Posterior Fossa Hemorrhage Research Articles

Spontaneous posterior fossa hemorrhage: profile and functional outcome in patients attending Tanta stroke unit

BackgroundThe most dangerous and least curable type of stroke is spontaneous intracerebral hemorrhage (ICH), and prognosis is highly correlated with location and size in the posterior fossa. The objective of this work was to estimate the frequency of posterior fossa hemorrhage (PFH) in Tanta University Hospitals, as well as identify functional outcomes and mortality in PFH.MethodsThis study was performed on 33 posterior fossa hemorrhagic patients and 119 posterior ischemic stroke patients (PCIS) submitted to the CT brain and the MRI brain, using the following scales: GCS and NIHSS, and the intracerebral hemorrhage scale (ICH score).ResultsPosterior fossa hemorrhage (PFH) represents 16.83% of total hemorrhagic stroke in the ER. Vertigo and DCL are more common in PFH (60.6%, 48.4%) than in PCIS. 82% of PFH patients had hypertension (HTN) hemorrhage. The cerebellum is the most common site for PFH (48%), pontine (24%), thalamic (18%), and midbrain (9%). PFH had unfavorable outcomes in 55% of the studied patients; the MRS mean was 4; and 39% died in the follow-up.ConclusionPosterior fossa hemorrhage is a potentially serious neurovascular emergency associated with complex symptomatology. PFH demonstrates diverse prognoses depending on the location of the intracerebral hemorrhage and the size of the hematoma.

Reoperation-requiring postoperative intracranial haemorrhage after posterior fossa craniotomy: Retrospective case-series

IntroductionStudies report rates of treatment-requiring postoperative intracranial haemorrhage after craniotomy around 1–2%, but do not distinguish between supratentorial and posterior fossa operations. Reports about intracranial haemorrhages’ temporal occurrence show conflicting results. Recommendations for duration of postoperative monitoring vary. Research questionTo determine the rate, temporal pattern and clinical presentation of reoperation-requiring postoperative intracranial posterior fossa haemorrhage. Material and methods: This retrospective case-series identified cases operated with posterior fossa craniotomy or craniectomy between January 1, 2007 and December 31, 2021 by an electronic search in the patient administrative database, and collected data about patient- and treatment characteristics, postoperative monitoring, and the occurrence of haemorrhagic and other serious postoperative complications. ResultsWe included 62 (n = 34, 55% women) cases with mean age 48 (interquartile range 50) years operated for tumours (n = 34, 55%), Chiari malformations (n = 18, 29%), ischemic stroke (n = 6, 10%) and other lesions (n = 3, 5%). One (2%) 66-year-old woman who was a daily smoker operated with decompressive craniectomy and infarct resection, developed a reoperation-requiring postoperative intracranial haemorrhage after 25.5 h. In four (6%) cases, other serious complications requiring reoperation or transfer from the post anaesthesia care unit or regular bed wards to the intensive care unit occurred after 0.5, 6, 9 and 54 h, respectively. Discussion and conclusionTreatment-requiring postoperative intracranial haemorrhage and other serious complications after posterior fossa craniotomies occur over a wide timespan and are difficult to capture with a standardized postoperative monitoring time. This indicates that the duration of monitoring should be individualized based on assessment of risk factors.

Comprehensive Clinical and Neuroimaging Review of Posterior Fossa Hemorrhage in Preterm and Term Newborns

AbstractPosterior fossa hemorrhage (PFH) is a highly morbid condition in preterm and term infants. In this article, we aim to first describe a case of PFH, and using this example, provide a comprehensive narrative review of the pathophysiology, risk factors, diagnosis, and management of PFH. Management may differ depending on the etiology and based on careful consideration of the risks and benefits of surgical versus conservative management.

Management and Outcome of Intracranial Dural Arteriovenous Fistulas That Have Caused a Hemorrhage in the Posterior Fossa : A Clinical Study.

