Massive Intracerebral Hemorrhage Research Articles

Successful treatment with urgent revascularization and parent artery occlusion for a ruptured intratumoral aneurysm following prior meningioma surgery: illustrative case.

An intratumoral aneurysm encased within the associated intracranial tumor is rare, and hemorrhage caused by its rupture is even more rare. While urgent and adequate surgical treatment is important, the treatment can be difficult given the limited understanding of this rare condition. A 69-year-old man who had undergone meningioma surgery 30 years prior presented with a disturbance in consciousness. Magnetic resonance imaging revealed massive intracerebral and subarachnoid hemorrhage. A round, partially calcified mass, which was diagnosed as recurrent meningioma, was also observed. Subsequent cerebral angiography revealed that the source of the hemorrhage was an intratumoral aneurysm in the dorsal internal carotid artery (ICA) encased within the recurrent meningioma. Urgent surgical ICA trapping and high-flow graft bypass were conducted. The postoperative course was uneventful, and he was referred to another hospital for rehabilitation. This is the first case report of a ruptured intratumoral aneurysm being treated with urgent combined revascularization and parent artery trapping surgery. This surgical approach may be a feasible treatment option for such a challenging condition. Additionally, this case highlights the importance of diligent long-term follow-up after skull-base surgery, as minor intraoperative vascular wall injury may trigger the development and rupture of an intracerebral aneurysm.

Autopsy Pathology of Hypertensive Cardiovascular Disease: Case Reports

An Autopsy is performed on a dead body primarily to determine the cause of death. Two autopsies of death from hypertensive cardiovascular disease were performed at Abia State University Teaching Hospital, Aba, Nigeria. The first autopsy was on a 51 year old man diagnosed about 12 years before his death with hypertension. Autopsy report after his death revealed pan-valvular dilatation, benign nephrosclerosis, chronic pyelonephritis, hepatomegaly with chronic passive congestion of the liver, splenomegaly, pleural effusion, pulmonary edema, ascites and moderate cerebral edema. The cause of death was ruled as congestive cardiac failure and hypertensive cardiovascular disease. The second autopsy was on a 60 year old woman who died after a 5 day history of headache and a day history of loss of consciousness. Autopsy report after her death revealed massive intracerebral and intraventricular haemorrhage, pontine haemorrhage, laryngotracheobronchitis, pulmonary edema, and congested liver and spleen. The cause of death was ruled as hypertensive cardiovascular disease with massive intracranial haemorrhage. A thorough autopsy of deaths from hypertensive cardiovascular disease to reveal other associated pathologies was recommended. Keywords: Autopsy, Hypertensive cardiovascular disease, Intracranial haemorrhage, Congestive cardiac failure, Hypertension

Endovascular Treatment of Arterial Steno-Occlusive Lesions in Symptomatic Moyamoya Disease.

The efficacy and safety of endovascular treatment (EVT) for moyamoya disease (MMD) have rarely been investigated. The objective of this study was to summarize the clinical outcomes of EVT for MMD and determine the potential role of EVT in treating symptomatic steno-occlusive lesions in MMD. Reports from January 2000 to December 2021 describing EVT in MMD were collected through a literature search. The search terms included "moyamoya", "stent", "angioplasty", and "endovascular". Data regarding baseline demographics, previous medical history, treated vessel, periprocedural complications, and angiographical recurrence were retrieved. This review included 10 studies with details of 19 patients undergoing a total of 31 EVT procedures. Twenty-one EVTs were performed as initial treatments for MMD, and 10 were performed as additional treatments for angiographical recurrence. The mean follow-up period of the initial EVTs was 9.0±11.9 months, with angiographical recurrence in 11 (68.8%) cases. The mean follow-up period of additional EVTs was 4.3±3.9 months, and seven (70.0%) EVTs showed restenosis of the re-treated vessel. Across all initial and additional EVTs, there were no differences in characteristics between the recurrence and non-recurrence groups. Overall, two periprocedural complications (9.5%) occurred, one vessel rupture and one massive intracerebral hemorrhage with subarachnoid hemorrhage. EVT plays a limited role in the management of symptomatic intracranial arterial steno-occlusive lesions of MMD. Recent advances in understanding the pathomechanism of MMD may urge neuro-interventionists to find a new endovascular approach with better balloon angioplasty or stenting mechanisms.

