Remote Hemorrhage Research Articles

Remote Intracerebral Haemorrhage Secondary to Vessel Rupture Following Bridging Intravenous Thrombolysis (Causal or Incidental) with Successful Endovascular Treatment: A Rare Case Report.

Remote Intracerebral Haemorrhage Secondary to Vessel Rupture Following Bridging Intravenous Thrombolysis (Causal or Incidental) with Successful Endovascular Treatment: A Rare Case Report.

Thrombolytic Therapy as a Superior Option: Insights from Three Cases of Acute Subdural Hematoma Following Surgery for Chronic Subdural Hematoma

Chronic subdural hematoma (cSDH) ranks among the most prevalent neurosurgical conditions, with burr-hole drainage typically yielding favorable prognoses. Nevertheless, perioperative complications may arise, with remote intraparenchymal hemorrhage and subarachnoid hemorrhage occurring infrequently, while acute subdural hematoma (aSDH) remains a relatively common complication post-cSDH removal. The standard treatment for aSDH, typically large craniotomy, substantially elevates surgical risk. Patients admitted over the course of 51 months (February 2022 to May 2024) to a single institution for treatment of cSDH were retrospectively evaluated, with three cases of postoperative aSDH in elderly patients with cSDH, examining potential causative factors and proposing pertinent strategies. Three elderly patients, admitted urgently due to exacerbating symptoms, underwent preoperative assessment followed by emergency parietal burr-hole drainage. Regrettably, all three patients developed aSDH postoperatively. Various treatment approaches were employed: two cases received thrombolysis with 50,000 units of urokinase, while one case required a large craniotomy. Despite the patients achieving satisfactory outcomes without significant neurological deficits, this study advocates thrombolytic therapy as a potentially superior option for aSDH following cSDH surgery. Urokinase-mediated subdural thrombolysis enhances hematoma clearance rates, suggesting a shift toward minimally invasive treatments to mitigate greater trauma. However, the paucity of evidence necessitates extensive research to validate its safety and efficacy.

Prediction factors and clinical significance of different types of hemorrhagic transformation after intravenous thrombolysis

Background and purposeHemorrhagic transformation (HT) after intravenous thrombolysis (IVT) in acute ischemic stroke seriously affects the prognosis of patients. This study aimed to investigate the risk factors of different types of HT and their correlation with prognosis after IVT.MethodsBased on the CASE II registry, we included patients with acute ischemic stroke who received IVT within 4.5 h of onset. HT was further divided into hemorrhagic infarction (HI) and parenchymal hemorrhage (PH). Poor outcome was defined as a modified Rankin Scale (mRS) score of 3–6 at 3 months. Multivariate logistic regression analysis was used to determine the independent influencing factors of HT subtypes and clinical outcome.ResultsAmong 13108 included patients, 541 (4.1%) developed HI and 440 (3.4%) developed PH. In multivariate analysis, age (OR 1.038, 95% CI 1.028 to 1.049, p < 0.001), atrial fibrillation (OR 1.446, 95% CI 1.141 to 1.943, p = 0.002), baseline diastolic pressure (OR 1.012, 95% CI 1.004 to 1.020, p = 0.005), baseline NIHSS score (OR 1.060, 95% CI 1.049 to 1.071, p < 0.001) and onset to treatment time (OR 1.002, 95% CI 1.000 to 1.004, p = 0.020) independently predicted PH after IVT. In the patients with HT, PH (OR 3.611, 95% CI 2.540 to 5.134, p < 0.001) and remote hemorrhage (OR 1.579, 95% CI 1.115 to 2.235, p = 0.010) were independently related to poor outcome.ConclusionsDifferent types of HT after IVT had different risk factors and clinical significance. The occurrence of PH and remote hemorrhage independently increased the risk of poor outcome.

Prevalence, Risk Factors, and Clinical Outcomes of New Cerebral Microbleeds After Intravenous Thrombolysis in Acute Ischemic Stroke: aSystematic Review and Meta-analysis.

