Multiple Cerebral Hemorrhages Research Articles

Fibrinogen BOE II: dysfibrinogenemia with bleeding and defective thrombin binding

BackgroundVariants of fibrinogen sequences that bind to thrombin’s catalytic sites are mostly associated with bleeding phenotypes, while variants with fibrinogen nonsubstrate-thrombin–binding sites are commonly believed to cause thrombosis. AαGlu39 and BβAla68 play important roles in fibrin(ogen)-thrombin–nonsubstrate binding. The BβAla68Thr variant has been described in several unrelated families with apparent thrombotic phenotypes. ObjectivesHomozygous AαGlu39Lys variant (fibrinogen BOE II) was identified in a boy with dysfibrinogenemia who had multiple cerebral hemorrhages. A series of analyses were performed to assess the variant’s functions and elucidate underlying bleeding mechanisms. MethodsAbnormal fibrinogen was purified from plasma and subjected to Western blot, fibrinogen and fibrin monomer polymerization, clottability, fibrinopeptides release, activated factor (F)XIII (FXIIIa) cross-linking, fibrinolysis, and scanning electron microscopy analyses. ResultsFibrinogen BOE II weakened the binding capacity of thrombin to fibrinogen and delayed the formation of fibrin clots. The release of fibrinopeptides, polymerization of fibrinogen catalyzed by thrombin, and cross-linking of FXIIIa of fibrinogen BOE II were impaired. In contrast, batroxobin-catalyzed fibrinogen polymerization and desA/desAB fibrin monomer polymerization did not differ from those in normal controls. Fibrin clots formed by fibrinogen BOE II were composed of thicker fibrin fibers and showed a faster fibrinolysis rate. ConclusionDefective fibrin(ogen)-thrombin–nonsubstrate binding is not necessarily associated with thrombotic disorders. When the hypercoagulable state created by increased circulating free thrombin is insufficient to compensate for defective hemostasis caused by slowly formed but rapidly lysed clots, the primary concern of thrombin-binding deficiency dysfibrinogenemia appears to be hemorrhage rather than thrombosis.

Multifocal primary central nervous system angiosarcoma: illustrative case.

Angiosarcoma is a malignant mesenchymal tumor derived from vascular endothelial cells in which a primary intracranial origin is extremely rare. Most previous reports of primary central nervous system (CNS) angiosarcoma have been solitary cases. The authors report a case of primary CNS angiosarcoma that caused the development of multiple disseminated cerebral hemorrhagic lesions within a short period of time. This rapid progression of symptoms resulted in the death of the patient. During surgery, several nodules suggestive of a tumor were removed from just below the surface of the brain, mixed into the hematoma. A pathological examination revealed atypical cells mimicking blood vessels in the subarachnoid space that were positive for specific vascular endothelial markers. In this case, multifocal angiosarcoma occurred on the brain surface and ventricles, suggesting cerebrospinal fluid dissemination. If multiple cerebral hemorrhages are found on the brain surface, multifocal angiosarcoma should also be considered.

Cerebral hemorrhage due to amyloid angiopathy that was difficult to differentiate from breast cancer metastasis: a case report

BackgroundBreast cancer patients are known to develop brain metastasis at a relatively high frequency. However, imaging findings of brain metastases vary, and it is sometimes very difficult to distinguish these from other tumorous lesions and non-neoplastic lesions, such as cerebral hemorrhage. Meanwhile, there are various causes of cerebral hemorrhage; a major one is cerebral amyloid angiopathy (CAA). With the advancement of imaging technology, CAA-related cerebral hemorrhage can be more precisely diagnosed with magnetic resonance imaging (MRI), but definitive diagnosis of CAA can only be made based on pathological assessment. Herein, we report a case of consciousness disorder appearing during adjuvant therapy for breast cancer. We initially considered that the patient’s cerebral hemorrhage was due to a metastatic tumor, but based on excisional biopsy, she was diagnosed with CAA.Case presentationA 73-year-old Japanese woman underwent curative surgery for left breast cancer. Her disease was hormone receptor-positive and human epidermal growth factor receptor 2 (HER2)-positive invasive ductal carcinoma (pStage IIB). While receiving adjuvant treatment, she developed disorientation, and emergent imaging revealed multiple cerebral hemorrhages. There was no apparent enhancement in the cerebral parenchyma on MRI, and differential diagnosis included hemorrhage due to a metastatic tumor, intravascular large B-cell lymphoma, CAA and thrombotic intracranial bleeding. After hospitalization, the bleeding lesion enlarged, resulting in cerebral hernia, and she needed emergency drainage surgery. The tissue surrounding the hemorrhage was pathologically assessed, and she was diagnosed with CAA. Although we initially suspected the lesion to be a metastatic tumor from breast cancer, there were no tumorous cells.ConclusionAtypical MRI findings made diagnosis difficult in this case, but it should be considered for differential diagnosis when multiple cerebral hemorrhages in elderly patients are observed, especially in cases with symptoms such as transient multifocal neurological deficits and dementia.

