Multiple Intracerebral Hemorrhages Research Articles

Multiple recurrent intracerebral hemorrhages and hepatopulmonary syndrome

Patients with liver cirrhosis complicated by hepatopulmonary syndrome may show vascular changes in cerebral angiography, which may predispose them to spontaneous intracerebral hemorrhage.

A Case Report of Multiple Intracerebral Hemorrhages Occurring Immediately after the Evacuation of a Chronic Subdural Hematoma

A Case Report of Multiple Intracerebral Hemorrhages Occurring Immediately after the Evacuation of a Chronic Subdural Hematoma

Diffuse Brain Injury-Review of Literature and Representative Case Reports

Review of Literature: Diffuse brain injury includes diffuse axonal injury (DAI), diffuse vascular injury, hypoxic-ischemic injury and brain swelling. Adams described three grades of DAI. Diffuse vascular injury is usually incompatible with life. Ischemic hypoxia results in hemispheric hypodensity. Cerebral hemispheric swelling has the highest mortality. Administration of mannitol, hyperventilation for short duration and infusion of barbiturate are useful to control ICP. Decompressive craniectomy is recommended in patients with severe brain edema. Transgastric jejunal feeding and early tracheostomy are recommended in ventilated patients. Cognitive rehabilitation therapy (CRT) is the fundamental component of comprehensive rehabilitation. Case Reports: The 28 year male with DAI grade 1 improved in 2 weeks. The 19 year male with DAI grade 3 needed prolonged ventilation, tracheostomy and jejunal feeding. He improved by 2 months. A 3 year old child with DAI grade 1 improved in 2 weeks. A 15 year old boy had progressive multiple intracerebral haemorrhages, suggestive of vascular injury. Decompressive craniectomy was done. He improved by three months. A 20 year male with polytrauma had hemispheric hypodensity due to hypoxic ischaemia. He died after 18 hours. A 27 year male had severe diffuse brain swelling, for which decompressive craniectomy was done. He died after 23 hours. Conclusions: The classification of diffuse brain injury into four types and the various grading systems based on imaging are useful for prognostication. Brainstem lesions delay recovery of consciousness. Absence of basal cisterns and positive midline shift are predictors of death. Hypoxic ischaemia and brain swelling have poor prognosis.

Multiple simultaneous intracerebral hemorrhages: Clinical presentations and risk factors

ObjectiveMultiple simultaneous intracerebral hemorrhages (MSICH) are a rare clinical entity. The mechanism and risk factors have yet to be elucidated. The purpose of this study was to clarify clinical presentations and risk factors of MSICH compared with solitary intracerebral hemorrhages (ICH). Patients and methodsMedical records of 313 consecutive patients with ICH admitted to our institution between April 2011 and September 2014 were retrospectively reviewed. Seventeen cases of MSICH were identified, and 10 clinical and neuroimaging variables were compared between MSICH cases and solitary ICH cases using the unpaired t-test, chi-square test, and multiple logistic regression analysis. ResultsThere were significant differences in size between larger hematomas (mean 59.2±69.1mL) and smaller hematomas (mean 1.7±2.1mL) in patients with MSICH (p=0.001). Larger hematoma volume was the only independent risk factor for MSICH in multiple logistic regression analysis (OR=1.012, 95%CI 1.004–1.021, p=0.004). ConclusionsPatients with MSICH have clinical characteristics and outcomes similar to patients with solitary ICH. They present with two significantly different hematoma sizes, both of which are significantly larger than patients with solitary ICH, suggesting that a larger hematoma can trigger smaller hematomas. A future prospective study with a larger number of patients will explore the precise mechanism of this rare entity.

REDUCING COGNITIVE DECLINE WITH PROBUCOL IN ISCHEMIC STROKE PATIENTS WITH HIGH RISK OF CEREBRAL HEMORRHAGE: PICASSO-COG TRIAL