Cerebral microbleeds (CMBs) are common in the elderly population, and are associated with an increased risk of stroke and dementia. An acute ischemic stroke event can make CMBs develop rapidly. However, the progression of CMBs after intravenous thrombolysis is not well understood. Following apreviously registered protocol, PubMed, Web of Science, and Embase databases were systematically searched to identify relevant literature up to August 2022. Cohort studies that reported new CMBs in patients with acute ischemic stroke undergoing intravenous thrombolysis were included. Random effects models were used to calculate the pooled estimates. Seven studies with 1079 patients were included in the meta-analysis. The pooled new CMBs prevalence was 7.6% (95% CI 3.9-14.3%) and 63.6% new CMBs were located in the cerebral lobes. Compared with patients without new CMBs, those with new CMBs were older, had ahigher proportion of hypertension, and had higher systolic blood pressure and baseline CMBs burden. The presence of new CMBs increased the likelihood of remote intracerebral hemorrhage (OR 28.75, 95% CI 8.58-96.38) and symptomatic intracerebral hemorrhage (OR 15.49, 95% CI 3.21-74.73) but was not related to functional outcomes or hemorrhagic transformation. The prevalence of new CMBs after intravenous thrombolysis was approximately 7.6%. The presence of new CMBs is associated with remote and symptomatic intracerebral hemorrhage following intravenous thrombolysis. Considering the potential long-term adverse effects of CMBs progression, patients at ahigh risk of developing new CMBs should be identified based on potential risk factors.

Remote Site Hemorrhage following Evacuation of Left Fronto-Temporo-Parietal Subdural Hematoma: A Rare Case Report and Comprehensive Literature Review

AbstractThis report presents a compelling case of remote site hemorrhage (RSH), a rare but severe complication associated with neurosurgery. RSH involves cerebral bleeding away from the surgical site and was first documented in 1937 by Van Gehuchten. Despite its rarity, RSH remains challenging, affecting less than 1% of cases, with an unclear cause. The case involves a 67-year-old male who developed severe symptoms within 24 hours post-surgery. The initial computed tomography scan showed an acute subdural hematoma. Surgical evacuation was followed by rapid deterioration, leading to multiple RSH and brain stem infarctions. Unfortunately, the patient did not survive. RSH poses significant morbidity and mortality risks. Potential factors include volume loss, dural opening, and blood pressure fluctuations. Management ranges from conservative approaches to surgery, with poor prognosis post-RSH intervention. This case highlights the need for thorough preoperative assessment and careful intraoperative management. It emphasizes the complexities of neurosurgery and underscores the importance of ongoing research for managing rare complications like RSH, ultimately improving patient outcomes.

Brain hemorrhage on 24h-CT and functional outcome in stroke patients with cerebral amyloid angiopathy features on pre-thrombolysis MRI treated with intravenous thrombolysis: A case series