Etiology of Multiple Acute Cerebral Hemorrhage and Associated Comorbidities (4311)

Etiology of Multiple Acute Cerebral Hemorrhage and Associated Comorbidities (4311)

From Heart Failure via Biventricular Assist Device to Heart Transplantation

Purpose The Berlin Heart® EXCOR biventricular assist device (BVAD) can be used in pediatric as well as adult patients for bridge to heart transplantation (HTX). This study represents the largest population of BVAD implantations in adult patients reported so far. Methods Adult patients (>16 years) receiving a BVAD from 2006-2020 were included. Patient characteristics and outcomes were analyzed in a retrospective single center study. Results Out of the 54 patients, 45 (83%) were male, mean age of 47.4 ± 11.8 years. Mean body mass index (BMI) was 26 kg/m2 with 15 patients >30kg/m2 BMI. INTERMACS classifications were: I =23 patients (43%), II-III = 17 (31%) and IV-V= 14 (26%). Eight patients (14.8) had previous cardiac surgery before BVAD. 30% suffered from ischemic cardiomyopathy. Before BVAD 33 patients (61%) needed temporary MCS (IABP n=14, v-a ECMO n=26; with 7 patients (13%) receiving both). Mean ICU stay after BVAD was 30 days. 26 patients (48%) died on BVAD with mean time to death of 64.6 days. Causes of death were multiple organ failure (27%), septic shock (19%), cerebral hemorrhage (15%), bleeding (11%), cardiogenic shock (11%) and thrombembolic event (8%). In all 54 BVAD patients we performed 83 chamber exchanges. 28 patients were listed as high-urgency (HU) before HTX. Causes for HU-listing were VAD infections (46%, deteriorating HF under BVAD (18%), multiple VAD-related complications (14%), pump thrombosis (7%), stroke (7%), gastrointestinal bleeding (4%) and cardiac arrhythmia (4%). Complications after BVAD and HTX are listed in table 1. Mean time to HTX was 305 days. 30-day-survival after HTX was 96%. 1- and 3-year-mortality were 18 and 30% respectively. Post-HTX causes of death were cardiogenic (27%) and septic shock (36%). Conclusion These retrospective data show secondary organ failure and bleeding represented the main complications under BVAD support. Only 50% of BVAD patients were successfully transplanted but post HTX survival in BVAD patients was comparable to other HTX candidates.

Varying Patterns of CNS Imaging in InfluenzaA Encephalopathy in Childhood.

The brain imaging findings in children with neurological complications associated with influenza Ainfections are presented and analyzed and pathological imaging changes including atypical intracerebral hemorrhages in these patients are discussed. Neuroimaging findings in six children with influenza encephalopathy following influenza Ainfection between 2012-2017 were retrospectively investigated. Of these five underwent magnetic resonance imaging (MRI) and one computed tomography (CT). Gene analysis was performed in two cases with acute necrotizing encephalitis of childhood (ANEC). The MRI findings of one child were concordant with mild encephalopathy with areversible splenial lesion (MERS); this patient recovered but remained aphasic. In two cases MRI showed typical bilateral thalamic lesions as afeature of ANEC; genetic testing facilitated the diagnosis in one case. One of the patients died, the other showed little improvement. The remaining three patients had multiple diffuse cerebral hemorrhages predominantly affecting the supratentorial white matter after influenza Ainfection complicated by pneumonia, rhabdomyolysis and sepsis requiring extracorporeal membrane oxygenation (ECMO). Neurological complications in children associated with influenza Ainfection may include MERS and ANEC. Additionally, atypical disseminated intracerebral hemorrhages as a complication of influenza Ainfection is reported.

