Progression Of Hemorrhage Research Articles

The significance of platelet count in traumatic brain injury patients on antiplatelet therapy.

Platelet dysfunction has been attributed to progression of initial intracranial hemorrhage (ICH) on repeat head computed tomographic (RHCT) scans in patients on prehospital antiplatelet therapy. However, there is little emphasis on the effect of platelet count and progression of ICH in patients with traumatic brain injury. The aim of this study was to determine the platelet count cutoff for progression on RHCT and neurosurgical intervention in patients on antiplatelet therapy. We performed a prospective cohort analysis of all traumatic brain injury patients with an ICH on prehospital antiplatelet therapy. Antiplatelet therapy was defined as aspirin, clopidogrel, or a combination of both. Admission platelet count was recorded and used for analysis. Receiver operating characteristic curves were plotted to identify the optimal platelet count for progression on RHCT scan and neurosurgical intervention in patients on antiplatelet therapy. A total of 264 patients were enrolled. Platelet count of 135,000/µL or less (area under the curve, 0.80) and platelet count of 95,000/µL or less (area under the curve, 0.92) were the optimal threshold points for progression on RHCT scan and neurosurgical intervention, respectively. Patients with platelet count of 135,000/µL or less were 12.4 times (95% confidence interval, 7.1-18.4) more likely to have progression on RHCT scan and patients with platelet count 95,000/µL or less were 31.5 times (95% confidence interval, 19.7-96.2) more likely to require neurosurgical intervention. A platelet count of less than 135,000/µL in patients on antiplatelet therapy is predictive of both radiographic and clinical worsening. This is a clinically relevant target intended to help tailor and improve management in patients on antiplatelet therapy. Therapeutic study, level III.

The Parkland Protocol's modified Berne-Norwood criteria predict two tiers of risk for traumatic brain injury progression.

As a basis for venous thromboembolism (VTE) prophylaxis after traumatic brain injury (TBI), we have previously published an algorithm known as the Parkland Protocol. Patients are classified by risk for spontaneous progression of hemorrhage with chemoprophylaxis regimens tailored to each tier. We sought to validate this schema. In our algorithm, patients with any of the following are classified "low risk" for spontaneous progression: subdural hemorrhage ≤8 mm thick; epidural hemorrhage ≤8 mm thick; contusions ≤20 mm in diameter; a single contusion per lobe; any amount of subarachnoid hemorrhage; or any amount of intraventricular hemorrhage. Patients with any injury exceeding these are "moderate risk" for progression, and any patient receiving a monitor or craniotomy is "high risk." From February 2010 to November 2012, TBI patients were entered into a dedicated database tracking injury types and sizes, risk category at presentation, and progression on subsequent computed tomgraphies (CTs). The cohort (n=414) was classified as low risk (n=200), moderate risk (n=75), or high risk (n=139) after first CT. After repeat CT scan, radiographic progression was noted in 27% of low-risk, 53% of moderate-risk, and 58% of high-risk subjects. Omnibus analysis of variance test for differences in progression rates was highly significant (p<0.0001). Tukey's post-hoc test showed the low-risk progression rate to be significantly different than both the moderate- and high-risk arms; no difference was noted between the moderate- and high-risk arms themselves. These criteria are a valid tool for classifying TBI patients into two categories of risk for spontaneous progression. This supports tailored chemoprophylaxis regimens for each arm.

Clinical outcomes in patients on preinjury ibuprofen with traumatic brain injury

BackgroundThe aim of our study was to evaluate the clinical outcomes in patients on preinjury Ibuprofen with traumatic brain injury. MethodsWe performed a 2-year analysis of all patients on prehospital Ibuprofen with traumatic brain injury and intracranial hemorrhage. Patients on preinjury Ibuprofen were matched using propensity score matching to patients not on Ibuprofen in a 1:2 ratio for age, Glasgow Coma Scale, head-abbreviated injury scale, injury severity score, International Normalized Ratio, and neurologic examination. Outcome measures were progression on repeat head computed tomography (RHCT) and neurosurgical intervention. ResultsA total of 195 matched (Ibuprofen 65, no-Ibuprofen 130) patients were included. There was no difference in the progression on RHCT (Ibuprofen 18% vs no-Ibuprofen 24%; P = .50). The neurosurgical intervention rate was 18.9% (n = 37). There was no difference for need for neurosurgical intervention (26% vs 16%; P = .10) between the 2 groups. ConclusionsIn a matched cohort of trauma patients, preinjury Ibuprofen use was not associated with progression of initial intracranial hemorrhage and the need for neurosurgical intervention. Preinjury use of Ibuprofen as an independent variable should not warrant the need for a routine RHCT scan.