We evaluated the diagnosis, treatment, and long-term results of patients with dural arteriovenous fistula (dAVF), which is a very rare cause of posterior fossa hemorrhage. This study included 15 patients who underwent endovascular, surgical, combined, or Gamma Knife treatments between 2012 and 2020. Demographics and clinical features, angiographic features, treatment modalities, and outcomes were analyzed. The mean age of the patients was 40 ± 17 (range 17-68), and 68% were men (11/15). Seven of the patients (46.6%) were in the age group of 50 years and older. While the mean Glasgow Coma Scale was 11.5 ± 3.9 (range 4-15), 46.3% presented with headache, and 53.7% had stupor/coma. Four (26.6%) patients had only cerebellar hematoma and headache. All dAVFs had cortical venous drainage. In 11 (73.3%) patients, the fistula was located in the tentorium and was the most common localization. Three (20%) patients had transverse and sigmoid sinus localizations, while one (6.7%) patient had dAVF located in the foramen magnum. Eighteen sessions were performed on the patients during endovascular treatment. Sixteen (88.8%) sessions were performed with the transarterial (TA) route, one (5.5%) session with the transvenous (TV) route, and one (5.5%) session with the TA + TV route. Surgery was performed in two (14.2%) patients. One (7.1%) patient passed away. While there were nine (64.2%) patients with a Rankin score between 0 and 2, the total closure rate was 69.2% in the first year of control angiograms. In the differential diagnosis of posterior fossa hemorrhages, the differential diagnosis of dAVFs, which is a very rare entity, should be considered, even in the middle and elderly age groups, in patients presenting with good clinical status and pure hematoma. The treatment of such patients can be done safely and effectively in a multidisciplinary manner with a good understanding of pathological vascular anatomy and appropriate endovascular treatment approaches.

Angiographic analysis on posterior fossa hemorrhages and vascular malformations beyond aneurysms by CT angiography and digital subtraction angiography

BackgroundPosterior fossa malformations are less common than supratentorial malformations, but hemorrhages in posterior fossa are more serious due to presence of vital structures within this region. Most common cause of bleed in posterior fossa apart from hypertension is aneurysms but other vascular malformations are also there which cause hemorrhage. Here we discuss other causes of posterior fossa bleed beyond aneurysms.ResultsA total of 80 patients were evaluated: 47 (58.8%) had aneurysms, 29 (36.3%) had arteriovenous malformations, one each had developmental venous anomaly and brainstem cavernoma. Thirty vascular malformations were detected, of which 18 (62.1%) were pial arteriovenous malformations (AVMs), 11 (37.9%) were dural arteriovenous fistulas (dAVF), and one had developmental venous anomaly (DVA). Six patients of AVM underwent both DSA and CTA, and CTA could correctly diagnose only 2 of 4 pial AVMs detected by DSA. Among two dAVFs detected by DSA, CTA could demonstrate dAVF only in one patient.ConclusionCTA could be used as alternative to DSA in diagnosis and characterizing aneurysms in posterior fossa but for AVMs, 3D-CTA cannot replace DSA; however potential of time-resolved CTA (TR-CTA) appears promising.

308 Comparison of Demographics and Outcomes Between Surgical and Conservative Management in Patients Undergoing Treatment for Posterior Cranial Fossa Hemorrhages—Experience from a Low-Resource Country

INTRODUCTION: Posterior Cranial Fossa Hemorrhages (PCFH) often require surgical intervention. However, comparison between outcomes in surgical vs conservative management has ben rarely sought in the literature. METHODS: Retrospective review of patient data was conducted under IRB approval. All patients managed for PCFH at Aga Khan University, Karachi, Pakistan, from January 2009 to December 2020 were included. SPSS (IBM) was utilized to analyze data. RESULTS: Surgery vs Conservative: Out of 79 patients, 30.7% vs 69.6% patients underwent each, respectively. Mean age 51 +/- 16.4 vs 56+/-10.7. Males (62.5% vs 70.9%), and females (37.5% v 29.1%). Median GCS at presentation was 9 vs 13. Surgery was indicated at initial presentation (54.2%) or if clinical deterioration was observed (29.2%). Radiographically, significant differences were noted in the mean Intracranial Hemorrhage Score (ICH) (3 vs 2; p = 0.036), maximum hematoma diameter (3.37 vs 2.31 cm; p < 0.001), brainstem involvement (2 vs 32; p < 0.001), 4th ventricle abnormality (100% vs 23%; p < 0.001); intraventricular hemorrhage (78.3% vs 29.4%; p < 0.001), tight posterior fossa (87% vs 37.3%; p < 0.001); clot location (hemispheric vs brainstem; 41.7% vs 52.9%; p = 0.001); median temporal horn width (2.1 vs 0.38 cm; p < 0.001) and clot volume (14.7 cm3 vs 5.5 cm3; p < 0.001). Differences in median length of hospital, ventilator, and ICU stays (14.5 vs 4; p < 0.001, 1.5 vs 0; p < 0.001 and 3 vs 0 days; p < 0.001 respectively), tracheostomy (5% vs 1%; p = 0.003), Infection rate (66.6 vs 29.1%; p < 0.001) and median overall survival (53 vs 10 months; p = 0.046) were all significant. CONCLUSION: While surgery increased survival, significant morbidity and late hospital discharge was observed in patients undergoing surgery for PCFH.