凝固障害により遅発性脳出血を来したサリチル酸中毒の1例(Acute salicylate poisoning with delayed intracranial hemorrhage according to coagulopathy: a case report)

要旨今回我々は，血液凝固機能障害により内服2日後に頭蓋内出血を来した急性サリチル酸中毒の1例を経験した。症例は27歳の女性，アセチルサリチル酸を過量内服（18.5g）して前医へ救急搬送され，サリチル酸中毒の診断で入院。意識レベルや血液検査に問題はなく翌日退院した。帰宅後より意識障害が出現したため，当院へ救急搬送となった。来院時意識レベルはJCS 30，重篤な代謝性アシドーシスと血液凝固機能障害（PT–INR 5.2）を認めた。過量内服より50時間経過していたが血中サリチル酸濃度は42mg/dLと高値であった。来院後さらに意識レベルが低下したため緊急気管挿管を行い，頭部CTを施行したところ，多発脳出血と少量のくも膜下出血を認めた。急性サリチル酸中毒の診断にて入院，緊急血液透析を施行した。血液凝固機能障害に対してはメナテトレノン（ビタミンK）40mgを静注した。第2病日にサリチル酸血中濃度は低下し，血液凝固機能障害も改善した。保存的治療にて意識レベルは徐々に改善し，第13病日に自宅退院した。本症例では外因系凝固機能に異常があり，ビタミンKの補充で改善を認めた。サリチル酸はビタミンK代謝を間接的に阻害するため，本症例のような大量過量内服の際には血液凝固機能異常が生じる可能性がある。重症のサリチル酸中毒では数日間血液凝固機能検査を行い，意識障害の遷延を認めた場合は積極的に画像診断を行う必要がある。

A Case of Metastatic Brain Tumor Complicated by Multiple Repeated Hemorrhages

Metastatic brain tumor occasionally results in multiple cerebral hemorrhages. Here, we report a case of metastatic brain tumor complicated by multiple repeated cerebral hemorrhages. An 80-year-old man with a history of removal of lung cancer was admitted to our hospital because of disturbed consciousness following headache. A brain CT revealed a mass lesion of 40-mm diameter in the left cerebellum and a mass lesion of 2-mm diameter in the right temporal lobe. The cerebellar mass lesion showed homogeneous iso-density, indicating a subacute phase hemorrhage. Two days later, a follow-up CT revealed that the mass lesion had become high-density, indicating complication by a fresh hemorrhage. Hematoma was removed and histological examination was performed on the cerebellar lesion. There was leakage of dark-red liquid intraoperatively, and histological examination revealed an adenocarcinoma, indicating metastasis of the lung cancer. Additionally, necrosis and hemorrhage were identified. Postoperatively, whole brain irradiation was performed. The right temporal lesion gradually enlarged but disappeared after irradiation. In conclusion, multiple brain metastases may result in multiple cerebral hemorrhages. Repeated hemorrhage from necrosis of the carcinoma causes a slowly growing hematoma.

Choriocarcinoma of unknown origin with multiple organ metastasis and cerebral hemorrhage: A case report and literature review.

A 26-year-old man was admitted to Beijing Friendship Hospital, Capital Medical University (Beijing, China) with a 4-day history of headache, moderate fever and numbness in the right upper limb. Prior to this, the patient had been diagnosed with cerebral hemorrhage by computed tomography (CT) scan upon visiting a local hospital. Chest X-ray revealed multiple lesions in the lungs. Following referral, no abnormalities were found elsewhere, including in the testes, during a physical examination. Additional examination of other tumor biomarkers was unremarkable, and the initial suspicion of parasitic infection was ruled out. Tests revealed extremely high levels of β-human chorionic gonadotropin (>200,000 mIU/ml). In addition, CT scans showed multiple metastases in the head, lungs, liver and kidneys. An ultrasound-guided Tru-Cut biopsy of the liver was performed in order to form a definitive diagnosis. Although the patient was treated with mannitol to reduce intracranial pressure, and with cefoperazone sodium and sulbactam sodium to fight infection, the patient succumbed to a cerebral hernia on the fourth day of hospitalization. Following this, the ultrasound-guided Tru-Cut liver biopsy result was received, which suggested a diagnosis of choriocarcinoma.