Multiple cerebral microbleeds (CMBs) and prior intracerebral hemorrhage (ICH) are associated with higher risk of cognitive decline after stroke. We aimed to investigate the efficacy of probucol, a lipid-lowering and anti-oxidative agent, to prevent cognitive decline in stroke patients with multiple CMBs or prior ICH. PICASSO-Cog study is a predefined substudy of a randomized controlled clinical trial, PreventIon of CArdiovascular events in iSchemic Stroke patients with high risk of cerebral hemOrrhage (PICASSO). Patients with non-cardioembolic ischemic stroke or transient ischemic attack within 180 days and with previous ICH or multiple CMBs on gradient echo imaging were randomized to probucol versus no probucol groups from 61 institutes of South Korea. Mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA) was conducted at 4 (baseline), 13, 25, 37, and 49 months after index-stroke. Changes in MMSE and MoCA scores over time from baseline were analyzed using mixed effects model. A total 892 subjects were included in the analysis, with a median follow-up of 20.9 months. Mean age was 64.9 ± 10.8 years, median National Institute of Health Stroke Scale score 1 (IQR 0 - 3), and baseline MMSE score 25.0 ± 4.6. Mean changes of MMSE from baseline to each follow-up was 0.02±2.45 (1st, n=888), -0.15±2.65 (2nd, n=593), -0.24±3.11 (3rd, n=361), and -0.88±3.06 (4th, n=138). The MMSE scores over time showed a favorable trend for probucol treatment, but not significant. Among them, a total of 877 subjects underwent MoCA at least twice after randomization. Baseline MoCA score 19.3 ± 6.2, and mean changes of MoCA from baseline to each follow-up was 0.02 ± 2.83 (1st, n=871), -0.20 ± 3.17 (2nd, n=582), -0.09 ± 3.59 (3rd, n=354), and -0.52 ± 3.49 (4th, n=132). Probucol could significantly prevent cognitive decline in MoCA scores compared to placebo (p=0.01 for treatment effect). These effects were observed in the subgroups without diabetes mellitus, with concomitant lipid-lowering agent, baseline MMSE score > 24, and mild to moderate white matter hyperintensities.

Simultaneous Multiple Intracerebral Hemorrhages (SMICH).

Simultaneous multiple intracerebral hemorrhages (SMICHs) are uncommon. Few single-center studies have analyzed characteristics and outcome of SMICH. We analyzed clinical characteristics and outcome of SMICH patients from 2 comprehensive stroke centers. Baseline imaging from consecutive intracerebral hemorrhage (ICH) patients (n=1552) from Helsinki ICH study and Royal Melbourne Hospital ICH study was screened for SMICH. ICH pathogenesis was classified according to the structural lesion, medication, amyloid angiopathy, systemic/other disease, hypertension, undetermined classification system (SMASH-U). ICH caused by trauma, tumor, and aneurysmal rupture was excluded. Baseline clinical and radiological characteristics and 90-day mortality were compared between SMICH and single ICH patients. Association of SMICH with 90-day mortality was assessed in multivariable logistic regression models adjusted for predictors of ICH outcome. Of 1452 patients, 85 (5.9%) were classified as SMICH. SMICH were more often female (58% versus 42%; P=0.004), had lower baseline Glasgow Coma Scale (12 versus 14; P=0.008), and more frequent lobar location (59% versus 34%; P<0.001) compared with single ICH. The SMASH-U pathogenesis of SMICH patients was less often hypertensive (20% versus 37%; P=0.001), more often systemic coagulopathy (12% versus 3%; P<0.001), and trended toward more cerebral amyloid angiopathy (32% versus 23%; P=0.071). SMICH was not associated with 90-day mortality on univariate (37% versus 35%; P=0.610), multivariable (odds ratio, 0.783; 95% confidence interval, 0.401-1.529; P=0.473), or propensity score-matched analyses (odds ratio, 0.760; 95% confidence interval, 0.352-1.638; P=0.484). SMICH occurs in ≈1 in 20 ICH, more commonly with lobar located hematomas and systemic coagulopathy with less hypertensive angiopathy. The associated mortality is similar to single ICH. Given varied etiologies, SMICH management should target the underlying pathology.

Abstract TP339: Simultaneous Multiple Intracerebral Hemorrhages (SMICH)