Background and objectivesIn stroke patients treated with intravenous thrombolysis (IVT), presence and high number of strictly lobar cerebral microbleeds (compatible with cerebral amyloid angiopathy, CAA) seems to be associated with increased risk of hemorrhagic transformation, symptomatic hemorrhagic transformation, remote hemorrhage, and poor functional outcome. Some of these CAA patients with cerebral microbleeds also have chronic lobar intracerebral hemorrhage. Few data are available on IVT-treated CAA patients showing cortical superficial siderosis. There are no reports studying factors associated with brain hemorrhagic complication or functional outcome in IVT-treated CAA patients. We present a case series study of IVT-treated stroke patients with CAA features on pre-IVT MRI in whom we have evaluated brain hemorrhagic complications on 24 h-CT and functional outcome after IVT. Material and methodsIn our stroke center, IVT decision in patients with CAA MRI features is at the physician's discretion. We retrospectively screened our stroke database between January 2015 and July 2022 for pre-IVT imaging of 959 consecutive IVT-treated stroke patients without ongoing anticoagulation therapy for probable CAA MRI features defined by modified Boston criteria. After exclusion of 119 patients with missing MRI (n = 47), MRI showing motion artefacts (n = 49) or with alternative chronic brain hemorrhage cause on MRI (n = 23), 15 IVT-treated patients with probable CAA on pre-IVT MRI were identified. In these 15 patients, clinical, biological and MRI characteristics were compared between patients with vs. without post-IVT hemorrhage and between patients with poor (MRS 3–6) vs. good (MRS 0-2) functional outcome at discharge. ResultsTwo patients showed brain hemorrhage on 24 h-CT and both died after 40 and 31 days respectively. The remaining patients had no brain hemorrhage and showed very good outcome except one. Atrial fibrillation (p = 0.029) and Fazekas scale (p = 0.029) were associated with brain hemorrhage whereas atrial fibrillation (p = 0.0022), NIHSS (p = 0.027), blood glucose level (p = 0.024), CRP (p = 0.022) and DWI ASPECT (p = 0.016) were associated with poor outcome. DiscussionConsequences of IVT in CAA patients can be dramatic. Larger studies are needed to compare IVT risks and outcome between CAA and non-CAA patients, also including CAA patients with chronic intracerebral hemorrhage or cortical superficial siderosis. In addition, future studies should try to identify clinical, biological and radiological features at high risk for brain hemorrhage and poor outcome in order to assess the risk-benefit ratio for IVT in CAA. Clinical trial registration-URL:http://www.clinicaltrials.gov. Unique identifier: NCT05565144

Total Cerebral Small Vessel Disease Score and Cerebral Bleeding Risk in Patients With Acute Stroke Treated With Intravenous Thrombolysis.

ObjectiveThe aim of this study was to investigate the association of total cerebral small vessel disease (cSVD) score with the risk of intracerebral hemorrhage (ICH) in patients with acute ischemic stroke who received intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA).MethodsWe retrospectively reviewed clinical data from two stroke registries of patients with acute ischemic stroke treated with IVT. We assessed the baseline magnetic resonance (MR) visible cSVD markers and total cSVD score (ranging from 0 to 4) between patients with and without ICH after IVT. Logistic regression analysis was used to determine the association of total cSVD score with the risk of ICH after IVT, adjusted for cofounders selected by least absolute shrinkage and selection operator (LASSO). We additionally performed an E-value analysis to fully explain away a specific exposure-outcome association. Receiver operating characteristic (ROC) curve analysis was used to quantify the predictive potential of the total cSVD score for any ICH after IVT.ResultsAmong 271 eligible patients, 55 (20.3%) patients experienced any ICH, 16 (5.9%) patients experienced a symptomatic ICH (sICH), and 5 (1.85%) patients had remote intracranial parenchymal hemorrhage (rPH). Logistic regression analysis showed that the risk of any ICH increased with increasing cSVD score [per unit increase, adjusted odds ratio (OR) 2.03, 95% CI 1.22–3.41, P = 0.007]. Sensitivity analyses using E-value revealed that it would need moderately robust unobserved confounding to render the exposure-outcome (cSVD-any ICH) association null. ROC analysis showed that compared with the National Institutes of Health Stroke Scale (NIHSS) score alone, a combination of cSVD and NIHSS score had a larger area under the curve for any ICH (0.811, 95% CI 0.756–0.866 vs. 0.784, 95% CI 0.723–0.846, P = 0.0004).ConclusionThe total cSVD score is associated with an increased risk of any ICH after IVT and improves prediction for any ICH compared with NIHSS alone.