Hématome surrénalien néonatal : diversité des modes de révélation

Neonatal adrenal hematoma is a rare condition, most frequently caused by trauma. We report three cases of adrenal hematoma admitted to the Neonatology and Neonatal Intensive Care Unit in the A. Harouchi Children's Hospital, the Ibn Rushd University Hospital in Casablanca, Morocco, over a 2-year period from January 2011 to December 2012. The average age of these patients was 5 days. The clinical presentations were diverse; the most common manifestations were intense jaundice in one case, acute adrenal insufficiency in one case, and severe anemia in the other case. Abdominal ultrasonography was used to confirm the diagnosis and monitor adrenal hemorrhage in all the patients. Analysis of clinical, laboratory, and ultrasonography data showed a favorable prognosis in all the patients. Based on these observations, we discuss the risk factors, clinical presentations, progression and management of neonatal adrenal hemorrhage.

Early hemorrhagic progression of traumatic brain contusions: frequency, correlation with coagulation disorders, and patient outcome: a prospective study.

The focus of this paper is to identify and quantify risk factors for early hemorrhagic progression of brain contusions (HPC) in patients with traumatic brain injury (TBI) and to evaluate their impact on patients' outcome. Further, based on abnormal values in routine blood tests, the role of trauma-induced coagulopathy is analyzed in detail. Therefore, a prospective study of 153 TBI patients was completed at one institution between January 2008 and June 2012. The collected data included demographics, initial Glasgow Coma Scale pupillary response, initial and 6 h follow-up computed tomography scan findings, coagulation parameters (international normalized ratio, partial thromboplastin time, platelet count, fibrinogen, D-dimer and factor XIII), as well as outcome data using the modified Rankin score at discharge and after one year. The overall rate of early HPC within the first 6 h was 43.5%. The frequency of coagulopathy was 47.1%. When analyzing for risk factors that independently influenced outcome in the form of mRS ≥4 at both points, the following variables appeared: elevated D-dimer level (≥10,000 μg/L), HPC, and initial brain contusions ≥3 cm. Patients sustaining early HPC had a hazard ratio of 5.4 for unfavorable outcome at discharge (p=0.002) and of 3.9 after one year (p=0.006). Overall, patients who developed early HPC were significantly more likely to be gravely disabled or to die. Unfavorable neurological outcome after an isolated TBI is determined largely by early HPC and coagulopathy, which seem to occur very frequently in TBI patients, irrespective of the severity of the trauma.

Treatment with Metadoxine and its impact on early mortality in patients with severe alcoholic hepatitis

Background & Aim. Despite treatment with glucocorticoids, mortality remains high in patients with severe alcoholic hepatitis. Oxidative stress and depletion of mitochondrial glutathione are implicated factors in liver injury. The aim of this study was to evaluate the impact of the addition of metadoxine, a drug which possesses a multifactorial mechanism of action, including antioxidant properties, to standard treatment with glucocorticoids in patients with severe alcoholic hepatitis.Material and methods. This randomized open label clinical trial was performed in Mexico’s General Hospital (Registry Key DIC/10/107/03/043). We randomized 70 patients with severe alcoholic hepatitis. The first group received prednisone (40 mg/day), and the second group received prednisone (40 mg/day) plus metadoxine tablets (500 mg three times daily). The duration of treatment in both groups was 30 days. Survival at 30 and 90 days, development of complications, adverse events and response to treatment (Lille model) were assessed.Results. In the group receiving metadoxine, significant improvements were observed, as follows: survival at 30 days (74.3 vs. 45.7%, P = 0.02); survival at 90 days (68.6 vs. 20.0%, P = 0.0001). There was less development or progression of encephalopathy (28.6 vs. 60.0%, P = 0.008) and hepatorenal syndrome (31.4 vs. 54.3%, P = 0.05), and the response to treatment (Lille model) was higher in the metadoxine group (0.38 vs. 0.63, P = 0.001; 95% CI 0.11 to 0.40). There were no differences between groups regarding the development or progression of variceal hemorrhage or infection. The incidence of adverse events, mainly gastrointestinal, was similar in both groups.Conclusions. Addition of metadoxine to glucocorticoid treatment improves the short-term survival of patients with severe alcoholic hepatitis and diminishes the development or progression of encephalopathy and hepatorenal syndrome.

