Intracranial Vascular Lesions Research Articles

Posterior fossa Hodgkin's lymphoma radiographically mimicking an arteriovenous malformation: illustrative case.

Intracranial Hodgkin's lymphoma (HL) is an exceedingly rare condition that is at an increased risk of misdiagnosis and mismanagement, especially when initial radiographic evidence points to an alternative pathology. The authors describe the case of a 75-year-old female who presented with a posterior fossa lesion initially concerning for a vascular malformation on computed tomography imaging due to perilesional hypervascularity. Subsequent angiography revealed a developmental venous anomaly (DVA) but no arteriovenous shunting. The patient's clinical history combined with magnetic resonance imaging findings prompted a tissue biopsy, which demonstrated a rare case of central nervous system (CNS) HL. The neoangiogenesis of this CNS HL with an adjacent DVA contributed to the original radiographic misdiagnosis of an arteriovenous malformation. HL's angiogenic potential, coupled with the proangiogenic environment induced around DVAs, may have contributed to this rare CNS HL metastasis to the cerebellum. The potential misdiagnosis of posterior fossa CNS HL has also been seen in several prior cases reviewed herein. Hypervascular tumors, especially when associated with an adjacent DVA, should also be considered when first evaluating suspected intracranial vascular lesions. Although rare, CNS HL should be included in the differential diagnosis for patients with a prior history of HL. https://thejns.org/doi/10.3171/CASE24238.

The Endoscopic Transorbital Approach for Vascular Surgery: An Anterior Circulation Anatomic Study, 2-Dimensional Operative Video.

Minimally invasive endoscopic approaches in cranial base surgery have been developing in the past decades. The transorbital (TO) route is one promising alternative, yet its adequacy for intracranial vascular lesions remains unclear. The present anatomic work aimed to test the feasibility and to provide a qualitative description of the endoscopic TO approach for the anterior circulation, namely the internal carotid artery and the middle cerebral artery. Seven embalmed adult cadaveric specimens (12 sides) were used in the study. Each side was approached in 3 successive steps: (1) Superior-eyelid TO approach, with great and lesser sphenoid wing removal. (2) Removal of anterior clinoid process (ACP). (3) Removal of the lateral orbital rim. All the procedures were performed under endoscopic view. The TO approach without removing the ACP allowed to dissect the sphenoidal and lateral segments of the Sylvian fissure with an adequate identification of the middle cerebral artery bifurcation in all specimens. The removal of the ACP allowed further dissection toward the opticocarotid cistern, with the identification of the ophthalmic, posterior communicating, and the anterior choroidal arteries. The internal carotid artery bifurcation and A1 segment were also readily identified. Finally, removal of the lateral orbital rim provided a wider and more comfortable access to the above-mentioned vascular structures. According to our anatomic data, the TO approach can be used to reach the main vascular components of the anterior circulation. This opens the field for exploring its application in the treatment of vascular pathology, particularly aneurysms.

Periprocedural management of ruptured blister aneurysms treated with pipeline flow diversion.

Blister aneurysms are high-risk intracranial vascular lesions. Definitive treatment of these lesions has been challenging. Severe disability or mortality rates are as high as 55% when these lesions are treated with open surgery. Recent data show that flow diversion is a safe and effective alternative treatment for blister aneurysms. Rerupture of the functionally unsecured lesion remains a concern as flow diversion does not immediately exclude the aneurysm from the circulation. A retrospective review was performed of any patients with ruptured blister aneurysms treated with a pipeline embolization device between 2010 and 2020 at the University of Colorado. In this paper, we present the results of the intensive care management of ruptured intracranial blister aneurysms after flow-diverting stent placement. Despite the need for dual antiplatelet therapy and the delayed occlusion of blister aneurysms treated with flow diversion, we did not find an increase in periprocedural complications.