Posterior Fossa Hemorrhage Following the Use of Low-Molecular-Weight Heparin: Lessons Learned and Recommendations for the Treatment and Prophylaxis of Postoperative Venous Thromboembolism.

IntroductionVenous thromboembolism (VTE) is the most common preventable cause of morbidity and mortality among neurosurgery patients. Several studies have concluded that the use of chemical prophylaxis among patients undergoing a craniotomy reduces the incidence of VTE, and it is presumed to be safe. However, these studies do not differentiate between a supratentorial and posterior fossa craniotomy. Furthermore, the prophylactic or therapeutic use of low-molecular-weight heparin (LMWH) has been reported to increase the risk of intracranial hemorrhage. In this study, we describe the clinical details and outcomes for all patients who underwent posterior fossa craniotomy and developed posterior fossa hemorrhage secondary to postoperative use of LMWH during the study period. We also propose recommendations pertaining to postoperative heparin use after posterior fossa surgeries.MethodsData were retrospectively collected for patients presenting with posterior fossa hemorrhage following anticoagulant use among those who previously underwent posterior fossa craniotomy by the senior author (R.W.P.) from January 1, 2011, through December 31, 2018.ResultsWe identified five patients who experienced postoperative hemorrhage while receiving LMWH in the initial setting of posterior fossa craniotomy. After hemorrhaging, four patients had low Glasgow Outcome Scale (GOS) scores (≤3) and failed to return to their baseline neurological status. These four patients had a Glasgow Coma Scale (GCS) score of 15/15 in the immediate postoperative period and received heparin within 72 hours of surgery.ConclusionsBased on our findings, there is a possible association between the increased risk of hemorrhage and the early postoperative use of LMWH. The debilitating outcomes among the majority of these patients warrant the cautious use and further investigation of postoperative LMWH to appropriately quantify the risk. Further comparative studies with a larger sample size are required to provide insight into the pathophysiology of our findings.

Detection and Evaluation of Intracranial Aneurysms in the Posterior Fossa by Multidetector Computed Tomography Angiography - Comparison with Digital Subtraction Angiography.

Introduction:Posterior fossa hemorrhages are not so frequent but as posterior cranial fossa space is narrow and has many vital structures, even a small amount of bleed can lead to compression of brain stem and serious consequences. Identification and planning management of cause of bleed requires angiogram. Digital subtraction angiography (DSA) being invasive modality but is gold standard, so noninvasive computed tomography angiography (CTA) is compared to detect cause of bleed in the posterior fossa in this study.Materials and Methods:From January 2017 to October 2018, all patients with posterior fossa bleed who underwent CTA and DSA for evaluation were compared regarding identification of aneurysm as cause of bleed.Results:A total of 49 patients were evaluated in this study during study duration, of which 26 (53%) were male and 23 (47%) were female. Out of 49 patients evaluated, 47 patients had aneurysms detected on DSA. Of 25 patients who underwent both procedures, 23 patients had aneurysms, and correct diagnosis was made with CTA in 24 out of 25 aneurysms. One aneurysm missed by CTA was close to bony structure.Discussion:With advancement of CTA technology, sensitivity of detecting intracranial aneurysms has increased to >96%. The overall sensitivity in detecting aneurysms is 96% with sensitivity in detecting aneurysms >4 mm being 100%. The sensitivity of CTA for smaller sized aneurysms is low which is attributed partially to lower spatial resolution of CT compared to DSA.Conclusion:CTA is a simple, fast, and noninvasive imaging modality that can be used to detect and characterize intracranial aneurysms in the posterior fossa.

