH, we obtained ICP values from nursing documentation of hourly vital signs and reviewed charts to rule out spurious ICP recordings. We used multiple logistic regression to explore factors associated with intracranial hypertension, and ordinal logistic regression controlling for the ICH score to examine the relationship between intracranial hypertension and the mRS score at 12months. Among 243 patients, 57 (24%) underwent ICP monitoring, of whom 40 (70%; 95% CI 57-82%) had an episode of ICP>20mmHg. Intracranial hypertension was less likely in older patients (OR per decade 0.6, 95% CI 0.3-0.9) and after infratentorial hemorrhage (OR 0.1, 95% CI 0-0.7). Intracranial hypertension was not independently associated with mRS scores (OR 0.8, 95% CI 0.3-2.3); this remained true for a threshold of >25mmHg (OR 0.5, 95% CI 0.2-1.5), number of elevations (OR 0.98 per elevation, 95% CI 0.96-1.00), or area under the curve (OR 1.00 per mmHg×h, 95% CI 0.99-1.01). Among patients with intracranial hypertension, seven (18%) were functionally independent (mRS 0-2) at 12months. Our results were not significantly changed after excluding patients with early DNR orders. Intracranial hypertension is common after ICH, especially in younger patients with supratentorial hemorrhage. Given active treatment of elevated ICP, intracranial hypertension does not appear associated with long-term outcomes, suggesting that ICP elevations should not necessarily be taken to signify a poor prognosis.

Multiple Intracranial Hemorrhages After Cervical Spinal Surgery

A 69-year-old woman presented with a rare case of multiple supra- and infratentorial intracranial hemorrhages after cervical laminoplasty for cervical spondylotic myelopathy without intraoperative liquorrhea. A wound drainage tube under negative pressure was placed with subsequent 380 ml of drainage in the first 12 hours. She had no complaint of headache and nausea at that time. Computed tomography of the brain obtained at 15 hours after surgery demonstrated cerebellar hemorrhage, acute subdural hemorrhage, subarachnoid hemorrhage, supratentorial intraparenchymal hemorrhage, and pneumocephalus. She was treated medically without consequent neurological deficits other than right hemianopsia. Overdrainage of cerebrospinal fluid through an occult dural tear might cause severely low intracranial pressure with subsequent multiple intracranial hemorrhages. Wound drainage should be controlled thoroughly even in patients without intraoperative liquorrhea.

Intrazerebrale Blutung - wann ist eine chirurgische Behandlung sinnvoll?

Intracerebral haemorrhages (ICH) are responsible for 10-17% of all strokes and are associated with a high mortality and morbidity. More than 50% of the primary cases of ICH are associated with an underlying arterial hypertension and up to 30% with a cerebral amyloidosis. In supratentorial ICH, primary treatment generally should be conservative, as clinical studies could not show favourable outcomes after surgical haematoma evacuation. However, in patients with infratentorial haemorrhages and neurologic deterioration, early surgical evacuation should be considered. Modern therapeutic strategies and the focus of current and recent clinical research include early haemostasis, improvement of intensive care, and less invasive neurosurgical interventions, with the aim to reduce secondary brain damage. This review provides an overview of the clinical presentation of ICH and includes up-to-date recommendations concerning diagnostic and therapeutic options.

Multiple Supra- and Infratentorial Intraparenchymal Hemorrhages Presenting With Seizure After Massive Sacral Cerebrospinal Fluid Drainage

Case report and review of the literature. To describe a case of multiple supra- and infratentorial hemorrhages after spinal surgery presenting with seizure. Cerebrospinal fluid overdrainage is a well-documented factor associated with remote cerebellar hemorrhage, but supratentorial hemorrhages after spinal surgery have been reported rarely. A 64-year-old woman underwent a sacral laminectomy for recurrent chordoma. A negative pressure wound drain was left in after surgery and drained 1300 mL in the first 48 hours. On the fourth postoperative day, the patient presented with tonic-clonic seizures. Diagnostic imaging showed multiple supra- and infratentorial intraparenchymal hemorrhages and a massive sacral cerebrospinal fluid leak. The patient underwent emergent surgery for a primary repair of the presumed dural defect. Patients who present with severe positional headache, altered mental status, or tonic-clonic seizures after undergoing intradural spinal procedures involving massive cerebrospinal fluid loss may be suffering from multiple supra- and infratentorial intracranial hemorrhages.

