Massive Intracerebral Hemorrhage Research Articles

Variability and/or Consistency in Picture Naming by a Person with Aphasia? A Single Case Study

Variability and/or Consistency in Picture Naming by a Person with Aphasia? A Single Case Study

Intracerebral Bleeding in Young Infants due to Rare Etiologies–A Report of two Cases

Neonates and young infants are physiologically encumbered by an inadequate hemostatic mechanism. They may also have inherited or acquired bleeding disorders which may have a catastrophic presentation with intracerebral hemorrhage. The need to reach an accurate diagnosis is paramount in order to provide accurate therapy and genetic counseling. We report two infants who presented with unprovoked life threatening massive intracerebral hemorrhage. The first infant was diagnosed and managed for congenital factor V deficiency while the second infant had Glanzmann thrombasthenia.

Delayed treatment with ADAMTS13 ameliorates cerebral ischemic injury without hemorrhagic complication

Tissue plasminogen activator (tPA) is the only approved therapy for acute ischemic stroke. However, delayed tPA treatment increases the risk of cerebral hemorrhage and can result in exacerbation of nerve injury. ADAMTS13, a von Willebrand factor (VWF) cleaving protease, has a protective effect against ischemic brain injury and may reduce bleeding risk by cleaving VWF. We examined whether ADAMTS13 has a longer therapeutic time window in ischemic stroke than tPA in mice subjected to middle cerebral artery occlusion (MCAO). ADAMTS13 (0.1mg/kg) or tPA (10mg/kg) was administered i.v., immediately after reperfusion of after 2-h or 4-h MCAO for comparison of the therapeutic time windows in ischemic stroke. Infarct volume, hemorrhagic volume, plasma high-mobility group box1 (HMGB1) levels and cerebral blood flow were measured 24h after MCAO. Both ADAMTS13 and tPA improved the infarct volume without hemorrhagic complications in 2-h MCAO mice. On the other hand, ADAMTS13 reduced the infarct volume and plasma HMGB1 levels, and improved cerebral blood flow without hemorrhagic complications in 4-h MCAO mice, but tPA was not effective and these animals showed massive intracerebral hemorrhage. These results indicated that ADAMTS13 has a longer therapeutic time window in ischemic stroke than tPA, and ADAMTS13 may be useful as a new therapeutic agent for ischemic stroke.

Spontaneous closure of a dural arteriovenous fistula

Spontaneous closure of a dural arteriovenous fistula (dAVF) is a rare condition and only a few cases have been reported since its first description in 1976. We report delayed and...

Diffuse Astrocytoma Initially Presenting as a Massive Intracerebral Hemorrhage: Case Report

We report the case of a 58-year-old woman with low-grade astrocytoma, who developed massive intracranial hemorrhage as the first presentation of this disease, and become comatose and subsequently underwent an emergency craniotomy. A small amount of tumor-like tissue was observed on the wall of the hematoma cavity. Histological analysis of the resected specimen indicated diffuse astrocytoma [World Health Organization (WHO) grade II]. The patient was discharged without neurological deficits 2 weeks after the operation. A non-enhanced tumor-like nodule was observed on magnetic resonance imaging 3 months after the operation, which was monitored carefully but was not treated by adjuvant therapy. The tumor grew gradually, and a second operation was performed 3 years after the first, in which the tumor was completely resected. Histological analysis of the resected specimen again indicated diffuse astrocytoma (WHO grade II). Although rare, brain tumors, including low-grade astrocytoma, should be considered a possible cause of subcortical hemorrhage in patients without risk factors for intracranial hemorrhage.