多発脳梗塞，脳出血を合併した僧帽弁位感染性心内膜炎に対し外科的治療により救命し得た1例

多発脳梗塞，脳出血を合併した僧帽弁位感染性心内膜炎に対し外科的治療により救命し得た1例

Herpes zoster encephalitis presenting as multiple cerebral hemorrhages – a rare presentation: a case report

IntroductionAn infection by herpes zoster virus is a common and important cause of encephalitis. Herpes zoster virus encephalitis if not treated promptly can result in significant morbidity and mortality. The diagnosis of herpes zoster virus encephalitis is based on clinical history, examination, neuroradiological imaging (magnetic resonance imaging and/or computed tomography scan), cerebrospinal fluid analysis and identification of the pathogen in cerebrospinal fluid by polymerase chain reaction amplification and/or anti-herpes zoster virus immunoglobulin G antibody in cerebrospinal fluid. Although ischemic intracerebral infarcts in patients with herpes zoster virus encephalitis or vasculopathy are reported in the literature, multiple intracerebral hemorrhages as a complication of herpes zoster virus encephalitis in an immunocompetent individual are extremely rare.Case presentationA 40-year-old Indian man presented with an acute history of four episodes of seizures, fever, headache, drowsiness, focal neurological deficits and vesicular eruptions over the abdomen in a typical dermatomal distribution. His head computed tomography scan revealed multiple cerebral hemorrhages. Investigations (positive ratio between the cerebrospinal fluid/serum quotients for anti-herpes zoster virus immunoglobulin G and total immunoglobulin G antibodies) established its infective origin due to herpes zoster virus. He developed bilateral pneumonia during the hospital course. He had an excellent recovery following a 2 weeks’ course of intravenous acyclovir.ConclusionHerpes zoster virus encephalitis or vasculopathy is a rare cause of multiple intracerebral hemorrhages and must be considered in the differential diagnosis of patients presenting with an acute history of fever, altered consciousness, and focal neurologic deficits with history of a typical herpetic rash. Its prompt recognition and treatment could alter the course of illness.

Multiple intracranial tumors in Philadelphia chromosome-positive acute lymphoblastic leukemia

A three-year-old female presented with prolonged fever and petechiae. Her initial complete blood workup showed a white blood cell (WBC) count of 159 9 10/L with 92 % lymphoblasts, hemoglobin of 9.3 g/dL, and a platelet count of 22 9 10/L. Marked elevations of C-reactive protein (CRP) and lactate dehydrogenase were identified. The immunophenotype of the blast cells was CD10, CD19, HLA-DR, smIg, and smIg j=k , which is compatible with a diagnosis of precursor B cell lymphoblastic leukemia (pre-B ALL). CD66c expression was also detected, so we confirmed the bcr/abl rearrangement by fluorescence in situ hybridization analysis, and used transcriptase-polymerase chain reaction analysis to detect the minor bcr/abl fusion gene transcript. Given these results, the patient was diagnosed with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph ALL). By conventional cytogenetic analysis of bone marrow and peripheral blood cells at the onset, abnormalities of 9pq and 22q were suggested, but the complete karyotype of this case could not be confirmed at the time; however, the karyotype was later revealed at her first relapse to be 46, XX, dup(1)(q25q32), add(1)(q32), del(3)(q2?), der(9)t(9;22)(q34;q11)del(9)(p13), del(14)(13). As she presented with severe hyperleukocytosis, she received intravenous hyperhydration and prednisone at low doses for the purpose of cytoreduction until the beginning of remission induction therapy. A broad-spectrum antibacterial agent and fluconazole were also administered intravenously against her suspected systemic infection. However, her blood culture was negative, and her serum b-D glucan was not elevated. Whole-body computed tomography (CT) imaging was performed and high-density multiple intracranial tumors were detected (Fig. 1a–c) despite the absence of focal neurological symptoms or meningeal irritation. However, an analysis of her cerebrospinal fluid (CSF) showed no nucleated cells, and normal protein (18 mg/dL) and glucose (69 mg/dL) levels. The CRP level became negative at 3 days before starting induction chemotherapy, so both the antibacterial agent and fluconazole were stopped. During the period of myelosuppression after starting induction therapy, she remained afebrile with no elevation of CRP. Head CT scans at 16 days and 30 days after induction therapy, showed the intracranial masses to be markedly reduced compared with those on her head CT scans before induction therapy (Fig. 2a–c). Her intracranial tumors completely disappeared after two cycles of chemotherapy and never recurred. Unfortunately, she died from refractory leukemia, although she received allogeneic cord blood transplantation twice. At first, the intracranial lesions were suspected to be multiple brain abscesses or cerebral hemorrhage. If either were the case, rapid regression of intracranial lesions such as those observed in the present case would not be expected to occur. Moreover, several patients with acute leukemia who developed multiple intracranial hemorrhages associated with hyperleukocytosis have been reported. In such patients, severe neurological symptoms are commonly N. Hatakeyama (&) T. Hori M. Yamamoto N. Inazawa K. Igarashi H. Tsutsumi N. Suzuki Department of Pediatrics, Sapporo Medical University School of Medicine, South-1, West-16 Chuo-ku, Sapporo, Hokkaido 060-8543, Japan e-mail: nhatake@sapmed.ac.jp