Craniocervical Junction and Posterior Fossa Dimensions can Affect Need for Decompressive Craniectomy in Posterior Cranial Fossa Hemorrhage

Posterior fossa hemorrhage (PFH) of the cerebellum is managed by decompressive craniectomy when there is clinical deterioration. There is no current consensus on an objective imaging method to determine which patients need surgery before clinical deterioration. We developed an imaging scoring tool by assessing initial hemorrhage diameter and posterior fossa (PF) measurements to determine which patients will benefit from early surgical intervention. For this case-control study, we reviewed the electronic medical record to identify adults who presented with PFH over a 10-year period at our institution. Chart review for clinical findings and inciting factors were documented. The average diameter of PFH and the surrogate PF volume on initial imaging studies were measured. These measurements were correlated with surgical intervention. A scoring tool was developed based on radiographic and clinical data. Fifty-one patients met the inclusion criteria. The average hemorrhage diameter and the surrogate PF volume measurements were statistically different between surgical and nonsurgical cases (P < 0.001 and P= 0.019, respectively). The scoring system was created by dividing average hemorrhage diameter by surrogate PF volume and multiplying by 1000. The median score of nonsurgical patients was 9.1, and the median score of surgical patients was 15.6. Patients presenting with PFH with smaller PF volumes may be more likely to require surgery as determined by clinical standards. The proposed scoring system based on simple measurements on initial computed tomography and magnetic resonance imaging may help surgeons consider early surgical intervention in those patients with PFH with smaller PF volumes.

Posterior fossa and cerebellar haemorrhages. Imaging technique and long term outcome

This presentation gives an approach to image acquisition for the structures of the posterior cranial fossa. There will be an overview of the common structural abnormalities and a focus on cerebellar haemorrhages and infarction. Attention will be paid to the importance of the detection of these lesions and the growing body of evidence regarding their impact on long term neurodevelopmental outcomes.

Foramen magnum syndrome after iatrogenic cerebrospinal fluid leak during lumbar spine surgery: A series of two cases

Foramen magnum syndrome (FMS) is a rare complication from lumbar spine surgery. Cerebrospinal fluid (CSF) leaks can be difficult to treat. FMS is a dangerous complication due to excessive distal CSF drainage from a dural tear or secondary to a “controlled” lumbar drainage. We present two cases of FMS after iatrogenic CSF leaks. Both patients underwent decompressive laminectomy as a part of the index surgery. Intraoperative dural tear was not identified in either case. A postoperative computed tomography (CT) myelogram ordered in view of the positional headaches indicated a CSF leak. A lumbar drain was placed, but both the patients worsened symptomatically. CT head in Case 1 indicated tonsillar ectopia within the foramen magnum, while that in Case 2 revealed a posterior fossa hemorrhage with fullness of the foramen magnum and profound hydrocephalus. Both patients were treated surgically. Additional corrective measures were also initiated to reverse the pathology. Both patients made a good recovery with resolution of symptoms. Development of neurological changes in a patient with CSF leak may indicate an acute intracranial process. Treatment of foramen magnum syndrome requires prompt realization of the underlying pathology and measures to cease or modulate the CSF drainage. The dangers of excessive distal CSF drainage, whether it is from a dural tear or from “controlled” lumbar drainage, should be considered.

Hypertrophic olivary degeneration in children after posterior fossa surgery. An underdiagnosed condition

Hypertrophic olivary degeneration (HOD) is a rare transsynaptic form of degeneration occurring after injury to the dentato-rubro-olivary pathway ("Guillain-Mollaret triangle"). The majority of studies have described HOD resulting from posterior fossa (PF) hemorrhage or infarction. HOD in patients undergoing PF surgery has not been well characterized. These lesions are rare and symptomatic children with HOD are even more uncommon. The purpose of this study was to evaluate HOD that develops after PF operations in children. A literature review was carried out describing 37 pediatric cases of HOD in 13 articles. In addition, two new cases of our own experience were included. HOD is a rare complication related after PF tumors surgery and symptoms may be misdiagnosed with pediatric cerebellar mutism syndrome. Children with HOD usually do not develop palatal tremor but ataxia is common.