Two cases of Degos disease with different prognosis.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Li Z, Jin P, Wang B, Feng S. Letter to the EditorTwo cases of Degos disease with different prognosis. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii. 2014;31(6):425-427. doi:10.5114/pdia.2014.44020. APA Li, Z., Jin, P., Wang, B., & Feng, S. (2014). Letter to the EditorTwo cases of Degos disease with different prognosis. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 31(6), 425-427. https://doi.org/10.5114/pdia.2014.44020 Chicago Li, Zhiliang, Peiying Jin, Baoxi Wang, and Suying Feng. 2014. "Letter to the EditorTwo cases of Degos disease with different prognosis". Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii 31 (6): 425-427. doi:10.5114/pdia.2014.44020. Harvard Li, Z., Jin, P., Wang, B., and Feng, S. (2014). Letter to the EditorTwo cases of Degos disease with different prognosis. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 31(6), pp.425-427. https://doi.org/10.5114/pdia.2014.44020 MLA Li, Zhiliang et al. "Letter to the EditorTwo cases of Degos disease with different prognosis." Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, vol. 31, no. 6, 2014, pp. 425-427. doi:10.5114/pdia.2014.44020. Vancouver Li Z, Jin P, Wang B, Feng S. Letter to the EditorTwo cases of Degos disease with different prognosis. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii. 2014;31(6):425-427. doi:10.5114/pdia.2014.44020.

Unpredicted Sudden Death due to Recurrent Infratentorial Hemangiopericytoma Presenting as Massive Intratumoral Hemorrhage: A Case Report and Review of the Literature.

Unpredicted sudden death arising from hemangiopericytoma with massive intracranial hemorrhage is quite rare. We encountered a patient with recurrent infratentorial hemangiopericytoma presenting as life-threatening massive intracerebral hemorrhage. A 43-year-old man who had undergone craniotomy for total resection of an infratentorial hemangiopericytoma 17 months earlier presented with morning headache and generalized convulsions. Computed tomography revealed a massive hematoma in the right infratentorial region causing tonsillar herniation and emergency surgery was performed to evacuate the hematoma. Histological findings revealed hemangiopericytoma with hemorrhage. Neurological status remained unimproved and brain death was confirmed postoperatively. Hemangiopericytoma presenting as massive hemorrhage is quite rare. Since the risk of life-threatening massive hemorrhage should be considered, careful postoperative long-term follow-up is very important to identify tumor recurrences, particularly in the posterior cranial fossa, even if the tumor is completely removed.

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Introduction: Introduction End organ dysfunction related to infective endocarditis (IE) is a common cause for the referral to the intensive care unit. A thorough history and physical examination remains an integral part of management of patients with IE. Intensivists should maintain a high index of suspicion towards detecting rare manifestations of IE. We present a case of Methicillin sensitive Staphylococcus aureus (MSSA) endocarditis with two such rare complications in the form of bilateral endophthalmitis and parotitis which were diagnosed early and treated promptly. Case presentation A 63 year old male with a past history of mitral valve annuloplasty was hospitalized for fever with rigors of four day duration. His admission vitals were notable for fever (103 F), tachycardia and tachypnea. Physical examination revealed an apical holosystolic murmur and painful erythematous finger nodules (Osler's nodes).Pertinent positive labs included thrombocytopenia (count of 40,000), elevated BUN (60) and creatinine (1.7). Appropriate antibiotics were initiated for concern of IE; blood cultures grew Methicillin sensitive Staphylococcus aureus (MSSA) and subsequent work up with Trans-esophageal echocardiography showed mitral valve vegetation's (> 2 cm) on the anterior leaflet of the mitral valve with concomitant severe mitral regurgitation. Hospital course was complicated by the development of sudden painful bilateral parotid gland enlargement, bilateral decreased visual acuity and confusion. A thorough visual, neck and neurological exam revealed findings of bilateral endophthalmitis which was emergently treated with vitreous aspiration and intravitreal antibiotic instillation leading to an improvement in vision. Vitreal fluid cultures were positive for MSSA. Bilateral Parotid gland enlargement- acute parotitis secondary to disseminated sepsis was successfully treated with antibiotics and hydration. MRI of brain revealed multiple small cerebral infarcts and small areas of intracerebral hemorrhage consistent with septic infarcts and secondary hemorrhagic conversion. While the risks and benefits of emergent mitral valve replacement surgery were being contemplated, unfortunately only four days into the hospital course patient suffered a massive intracerebral hemorrhage and passed away. Discussion The pathogenesis for complications in IE includes embolic, local spread of infection, metastatic infection or immune-mediated damage. Embolization remains a distressingly common complication of IE and can occur even after appropriate therapy. Endogenous endophthalmitis is a rare complication of infective endocarditis that occurs due to direct invasion of ocular tissues (septic emboli) or by changes in vascular endothelium caused by substrates released during infection. The most common cause of the infection is Staphylococcus aureus. Endogenous endophthalmitis due to MSSA infective endocarditis is an extremely rare complication. Intravitreal and systemic antibiotic therapy should be initiated promptly. Acute bilateral parotitis is rare and is associated with mumps and connective tissue disorders; while in our case it seems to be secondary to MSSA bacteremia and septic emboli. Bilateral Endophthalmitis and Parotitis are very rare complications of infective endocarditis with only a few case reports published to date. Our patient is the first case in literature where both manifestations occurred together as a part of embolic phenomenon. Most common pathogen implicated in the setting of endocarditis is Staphylococcus aureus. Conclusion: Infective endocarditis (IE) is associated with a myriad of complications. It is important to recognize rare complications of IE like bilateral endophthalmitis and parotitis and act rapidly to prevent morbidity associated with it.