REMOVED: Neurosurgical Steps and Lessons Learned in Final Separation of 3-Year-Old Craniopagus Twins

The only published paper1 describing the separation of the conjoined twins did not describe the novel steps and techniques of the microsurgery part, which lasted 26 hours. That paper did not include the neurosurgical video, either. The massive intracerebral hemorrhage that occurred on postoperative day 33 was not reported, and its potential causes have not been scrutinized. The strategy of final separation was developed during day-by-day microsurgical practice on cadavers and did lead us to novel surgical solutions as the introduction of the application of hinge and distractors. One of the twins advanced to GOS 5 status during first 5 postoperative months. The other twin slowly advanced to GOS 3 status and remained at that functional level. The latter suffered the massive brain hemorrhage on postoperative day 33, which led to delayed rehabilitation and interfered with a potentially better outcome. The thorough analysis of the potential causative factors revealed the possible pathophysiologic mechanism behind that complication.2 Two major factors have been identified, one of which is the traction-related traumatic brain injury that evolved during supine position. Another probable theory is the lack of sufficient reconstruction of the posterior part of the skull, which caused a recurring tactile microtrauma of the brain due to the supine position. The hemorrhage may have been facilitated by the fact that their coagulation tests were on the lower edge of normal parameters. It was a mistake that this part of the surgery was not performed by the neurosurgeons who designed it and practiced extensively on fresh cadavers using 3-dimensional models. Sufficient cranioplasty was performed 3 months later. It is impossible to say with certainty the cause of the hemorrhage, since there may have been other unknown causes (e.g., blood pressure spike). As a contributing factor, congestion of the veins is also possible.3 We concluded that closer monitoring, a stricter management of the interdisciplinary team work, and realizing the seriousness of the lack of sufficient structural support earlier could have prevented this unfortunate complication. In a similar case we advise future professionals to use a halo ring postoperatively for posterior protection until a sufficient cranioplasty can safely be done.

Therapeutic effect of anti-HMGB1 antibody in a mouse model of 4-h middle cerebral artery occlusion: comparison with tissue plasminogen activator.

Delayed tissue plasminogen activator (tPA) treatment increases the risk of intracerebral hemorrhage in patients with ischemic stroke. We previously demonstrated that tPA treatment caused hemorrhagic complications in a 4-h middle cerebral artery occlusion (MCAO) mouse model when administered after reperfusion. In the present study, we administered an anti-high mobility group box 1 (αHMGB1) antibody to 4-h MCAO mice to evaluate the usability of αHMGB1 antibody treatment in the delayed phase of ischemia, beyond the therapeutic time window of tPA. αHMGB1 antibody, tPA and control IgG were dissolved in normal saline and administered intravenously into the tail vein of the mice after reperfusion. Infarct volume, hemorrhagic volume, brain swelling, functional outcomes and levels of pro-inflammatory cytokines, such as HMGB1, interleukin (IL)-6 and tumor necrosis factor (TNF)-α, were evaluated 24 h after MCAO. tPA treatment was not only ineffective but also caused a massive intracerebral hemorrhage. Treatment with αHMGB1 antibody reduced the infarct volume and swelling and ameliorated neurologic impairment and motor coordination without hemorrhagic complications by inhibiting HMGB1 activity. Moreover, the αHMGB1 antibody suppressed pathways of secondary inflammatory responses, such as IL-6 and TNF-α, after cerebral ischemia. These results indicate that αHMGB1 antibody may be therapeutically efficient in the delayed phase of ischemia, where tPA treatment is no longer an eligible option. Treatment with an αHMGB1 antibody may be an effective therapeutic option in patients who exceed the tPA therapeutic time window.