Remote Cerebral and Cerebellar Hemorrhage after Massive Cerebrospinal Fluid Leakage

Dural tears can occur during spinal surgery and may lead to cerebrospinal fluid (CSF) leakage which is rarely involved in remote cerebellar hemorrhage. Only a few of cases of simultaneous cerebral and cerebellar hemorrhage have been reported in the English literature. We experienced a case of multiple remote cerebral and cerebellar hemorrhages in a 63-year-old man who exhibited no significant neurologic deficits after spinal surgery. Magnetic resonance imaging (MRI) performed 4 days after the surgery showed a large amount of CSF leakage in the lumbosacral space. The patient underwent the second surgery for primary repair of the dural defect, but complained of headache after dural repair surgery. Brain MRI taken 6 days after the dural repair surgery revealed multifocal remote intracerebral and cerebellar hemorrhages in the right temporal lobe and both cerebellar hemispheres. We recommend diagnostic imaging to secure early identification and treatment of this complication in order to prevent serious neurologic deficits.

A female case of West syndrome with remission of spasms following multiple cerebral hemorrhages

Multiregional wide-distribution hemorrhages of the left hemisphere occurred at 1 month of age in a girl with congenital factor V deficiency. At the age of 4 months, symmetrical spasms appeared in clusters and electroencephalography showed diffuse background attenuation in the left side and hypsarrhythmia only in the right. Brain CT scan showed that the left hemisphere including Rolandic area was completely infarcted. She was diagnosed with West syndrome and spasms were not controlled by anti-epileptic drugs. Following multiple intracerebral and subarachnoid hemorrhaging involving the right hemisphere at approximately 2 years of age, spasms and hemi-hypsarrhythmia abruptly disappeared, and complete remission of spasms persisted for 2 years. Taken together, the right-hemispheric cortex seemed to be primarily responsible for generation of symmetric spasms and hemi-hypsarrhythmia on electroencephalography. This case study failed to support the hypothesis that ictal discharges needs to be propagated from one to the other side though the corpus callosum in order to generate symmetric spasms. Rather, symmetric spasms can be explained by activation of subcortical structures such as the brain stem, ipsilateral spreading of electrographic discharges from the residual hemisphere, or intra-hemispheric propagation of ictal discharges.

An Unusual Cause of Multiple Cerebral Hemorrhages: Drotrecogin Alpha (Activated Protein C): Fig 1.

The mortality of severe sepsis is still high, despite improved treatment modalities. It is known that treatment with DAA reduces mortality in this condition; however, major bleeding may occur as a complication. We present a patient with normal findings on platelet and coagulation tests who developed multiple cerebral hemorrhages after DAA infusion. Patients with septic shock who undergo DAA infusion should be followed closely for possible intracranial bleeding. When intracranial hemorrhage is detected in patients in the intensive care unit, treatment with DAA infusion should be questioned.