EP03.03: Fetal neurosonography: experience and correlation with magnetic resonance images (MRI) in T2 weighted images (WI) at Hospital Italiano of Buenos Aires

The aim is to describe our experience in fetal neurosonography, correlating them with the RMI T2WI and with the early evolution of the newborns. Retrospective evaluation of a series of cases evaluated with neurosonography between September 2014 and March 2017. In a total of 54 patients 61 evaluations were performed. The neurosonography was indicated: in 87% (47/54) of the cases due to CNS anomalies in routine obstetric ultrasound, in 3.7% (2/54) had previous child with CNS malformation, 3.7% (2/54) was indicated by the death of a twin monochorial pregnancy, 1.85% (1/54) had IUGR and 1.85% (1/54) for cardiac tumours. The mean gestational age (GA) at neurosonography was 29.4 weeks (range 21-37 weeks). The findings were: 15 normal ultrasound,10 corpus callosum alterations, 9 ventriculomegaly; 8 megacisterna Magna; 7 Blake's pouch cyst; 1 brain tumour; 1 Arachnoid cyst; 1 intracranial hemorrhage; 3 ventricular asymmetry; 1 posterior fossa hemorrhage; 4 holoprosencephaly; 1 microcephaly. MRI was performed in 57.4% (31/54) of the patients. In 96% (30/31) the findings visualised in T2WI were correlated with those of neurosonography. An evolutionary control was performed in 70.3% (38/54) of the newborns, of whom the 92.1 (35/38) presented evolution as expected for age, and 7.89% (3/38) neonatal died. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Randomized Controlled Trial of Talactoferrin Oral Solution in Preterm Infants

To evaluate the safety and explore the efficacy of recombinant human lactoferrin (talactoferrin [TLf]) to reduce infection. We conducted a randomized, double blind, placebo-controlled trial in infants with birth weight of 750-1500 g. Infants received enteral TLf (n = 60) or placebo (n = 60) on days 1 through 28 of life; the TLf dose was 150 mg/kg every 12 hours. Primary outcomes were bacteremia, pneumonia, urinary tract infection, meningitis, and necrotizing enterocolitis (NEC). Secondary outcomes were sepsis syndrome and suspected NEC. We recorded clinical, laboratory, and radiologic findings, along with diseases and adverse events, in a database used for statistical analyses. Demographic data were similar in the 2 groups of infants. We attributed no enteral or organ-specific adverse events to TLf. There were 2 deaths in the TLf group (1 each due to posterior fossa hemorrhage and postdischarge sudden infant death), and 1 death in the placebo group, due to NEC. The rate of hospital-acquired infections was 50% lower in the TLf group compared with the placebo group (P<.04), including fewer blood or line infections, urinary tract infections, and pneumonia. Fourteen infants in the TLf group weighing <1kg at birth had no gram-negative infections, compared with only 3 of 14 such infants in the placebo group. Noninfectious outcomes were not statistically significantly different between the 2 groups, and there were no between-group differences in growth or neurodevelopment over a 1-year posthospitalization period. We found no clinical or laboratory toxicity and a trend toward less infectious morbidity in the infants treated with TLf. ClinicalTrials.gov: NCT00854633.

Acute Posterior Cranial Fossa Hemorrhage—Is Surgical Decompression Better than Expectant Medical Management?

Background To compare the in-hospital mortality and institutional morbidity from medical therapy (MT), external ventricular drainage (EVD) and suboccipital decompressive craniectomy (SDC) following an acute hemorrhagic posterior cranial fossa stroke (PCFH) in patients admitted to the neurosciences critical care unit (NCCU). Retrospective observational single-center cohort study in a tertiary care center. All consecutive patients (n = 104) admitted with PCFH from January 1st 2005–December 31st 2011 were included in the study.Methods All patients with a PCFH were identified and confirmed by reviewing computed tomography of the brain reported by a specialist neuroradiologist. Management decisions (MT, EVD, and SDC) were identified from operative notes and electronic patient records.ResultsFollowing a PCFH, 47.8 % (n = 11) patients died after EVD placement without decompression, 45.7 % (n = 16) died following MT alone, and 17.4 % (n = 8) died following SDC. SDC was associated with lower mortality compared to MT with or without EVD (χ 2 test p = 0.006, p = 0.008). Age, ICNARC score, brain stem involvement, and hematoma volume did not differ significantly between the groups. There was a statistically significant increase in hydrocephalus and intraventricular bleeds in patients treated with EVD placement and SDC (χ 2 test p = 0.02). Median admission Glasgow Coma Scale scores for the MT only, MT with EVD, and SDC groups were 8, 6, and 7, respectively (ranges 3–15, 3–11 and 3–13) and did not differ significantly (Friedman test: p = 0.89). SDC resulted in a longer NCCU stay (mean of 17.4 days, standard deviation = 15.4, p < 0.001) and increased incidence of tracheostomy (50 vs. 17.2 %, p = 0.0004) compared to MT with or without EVD.ConclusionsSDC following PCFH was associated with a reduction in mortality compared to expectant MT with or without EVD insertion. A high-quality multicenter randomized control trial is required to evaluate the superiority of SDC for PCFH.