In vivo optical imaging correlates with improvement of cerebral ischemia treated by intravenous bone marrow stromal cells (BMSCs) and edaravone

Objective:Recent studies show that modern in vivo optical imaging can detect matrix metallopeptidase (MMP) activation in the ischemic brain. In this study, we analyze the protective effects of bone marrow stromal cells (BMSCs) and edaravone (EDA) against tissue plasminogen activator (tPA) risk in the ischemic brain with in vivo optical fluorescence MMP imaging.Methods:At 48 hours after 60 minutes of transient middle cerebral artery occlusion (tMCAO) with tPA, C57BL/6J mice were subjected to motor function analysis, in vivo and ex vivo optical imaging for MMP activation, gelatin zymography, and double immunofluorescent analyses with or without intravenous BMSC transplantation and the intravenous free radical scavenger EDA.Results:In vivo fluorescent signals for MMP were detected over the heads of living mice 48 hours after tMCAO; the strongest were in the tPA group, which were reduced by BMSC or EDA treatment. These in vivo data were confirmed by ex vivo fluorescence imaging. While massive intracerebral hemorrhages were observed in the ischemic hemispheres of the tPA group, only slight hemorrhages were found in the tPA/BMSC, tPA/EDA, and EDA groups. Gelatin zymography showed the strongest MMP-9 activation in the tPA group after tMCAO, which was reduced by BMSC or EDA treatment.Conclusion:The present study provides a correlation between in vivo optical imaging of MMP activation and the improvement of ischemic brain damage caused by tPA after tMCAO and treated by BMSC and EDA.

Primary CNS lymphoma arising in the region of the optic nerve presenting as loss of vision: 2 case reports, including a patient with a massive intracerebral hemorrhage

We report 2 cases of primary central nervous system (CNS) lymphoma arising in the region of the optic nerve. For both patients, diagnosis of lymphoma was impossible without histological examination because of the rarity of the lymphoma location. The first case involved an 84-year-old woman who developed loss of vision and hypopituitarism. Intraoperative finding was optic glioma; histological diagnosis was diffuse large B cell lymphoma, however. The second case involved a 67-year-old man who developed loss of vision. The pre-surgical diagnosis was optic nerve neuritis; this was then revised to granuloma. The tumor arose in the optic nerve. Methotrexate and rituximab were administered and the patient remained in complete remission for 3 years. However, a sudden intratumoral hemorrhage occurred. Although most of the lymphoma cells obtained from the initial surgery were negative for vascular endothelial growth factor (VEGF) immunoreactivity, high levels of VEGF immunoreactivity in lymphoma cells was detected in the specimen obtained after intratumoral bleeding at recurrence, and correlation between VEGF reactivity and tumor recurrence was suggested. To date, primary CNS lymphomas with intracerebral hemorrhage have been reported in 3 cases only, and a correlation between intratumoral hemorrhage and the degree of VEGF expression has been suggested. VEGF also might have predictive significance for recurrence.