Congenital CMV infection presenting with massive intracerebral hemorrhage

Cytomegalovirus (CMV) is a common intrauterine infection and the developing nervous system is a frequent target, suffering a range of injuries from subclinical to catastrophic. A 20-week gestational age fetus was found to have a large echogenic focus in one cerebral hemisphere. Congenital CMV infection was identified by amniocentesis and maternal serology. Postmortem examination of the brain revealed massive intracerebral hemorrhage as the correlate for the sonographic finding. The microscopic examination of the brain was also striking for extensive polymicrogyria, a high burden of CMV, and abundant angiocentric CMV pathology. Catastrophic intracerebral hemorrhage has not been previously reported in association with congenital CMV infection. The present case expands the range of potential injuries to the developing brain in congenital CMV infection and raises the possibility of a direct vascular injury.

Massive Intracerebral Hemorrhage as a First Manifestation of Large Vessel Vasculitis: Case Report

Massive Intracerebral Hemorrhage as a First Manifestation of Large Vessel Vasculitis: Case Report

Congenital CMV Infection Presenting with Massive Intracerebral Hemorrhage

Cytomegalovirus (CMV) is among the most common of intrauterine infections against which we have no effective preventative or therapeutic options. The developing nervous system is a frequent target of CMV and while most injuries are subclinical, severe insults leading to microcephaly and migration defects are well known. A 20-week gestational age fetus was found to have several abnormalities on prenatal ultrasound, the most prominent of which was a large echogenic focus in one cerebral hemisphere. Congenital CMV infection was identified by amniocentesis and maternal serology. The pregnancy was ended by early induction of labour for a 368g stillborn infant. Postmortem examination revealed massive intracerebral hemorrhage as the correlate for the sonographic finding. The microscopic examination of the brain was also striking for extensive polymicrogyria, a high burden of CMV and abundant angiocentric CMV pathology. Catastrophic intracerebral hemorrhage has not been previously reported in association with congenital CMV infection. The present case expands the range of potential injuries the developing brain is subject to in the setting of CMV infection and raises the possibility of a direct vascular injury.Learning ObjectivesConsider intracerebral hemorrhage in the range of potential outcomes in congenital CMV infectionDescribe how polymicrogyria may result from an insult during proliferation and migrationDiscuss possible mechanisms of injury to the developing brain by CMV

Functional Outcome Following Ultra-Early Treatment for Ruptured Aneurysms in Patients with Poor-Grade Subarachnoid Hemorrhage.

Little is known regarding functional outcome following poor-grade (World Federation of Neurosurgical Societies grades IV and V) aneurysmal subarachnoid hemorrhage (aSAH), especially in individuals treated aggressively in the early phase after ictus. We provided patients with aSAH with ultra-early definitive treatment, coiling or clipping, within 6 hours from arrival as per protocol. We classified the patients into 3 groups according to their computed tomography findings: Group 1, intraventricular hemorrhage with obstructive hydrocephalus; Group 2, massive intracerebral hemorrhage with brain herniation; and Group 3, neither Group 1 nor Group 2. We retrospectively evaluated patients with poor-grade aSAH who were admitted to our department between January 2013 and December 2016. We evaluated functional outcome at 6 months, defining modified Rankin Scale (mRS) scores of 0-2 as good and those of 3-6 as poor outcomes. A good functional outcome was observed in 39.4% (28/71) of all cases. All-cause mortality at 6 months was 15.5% (11/71). A good outcome in Group 3 was significantly higher than that in the other two groups (Group 1 and 2 vs. Group 3, 20.8% vs. 48.9%, p = 0.02), even after adjustment with a multiple logistic regression analysis (odds ratio 6.1, 95% confidence interval 1.1 to 34.8). Approximately 40% of patients with poor-grade aSAH became functionally independent, and approximately half of the patients with poor-grade aSAH who had neither intraventricular hemorrhage with obstructive hydrocephalus nor with brain herniation had good functional outcomes. Although further trials are required to confirm our results, ultra-early surgery may be considered for patients with poor-grade aSAH.