Intra- and Postoperative Risks and Complications of Small-Gauge (23-G) versus Conventional (20-G) Vitrectomy for Macular Surgery

To compare the complication spectrum and rate of 23-G and 20-G vitrectomy for macular surgery. This was a retrospective comparative analysis of 20-G and 23-G vitrectomy (introduced in 2007) for macular surgery due to macular pucker or macular hole performed between 2006 and 2010 in 61 and 59 eyes, respectively, by 2 experienced surgeons and 2 trainees. We assessed the adjusted hazard ratio for vitrectomy 23-G vs 20-G with a Cox proportional hazard model. We counted retinal detachment, vitreous hemorrhage, endophthalmitis (as early postoperative complications), or cataract progression (as late postoperative complication) as endpoint. We adjusted for indication, surgeon, retinopexy method, and the endotamponade. Follow-up averaged 712 days. Median time to first event was 385 days in the 23-G group and 342 days in the 20-G group. Cox proportional hazard analysis showed no significant difference between vitrectomy 23-G vs 20-G with regard to postoperative complications (hazard ratio 0.79, 95% confidence interval 0.41-1.52). The other covariates did not exert a statistically significant effect on the risk of adverse events. Looking at individual complications, retinal detachment was exclusively found after 20-G. In this homogenous large cohort, we did not find a statistically significant difference in rates of complications between 23-G and 20-G vitrectomy techniques for macular surgery. Trainees performed equally well as experienced surgeons.

Blood Pressure Regulation to Prevent Progression of Blunt Traumatic Intracranial Hemorrhage in Stable Patients

Target blood pressure (BP) in stable (non-hypotensive) patients with acute isolated blunt traumatic intracranial hemorrhage (TICH) is unknown. To address this issue, our study correlated BP with radiological volumetric progression (RP) and neurological deterioration (ND) in these patients. A retrospective review of hemodynamically stable adults (n = 184) with isolated TICH not requiring emergent surgery consecutively admitted to a Level I trauma center. BPs before admission computed tomography (CT) scan (CT1) and between CT1 and a follow-up CT (CT2) were correlated with TICH volume and Glasgow Coma Scale (GCS) during these time periods. Predictors for deterioration were studied. Primary outcomes were increased measured TICH and decreased GCS at the CT1-CT2 interval. Age (57 years), % male (73), ISS (17), % falls (77), comorbidities (1.2/pt), and % anticoagulation (20) were similar in patients with or without RP (n = 107, 58%) or ND (n = 34, 18%). By univariate analysis, RP patients had an average systolic (SBP), diastolic (DBP), and mean BP (MAP) similar to non-RP patients; whereas ND patients compared to non-ND patients had a higher mean admission DBP (p < 0.02) and MAP (p < 0.04), a higher mean admission peak MAP (p < 0.01) and DBP (p < 0.01), a higher CT1-CT2 interval peak DBP (p < 0.01) and peak MAP (p < 0.01), and a lower CT1-CT2 nadir SBP (p < 0.04). Spearman rank correlation test did not show association among average SBP, MAP, DBP, absolute or % change in BPs, and absolute or % change in TICH volumes in any phase. Multivariate analysis identified higher nadir admission SBP [adjusted odds ratio (AOR) 1.29 per 10 mmHg increase] and lower peak MAP during the CT1-CT2 period (AOR 0.71 per 10 mmHg decrease) as independent predictors of RP, and a peak DBP in the CT1-CT2 interval (AOR 1.48) as an independent predictor of ND. Other predictors of ND included bilateral admission TICH (AOR 3.31) and increased injury volume (AOR 1.36), while the number of comorbidities/patient (AOR 4.34), bilateral injury (AOR 3.12), and midline shift (AOR 4.34) predicted RD. A comprehensive dynamic analysis correlating repeated BP determinations with quantifiable repeated parameters of TICH deterioration (injury volume and GCS) did not demonstrate a clinically relevant protective target BP value. Current practices of BP control in this specific group of patients should be further investigated. Prognostic, Level II study.