Acute Promyelocytic Leukemia Complicated by Massive Intracerebral Hemorrhage: Safety and Efficacy of Replacing Conventional Chemotherapy with Arsenic Trioxide in an Adolescent

Acute Promyelocytic Leukemia Complicated by Massive Intracerebral Hemorrhage: Safety and Efficacy of Replacing Conventional Chemotherapy with Arsenic Trioxide in an Adolescent

Malignant atrophic papulosis (Köhlmeier-Degos disease) - A review

Definition of the diseaseMalignant atrophic papulosis (MAP), described independently by Köhlmeier and Degos et al., is a rare, chronic, thrombo-obliterative vasculopathy characterized by papular skin lesions with central porcelain-white atrophy and surrounding teleangiectatic rim.EpidemiologyLess than 200 cases have been described in the literature. The first manifestation of MAP usually occurs between the 20th and 50th year of life.Clinical descriptionThe cutaneous clinical picture is almost pathognomonic. The histology is not consistent but in most cases it shows a wedge-shaped connective tissue necrosis in the deep corium due to a thrombotic occlusion of the small arteries. In the systemic variant, manifestations mostly occur at the intestine and central nervous system.EtiologyThe etiopathogenesis of the disease remains unknown, a genetic predisposition may occur. Vasculitis, coagulopathy or primary dysfunction of the endothelial cells have been implicated.Diagnostic methodsDiagnosis is only based on the characteristic skin lesions.Differrential diagnosisIt depends on the clinical presentation of MAP, but systemic lupus erythematosus and other connective tissue diseases need to be considered.ManagementNo effective treatment exists for the systemic manifestations, while compounds that facilitate blood perfusion have achieved a partial regression of the skin lesions in single cases.PrognosisAn apparently idiopathic, monosymptomatic, cutaneous, benign variant and a progressive, visceral one with approx. 50% lethality within 2–3 years have been reported. Systemic manifestations can develop years after the occurrence of skin lesions leading to bowel perforation and peritonitis, thrombosis of the cerebral arteries or massive intracerebral hemorrhage, meningitis, encephalitis, radiculopathy, myelitis.

Predictors of massive intracerebral hemorrhages in arterial hypertension

In 125 autopsies cases of massive intracerebral hemorrhages (ICH), caused by arterial hypertension (AH), retrospective clinical analysis and macro- and microscopic investigation of brain and its vascular system were conducted. There were 54 females and 71 males aged from 21 to 75 (average age is 53±11). 78% of patients suffered from essential AH, 22% – from nephrogenic AH. In 50% of cases duration of AH was over 10 years. In 62% of cases the disease was severe, with uneffective treatment, and often hypertensive cerebral crises. Over 30% of these patients suffered from strokes. In all cases brain analysis showed large ICHs (over 40 cm3), which in 84% of cases were located in cerebral hemispheres (lateral ICHs – 49%, mixed – 38%, medial – 13%), in brainstem – 9%, and in cerebellum – 7%. In 79% of cases massive penetration of blood into ventricular system was noted. Macroscopic analysis revealed local brain changes in 63% of all cases: 35% in the form of large post-haemorrhagic cysts, 44% in the form of a single or multiple lacunar infarcts (LIs). In 38% of cases with multiple LIs lacunar condition of brain was diagnosed. In 16% of these cases both cysts and multiple LIs were revealed. Local changed were found in the same deep brain areas as ICHs: more often in basal ganglions and cerebral white matter, and less often – in thalamus, pons and cerebellum. In microscopic examination morphological changes characteristic of hypertensive angioencephalopathy were detected: LIs, incomplete necrosis foci, white matter spongiosis, perivascular encephalolysis foci, criblurs, microhemorrhages. Examination of hemorrhage foci revealed structural elements of LIs located on the edge and around hemorrhage. According to our data, we suppose, that previous local and diffuse brain tissue changes, which are typical for hypertensive angioencephalopathy and lacunar condition, are predictors of massive ICHs.