Management of Simultaneously Occurring Multiple Massive Intracerebral Hemorrhages

Occurrence of simultaneous multiple intracerebral hemorrhages (ICHs) in different arterial territories is an uncommon presentation. We report the cases of concurrent ocular and ICHs. The rarity of these lesions leads to delay in the diagnosis. Further lack of clear management guidelines for these pathologies makes further delay in the institution of appropriate therapy. In addition, the pathogenesis, diagnosis, and management along with pertinent literature are also reviewed.

A case of multiple infectious intracranial aneurysms concurrently presenting with intracerebral hemorrhage and epistaxis

Abstract Infectious intracranial aneurysms (IIAs) have the specific features of rapid growth and multiplicity, which often show various pathologies and serious symptoms when ruptured. There are few previous reports of multiple IIAs that concurrently present with intracerebral hemorrhage (ICH) and epistaxis. A 62-year-old man with a history of tooth extraction 1.5 months before experienced an intracranial abscess in the left Sylvian fissure and insula cortex. The patient underwent a craniotomy to drain the abscess and he experienced a heavy epistaxis, which required intranasal gauze packing immediately after surgery. Subsequently, he had a massive ICH on the left temporal lobe resulting from a ruptured IIA in the left middle cerebral artery on day 8. Surgical trapping of the aneurysm contributed to a complete cure. Oral indigenous bacteria was obtained by culturing an aspirate of the abscess cavity. A follow-up radiological examination revealed that the right internal carotid artery (ICA) aneurysm in the cavernous segment concurrently grew and the aneurysmal rupture had caused the epistaxis. We performed stent-assisted coil embolization for the aneurysm on day 20 and achieved radiological resolution. Although right hemiparesis and some communication problems remained, the patient recovered but needed minimal assistance. Given multiple progressions and their destructive pathology, more attention needs to be paid to IIAs. Our multimodal strategy achieved clinical resolution, and IIAs should be treated immediately with appropriate radical intervention depending on the lesion location.

Blue rubber bleb nevus syndrome associated with adult-onset cutaneous lesions and spontaneous intracranial hemorrhage: A case report and literature review

Abstract Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder. Since 1860, only 200 case reports of BRBNS have been reported. BRBNS is characterized by numerous malformations of the vascular system that significantly involve the skin, gastrointestinal tract, and other internal organs. We describe a 72-year-old Taiwanese man with BRBNS. Besides typical adult-onset cutaneous lesions, he had venous malformation in the central nervous system, which caused massive intracerebral hemorrhage. He has been in a stupor ever since. Physicians should recognize cutaneous BRBNS lesions early and be aware of the possible complications that arise from internal organs involved.

Massive intracerebral and intraventricular hemorrhage following ventriculoperitoneal shunt

Post-ventriculoperitoneal (VP) shunt placement intracerebral hemorrhage is a rare complication and carries a high mortality. In the present article, we describe a case of a 22-year-old male who underwent VP shunt placement and developed massive intracerebral hemorrhage with intraventricular extension and review the relevant literature to understand the underlying causative pathophysiology.

Neonatal EEG- an overview

Electro-encephalogram (EEG) is the best non-invasive modality for brain monitoring. As brain continues to develop and mature in neonatal period, EEG of a normal newborn varies from time to time. Wave patterns may be normal at one developmental stage and abnormal at another stage. There are many types of EEG waves like alpha, beta, gamma & delta waves. Burst suppression occurs in very sick neonates following brain damage due to asphyxia & predicts poor prognosis. Isoelectric pattern occurs in severe asphyxia, circulatory collapse, massive intracerebral hemorrhage, severe inborn metabolic deficits, CNS bacterial or viral infections, drug-induced state, hypothermia, postictal recording and in malformations like hydranencephaly or massive hydrocephalus. Grading of severity of disease condition can be done based on EEG. They can be vital in arriving etiological diagnosis. EEG distinguishes between normal paroxysmal movements from epileptic seizures. Nearly 90% of abnormal movements mimiking seizures may be nonepileptic after EEG study. Early recordings, prolonged recordings at different activity states, serial short interval EEGs increase the prognostic value of EEGs. Long-time bedside monitoring of brain function can be done by amplitude-integrated EEG (aEEG). Some rare neonatal epilepsy syndromes have characteristic EEG features. Artifacts mimicking electrical seizures include environmental interference, electrode impedence abnormalities, motion artifacts and endogenous non-cerebral potentials which can be distinguished by Polygraphy. Drugs can alter background activity. EEG is a boon for noninvasive bedside continuous monitoring of the brain. Judicious application of this technique can help in prompt management of various pathologies like seizures , encephalopathies, epilepsy and asphyxia.