Ethnic differences in do-not-resuscitate orders after intracerebral hemorrhage

To explore ethnic differences in do-not-resuscitate orders after intracerebral hemorrhage. Population-based surveillance. Corpus Christi, Texas. All cases of intracerebral hemorrhage in the community of Corpus Christi, TX were ascertained as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. None. Medical records were reviewed for do-not-resuscitate orders. Unadjusted and multivariable logistic regression were used to test for associations between ethnicity and do-not-resuscitate orders, both overall ("any do-not-resuscitate") and within 24 hrs of presentation ("early do-not-resuscitate"), adjusted for age, gender, Glasgow Coma Scale, intracerebral hemorrhage volume, intraventricular hemorrhage, infratentorial hemorrhage, modified Charlson Index, and admission from a nursing home. A total of 270 cases of intracerebral hemorrhage from 2000-2003 were analyzed. Mexican-Americans were younger and had a higher Glasgow Coma Scale than non-Hispanic whites. Mexican-Americans were half as likely as non-Hispanic whites to have early do-not-resuscitate orders in unadjusted analysis (odds ratio 0.45, 95% confidence interval 0.27, 0.75), although this association was not significant when adjusted for age (odds ratio 0.61, 95% confidence interval 0.35, 1.06) and in the fully adjusted model (odds ratio 0.75, 95% confidence interval 0.39, 1.46). Mexican-Americans were less likely than non-Hispanic whites to have do-not-resuscitate orders written at any time point (odds ratio 0.37, 95% confidence interval 0.23, 0.61). Adjustment for age alone attenuated this relationship although it retained significance (odds ratio 0.49, 95% confidence interval 0.29, 0.82). In the fully adjusted model, Mexican-Americans were less likely than non-Hispanic whites to use do-not-resuscitate orders at any time point, although the 95% confidence interval included one (odds ratio 0.52, 95% confidence interval 0.27, 1.00). Mexican-Americans were less likely than non-Hispanic whites to have do-not-resuscitate orders after intracerebral hemorrhage although the association was attenuated after adjustment for age and other confounders. The persistent trend toward less frequent use of do-not-resuscitate orders in Mexican-Americans suggests that further study is warranted.

Ethnic differences in do-not-resuscitate orders after intracerebral hemorrhage

Objective: To explore ethnic differences in do-not-resuscitate orders after intracerebral hemorrhage. Design: Population-based surveillance. Setting: Corpus Christi, Texas. Patients: All cases of intracerebral hemorrhage in the community of Corpus Christi, TX were ascertained as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. Interventions: None. Measurements and Main Results: Medical records were reviewed for do-not-resuscitate orders. Unadjusted and multivariable logistic regression were used to test for associations between ethnicity and do-not-resuscitate orders, both overall (“any do-not-resuscitate”) and within 24 hrs of presentation (“early do-not-resuscitate”), adjusted for age, gender, Glasgow Coma Scale, intracerebral hemorrhage volume, intraventricular hemorrhage, infratentorial hemorrhage, modified Charlson Index, and admission from a nursing home. A total of 270 cases of intracerebral hemorrhage from 2000–2003 were analyzed. Mexican-Americans were younger and had a higher Glasgow Coma Scale than non-Hispanic whites. Mexican-Americans were half as likely as non-Hispanic whites to have early do-not-resuscitate orders in unadjusted analysis (odds ratio 0.45, 95% confidence interval 0.27, 0.75), although this association was not significant when adjusted for age (odds ratio 0.61, 95% confidence interval 0.35, 1.06) and in the fully adjusted model (odds ratio 0.75, 95% confidence interval 0.39, 1.46). Mexican-Americans were less likely than non-Hispanic whites to have do-not-resuscitate orders written at any time point (odds ratio 0.37, 95% confidence interval 0.23, 0.61). Adjustment for age alone attenuated this relationship although it retained significance (odds ratio 0.49, 95% confidence interval 0.29, 0.82). In the fully adjusted model, Mexican-Americans were less likely than non-Hispanic whites to use do-not-resuscitate orders at any time point, although the 95% confidence interval included one (odds ratio 0.52, 95% confidence interval 0.27, 1.00). Conclusions: Mexican-Americans were less likely than non-Hispanic whites to have do-not-resuscitate orders after intracerebral hemorrhage although the association was attenuated after adjustment for age and other confounders. The persistent trend toward less frequent use of do-not-resuscitate orders in Mexican-Americans suggests that further study is warranted.