Comparison of Spontaneous Intracerebral Hemorrhage Treatment in Germany Between 1999 and 2009

The aim of our study was to examine surgical practice in the therapy of spontaneous intracerebral hemorrhage in Germany over a period of 10 years. In 1999 and 2009 a questionnaire with 10 different cases of spontaneous intracerebral hemorrhage was sent to all neurosurgical centers in Germany. It included a cranial CT as well as a case description. The question asked if a conservative or surgical procedure was most suitable. When choosing surgery, the participants could decide between large open approach or microsurgery as well as stereotactic aspiration or external ventricular drainage. In 1999, 85 of 121 (70%) and in 2009 111 of 125 (89%) questionnaires could be evaluated. The results of the questionnaires from 1999 and 2009 showed no difference in the decision for or against a surgical procedure, except for a move toward conservative treatment in 1 patient with a massive spontaneous intracerebral hemorrhage. In 2 cases of isolated basal ganglia bleeding, a conservative approach was chosen by approximately 98% of the participants both in 1999 and in 2009. In all other cases of spontaneous intracerebral hemorrhage, in particular when the patient was in poor clinical condition, the decision was very heterogeneous. Despite new studies, there were no significant differences regarding the decision for or against a surgical procedure in 1999 and 2009. Although clearly unfavorable prognostic factors are known, many patients still undergo a surgical procedure. It appears that at least spontaneous intracerebral hemorrhage in the area of the basal ganglia is a unique domain of conservative treatment.

A randomized study of urgent computed tomography–based hematoma puncture and aspiration in the emergency department and subsequent evacuation using craniectomy versus craniectomy only

When treating patients with a spontaneous supratentorial massive (≥ 70 ml) intracerebral hemorrhage (ICH), the results of surgery are gloomy. A worsening pupil response has been observed in patients preoperatively, despite blood pressure control and diuretic administration. Because open surgery needs time for decompression to occur, the authors conducted a prospective randomized study to determine whether patients who have suffered a massive ICH can benefit from a more urgently performed decompressive procedure. Overall, 36 eligible patients admitted 6 or fewer hours post-ictus were enrolled in the study. In Group A, 12 patients underwent CT-based hematoma puncture and partial aspiration in the emergency department (ED) and subsequent evacuation via a craniectomy; in Group B, 24 patients underwent hematoma evacuation via a craniectomy only. Pupil responses were categorized into 5 grades (Grade 0, bilaterally fixed; Grade 1, unilaterally fixed with the fixed pupil > 7 mm; Grade 2, unilaterally fixed with the fixed pupil ≤ 7 mm; Grade 3, a unilaterally sluggish response; and Grade 4, a bilaterally brisk response). Grades were obtained on admission, at surgical decompression (defined as the point at which liquid hematoma began to flow out in Group A and at dural opening in Group B), and at completion of craniectomy. The Barthel Scale was used to assess survivors' functional outcome at 12 months. Comparisons were made between Groups A and B. Logistic regression analysis was used to evaluate the positive likelihood ratio of all variables for survival and function (Barthel Scale score of ≥ 35 at 12 months). Decompressive surgery was undertaken approximately 60 minutes earlier in Group A than B. A worsening pupil reflex before decompression was observed in no Group A patient and in 9 Group B patients. At the time of decompression pupil response was better in Group A than B (p < 0.05). Although only approximately one-third of the hematoma volume documented on initial CT scanning had been drained before the craniectomy in Group A, when partial aspiration was followed by craniectomy, better pupil-response results were obtained in Group A at the completion of craniectomy, and survival rate and 12-month Barthel Scale score were better as well (p < 0.05). Logistic regression analysis revealed that one variable, a minimum pupil grade of 3 at the time of decompression, had the highest predictive value for survival at 12 months (8.0, 95% CI 2.0-32.0), and a pupil grade of 4 at the same time was the most valuable predictor of a Barthel Scale score of 35 or greater at 12 months (15.0, 95% CI 1.9-120.9). Patients with massive spontaneous supratentorial ICHs may benefit from more urgent surgical decompression. The results of logistic regression analysis implied that, to improve long-term functional outcome, decompression should be performed in patients before herniation occurs. Due to the fact that most of these patients have signs of herniation when presenting to the ED and because conventional surgical decompression requires time to take effect, this combination of surgical treatment provides a feasible and effective surgical option.