Compare the Intracranial Pressure Trend after the Decompressive Craniectomy between Massive Intracerebral Hemorrhagic and Major Ischemic Stroke Patients.

ObjectiveMassive intracerebral hemorrhage (ICH) and major infarction (MI) are devastating cerebral vascular diseases. Decompression craniectomy (DC) is a common treatment approach for these diseases and acceptable clinical results have been reported. Author experienced the postoperative intracranaial pressure (ICP) trend is somewhat different between the ICH and MI patients. In this study, we compare the ICP trend following DC and evaluate the clinical significance.MethodsOne hundred forty-three patients who underwent DC following massive ICH (81 cases) or MI (62 cases) were analyzed retrospectively. The mean age was 56.3±14.3 (median=57, male : female=89 : 54). DC was applied using consistent criteria in both diseases patients; Glasgow coma scale (GCS) score less than 8 and a midline shift more than 6 mm on brain computed tomography. In all patients, ventricular puncture was done before the DC and ICP trends were monitored during and after the surgery. Outcome comparisons included the ictus to operation time (OP-time), postoperative ICP trend, favorable outcomes and mortality.ResultsInitial GCS (p=0.364) and initial ventricular ICP (p=0.783) were similar among the ICH and MI patients. The postoperative ICP of ICH patients were drop rapidly and maintained within physiological range if greater than 80% of the hematoma was removed. While in MI patients, the postoperative ICP were not drop rapidly and maintained above the physiologic range (MI=18.8 vs. ICH=13.6 mmHg, p=0.000). The OP-times were faster in ICH patients (ICH=7.3 vs. MI=40.9 hours, p=0.000) and the mortality rate was higher in MI patients (MI=37.1% vs. ICH=17.3%, p=0.007).ConclusionThe results of this study suggest that if greater than 80% of the hematoma was removed in ICH patients, the postoperative ICP rarely over the physiologic range. But in MI patients, the postoperative ICP was above the physiologic range for several days after the DC. Authors propose that DC is no need for the massive ICH patient if a significant portion of their hematoma is removed. But DC might be essential to improve the MI patients’ outcome and timely treatment decision.

Intracerebral haemorrhage following uncontrolled autonomic dysreflexia post suprapubic catheter placement surgery.

We describe a case of intracerebral haemorrhage (ICH) following uncontrolled episodes of autonomic dysreflexia (AD) within 24 h of a minor urological procedure. A 33-year-old active paraplegic patient T1 Association Impairment Scale A underwent an elective suprapubic catheter (SPC) placement for bladder management. The surgery was done under general anaesthesia and was uneventful. Four hours after surgery, he developed haematuria and multiple blood clots in the urine, which eventually caused blockage of the SPC and resulted in symptomatic AD. The clots and blockage persisted, which continued to trigger repeated episodes of increased blood pressure (BP) and AD. Despite medical treatment with sublingual nitrate to lower the increased BP, the patient subsequently developed massive left ICH presenting with right upper limb weakness, facial asymmetry and inability to speak. He continued to have fluctuating BP measurements for 11 days post event with severe hypertensive and hypotensive episodes. This presented a challenge in the BP management as well as post-ICH management. He underwent an intensive neurorehabilitation programme as soon as the BP had stabilized. Severe neurological complications of AD are rare. In this case report, we highlight the importance of close monitoring of BP and AD symptoms after an SPC procedure, the challenges in BP management and the subsequent importance of an early rehabilitation programme after ICH secondary to uncontrolled AD.