Challenges in the management of pediatric ruptured brain arteriovenous malformation: a case report

Brain arteriovenous malformations (bAVMs) are intracranial vascular lesions characterized by abnormal connections between the arterial and venous systems without an interposed capillary bed. Pediatric bAVMs constitute merely 12–18% of all diagnosed bAVMs, but an initial finding of bAVM rupture occurs more frequently in the pediatric population than in adults, accounting for 58–77% of all pediatric bAVM admissions.1,2 Although spontaneous pediatric intracerebral hemorrhage has an annual incidence of 1.4 per 100,000 people per year, it carries a risk of severe permanent neurological deficits, occurring in 20–40% of patients and significant mortality in up to 25% of affected individuals.3,4,5 Ruptured bAVMs are the cause of 30-50% of intracranial hemorrhages in the pediatric population and the most common cause of hemorrhagic stroke in children.1 Current therapeutic approaches for ruptured bAVMs in children include open microsurgery, endovascular embolization, as well as stereotactic radiosurgery (SRS), be it isolated or as a multimodal treatment strategy. Herein, we present the case of a 6-year-old boy with a ruptured bAVM successively managed with hemicraniectomy decompression and intracranial bleeding evacuation, followed by stereotactic radiosurgery (SRS) using gamma knife for the small AVM which was inaccessible during open surgery.

Teleproctoring in therapeutic neurointervention: Experience from Iraq-Saudi Arabia collaboration.

Proctoring in neuroendovascular surgery is one of the potential solutions for the shortage of personnel and experience, particularly in unstable and limited-resource areas such as Iraq. The study was conducted at the Baghdad Neurovascular Center (BNC), the first Hybrid neurovascular institution in Iraq, where sequential online zoom-based meetings between the BNC team and the expert from the Kingdom of Saudi Arabia were used for teleproctoring for neurointerventional procedures. A total of 28 sessions were conducted, four sessions for each case. Seven cases with various intracranial vascular lesions were operated for neuroendovascular procedures from July/2021 to March/2022. The teleproctoring for each case included four sequential sessions: (1) preoperative planning, (2) device selection and preparation, (3) intraoperative live-stream proctoring, and (4) postoperative reflection and follow-up planning. The procedures include coiling for dural arteriovenous fistula; preoperative tumor embolization; preoperative, partial, and staged embolization for arteriovenous malformation; coiling for intracranial aneurysm; and attempted Giant aneurysm flow-diversion. Major complications were avoided through teleproctoring, and all patients had good outcomes. In addition, the teleproctoring provided an effective training experience to the local neuroendovascular team that is otherwise not feasible. Teleproctoring is an effective and feasible tool to improve patient outcomes and provide a training experience to the local neuroendovascular teams in resource-limited regions.

Fetal Vein of Galen Aneurysmal Malformation (VGAM) Detected at 36 Weeks: Review of Literature and Case Report

Abstract Vein of Galen malformation is a rare intracranial vascular lesion most often concomitant with poor prognosis when associated with high-output cardiac failure. We present a case that was diagnosed late in the third trimester, but due to the limitations in our local settings, immediate operative intervention could not be done. A 24-year-old primigravida was sent for a routine 36-week obstetric ultrasound scan (USS), which revealed a midline cystic structure with mosaic color signals on a duplex Doppler USS within the fetal head. The unavailability of fetal magnetic resonance venography (MRV) delayed confirmation until the postnatal period. An MRV done on the second day of delivery showed a dilated, tortuous midline structure in the region of the vein of Galen, which confirmed the findings. Echocardiography revealed multiple cardiac lesions. Although, both antenatally and at birth, there was no cardiac failure, the baby died on the seventh day of life from possible cardiac compromise.

Dual trained endovascular neurosurgeons. A boon or a necessity?

Objective: The aim of this research study is to emphasize the necessity to train neurosurgeons in both endovascular procedures as well as microsurgical clipping in the management of intracranial vascular lesions. Material and methods: In this study, the retrospective data collected from our institution from 2021-2022 is presented. Here we present six cases of intracranial vascular lesions that were initially planned for endovascular procedure and later ended up being managed by microsurgical clipping/ excision. Written informed consent was obtained from relevant individuals for publishing the data. Results: All six patients recovered well in the postoperative period. Therefore, a neurosurgeon who is adequately trained in vascular neurosurgery along with endovascular tutoring shall have an extensive grasp of cerebral vascular diseases and all the available treatment alternatives. Since we live in a result-oriented scenario - patients shall be best served by a hybrid neurosurgeon in the long run. Conclusion: This study provides the intra-operative difficulties faced during endovascular management of intracranial vascular lesions. These difficulties require real-time management. Any delay in the process of intra-procedural decision-making making, the non-availability of trained neurosurgeons can have devastating consequences. Hence, this study further fortifies the want for a dual-trained neurosurgeon to handle cerebrovascular lesions.