Abstract 10: Recurrent Ischemic Infarcts And Hemorrhages On MRI Within 30 Days Of Anticoagulation Commencement For Ischemic Stroke: Preliminary Results From The Attune Registry

Introduction: Anticoagulation reduces recurrent ischemic stroke based on clinical definitions in patients with atrial fibrillation (AF). However, neuroimaging registries suggested a significant proportion developed ischemic lesions on magnetic resonance imaging (MRI) at 12 months follow up. The rate of early recurrent ischemic stroke identified by MRI remains unclear. ATTUNE (Atrial fibrillation in stroke - Utility of Neuroimaging Evaluation) is a prospective, multicentre study of clinical and radiological outcomes in patients commenced on anticoagulation after ischaemic stroke or TIA. We aimed to investigate the incidence of early ischemic stroke on MRI in this group of patients who were anticoagulated. Aims/Methods: We performed an interim analysis of the ATTUNE database to determine the proportion of patients with radiological evidence of infarction and haemorrhage on (MRI), one month after index ischemic stroke or transient ischemic attack (TIA). MRIs performed at one month were analysed independently by two experienced neuroimage assessors and the number of new infarcts and haemorrhages determined for each patient. Results: A total of 216 patients were analysed. The median age was 74 (IQR 68-81). Anticoagulation was commenced a median of 4 days after index event (IQR 2-6). Twenty-eight patients had new infarcts on follow-up MRI (13%). Fifty-six had new haemorrhage on follow up MRI (26%). Of these, 41 patients had hemorrhagic transformation of the initial infarct and 15 had a remote haemorrhage. Conclusion: There is a high rate of recurrent ischemic lesions and haemorrhages on MRI in patients commenced on anticoagulation within 30 days of index stroke or TIA.

Presence of Vessel Wall Hyperintensity in Unruptured Arteriovenous Malformations on Vessel Wall Magnetic Resonance Imaging: Pilot Study of AVM Vessel Wall "Enhancement".

Purpose: High-resolution vessel wall magnetic resonance imaging (VW-MRI) could provide a way to identify high risk arteriovenous malformation (AVM) features. We present the first pilot study of clinically unruptured AVMs evaluated by high-resolution VW-MRI.Methods: A retrospective review of clinically unruptured AVMs with VW-MRI between January 1, 2016 and December 31, 2018 was performed documenting the presence or absence of vessel wall “hyperintensity,” or enhancement, within the nidus as well as perivascular enhancement and evidence of old hemorrhage (EOOH). The extent of nidal vessel wall “hyperintensity” was approximated into five groups: 0, 1–25, 26–50, 51–75, and 76–100%.Results: Of the nine cases, eight demonstrated at least some degree of vessel wall nidus “hyperintensity.” Of those eight cases, four demonstrated greater than 50% of the nidus with hyperintensity at the vessel wall, and three cases had perivascular enhancement adjacent to nidal vessels. Although none of the subjects had prior clinical hemorrhage/AVM rupture, of the six patients with available susceptibility weighted imaging to assess for remote hemorrhage, only two had subtle siderosis to suggest prior sub-clinical bleeds.Conclusion: Vessel wall “enhancement” occurs in AVMs with no prior clinical rupture. Additional studies are needed to further investigate the implication of these findings.

Treatment Outcomes After Single-Device Flow Diversion for Large or Giant Aneurysms

We aimed to evaluate the efficacy and safety of single-device flow diversion in patients with aneurysms measuring ≥15 mm in diameter. For this retrospective study, we extracted medical record data for patients with unruptured intracranial aneurysms, who underwent flow diversion, at the authors' institution between July 2014 and August 2019. The primary effectiveness outcome was defined as angiographic occlusion of the target aneurysm within 18 months without major (>50%) parent artery stenosis, major adverse events, or additional treatment. Thirty-five aneurysms in 35 patients were analyzed. Most aneurysms (n= 29, 82.9%) involved the anterior circulation. The median aneurysmal diameter was 18.3 mm, and the median neck size was 7.6 mm. Eleven (31.4%) aneurysms were considered giant (≥25 mm). The primary effectiveness outcome was achieved in 20 (57.1%) patients at a median of 10 months (interquartile range, 4.3-12.5) after flow diversion. Major adverse events occurred in 6 (17.1%) patients, including remote intraparenchymal hemorrhages (n= 2), a major ischemic stroke (n= 1), a delayed rupture of the target aneurysm (n= 1), and clinical deterioration caused by aggravated mass effect (n= 2). Multivariate logistic regression analysis found 2 independent predictors of the primary effectiveness outcome: the aneurysmal diameter (odds ratio, 0.71; 95% confidence interval, 0.54-0.86; P= 0.004) and the parent-vessel angle (odds ratio, 0.97; 95% confidence interval, 0.93-0.99; P= 0.017). Single-device flow diversion was shown to be ineffective for large or giant intracranial aneurysms with a high parent vessel angle.

Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach.

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

High fibrin/fibrinogen degradation product value as a risk factor for progressive remote traumatic intracranial haemorrhage following neurosurgery

Introduction Remote traumatic intracranial haemorrhage (RTIH) may develop after neurosurgery. Recognition of the risk factors for RTIH before surgery might be of great value. The purpose of this study was to verify if the fibrin/fibrinogen degradation product (FDP) value may be a risk factor for RTIH. Methods This was a retrospective study of the data of 56 patients with traumatic intracranial hematomas shown on initial computed tomography (CT) who were treated with craniotomy or decompressive craniectomy and underwent a follow-up CT at a single centre over a period of approximately 10.5 years. We divided the patients into 2 groups: those who developed RTIH (Positive: P-group) and those who did not (Negative: N-group). We compared the 2 groups in terms of not only the laboratory data before surgery, but also patient age, sex, antiplatelet/antithrombotic medications received, cause of injury, and GCS score on arrival. Results RTIH was observed in 22 patients (P-group, 39.3%). The FDP value was the only significant risk factor identified in this study (p = 0.00076). The cut-off value was estimated on the basis of the area under the receiver operating characteristic (ROC) curve. The cut-off FDP value was 120 µg/mL (63.6% sensitivity and 85.3% specificity). Conclusions FDP levels over 120 µg/mL were determined to be a risk factor for progressive RTIH after neurosurgery. We suggest the FDP level be checked before surgery for traumatic intracranial haemorrhage and follow-up CT be done as soon as possible after the surgery if the serum FDP level is over 120 µg/mL.

Welling-up of cerebrospinal fluid is a sign of remote supratentorial hemorrhage during microvascular decompression: a case report

BackgroundSubdural hematoma (SDH) at a remote operative site is uncommon following neurosurgical procedures. However, supratentorial SDH is one of the rare complications following microvascular decompression (MVD). We report a case of supratentorial SDH following MVD. The welling of cerebrospinal fluid (CSF) in the cerebellomedullary fissure was observed unexpectedly during the dissection. It is a signal case that can improve our understanding of the occurrence of such rare complications and of possible mechanisms.Case presentationA 54-year-old woman was diagnosed with left hemifacial spasm (HFS) and had been receiving botulinum toxin injections since 10 years before surgery. CSF welling-up in the cerebellopontine cistern was noticed by the surgeon during the arachnoid dissection. MVD was performed completely. A thin supratentorial SDH was found on the right side (contralateral) on immediate postoperative computed tomography (CT). The SDH was asymptomatic, and the size of hematoma did not increase in follow-up CT scans after surgery. During the follow-up period, she was relieved of HFS. CSF welling-up can be considered the time of initiation of the hemorrhage.ConclusionLimited case reports of supratentorial SDH following MVD have been published, and none of them have reported time of initiation of the hemorrhage. The phenomenon of abnormal CSF welling-up in the cistern could be a sign of remote supratentorial hemorrhage.