Background and Purpose: Simultaneous multiple intracerebral hemorrhages (SMICH) are uncommon. Few single center studies have analyzed characteristics and outcome of SMICH. We analyzed clinical characteristics and outcome of SMICH patients from two comprehensive stroke centers. Methods: Baseline imaging from consecutive intracerebral hemorrhage (ICH) patients (n=1552) from Helsinki ICH study and Royal Melbourne Hospital ICH study were screened for SMICH. ICH etiology was classified according to the SMASH-U classification system. ICH due to trauma, tumor and aneurysmal rupture were excluded. Baseline clinical and radiological characteristics and 90-day mortality were compared between SMICH and single ICH patients. Association of SMICH with 90-day mortality was assessed in multivariable logistic regression models adjusted for predictors of ICH outcome. Results: 1452 patients were included in the analysis and 85 (5.9%) were classified as SMICH. SMICH were more often female (58% vs 42%;p=0.004), had lower baseline Glasgow Coma Scale (12 vs 14;p=0.008), and more frequent lobar location (59% v 34%;p&lt;0.001) compared to single ICH. The SMASH-U etiology of SMICH patients was less often hypertensive (20% vs 37%;p=0.001), more other systemic coagulopathy (12% vs 3%;p&lt;0.001) and trended towards more cerebral amyloid angiopathy (32% vs 23%;p=0.071). SMICH was not associated with 90-day mortality on univariate (37% vs 35%;p=0.635), multivariable (OR 0.783 95%CI 0.401-1.529;p=0.473), or propensity score matched analyses (OR 0.817 95% CI 0.400-1.668,p=0.578). Conclusion: SMICH occurs in approximately 1 in 20 ICH with more often lobar located hematomas, less often hypertensive and associated with more systemic coagulopathy. The mortality is similar to single ICH. Given varied etiologies, SMICH management should target the underlying pathology.

Hypertensive Emergency with Multiple Spontaneous Intracerebral Hemorrhages

Hypertensive Emergency with Multiple Spontaneous Intracerebral Hemorrhages

Moyamoya disease manifested as multiple simultaneous intracerebral hemorrhages: A case report and literature review

Multiple simultaneous intracerebral hemorrhages (MSIH) caused by Moyamoya disease (MMD) is extremely rare. To date, the clinical manifestations, imaging characteristics and mechanism of MMD-induced MSIH have not yet been elucidated. In order to improve the understanding on such cases, the present study described a rare case of MSIH caused by MMD. A 40-year-old female patient with no history of hypertension or diabetes mellitus experienced a sudden headache followed by coma. Cranial computed tomography (CT) examination revealed MSIH in the left frontal area, temporal lobe and basal ganglia. CT angiography and digital subtraction angiography examinations revealed typical characteristics of MMD. Subsequent to excluding disorders of the blood system and blood coagulation, we concluded that the present case of MSIH was caused by MMD. Hematoma evacuation and decompressive craniectomy were performed with satisfactory results. In addition, after reviewing previous MSIH cases in the literature, potential mechanisms of MMD-mediated MSIH were considered. In conclusion, MMD should be considered as a possible cause of MSIH during diagnosis and treatment. MMD can lead to pathological changes in the fragility of small arteries; therefore, rupture and hemorrhage at one site may induce a transient increase in blood pressure, causing the rupture of small arteries at other sites, and thus leading to MSIH. Hematoma evacuation and decompression should be conducted in selective cases of MMD-induced MSIH in order to achieve a good prognosis.

Clinical features of multiple spontaneous intracerebral hemorrhages

Objective To analyze the clinical features of multiple spontaneous intracerebral hemorrhages (MICH). Methods Conservative therapy, puncture and drainage, hematoma removal and/or decompressive craniectomy were used in the treatment of 630 intracerebral hemorrhage (ICH) patients, who were divided into 2 groups: 30 cases with MICH and another 600 cases with solitary intracerebral hemorrhage (SICH). Three months after onset, modified Rankin Scale (mRS) was used to evaluate the prognosis of all cases. Results Compared with patients in SICH group, the occurrence rate of hypertension > 5 years ( P = 0.008), diabetes mellitus ( P = 0.024), hypercholesterolemia ( P = 0.050) and previous ischemic stroke ( P = 0.026) were all significantly higher in MICH group. The mean arterial pressure (MAP) level ( P = 0.002) and the incidence of limb movement disorder ( P = 0.000) were significantly higher in patients with MICH than those with SICH. Basal ganglia and thalamus were the predilection sites of hematoma ( P = 0.001). Patients with MICH had worse prognosis compared to those with SICH 3 months after onset ( P = 0.006). Conclusions Hypertension > 5 years, diabetes mellitus, hypercholesterolemia and ischemic stroke were identified to be the pathophysiological basis of MICH in this study. All patients with MICH had more serious clinical manifestations after onset and worse prognosis. DOI: 10.3969/j.issn.1672-6731.2016.01.008