Neuroimaging Findings in Acquired Esotropia Patients at Siriraj Hospital from 2009–2020

Objective: To analyze the neuroimaging findings in patients with acquired esotropia at Siriraj Hospital from 2009 to 2020. Materials and Methods: A retrospective review of the medical records of all patients aged above 6 months old who presented with acquired esotropia was done. All the patients had an angle of deviation 10 prism diopters (PD), refraction < +3.0 diopters (D), and had neuroimaging performed. The patients with restrictive myopathy and extraocular neurological abnormalities were excluded from the study. Results: In total, 177 subjects aged between 8 months old to 81 years old (mean age 32.35 ± 24.40 years old) were included in the study. The patients’ demographic data, ocular findings, and neuroimaging findings were collected. The mean angle of deviation near and at distance were 26.88 ± 18.90 PD and 29.81 ± 17.25 PD, respectively. Of the 177 cases, 113 cases (63.8%) had no neuroimaging abnormalities, while 64 cases (36.2%) had abnormal neuroimaging findings. In those 64 cases with abnormal findings, there were 16 intracranial tumors, 6 inflammations, 4 vascular lesions, 7 degenerations, and 31 other lesions. Sixth nerve palsy was found to be significantly different between the positive and negative neuroimaging group from both the uni- and multivariate analysis. Conclusion: Although more than half of acquired esotropia patients had no abnormalities in neuroimaging, but 14.7% of those with abnormal neuroimaging findings had underlying serious conditions, which consisted of intracranial tumors, inflammation, and vascular lesions. Special attention should be concentrated to patients with sixth nerve palsy as it was the significant factor found to be associated with positive neuroimaging findings in acquired esotropia.

Detecting immunoglobulin G4-related intracranial arteriopathy with magnetic resonance vessel wall imaging: a preliminary experience in two cases

BackgroundDetecting immunoglobulin G4 (IgG4)-related intracranial arteriopathy, a rare neurovascular complication of IgG4-related disease, is challenging. While magnetic resonance (MR) vessel wall imaging (VWI) can visualize various neurovascular pathologies, its application to this arteriopathy has not been reported as of this writing.Case presentationA 74-year-old male and a 65-year-old female manifested multiple cranial nerve palsy and neck pain, respectively. Both cases exhibited multiorgan masses with markedly elevated serum IgG4 levels and were clinically diagnosed with IgG4-related disease. Three-dimensional T1-weighted black blood VWI with and without contrast agent identified intracranial vascular lesions characterized as nearly-circumferential mural thickening with homogeneous contrast enhancement in the internal carotid and vertebral arteries; some of the lesions had been unrecognized with screening MR angiography due to expansive remodeling. The former patient underwent corticosteroid therapy, and VWI after treatment revealed decreased mural thickening and enhancement.ConclusionFurther studies to elucidate characteristic findings of VWI might contribute to early detection of this treatable pathology.

Dolichoarteriopathy of Common Carotid Artery: An Unusual Entity

Dolichoarterial disease of the carotid arteries refers to elongated arteries with tortuous, coiling, and kinking anatomy. This morphology is usually met in the elderly and not associated with atherosclerotic risk factors. Current practice reserves surgical correction only in symptomatic patients. Significant tortuosity index may be associated with stroke and poses extra difficulties to the endovascular passage of guidewires and catheters for the treatment of extra- and intracranial vascular lesions. This article presents a typical case of bilateral dolichoarteriopathy of the common carotid artery and stresses the need for further categorization of the particular morphology based on modern angiography techniques and three-dimensional reconstruction software.