Application of T-Wave Alternans in Evaluation of Prognosis in Patients with Intracerebral Hemorrhage

Objective: To explore the application value of electrocardiograph (ECG) T-wave Alternans (TWA) anomaly in acute stage of intracerebral hemorrhage patients. Methods: We choose 1175 intracerebral hemorrhage patients whose conventional 12-lead ECG has TWA in our hospital from January 2011 to December 2015, 751 patients without TWA in the same period as the control group, compared the volume of intracerebral hemorrhage, bleeding site and mortality between the 2 groups. Results: In TWA group, 247 cases died, 361 cases with massive intracerebral hemorrhage, 298 cases with brain stem hemorrhage; in TWA negative group (control group), 41 cases died, 93 cases with massive brain hemorrhage, 64 cases with brain stem hemorrhage. There are statistical differences between two groups (P < 0.05). Multi factor Logistic regression analysis showed that massive intracerebral hemorrhage, brain stem hemorrhage, Glasgow score and TWA were the independent factors in the prognosis of intracerebral hemorrhage (P < 0.05). Conclusion: The occurrence of TWA is significantly related to the volume of bleeding, the bleeding site and mortality, and can be used as an important parameter in the prognosis of intracerebral hemorrhage.

Choriocarcinoma, A Rare Cause of Antepartum and Postpartum Haemorrhage, Report of A Case and Review of Literature

Objective: To present a case of choriocarcinoma as a cause of antepartum haemorrhage and of severe and fatal postpartum haemorrhage in a patient carrying her pregnancy to term. Method: Detailed clinical, postmortem gross and histopathological analysis of a patient who presented with severe persistent postpartum haemorrhage after a caesarian hysterectomy was carried out and histopathological findings correlated with clinical findings. Results: showed disseminated gestational choriocarcinoma at term, resulting in a massive intracerebral haemorrhage culminating in the death of the patient. Conclusion: choriocarcinoma is an uncommon cause of antepartum haemorrhage, severe primary and secondary postpartum haemorrhage and intracerebral haemorrhage, when clinically suspected the diagnosis should be pursued aggressively and patients vigorously treated.

Therapeutic outcomes for patients with aneurysmal subarachnoid hemorrhage complicated by Takotsubo cardiomyopathy.

There are no guidelines regarding the optimal treatment of subarachnoid hemorrhage (SAH) patients complicated by Takotsubo cardiomyopathy (TCM). Although coiling has been favored as the first-line treatment, clipping may also be indicated in patients with ruptured middle cerebral artery aneurysms or in those with massive intracerebral hemorrhage. The study objective is (1) to report the feasibility/safety of clipping/coiling and (2) to identify possible prognosticators in that population. Between January 2008 and December 2014, 371 consecutive patients with aneurysmal SAH underwent transthoracic echocardiography after admission, and 30 with TCM (7.7 %) were identified. We reviewed the incidence and type of perioperative complications among clipped (n = 11) and coiled (n = 19) patients. The 30 patients were dichotomized based on their 90-day modified Rankin scale (mRS) scores into favorable (mRS: 0-2) and unfavorable (mRS: 3-6) groups, and their demographic, laboratory and echocardiographic variables were compared. Neither clipped nor coiled patients developed serious perioperative cardiopulmonary complications, but coiled patients had a higher incidence of fatal procedure-related complications. Among the 30 patients, 13 (43 %) had favorable 90-day outcomes, and the favorable group was significantly younger. Age, but not the degree of cardiac dysfunction, correlated with outcomes by multivariate regression analysis. Clipping was shown to be a safe treatment modality in our cohort, and treatment selection may better be made on a case-by-case basis in most patients with SAH-induced TCM. The lack of correlation between the degree of cardiac dysfunction and outcomes indicates that aggressive intervention is justified in patients with severely impaired cardiac function.

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