Multiple Simultaneous Spontaneous Intracerebral Hemorrhages: A Rare Entity

Background: In hospital databases, multiple simultaneous spontaneous intracerebral hemorrhages (ICH-m) account for 0.7-5.6% of all ICHs. Their long-term outcome has never been systematically and prospectively investigated. We aimed at identifying the long-term outcome of patients with ICH-m. Methods: We prospectively recruited consecutive adults with ICH-m and followed them up for at least 4.5 years. We classified patients into the following 3 groups: (i) definite or probable cerebral amyloid angiopathy (CAA), (ii) deep perforating vasculopathy (DPV) and (iii) unknown causes. Results: Of 562 consecutive patients with ICH, 32 had ICH-m (5.7%): 8 (25%) with probable CAA, 5 (16%) with DPV and 19 (59%) with ICH-m of undetermined cause. At the last visit (cumulative follow-up of 39.5 person-year), 27 patients (84%) had died, and 3 of the 5 survivors were independent. Late-onset seizures, recurrent ICH-m (symptomatic or not) and new brain microbleeds were mainly found in patients with probable CAA. Conclusions: ICH-m is a rare but extremely severe expression of ICH. Survivors with CAA are more likely to develop late seizures and new hemorrhagic lesions. Because of low survival rates, large multicenter cohort studies are needed for a better understanding of this rare condition.

Owl Eye Appearance: Simultaneous Bilateral Hypertensive Putaminal Hematoma

Basal ganglia hemorrhage, one of the most devastating forms of cerebrovascular disease, is often as a result of poorly controlled long standing hypertension. Hypertension often leads to development of solitary intracerebral hematoma. The occurrence of multiple simultaneous intracerebral hemorrhages due to hypertension in same or different vascular territories is rare. We report the occurrence of simultaneous bilateral hypertensive putaminal hemorrhage appearing as mirror image (Owl eye appearance) in a 60 years old gentleman and discuss the probable pathophysiological mechanisms

Multiple Intracerebral Hemorrhages Prior to the Diagnosis of Acute Lymphocytic Leukemia

Intracerebral Hemorrhage (ICH) can be seen in patients with acute leukemia, however, it is extremely rare to present ICH as the initial presentation in previously undiagnosed acute leukemia. Only four cases were reported in the English literature. This 17-year-old male was admitted with sudden onset of headache, nausea and vomiting. Three days before this admission, he visited an ophthalmological department for bilateral blurred vision. Bilateral retinal hemorrhages were detected by the funduscopic examination; however, further examinations were not performed at that time. On arrival at our hospital, his Glasgow Coma Scale was 8 (E2, V3, M3) and urgent head CT scan showed multiple Computed Tomography (CT) head demonstrated multiple ICHs. On admission, his White Blood Cell (WBC) count was 584,000/μl with evidence of blast crisis, and platelet count was 18,000/μl. Despite urgent platelet and plasma transfusions, his conscious level deteriorated, and the patient died 12 hours after the admission due to respiratory failure. The importance of correct diagnosis and early management of leukemia is emphasized, which may prevent blast crisis and disseminated intravascular coagulation leading to fatal ICH.

Management of multiple intracerebral hemorrhages due to myxomatous aneurysms — /INS;A case report and literature review

Management of multiple intracerebral hemorrhages due to myxomatous aneurysms — /INS;A case report and literature review

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.

Presenilin-1 regulates the constitutive turnover of the fibronectin matrix in endothelial cells.

BackgroundPresenilin-1 (PS1) is a transmembrane protein first discovered because of its association with familial Alzheimer’s disease. Mice with null mutations in PS1 die shortly after birth exhibiting multiple CNS and non-CNS abnormalities. One of the most prominent features in the brains of PS1−/− embryos is a vascular dysgenesis that leads to multiple intracerebral hemorrhages. The molecular and cellular basis for the vascular dysgenesis in PS1−/− mice remains incompletely understood. Because the extracellular matrix plays key roles in vascular development we hypothesized that an abnormal extracellular matrix might be present in endothelial cells lacking PS1 and examined whether the lack of PS1 affects expression of fibronectin a component of the extracellular matrix known to be essential for vascular development.ResultsWe report that primary as well as continuously passaged PS1−/− endothelial cells contain more fibronectin than wild type cells and that the excess fibronectin in PS1−/− endothelial cells is incorporated into a fibrillar network. Supporting the in vivo relevance of this observation fibronectin expression was increased in microvascular preparations isolated from E14.5 to E18.5 PS1−/− embryonic brain. Reintroduction of PS1 into PS1−/− endothelial cells led to a progressive decrease in fibronectin levels showing that the increased fibronectin in PS1−/− endothelial cells was due to loss of PS1. Increases in fibronectin protein in PS1−/− endothelial cells could not be explained by increased levels of fibronectin RNA nor based on metabolic labeling studies by increased protein synthesis. Rather we show based on the rate of turnover of exogenously added biotinylated fibronectin that increased fibronectin in PS1−/− endothelial cells results from a slower degradation of the fibronectin fibrillar matrix on the cell surface.ConclusionsThese studies show that PS1 regulates the constitutive turnover of the fibronectin matrix in endothelial cells. These studies provide molecular clues that may help to explain the origin of the vascular dysgenesis that develops in PS1−/− embryonic mice.