A study on role of DSA in intracerebral vascular anomaly comparison with computed tomography angiography/magnetic resonance angiography

Background: Brain imaging techniques provide the ability to noninvasively map the structure and functions of the brain. Brain vascular malformation mainly affects people in the 5th decade followed by 4th and 3rd decade. Aims and Objectives: The aim of the study was to compare the diagnostic supremacy of computed tomography angiography (CTA)/magnetic resonance angiography (MRA) and Digital subtraction angiography (DSA) for the detection of intracranial vascular anomalies. Materials and Methods: An observational descriptive study with cross-sectional design was performed among 50 patients of both sexes undergoing DSA test at Medical College and Hospital, Kolkata with acute stroke syndrome or any other symptoms suggesting intracranial vascular lesion, who were investigated with one or more index tests and a reference standard diagnosed by computed tomography (CT) or MR scanning or other parameters. DSA served as the standard of reference for presence of intracranial vascular anomalies. Results: Out of the 50 patients included in the study, 41 were diagnosed with vascular malformations by DSA. Moya moya disease was diagnosed in three and distal AV fistula in six patients. In the 41 patients with vascular malformations, CTA could correctly identify 17 (41.5%) cases whereas MRA could identify 73.2% cases. Conclusion: DSA can be used for both diagnostic and interventional angiography. Its high spatial and temporal resolution have maintained DSA as a very important tool. The study reveal DSA is more superior to accurate angioarchitectural delineation of different intracerebral vascular malformation.

UPDATE ON MANAGEMENT OF DURAL ARTERIOVENOUS FISTULAS.

Dural Arteriovenous Fistulas (AVF) represent about 10% of all intracranial vascular lesions. Although they seem benign in nature, the presence of retrograde venous makes them aggressive, with a high risk of complications. Patients may be clinically asymptomatic or experience symptoms ranging from mild to severe hemorrhage, depending on their location. Different treatments are available, but recently, the development of catheter intervention allows most patients to be cured with transcatheter embolization. Stereotactic radiosurgery achieves excellent rates of obliteration for low-grade lesions. In this review, we try to highlight the recent advances in the management of dural AVF.

COMPUTED TOMOGRAPHY ANGIOGRAPHY VERSUS DIGITAL SUBTRACTION ANGIOGRAPHY FOR INTRACRANIAL VASCULAR PATHOLOGY

Computed tomography angiography is non-invasive and readily available technique for assessment of intracranial vascular lesions. It has broad acceptance by patients and is relatively inexpensive. However, there are some shortcomings with this modality, such as the decreased accuracy in small pathologies or calcied vessels and inability to assess dynamic cine view. DSA, on the other hand, provide excellent characterization and excellent anatomic delineation of small and large vascular pathologies. There is a signicant difference, in the inherent costs of DSA and CTA. In this article We have studied various intra cranial vascular pathologies on both CTA and DSA and compared their sensitivity and specicity for diagnosis. The comparative study was carried out with 80 patients. According to this study, computed tomography angiography remains the rst line of imaging for the intracranial pathology with high diagnostic accuracy rates with 92.4% sensitivity and 92.5% accuracy. In 5 patients where CTA were inconclusive, DSA was diagnostic investigation.

Diagnosis and Therapy for Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension is a pathological state of increased intracranial pressure without intracranial mass lesion, vascular lesion, or hydrocephalus. For the diagnosis of this pathology, various secondary and primary headaches, such as migraine and medication overuse headaches should be excluded. Radiological imaging, including diffusion tensor imaging may show secondary findings of intracranial hypertension. These imaging techniques may be useful to diagnose intracranial hypertension, because at present there is no reliable non-invasive method to measure intracranial pressure. The pathophysiology of idiopathic intracranial hypertension has not been revealed; however there are some theories include, the disorder of cerebrospinal fluid circulation, disturbance of intracranial venous circulation, and metabolic disorders. Headache, nausea, and optic disc edema are frequently observed. The disease is frequently seen in obese females of childbearing age. Several therapies, including weight reduction, medication, and surgery have been studied; however the level of evidence for these therapies remains low.