Remote Intracranial Hemorrhage Secondary to Brain Tumor Surgery

Postoperative remote intracranial hemorrhage (rICH) secondary to craniotomy surgery is an extremely rare but catastrophic complication. The present study aimed to investigate the incidence and the possible pathophysiological mechanism of rICH after brain tumor surgery. The clinical data from 9 rICH cases among 4588 patients undergoing brain tumor surgery were collected retrospectively. Remote intracranial hemorrhage occurred in 9 cases, including 6 cases of remote epidural hemorrhage (rEDH), 2 cases of remote subdural hemorrhage (rSDH), and 1 case of remote cerebellar hemorrhage (rCBH). Among the 9 cases, 2 were males and 7 were females, with an age range of 22 to 63 years (mean of 44.3 years). The incidence of rICH in the patients with ventricular system opening/drainage (4/258) was much higher than the patients without ventricular system opening/drainage (5/4330), and the difference was statistically significant (P < 0.01). Hematoma evacuation was performed in 7 patients with serious neurological status or massive hematoma. The outcome for most of the rICH cases was good, and the Glasgow outcome scale scores of 4-5 were found in 8 cases with a 3-month-long follow-up. Our results suggest that brain tumor surgery with ventricular system opening/drainage was more susceptible to rICH. Paying particlular attention to gradual reduction of intracranial pressure and avoiding excessive loss of cerebrospinal fluid may aid to prevent the occurrence of rICH. The authors suggest that a high index of suspicion, a prompt diagnosis, and emergent management is of vital importance to achieve good prognosis for rICH patients secondary to brain tumor surgery.

Ultra-Early Remote Intracranial Hemorrhage Complicating Intravenous Thrombolysis with Tenecteplase for Acute Ischemic Stroke.

Ultra-Early Remote Intracranial Hemorrhage Complicating Intravenous Thrombolysis with Tenecteplase for Acute Ischemic Stroke.

Remote brain hemorrhage after IV thrombolysis: Role of preexisting lesions.

To test the hypothesis that remote intracerebral hemorrhages (r-ICHs) after IV thrombolysis occur in preexisting brain lesions. We prospectively collected baseline data from consecutive patients treated with IV thrombolysis for cerebral ischemia and reviewed their baseline MRI scans to identify preexisting lesions in those who developed r-ICH. We evaluated outcomes with the modified Rankin Scale (mRS) and defined good outcomes as scores of 0 to 2 or similar to the preexisting mRS score. Of 944 patients, 24 (2.5%) had r-ICH: lobar in 14, deep in 7, and both in 3. Sixteen of them (1.7% of all patients, 66.7% of those with r-ICH) were asymptomatic. Of the 41 r-ICHs found in these patients, 17 (41%) occurred within a lesion present before thrombolysis: 6 cerebral microbleeds (CMBs), 6 old and 1 recent infarct, and 4 areas of white matter hyperintensity. Patients with r-ICH were more likely to have strictly lobar CMBs (p = 0.049). They were 10 years older (p = 0.007), had a 16-mm Hg higher systolic blood pressure (p = 0.035) at baseline, and had more CMBs (p = 0.007). r-ICHs were better predicted by clinical (age, baseline systolic blood pressure) than imaging (purely lobar CMBs and having >5 CMBs) variables. r-ICHs tended to be associated with worse outcomes. We identified preexisting brain lesions in nearly half of the patients with r-ICH. All were of vascular origin, supporting the hypothesis that r-ICHs occur in preexisting brain lesions. Higher-field machines could help identifying preexisting lesions in those who developed r-ICH in an apparently normal area.

A “human-proof pointy-end”: a robotically applied hemostatic clamp for care-under-fire

Providing the earliest hemorrhage control is now recognized as a shared responsibility of all members of society, including both the lay public and professionals, consistent with the Stop the Bleed campaign. However, providing early hemorrhage control in a hostile environment, such as the scene of a mass shooting, is extremely challenging. In such settings, the first access to a bleeding victim may be robotic. An all-purpose bomb robot was thus retrofitted with a commercial, off-the-shelf wound clamp and successfully applied to an extremity exsanguination simulator as a demonstration of remote robotic hemorrhage control. As this method can potentially control extremity hemorrhage, further development of the techniques, equipment and, most importantly, the guidelines and rules of engagement should continue. We suggest that in order to minimize the loss of life during an active shooter incident, the armamentarium of prehospital medical resources may be extended to include law-enforcement robots.