Abstract 209: Association Between Pharmacologic Thromboprophylaxis and Hemorrhage Progression in Patients With Hemorrhagic Stroke

Background: There is scant evidence on the safety of pharmacologic thromboprophylaxis (PTP) after hemorrhagic stroke. We sought to assess the association between PTP use and hemorrhage progression in patients who were diagnosed with primary hemorrhagic stroke. Methods: We reviewed patients with non-traumatic/spontaneous subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) from 1/2010 - 12/2012. We examined hemorrhage progression in two populations: patients with a stable initial f/u CT (no progression within one day of admission), and patients with an unstable initial f/u CT. Multivariate stepwise logistic regression was used to examine the association between hemorrhage progression and PTP. Results: In the 245 patients identified, 117 (48%) experienced hemorrhage progression. In the sub-group with unstable initial f/u CT (n=79, 32%) 24 patients (30%) had subsequent hemorrhage progression. Only one patient with an unstable initial f/u CT received PTP; thus, the association between PTP and subsequent hemorrhage progression was not analyzed further. Only SAH was independently associated with subsequent hemorrhage progression (OR: 4.3, p=0.03). In the sub-group with stable initial f/u CT (n=166, 68%), 38 patients (23%) had later hemorrhage progression; the rates of hemorrhage progression were similar for patients who received PTP and those who did not (26% vs. 22%, p=0.54). Variables that were independently associated with hemorrhage progression in the stable initial f/u CT group include non-ambulatory status (OR: 7.8, p=0.002), minor stroke (NIHSS&lt;8, OR: 4.1, p=0.02), male gender (OR: 4.4, p= 0.01), and hospital LOS (OR: 1.1/day, p&lt; 0.001); receiving PTP was not a predictor (OR: 0.6, p=0.42). Conclusions: This study demonstrated that in patients whose initial f/u CT was stable, the use of PTP was not associated with an increased risk of hemorrhage progression. There was insufficient evidence to determine the relationship between PTP and subsequent progression in the unstable f/u CT population. These data suggest that PTP may be safe in patients with hemorrhagic stroke whose initial f/u CT is stable.

The impact of preinjury anticoagulants and prescription antiplatelet agents on outcomes in older patients with traumatic brain injury

Anticoagulants and prescription antiplatelet (ACAP) agents widely used by older adults have the potential to adversely affect traumatic brain injury (TBI) outcomes. We hypothesized that TBI patients on preinjury ACAP agents would have worse outcomes than non-ACAP patients. This was a 5.5-year retrospective review of patients 55 years and older admitted to a Level I trauma center with blunt force TBI. Patients were categorized as ACAP (warfarin, clopidogrel, dipyridamole/aspirin, enoxaparin, subcutaneous heparin, or multiple agents) or non-ACAP. ACAP patients were further stratified by class of agent (anticoagulant or antiplatelet). Initial and subsequent head computerized tomographic results were examined for type and progression of TBI. Patient preadmission living status and discharge destination were identified. Primary outcome was in-hospital mortality. Secondary outcomes were progression of initial TBI, development of new intracranial hemorrhage (remote from initial), and the need for an increased level of care at discharge. A total of 353 patients met inclusion criteria: 273 non-ACAP (77%) and 80 ACAP (23%). Upon exclusion of three patients taking a combination of agents, 350 were available for advanced analyses. ACAP status was significantly related to in-hospital mortality. After adjustment for patient and injury characteristics, anticoagulant users were more likely than non-ACAP patients to show progression of initial hemorrhage and develop a new hemorrhagic focus. However, compared with non-ACAP users, antiplatelet users were more likely to die in the hospital. Among survivors to discharge, anticoagulant users were more likely to be discharged to a care facility, but this finding was not robust to adjustment. Older TBI patients on preinjury ACAP agents experience a comparatively higher rate of inpatient mortality and other adverse outcomes caused by the effects of antiplatelet agents. Our findings should inform decision making regarding prognosis and caution against grouping anticoagulant and antiplatelet users together in considering outcomes. Therapeutic study, level IV.