Multifocal cerebral hemorrhages in H1N1 SOIV influenza patients: Report of 2 cases

Background: Neurological complications of influenza have been scarcely reported possible under-recognized. The full description of clinical forms of the current pandemic influenza is currently underway. Several different neurological syndromes have been associated with influenza but no cases of multi-focal cerebral hemorrhages have been reported so far. The aim of this report is to present 2 cases of multiple focal cerebral hemorrhages in patients with influenza H1N1 pandemic. Methods: Clinical, laboratorial and imaging data of 2 cases of influenza and serious neurological symptoms are presented. Cranial CT scan was performed in both cases. Influenza virus identification in upper respiratory secretion (UPS) was performed by real-timereversetranscriptase-polymerase-chain-reaction assay. Cerebrospinal fluid (CSF) was analized. No necropsy or brain biopsy were performed Results: Case n° 1: 32 years old pregnant woman with flu like symptoms, evolved to severe pneumonia and ARDS requiring mechanical ventilation. She developed comma and cranial CT scan has shown multiple hemorrhagic foci scattered throughout the brain and subaracnoid hemorrhage (SAH) (Figure 1). CSF was hemorrhagic. No hemorrhagic disorder was found and eclampsia was ruled-out. Despite oseltamivir therapy she eventually died. H1N1 SOIV was isolated from UPS. Case n° 2: 51 years old male with flu like symptoms evolved to ARDS and respiratory insufficiency demanding ICU and mechanical ventilation. He developed status epilepticus. Cranial CT scan showed multifocal hemorrhages. Lumbar CSF was hemorrhagic. H1N1 SOIV was isolated from UPS. Despite therapy with oseltamivir he eventually died. Figure 1: Cranial CT scan showing multifocal hemorrhage in frontal, parietal, temporal and occipital lobes, as well as SAH and intraventricular hemorrhage Conclusion: Influenza has imposed an under-recognized burden of central nervous system disease so far. Well known neurological syndromes associated with influenza virus in humans have been febrile convulsions, acute encephalitis, acute encephalopathy, Reye's syndrome, Guillain-Barré syndrome, Kleine-Levin syndrome and post encephalitic Parkinson's disease. Some encephalitis cases with petechial lesions in the brain have also been reported. The highly pathogenic H5N1 influenza virus has shown neurological damage in both birds and humans. Current medical literature, including some up-to-date publications of H1N1 pandemic haven’t shown the occurrence of multifocal hemorrhagic neurological syndromes. The cases here presented should aware practitioners for such possibility especially because many seriously ill influenza patients in ICU have been kept under sedation so hiding several neurological symptoms. Abstracts for SupplementInternational Journal of Infectious DiseasesVol. 14Preview Full-Text PDF Open Archive

A case of limited systemic sclerosis with p-ANCA, complicated by multiple cerebral hemorrhages

ANCA associated vasculitides are a group of disorders characterized by the presence of necrotizing inflammation of blood vessels that involve venules, capillaries, arterioles, arteries, and veins. They are characterized by the presence of antineutrophil cytoplasmic antibodies (ANCA). ANCA associated vasculitis commonly affects the kidney producing proteinuria, hematuria and variable degrees of renal failure. Other organs involved include the lung, skin and peripheral nervous system. We present a patient with limited systemic sclerosis, who later developed pauci-immune glomerulonephritis with p-ANCA (antimyeloperoxidase) specificity and, whose disease was later complicated by cerebral vasculitis with multiple intracerebral hemorrhages.

A rare case of multiple sclerosis and cerebral hemorrhage associated with osteopetrosis

Osteopetrosis, or Albers-Schönberg disease, is a rare hereditary disease characterized by osteoclast dysfunction and consequent diminished bone resorption and disturbed bone building and remodeling, resulting in abnormally dense and brittle bones. Bone marrow failure, pathologic fractures, and neurologic deficits are common. Osteopetrosis is diagnosed on radiographs. Patients have generalized osteosclerosis, and radiographs may show evidence of fractures. We report a case of cerebral hemorrhage and multiple sclerosis associated with the benign adult form of osteopetrosis.

A case of ectopic parasitism: Fasciola hepatica larvae burrow through a human brain and mimic cerebral aneurysm

An 8-year-old boy from Xuan-Han County, Sichuan Province, China presented with 6 months headache, nausea and vomiting. A computed tomography scan revealed multiple cerebral hemorrhages. Etiology of the cerebral hemorrhages was investigated by digital subtraction angiography, and cerebral aneurysm was entertained. Twenty-six days after his admission to the hospital, a flatworm emerged from the right eye of the patient. The worm was identified as Fasciola hepatica, based on the morphological characteristics of the worm.

Multiple punctate cerebral hemorrhages in acute leukemia with blast crisis

A 56-year-old man and a 29-year-old woman presented to our hospital with symptoms of headache and encephalopathy. Both patients proved to have acute myeloid leukemia with marked leukocytosis, elevated blast …