Commentary on: "Remote Cerebellar Hemorrhage after Revision Lumbar Spine Surgery".

One exceptionally rare complication of spine surgery is a remote cerebellar hemorrhage, which is defined as a hemorrhage that is remote from the site of surgery, either in the cranium or the spinal column. The existence of a remote cerebellar hemorrhage has been reported by several authors,1 2 3 and it appears to be more common after supratentorial surgery rather than spine surgery. Haller et al presented a case of an unexpected hemorrhage in the posterior fossa, which occurred remotely in time as well as remote to the site of surgery. For this particular case, the remote site involved a revision lumbar spine surgery. Posterior fossa hemorrhages have variable presentations. Prompt identification of the hemorrhage is essential to properly manage it and to obviate deleterious sequelae. The authors used appropriate clinical judgment in accordance with current standards of care to identify the root cause of the patient's new neurologic deficits. It was quickly determined that the patient's symptoms did not correlate with the surgical site or procedure, allowing the authors to effectively intervene and achieve a positive outcome. The pathophysiology of remote cerebellar hemorrhages after spine surgery is not completely understood, and several theories have been proposed.4 5 The most common presentation continues to be hypertension, followed by embolic infarct and stroke with hemorrhagic conversion. Another theory involves the downward displacement of the cerebellum, which occurs when there is a rapid decrease in the volume of cerebrospinal fluid (CSF) in the posterior fossa. This sagging of the cerebellum results in increased tension of the bridging veins in the posterior fossa, consequently increasing the risk of intraparenchymal or extraparenchymal hemorrhage. In this case, Haller et al identified a CSF leak as the likely cause of the cerebellar hemorrhage secondary to a sagging cerebellum. For patients who have undergone spine surgery and who develop new neurologic deficits not attributable to the site of surgery, hemorrhage of the posterior fossa may be considered and evaluated with a computed tomography scan of the head. Clinicians must be cognizant of any subtle changes in a patient's neurologic status and accurately recognize when symptoms are unrelated to the operative procedures. The authors made a keen observation that remote cerebellar hemorrhages may occur even in the absence of an initial intraoperatively identified CSF leak. They were able to appropriately and promptly intervene, positively affecting the patient outcome.

Dilatation of the supra‐pineal recess on prenatal imaging: early clue for obstructive ventriculomegaly downstream of the third ventricle

The objective of this article is to describe the diagnostic significance of prenatal identification of dilated supra-pineal recess (SPR) in cases of ventriculomegaly. A retrospective study, based on neurosonography and magnetic resonance imaging, of a series of five prenatal cases referred to our institution because of ventriculomegaly associated with dilatation of the SPR. Ventriculomegaly of obstructive origin was diagnosed in all cases and related to obstruction downstream of the third ventricle. The diagnosis in the five prenatal cases, confirmed on early post-natal imaging, included the following: malformative aqueductal stenosis, ischemic-haemorrhagic parenchymal supra-tentorial insult complicated by aqueductal stenosis, Blake's pouch cyst, cystic lesion of the posterior fossa and sub-ependymal haemorrhage and Dandy-Walker malformation. In all cases, the third ventricle was prominent and associated with a dilated SPR. In two cases, the dilatation of the SPR was an early clue to e obstructive ventriculomegaly, which was initially minor and became severe on follow-up imaging. The presence of a dilated SPR prenatally in the presence of even mild ventriculomegaly should prompt evaluation and follow-up for the presence of obstructive ventriculomegaly with obstruction located downstream of the third ventricle.