Ibuprofen versus indomethacin treatment of patent ductus arteriosus: comparative effectiveness and complications

To compare the effectiveness and complications of intravenous ibuprofen versus indomethacin treatment of patent ductus arteriosus in preterm infants. Retrospective case series. A tertiary referral centre in Hong Kong. A total of 95 infants who had received at least one course of indomethacin or ibuprofen for closure of patent ductus arteriosus from January 2008 to December 2011 were studied. Following the total switch from indomethacin to ibuprofen in clinical use in April 2010, outcomes of infants receiving indomethacin and ibuprofen were compared. The primary outcomes including rates of failed medical closure and recourse to surgical ligation were compared. The secondary outcomes including rates of all-cause mortality, bronchopulmonary dysplasia, intestinal complications (necrotising enterocolitis, spontaneous intestinal perforation), change in urine output and serum creatinine, and progression of any intraventricular haemorrhage were also evaluated. The failure rate of medical treatment was similar in the indomethacin and ibuprofen groups, with 16 (31%) such infants in the indomethacin group and 14 (33%) in the ibuprofen group; for ibuprofen this yielded a relative risk of 1.06 (95% confidence interval, 0.66-1.67; P=0.852). The proportion of infants having surgical ligation was also similar. A higher rate of intestinal complications (necrotising enterocolitis or spontaneous intestinal perforation) was encountered in our ibuprofen group (P=0.043). No significant difference was observed in other secondary outcomes determined. In our clinical practice, ibuprofen and indomethacin were shown to be equally effective for medical closure of patent ductus arteriosus in premature infants. With the higher rates of intestinal complications and similar effects on renal function in the ibuprofen group, we conclude that ibuprofen may not have fewer adverse effects than indomethacin.

10206 衝撃圧力が管腔形成された血管内皮細胞に与える影響

Brain contusion caused by head impact might result in hemorrhagic progression. This hemorrhagic progression is thought to be causally related to pressure fluctuation in the skull, but that hasn't been investigated in detail. In this study, the relation between pressure fluctuation brain and hemorrhagic progression was investigated. Cultured endothelial cells were grown to tube formations for evaluating the capillary-like structure. The changes in the capillary-like network formed by endothelial cells were observed using an inverted microscope before and after pressure loading. As a result, the capillary-like structure was broken down following impulsive pressure, and the capillary network gradually disappeared until 24 h after loading.

Safety and efficacy of pharmacologic thromboprophylaxis following blunt head injury

Patients with blunt head injury are at high risk of venous thromboembolism. However, pharmacologic thromboprophylaxis (PTP) may cause progression of intracranial hemorrhage, and clinicians must often weigh up the risks and benefits. This review aimed to determine whether adding PTP to mechanical prophylaxis confers net benefit or harm and the optimal timing, dose, and agent for PTP in patients with blunt head injury. We searched MEDLINE, EMBASE, The Cochrane Library Central Register of Controlled Trials (CENTRAL), and www.clinicaltrials.gov on April 24, 2013, to identify controlled studies and ongoing trials that assessed the efficacy or safety of thromboprophylaxis interventions in the early management of head-injured patients. Studies were classified based on types of interventions and comparisons, and the quality of included studies was assessed using Cochrane risk-of-bias tool and the Newcastle-Ottawa Quality Assessment Scale. We intended to undertake a meta-analysis if studies were sufficiently similar. Sixteen studies met the inclusion criteria, including four randomized controlled trials. At least two randomized controlled trials were at high risk of bias owing to inadequate randomization and concealment of allocation, and observational studies were potentially confounded by substantial differences between comparison groups. Heterogeneity of included studies precluded meta-analysis. Results were mixed, with some studies supporting and others refuting addition of PTP to mechanical interventions. Little evidence was available about dose or choice of agent. The safety and efficacy of early PTP in patients without early progression of hemorrhage is unclear. There is currently insufficient evidence to guide thromboprophylaxis in patients with blunt head injury. Standardized definitions and outcome measurements would facilitate comparison of outcomes across future studies. Studies in mixed populations should report head-injured specific subgroup data. Future randomized controlled trials should investigate the efficacy and safety of early pharmacologic prophylaxis in addition to mechanical intervention. Systematic review, level IV.