Research progress in atrial fibrillation with cerebral small vessel disease.

Non-valvular atrial fibrillation is a common arrhythmia and a major risk factor for cardioembolic stroke. Small cerebral vascular disease is a syndrome of clinical, cognitive, imaging, and pathological manifestations caused by intracranial small vascular lesions. The imaging findings on cranial magnetic resonance usually shows recent subcortical small infarction, vascularised lacunae, white matter hypersignal, perivascular space enlargement, cerebral microhemorrhage, and brain atrophy. It is a major cause of neurological loss and cognitive function decline in the elderly. Current studies suggest that atrial fibrillation may increase the imaging load of cerebral small vessel disease through a series of mechanisms such as microembolization, hypoperfusion, inflammation, endothelial dysfunction, and lymphoid system dysfunction. The imaging of cerebral small vessel disease with atrial fibrillation has a potential relationship with cognitive function decline and is related to the occurrence and prognosis of stroke, even more has a potential role in suggesting the etiology and secondary prevention strategies of ischemic stroke.

The Plasma Level of IL-1β As a Biomarker of Angiopathy in Systemic Chronic Active EBV Infection

Background and aim: Systemic chronic active Epstein-Barr virus infection (sCAEBV) is an intractable rare disease revealing persistent systemic inflammation with clonal proliferation of EBV-infected T- or NK-cells. 25% of sCAEBV patients accompany angiopathy such as aneurysm and vasculitis. (Yonese et al. Blood advances. 2020). Because angiopathy degrades patients' quality of life and is one of the main causes of death in sCAEBV, it is crucial to clarify the mechanisms of angiopathy development in sCAEBV. Interleukin-1β (IL-1β) and tumor necrosis factor α (TNFα) are reported to be involved in angiopathy onset. We investigated if IL-1β and TNFα play roles to induce vascular endothelial cell damage in sCAEBV with angiopathy.Methods: sCAEBV patients were diagnosed when meeting all of the following four conditions: 1) inflammation persisting for more than 3 months, 2) increasing EBV-DNA in peripheral blood (PB) or in diseased tissue, 3) EBV infected T- or NK-cells, 4) not applying to other known diseases. We measured the plasma concentration of cytokines by high sensitivity cytokine beads assay (MILLIPLEX ®MAP Kit). We isolated EBV-infected cells and monocytes by magnetic beads (MACS ® Cell Separation). Ea.hy926, a human umbilical vein endothelial cell line, was used as a vascular endothelial cell model.Results: Samples from 17 sCAEBV patients (infected cell types: CD4 in 7; CD8 in 1; and CD56 in 9) and 8 healthy donors were examined. We detected elevated levels of IL-1β in 4 out of 17 sCAEBV patient's plasma. Interestingly, among the 4, 3 had clinically associated angiopathy: 1 aneurysm, 1 vasculitis, and 1 intracranial vascular lesions with multiple cerebral infarctions. The EBV-infected cells of these 3 patients were CD4-positive cells. The TNFα concentration of patients' plasma was higher than that of healthy donors, but there was no correlation with angiopathy. The mRNA of IL-1β in the EBV-infected cells of patients with high plasma IL-1β was not enhanced compared to that of patients with undetectable plasma IL-1β. In one patient with high plasma IL-1β, the level of IL-1β mRNA of the monocytes was 17.2 times higher than the level of the same patient's EBV-infected cells. IL-1β inhibited the proliferation of Ea.hy926 cells. IL-1β upregulated the mRNA expression of Tissue factor (TF) as well as Plasminogen activator inhibitor-1 (PAI-1) and suppressed the mRNA of Thrombomodulin (TM) in Ea.hy926 cells.Discussion: IL-1β originally exists in immunocompetent cells such as CD4-positive cells in the form of precursor protein (pro-IL-1β). In the occurrence of inflammation, pro-IL-1β is cleaved by caspase-1 activated by the inflammasome, and the production and the secretion of IL-1β is induced without mRNA elevation. The infected cells of sCAEBV patients with high level plasma IL-1β and vascular lesion were all CD4-positive. Consequently, we suspect that EBV-infected, CD4-positive cells are responsible for the production of IL-1β. Likewise, we detected high expression of IL-1β in monocytes derived from a patient with high plasma IL-1β. Based on these facts, we set two hypotheses on the production of IL-1β in sCAEBV. One is the production in EBV-infected cells by the cleavage of pro-IL-1β. The other is the production through transcription and translation in monocytes. IL-1β suppressed the proliferation of Ea.hy926 cells. In the same cells, IL-1β also induced TF and PAI-1 expression and suppressed TM expression. These results suggest that IL-1β may induce vascular damage and blood coagulation to cause angiopathy.Conclusion: In sCAEBV, IL-1β may be a biomarker of angiopathy. IL-1β may be a therapeutic target to treat sCAEBV accompanying vascular lesions. DisclosuresArai: Abbvie GK: Honoraria; BMS: Honoraria; Chugai Pharmaceutical Co Ltd: Honoraria, Research Funding; Eisai Co Ltd: Research Funding; Abbott Japan LLC: Honoraria; Kyowa Kirin Co ltd: Honoraria, Research Funding; Ono Pharmaceutical Co ltd: Honoraria, Research Funding; Nippon Shinyaku Co Ltd: Honoraria, Research Funding; Otsuka Pharmaceutical Co ltd: Research Funding; Novartis Pharma KK: Honoraria; Takeda Pharmaceuticals Co Ltd: Honoraria, Research Funding; Shionogi & Co ltd: Research Funding; Asahi Kasei Pharma Corporation: Research Funding; Sanofi KK: Honoraria; Pfizer Japan Inc: Honoraria; Astellas Pharma Inc: Honoraria.