Intracerebral Hemorrhage

Neurosarcoidosis has a variety of clinical presentations. Common manifestations include leptomeningeal inflammation with seizures, headache, cranial nerve palsies, hydrocephalus, or focal neurological deficits with white matter lesions or mass lesions. Stroke is relatively rare, and hemorrhage is much less common than ischemia due to vasculitis. We present a patient with histopathologically confirmed neurosarcoidosis presenting with headache, seizures, and cognitive decline with multiple recurrent primary intracerebral hemorrhages.

Multiple intracerebral hemorrhages in an elderly patient after adding quetiapine to a stable warfarin regimen

The efficacy of antipsychotics in patients with dementia exhibiting psychiatric symptoms has been overshadowed by safety concerns in recent years. Evidence suggests that the long-term use of antipsychotics in older adults is associated with a greater risk of cerebrovascular adverse events than accrues with short-term use (less than 30 days) [J Clin Psychiatry. 2010;71(6):689–98]. Here, we present an elderly male patient with dementia who developed multiple intracerebral hemorrhages (ICHs) 3 days after the addition of quetiapine to his stable warfarin regimen. To our knowledge, this is the second case of possible interaction between quetiapine and warfarin. We suggest mechanisms that may account for the patient's clinical presentation and highlight that combining treatment with quetiapine and warfarin may cause serious complications in patients with risk factors for ICH.

Subarachnoid Hemorrhage Due to Ruptured Posterior Cerebral Artery Aneurysm Simultaneously Associated With Multiple Remote Intracerebral Hemorrhages -Case Report-

A 61-year-old woman presented with aneurysmal subarachnoid hemorrhage (SAH) associated with multiple remote intracerebral hemorrhages (ICHs). She had undergone microsurgical neck clipping for ruptured right middle cerebral artery aneurysm and ventriculo-peritoneal shunting 16 years previously. Computed tomography revealed SAH predominantly in the basal cistern and ambient cistern, in association with multiple ICHs in the bilateral tegmentum of the brain stem and right caudate nucleus. Digital subtraction angiography revealed an aneurysm at the P(1) segment of the left posterior cerebral artery. The ruptured aneurysm was microsurgically clipped via a left subtemporal approach without complications. Simultaneous occurrence of aneurysmal SAH and multiple remote ICHs is rare. The spatial pattern of the ICHs in the present case is apparently unique.

Prevalence and Risk Factors for Multiple Simultaneous Intracerebral Hemorrhages

Background: Multiple simultaneous intracerebral hemorrhages (MSICH) are rare. We aimed to describe the frequency and potential risk factors for MSICH. Methods: We reviewed 522 consecutive patients admitted to our institution with spontaneous ICH between August 1, 2006 and November 30, 2009. Patients with traumatic hemorrhages, predominantly subarachnoid or intraventricular hemorrhages, hemorrhagic transformation of ischemic infarcts, and hemorrhages due to cerebral venous thrombosis were excluded. We defined MSICH as spontaneous hemorrhages in 2 discrete areas with similar density profiles on initial CT imaging. We then classified MSICH as primary (spontaneous) or secondary (due to an underlying condition). In a 1:5 ratio case-control design study, we assessed risk factors for primary MSICH compared to solitary ICH using logistic regression. Values of p < 0.05 were considered significant in the final analyses. Results: Of 522 ICH patients, 29 met the criteria for MSICH (5.6%) with a mean age of 59 years. The mean systolic blood pressure at presentation was 176 mm Hg. Fifteen cases had secondary causes while 14 were considered as having primary MSICH. In a multivariable model comparing primary MSICH cases to 70 solitary ICH controls, the presence of >5 chronic microhemorrhages on gradient echo imaging (adjusted OR 9.8, 95% CI 2.0–49.3, p = 0.006) was the only independent predictor of primary MSICH. Conclusions: In a single-center experience, we found that MSICH account for 5.6% of all spontaneous ICH. Prior microhemorrhage burden, perhaps due to severity of hypertension or cerebral amyloid angiopathy, may mark those at risk for primary MSICH occurrence.