Anticoagulation in patients with traumatic brain injury

A major challenge in the treatment of brain-injured patients is the decision on indication and timing of prophylactic anticoagulation. In addition, an increasing number of patients suffering from traumatic brain injury (TBI) are on preinjury anticoagulation therapy. Despite clear evidence for an increased risk of venous thromboembolic events and pulmonary embolism in traumatized patients without prophylactic anticoagulation, there is a lack of distinct recommendations and standardized clinical practice guidelines. This review summarizes current research evidence regarding post-traumatic prophylactic anticoagulation and management of patients with prehospital use of anticoagulants. In addition to nonpharmacological techniques like compression stockings, use of low-dose unfractionated heparin or low-molecular-weight heparin is effective in different studies in terms of thromboprophylaxis. If follow-up computed tomography scans and clinical neurological examinations do not show progression within 24 h after initial evaluation, prophylactic anticoagulation does not increase risk for hemorrhage progression and therefore seems to be safe after TBI. Stratification scores for identification of TBI patients with low, moderate, or high risk for spontaneous cerebral bleeding may help to allow early thromboprophylaxis while maintaining a good risk-benefit ratio. So far, these scores require validation by prospective trials. Therefore, current evidence requires control computed tomography scans prior to early pharmacological thromboprophylaxis.

Effect of platelet inhibition on bleeding complications in trauma patients on preinjury clopidogrel

Use of antiplatelet medications for acute coronary syndromes and stroke prevention continues to rise as the population ages, although their effects on trauma outcomes remain unclear. This study sought to determine if trauma patients on preinjury clopidogrel with a higher degree of platelet inhibition (PI), as determined by the VerifyNow P2Y12 Test, experienced bleeding complications more frequently than did patients with a lower degree of PI. Retrospective, cohort study of adult trauma patients admitted to a Level 1 trauma center between October 1, 2009, and August 31, 2011, with documentation of clopidogrel as a home medication. Patients were excluded if they did not receive the P2Y12 assay, had a platelet count at the time of assay less than 100 × 10/L, or had warfarin, dabigatran, or other thienopyridine therapy documented as a concomitant home medication. The primary outcome compared a composite of bleeding complications between patients with 20% PI or greater and those with less than 20% PI. Bleeding complications were defined as the progression of neurologic insult, postoperative hemorrhage or initiation of the institutional massive blood transfusion protocol. Baseline characteristics were similar between groups. The incidence of bleeding complications was not different between study groups (24.2% vs. 27.6%, p = 0.78). No difference in the secondary outcomes of length of stay, in-hospital mortality, and red blood cell transfusion were observed. Patients with 20% PI or greater received platelet transfusion more frequently than did patients with less than 20% PI (51.5% vs. 10.3%, p = 0.0008). The VerifyNow P2Y12 Test may be a tool to stratify trauma patients at a higher risk of bleeding and who subsequently may benefit from transfusion. More frequent platelet transfusion in patients with 20% PI or greater may have resulted in fewer bleeding complications, although confirmation in a prospective, randomized trial is warranted. Prognostic study, level III.

Time course of Keap1-Nrf2 pathway expression after experimental intracerebral haemorrhage: correlation with brain oedema and neurological deficit

Oxidative stress (OS) is involved in the progression of intracerebral haemorrhage (ICH)-induced secondary brain injury. The pathway involving Kelch-like ECH-associated protein 1 (Keap1) and nuclear factor erythroid 2-related factor 2 (Nrf2) is currently recognised as the major endogenous regulatory system against oxidative injury. Although its beneficial role has been described for ICH, the time course of Keap1-Nrf2 pathway expression, the activity of downstream antioxidative enzymes, and the association with brain oedema and neurological deficits have not been fully investigated. In this study, we investigated the temporal changes in expression of Keap1, Nrf2, and their downstream antioxidative proteins in the ICH rat brain. We additionally quantified the relationship between these gene and protein changes with brain water content and neurological behaviour scores. After blood infusion, Keap1 showed decreased expression starting at 8 h, whereas Nrf2 began to show a significant increase at 2 h with a peak at 24 h. Keap1 and Nrf2 are chiefly expressed in neuronal cells but not in glial cells. The downstream antioxidative enzymes such as haemeoxygenase-1 (HO-1), glutathione (GSH), thioredoxin (TRX), and glutathione-S-transferase (GST-α1) increased to different degrees during the early stages of ICH. Among these enzymes, HO-1 showed a significant time-dependent increase starting 8 h after ICH. In addition, there was a positive correlation between the HO-1 level and brain water content. In combination, these results suggest that activation of the Keap1-Nrf2 pathway may play an important endogenous neuroprotective role during OS after ICH. Because HO-1 expression is temporally associated with brain oedema – reflective of the severity of brain injury – it may be used as a biomarker of haeme-mediated oxidative damage after ICH.