Eelco Wijdicks: a neurocritical appraisal

Eelco Wijdicks: a neurocritical appraisal

Pituitary Apoplexy Manifesting as Massive Intracerebral Hemorrhage

A 68-year-old man presented with severe conscious disturbance caused by pituitary apoplexy resulting in massive intracerebral hemorrhage (ICH). He had been periodically followed up for asymptomatic pituitary adenoma at another hospital for 8 years. Neuroimaging examination revealed pituitary apoplexy and massive ICH located in the left frontal lobe, and the ICH was directly connected to the intratumoral hemorrhage. The diagnosis was massive ICH from pituitary apoplexy. The patient underwent emergent evacuation of hematoma and removal of the pituitary adenoma via bi-frontal craniotomy. Postoperatively, he continued to exhibit deep consciousness disturbance and died 1 month after the operation. Pituitary apoplexy is usually characterized by intra-tumoral hemorrhage. The treatment strategy for asymptomatic pituitary adenoma is still controversial. This case shows that we should always consider the risk of pituitary apoplexy manifesting as ICH which may cause a fatal outcome.

Massive Intracerebral Hemorrhage Caused by a Cavernous Malformation

We present a rare case of massive intracerebral hemorrhage resulting from a small, superficially-located supratentorial cavernous malformation, or cavernoma. These lesions rarely lead to massive, life-threatening intracerebral hemorrhages. A 17-year-old female presented with a 3-week history of declining mental status. Brain computed tomography and magnetic resonance imaging revealed a sizable intracranial hemorrhage, within the right occipital region, associated with a small nodule at the hematoma's posterior margin. An emergency operation removed the entire hematoma and nodule. Histological examination of the nodule was compatible with a diagnosis of cavernous malformation. The patient's post-operative course was uneventful.

Bilateral intracerebral hemorrhage following CPR

Intracranial hemorrhage is an extremely rare complication following cardiopulmonary resuscitation (CPR). Only a few cases of subarachnoid hemorrhage during the post-resuscitation period have been reported in the literature.A 55 year-old man, who was resuscitated following a cardiac arrest, sustained an intracranial hemorrhage during the post cardiac arrest period. His brain computerized tomography (CT), performed 4 hours after return of spontaneous circulation, showed no signs of intracranial hemorrhage. However, a brain CT performed 7 days after cardiac arrest revealed a massive intracerebral hemorrhage in both basal ganglia and thalami with an associated subarachnoid hemorrhage.This paper reports the first case of intracerebral hemorrhages in bilateral basal ganglia and thalami that developed following cardiac arrest and resuscitation.

Complete recovery after antepartum massive intracerebral hemorrhage in an atypical case of sudden eclampsia

Background:Intracerebral hemorrhage is an infrequent but severe complication in pregnant women with hypertension.Case Description:We describe an atypical case of a patient with no risk factors who developed sudden eclampsia and spontaneous intracerebral hemorrhage during the 34th week of pregnancy. She underwent successful emergent Cesarean section followed by craniotomy. Both intraoperative surveillance and postoperative magnetic resonance angiographic examination of the cerebral vessels failed to identify an aneurysm, arteriovenous malformation, tumor, or leptomeningeal disease.Conclusion:We discuss the management of this case and review the literature regarding the threshold for which initiation of antihypertensive treatment is indicated in pregnant patients.