Fibrin-Associated Diffuse Large B-Cell Lymphoma Occurring as a Pararenal Pseudocyst

Abstract A 60-year-old male underwent nephrectomy for a tumor on the posterior aspect of the right kidney. Grossly, a completely encapsulated 8 × 8 × 6.8-cm nodule was found in the perinephric fat adjacent to the renal capsule and indenting the renal surface. The renal parenchyma was microscopically unremarkable. The capsule of the lesion was composed of dense fibrous tissue with chronic inflammation, remote hemorrhage, and prominent calcifications. The nodule/pseudocyst contained predominantly amorphous, eosinophilic material with cholesterol clefts and calcifications. Within the pseudocyst, clusters of large cells were identified. These cells showed abundant amphophilic cytoplasm and large pleomorphic nuclei with dispersed chromatin, prominent nucleoli, and occasional mitotic figures. Immunohistochemical (IHC) staining showed that these cells were positive for CD20, CD79a, IRF4, BCL2 (&gt;90%), C-MYC (70-80%), and EBV-ISH; variably positive for CD30 and PAX5; and negative for CD3, CD10, CD68, CD138, ALK1, and BCL6. MYC FISH break-apart probe demonstrated no rearrangements or copy number changes. Based on the overall features, the diagnosis of fibrin-associated diffuse large B-cell lymphoma (FA-DLBCL) was rendered. This entity has been recently recognized under a larger category of diffuse large B-cell lymphoma associated with chronic inflammation (DLBCL-CI). Unlike DLBCL-CI, which is considered clinically aggressive, FA-DLBCL typically demonstrates a favorable outcome with surgical resection alone. FA-DLBCL is usually incidentally found at unusual sites (cardiac myxomas, prosthetic cardiac valves, thrombi, hematomas, and pseudocysts including intracranial, splenic, retroperitoneal, paratesticular, adrenal, and renal). To our knowledge, this is the first report of a FA-DLBCL arising in a pararenal location. In addition, our case demonstrates unusually high MYC IHC positivity. Although rare, this entity should be kept in mind, especially in an appropriate clinical setting, and should not be misclassified into a more aggressive category, such as “double expressor” DLBCL or DLBCL-CI.

Meatal Anterior Inferior Cerebellar Artery Aneurysm with AICA-PICA Complex: Endovascular Coiling and Parent Artery Preservation

AbstractSecondary stroke prevention requires early initiation of antiplatelet; therefore, stroke mimics need to be ruled out particularly in circumstances when antiplatelet therapy can be of disastrous consequences. A 54-year-old female patient presented to the emergency department with symptoms of sudden-onset deviation of angle of mouth to the right side, left eye ptosis, and occipital headache for past 4-hour duration. Neurologic examination revealed right-sided gaze-dependent torsional nystagmus and left lower motor neuron facial weakness. An embolic posterior circulation stroke secondary to vertebral artery dissection was suspected. Diffusion-weighted imaging (DWI) did not show any acute infarcts, and careful review of susceptibility-weighted imaging (SWI) scans showed hemorrhage in the fourth ventricle. Subsequent digital subtraction angiography (DSA) was done, which showed left anterior inferior cerebellar artery (AICA) aneurysm involving its intrameatal segment with AICA-posterior inferior cerebellar artery (PICA) complex. Retrospective review of computed tomographic (CT) angiography images showed small aneurysm in the internal auditory meatus, which is difficult to discern secondary to adjacent bony structure and smaller size of the aneurysm. The patient underwent endovascular coiling of the aneurysm with preservation of the parent artery. Our experience concluded that these clinical features suggest remote subarachnoid hemorrhage secondary to the ruptured of AICA intrameatal segment aneurysm with left facial nerve paralysis and peripheral cochlear vestibular changes secondary to either compression (mechanical or pulsations of the aneurysm sac) or ischemia of vestibular apparatus. The neurointerventionist should consider the possibility of aneurysmal rupture, especially in cases of atypical location of hemorrhage and no signs of infarct on neuroimaging of posterior circulation stroke.

Vzdálené intracerebelární krvácení po resekci tumoru spánkového laloku

Vzdálené intracerebelární krvácení po resekci tumoru spánkového laloku