Intracranial Involvement in Takayasu's Arteritis.

Takayasu’s arteritis (TAK) is a large-vessel vasculitis that targets the aorta and its major branches. Although extracranial vascular involvement is uniformly present in this disease, the frequency of intracranial involvement in TAK has not been well studied. We retrospectively reviewed the clinical and imaging records of patients diagnosed with TAK at a single Canadian university medical centre to determine the prevalence of intracranial vascular involvement. Intracranial vascular and non-vascular findings were described, and a review of the literature was performed. Of 20 patients with TAK, 12 had vascular neuroimaging completed. Intracranial vascular lesions were identified in 4 patients (33.3% of those with imaging available, 20% of all patients). The frequency of intracranial vessel involvement in TAK may be more common than appreciated. Imaging of both the intra- and extra-cranial vessels should be considered in these young patients.

Improved potential quality of intraoperative transcranial motor-evoked potentials by navigated electrode placement compared to the conventional ten-twenty system

Intraoperative neurophysiological monitoring of transcranial motor-evoked potentials (tcMEPs) may fail to produce a serviceable signal due to displacements by mass lesions. We hypothesize that navigated placement of stimulation electrodes yields superior potential quality for tcMEPs compared to the conventional 10–20 placement. We prospectively included patients undergoing elective cranial surgery with intraoperative monitoring of tcMEPs. In addition to electrode placement as per the 10–20 system, an electrode pair was placed at a location corresponding to the hand knob area of the primary motor cortex (M1) for every patient, localized by a navigation system during surgical setup. Twenty-five patients undergoing elective navigated surgery for intracranial tumors (n = 23; 92%) or vascular lesions (n = 2; 8%) under intraoperative monitoring of tcMEPs were included between June and August 2019 at our department. Stimulation and recording of tcMEPs was successful in every case for the navigated electrode pair, while stimulation by 10–20 electrodes did not yield baseline tcMEPs in two cases (8%) with anatomical displacement of the M1. While there was no significant difference between baseline amplitudes, mean potential quality decreased significantly by 88.3 µV (− 13.5%) for the 10–20 electrodes (p = 0.004) after durotomy, unlike for the navigated electrodes (− 28.6 µV [− 3.1%]; p = 0.055). For patients with an anatomically displaced M1, the navigated tcMEPs declined significantly less after durotomy (− 3.6% vs. 10–20: − 23.3%; p = 0.038). Navigated placement of tcMEP electrodes accounts for interindividual anatomical variance and pathological dislocation of the M1, yielding more consistent potentials and reliable potential quality.