Intracerebral Hemorrhage Volume Predicts Poor Neurologic Outcome in Children

Although intracerebral hemorrhage (ICH) volume and location are important predictors of outcome in adults, few data exist in children. A consecutive cohort of children, including full-term newborns to those younger than 18 years of age with nontraumatic, acute ICH and head CT available for analysis were studied. Clinical information was abstracted via chart review. Hemorrhage volume was expressed as percentage of total brain volume (TBV) with large hemorrhage defined as >or=4% of TBV. Hemorrhages were manually traced on each head CT slice and volumes were calculated by multiplying by slice thickness. Location was classified as supratentorial or infratentorial. Logistic regression was used to identify predictors of poor neurological outcome, defined as a Glasgow outcome scale <or=2 (death or persistent vegetative state). Thirty children were included, median age 6 years. Median ICH volume was 20.4 cm(3) and median ICH size as a percentage of TBV was 1.9%. Only 4 of 22 children with ICH <4% of TBV had poor outcomes, vs 5 of 8 children with ICH >or=4% of TBV (P=0.03). In multivariate analysis, hemorrhage >or=4% of TBV (OR, 22.5; 95% CI, 1.4-354; P=0.03) independently predicted poor outcome 30 days after ICH. In this small sample, infratentorial hemorrhage location and the presence of intraventricular hemorrhage did not predict poor outcome. ICH volume predicts neurological outcome at 30 days in children, with worst outcome when hemorrhage is >or=4% of TBV. Location and ICH etiology may also be important. These findings identify children with ICH who are candidates for aggressive management and may influence counseling regarding prognosis.

Cerebral Microbleeds in Patients With Intracerebral Hemorrhage Are Associated With Previous Cerebrovascular Diseases and White Matter Hyperintensity, but Not With Regular Use of Antiplatelet Agents

The validity of regular use of antiplatelet agents was retrospectively assessed in 106 patients with intracerebral hemorrhage (ICH) (supratentorial hemorrhage 92, lobar 22 and deep 70; and infratentorial hemorrhage 14) who underwent T(2)*-weighted gradient-echo magnetic resonance (MR) imaging between January 2005 and December 2006 in Kishiwada City Hospital. The prevalence of cerebral microbleeds was 54.7% (58/106), and the presence was significantly associated with higher age (odds ratio 3.09, p = 0.007), presence of white matter hyperintensity on T(2)-weighted MR imaging (odds ratio 2.36, p = 0.032), and previous ICH and/or cerebral infarction (odds ratio 4.77, p = 0.020). Previous ICH and/or cerebral infarction was independently associated with the presence of cerebral microbleeds after adjustment for age, white matter hyperintensity, and hypertension (odds ratio 4.07, p = 0.043). Regular use of antiplatelet agents was not associated with the presence of cerebral microbleeds, whether the patients had cerebrovascular diseases or not. Our findings suggest that antiplatelet medication can be justified for patients with cerebral microbleeds.

Initial and Serial Evoked Potentials in Cerebrovascular Critical Care Patients

Results of somatosensory evoked potential (SEP) and brainstem auditory evoked potential (BAEP) examinations performed early in the clinical course of patients with acute cerebrovascular disease correlate statistically significantly with outcome regardless of type and localization of the primary lesion. The prognostic value of serial examinations of SEP and BAEP has not been studied yet. The authors examined a group of 215 patients suffering from acute stroke requiring neurocritical care composed of 75 supratentorial and 36 infratentorial ischemic strokes, 58 supratentorial and 18 infratentorial hemorrhages, and 28 aneurysmatic subarachnoid hemorrhages prospectively using spinal and cortical SEP and BAEP according to routine procedures on admission as well as after 1 and 2 weeks. The findings were correlated to outcome at 4 weeks. Statistical assessment was performed using standard methods of contingency analysis. In all groups, SEP findings were significantly correlated with outcome at initial and all subsequent examinations, similar correlations were also found for BAEP. However, after partialling out the prognostic information gained from the initial examination of SEP and BAEP, the follow-up examinations rendered only a marginal increase in prognostic information. Therefore, the initial examination of evoked potentials supplies valuable prognostic information, however, serial examinations of evoked potentials during the first weeks of disease improve the prognostic information only marginally.

Diffuse pneumocephalus associated with infratentorial and supratentorial hemorrhages as a complication of spinal surgery

A 23-year-old woman was transferred to our department with loss of consciousness 6 h after undergoing rod placement for thoracolumbar scoliosis. Both computed tomography and magnetic resonance imaging of the brain revealed diffuse pneumocephalus and infra- and supratentorial hemorrhages. The pedicular screw tracts were analyzed with computed tomography and misplacement of a screw was noticed. It was thought that inadvertent dural injury had occurred at the time of insertion. The patient was re-operated and the dural tear was repaired. To our knowledge, this is the first description of these uncommon complications in one patient after spine surgery.