A Rare Presentation of Acute Coronary Syndrome with Posterior Fossa Intracranial Bleed

Without significant coronary artery stenosis, ischemic ECG changes including ST segment elevation, segmental wall abnormality & elevated serum cardiac specific markers may develop after central nervous system injuries. Misdiagnosing these patients as acute MI may result in catastrophic outcomes. By reporting case of 56 year old male with posterior cranial fossa haemorrhage mimicking ST segment elevation MI, we hope to underline that careful attention to neurological abnormalities is critical in making correct diagnosis.

The role of surgery in optic pathway/hypothalamic gliomas in children

Optic pathway/hypothalamic gliomas (OPHGs) are generally benign tumors situated in an exquisitely sensitive brain region. The location and natural history of OPHGs has led to much debate about optimal treatment. This paper revisits the role of and optimal timing of debulking surgery in OPHG. This paper presents a series of cases managed by the neuro-oncology team at Alder Hey Children's Hospital and a single surgeon. Data were collected retrospectively for periods prior to 2009 and prospectively thereafter. Tailored treatment strategies were used, including observation and combinations of surgery, chemotherapy, and radiotherapy. Tumor control rates and outcomes are reviewed. Forty-two patients were treated between 1998 and 2011. Their median age at diagnosis was 5 years 7 months. Nineteen patients were positive for neurofibromatosis Type 1 (NF1) and 23 patients were negative for NF1. The median duration of follow-up was 77 months (range 21.8-142.3 months). Presenting symptoms included visual impairment (in 50% of cases), headache (in 24%), and hypothalamic/pituitary dysfunction (in 29%). Twenty-two debulking procedures were performed in 21 patients. Four biopsies (3 open, 1 endoscopic) were also performed. The histological diagnosis was pilocytic astrocytoma in 21 patients and pilomyxoid astrocytoma in 2 patients. Ten patients (Group 1) had primary surgical debulking alone and were then observed. Four patients (Group 2) had surgical debulking, plus planned chemotherapy within 3 months. Seven patients (Group 3) required surgical debulking for progressive disease following a variety of treatments. Patient age had the greatest impact on subsequent tumor progression. In total, 13 patients received chemotherapy, 4 on initial presentation, 4 in combination with surgery, and 5 for further tumor progression. Five patients were treated with radiotherapy, 3 prior to referral to Alder Hey. Eleven patients required shunt insertion for hydrocephalus. Vision was stabilized for 74% of patients. The number of patients with hypothalamic/pituitary dysfunction increased from 12 at presentation to 16 by the end of treatment. The overall survival rate was 93%. Three patients died-1 from tumor progression, 1 from infective complications from tumor biopsy, and 1 from a spontaneous posterior fossa hemorrhage. NF1 was associated with improved outcome-fewer patients required active intervention and rates of visual impairment and/or or hypothalamic/pituitary dysfunction were lower. Good long-term survival and functional outcomes can be achieved in children with OPHG. Tumor control was achieved through an individualized approach using surgery, chemotherapy, or radiotherapy in varied combinations. The authors aim to limit radiotherapy to cases involving older children in whom other therapies have failed, due to the well-described and often devastating late effects associated with midline cranial irradiation. Surgery has a clear role for diagnosis, tumor control, and relief of mass effect. In particular, primary surgical debulking of tumor (without adjuvant therapy) is safe and effective. Recent advances in intraoperative MRI may add value and need further assessment.

Acute management of stroke – II: haemorrhagic stroke

Haemorrhagic strokes are relatively less common compared to ischaemic strokes, with the vast majority of haemorrhages being intracerebral as opposed to subarachnoid. The definitive diagnosis of a haemorrhagic stroke is based on non-contrast CT imaging of the brain. Acute care should focus on prompt identification of the cause, minimizing the risk of haemorrhage expansion by controlling blood pressure and correcting any underlying coagulopathy, and obliterating vascular lesions with a high risk of rebleeding. Patients should be closely monitored, and emergent surgery should be considered in those patients who display signs of clinical deterioration, especially in the presence of posterior fossa haemorrhages. Future directions include refining the use of bedside neuro-monitoring and neuro-imaging techniques as well as developing novel approaches to minimize the complications of haemorrhagic stroke.