Abstract P458: Systemic Inflammatory Response Syndrome is Associated With Hematoma Expansion in Intracerebral Hemorrhage

Objective: Systemic inflammatory response syndrome (SIRS) and hematoma expansion are both associated with worse outcomes after intracerebral hemorrhage (ICH), but their relationship remains unclear. We sought to determine the association between SIRS and hematoma expansion after ICH. Methods: We performed a retrospective cohort study of patients admitted to our hospital from 2013 to 2020 with primary spontaneous ICH with at least two head CTs within the first 24 hours. Patients were excluded if they had a decompressive craniectomy, intracranial vascular lesions or malignancy, or coagulopathy. Hematoma volume was measured using the ABC/2 method; hematoma expansion was defined as 6mL or 33% growth between the first and second scan. We compared patients with and without SIRS using Pearson’s χ2, students T and Wilcoxon rank sum tests. The relationship between admission SIRS and hematoma expansion was assessed using univariate and multivariate regression analysis. Results: Of 187 patients with ICH, 73 (39%; mean age 6617, 40% female) met inclusion criteria. Of those, 38 (52%) had SIRS on admission. Admission systolic blood pressure (SBP) was significantly higher in patients with SIRS compared to those without (169 [IQR 133- 205] vs 152 [125- 179] mm Hg, p= 0.02). There was no difference in mean days to first antibiotic administration (6.3 vs 5.6, p=0.78), admission platelets (227 vs 243, p= 0.38) or initial hematoma volume (23 vs 15, p=0.16). Hematoma expansion occurred in 14 patients, 11 (79%) of whom also had SIRS. A significantly greater percentage of patients with SIRS had mRS 4-6 at discharge (87 vs 67%, p=0.05). SIRS was significantly associated with hematoma expansion (OR 4.35, 95% CI 1.10-17.20, p= 0.04) on univariate analysis. The association remained statistically significant after adjusting for admission SBP, platelets, and initial hematoma volume (OR 4.54, 95% CI 1.01-20.60, p= 0.05). Conclusion: Presence of SIRS on admission is associated with hematoma expansion within the first 24 hours. Further research is needed to better understand this association, which may enable us to identify early on and treat those patients at highest risk for decompensation.

Etiology of intracerebral hemorrhage in children: cohort study, systematic review, and meta-analysis.

Understanding the etiological spectrum of nontraumatic pediatric intracerebral hemorrhage (pICH) is key to the diagnostic workup and care pathway. The authors aimed to evaluate the etiological spectrum of diseases underlying pICH. Children treated at the authors' institution for a pICH were included in an inception cohort initiated in 2008 and retrospectively inclusive to 2000, which was analyzed in October 2019. They then conducted a systematic review of relevant articles in PubMed published between 1990 and 2019, identifying cohorts with pICH. Identified populations and patients from the authors' cohort were pooled in a multicategory meta-analysis. A total of 243 children with pICH were analyzed in the cohort study. The final primary diagnosis was an intracranial vascular lesion in 190 patients (78.2%), a complication of a cardiac disease in 17 (7.0%), and a coagulation disorder in 14 (5.8%). Hematological and cardiological etiologies were disproportionately more frequent in children younger than 2 years (p < 0.001). The systematic review identified 1309 children in 23 relevant records pooled in the meta-analysis. Overall, there was significant heterogeneity. The dominant etiology was vascular lesion, with an aggregate prevalence of 0.59 (95% CI 0.45-0.64; p < 0.001, Q = 302.8, I2 = 92%). In 18 studies reporting a detailed etiological spectrum, arteriovenous malformation was the dominant etiology (68.3% [95% CI 64.2%-70.9%] of all vascular causes), followed by cavernoma (15.7% [95% CI 13.0%-18.2%]). The most frequent etiology of pICH is brain arteriovenous malformation. The probability of an underlying vascular etiology increases with age, and, conversely, hematological and cardiac causes are dominant causes in children younger than 2 years.