“Dynamic spot sign” on CT perfusion source images predicts haematoma expansion in acute intracerebral haemorrhage

To evaluate the association between dynamic progressive enhancing foci ("dynamic spot sign") in acute haematoma on CT perfusion source images (CTP-SI) and haematoma expansion. One hundred twelve consecutive patients with spontaneous intracerebral haemorrhage according to unenhanced CT, CTP and CT angiography within 6 h of symptom onset were prospectively evaluated. Patients were dichotomised according to the presence/absence of the dynamic spot sign on CTP-SI in haematoma. The predictive value of haematoma expansion was analysed. Haematoma expansion was detected in 28 patients (25.0 %) on follow-up unenhanced CT images. Thirty patients (26.8 %) demonstrated the dynamic spot sign on CTP-SI, about 83.3 % of patients with haematoma expansion (P < 0.001). Sensitivity, specificity, positive predictive value, negative predictive value and kappa value for expansion were 89.3 %, 94.0 %, 96.3 %, 83.3 % and 0.814, respectively. In multiple regression, the presence of the CTP dynamic spot sign within acute haematomas independently predicted haematoma expansion; the univariate analysis OR value was 131.667 (29.386-590.289), P < 0.0001. Moreover, the multivariate analysis CTP dynamic spot sign OR value was 203.996 (32.123-1295.488), P < 0.0001. The CTP-SI dynamic spot sign is associated with acute haematoma expansion, is more direct in showing active ongoing bleeding and has a higher predictive value than the CTA spot sign. • It is important to identify potential progression of spontaneous intracerebral haemorrhage. • Dynamic enhancement within CT perfusion source images is associated with haemorrhage expansion. • The CTP dynamic spot sign may be present throughout arterial to venous phase imaging. • The CTP dynamic spot sign carries a higher predive value for haematoma expansion than CTA.

Metastasis of osteosarcoma to stomach made clinically evident by hematemesis: a case report

BackgroundGastric metastasis from osteosarcoma is very rare and its clinical features are not well recognized.Case presentationA 73-year-old man was diagnosed with osteosarcoma and treated with four cycles of preoperative chemotherapy with ifosfamide and doxorubicin followed by wide resection. Two cycles of postoperative chemotherapy with ifosfamide and doxorubicin and ten cycles of chemotherapy with carboplatin and etoposide were administered. Eleven months after the surgery, he vomited fresh blood. Unusual progression of anemia was observed with the hematemesis. A biopsy was performed by gastrointestinal endoscopy, and the stomach tumor was diagnosed as metastasis of osteosarcoma.ConclusionsEven though gastric metastasis from osteosarcoma is very rare, all three previous reports and our case showed the presence of ulcer on the surface of the gastric lesion. We should consider the possibility of gastric metastasis in patients with osteosarcoma in whom progression of anemia or gastric hemorrhage is observed.

Remote Cerebellar Hemorrhage after Removal of a Supratentorial Glioma without Perioperative CSF Loss: A Case Report

A 44-year-old man presented with the rare complication of remote cerebellar hemorrhage (RCH) after removal of a supratentorial glioma without the loss of a large volume of cerebrospinal fluid (CSF). He presented with severe headache, nausea, and vomiting for a few days, then he developed neurological deterioration including progressive disturbance of consciousness and left hemiparesis. Magnetic resonance imaging revealed a large tumor with intratumoral hemorrhage in the right frontal lobe that led to subfalcial and transtentorial herniation. The tumor was removed en bloc without excessive loss of CSF throughout the perioperative period. Although the level of consciousness remained unchanged from the preoperative level and no new neurological deficit was detected, routine postoperative computed tomography showed a bilateral RCH. Careful conservative therapy was provided and follow-up computed tomography demonstrated no further progression of hemorrhage. Compensatory acute engorgement of venous sinuses derived from the rapid decrease in intracranial pressure that occurred due to removal of the huge tumor might have caused cerebellar hemorrhagic venous infarction.

Rapid Progression of Metastatic Pulmonary Calcification and Alveolar Hemorrhage in a Patient with Chronic Renal Failure and Primary Hyperparathyroidism

Rapid Progression of Metastatic Pulmonary Calcification and Alveolar Hemorrhage in a Patient with Chronic Renal Failure and Primary Hyperparathyroidism