Cases Of Spontaneous Intracerebral Hemorrhage Research Articles

The Usefulness of the 3.1-mm-diameter 4K Rigid Endoscope for Intracerebral Hematoma Evacuation.

The indication for surgical intervention in spontaneous intracerebral hemorrhage remains controversial. Although many clinical trials have failed to demonstrate its efficacy over medical treatment, less invasive endoscopic treatment is expected to demonstrate its superiority. A novel endoscopic system for hematoma removal consisting of a 3.1-mm-diameter 4K high-resolution rigid endoscope was used.The system was used in eight cases of spontaneous intracerebral hemorrhage. It provided improved maneuverability of the surgical instrument while maintaining satisfactory image quality. The surgical goal was achieved in all cases without any complications, including perioperative rebleeding.Endoscopic hematoma removal using the 3.1 mm high-resolution endoscope is an alternative minimally invasive approach to spontaneous intracerebral hemorrhage with improved reliability.

Deep Resequencing of the 1q22 Locus in Non-Lobar Intracerebral Hemorrhage.

Genome-wide association studies have identified 1q22 as a susceptibility locus for cerebral small vessel diseases, including non-lobar intracerebral hemorrhage (ICH) and lacunar stroke. In the present study, we performed targeted high-depth sequencing of 1q22 in ICH cases and controls to further characterize this locus and prioritize potential causal mechanisms, which remain unknown. A total of 95,000 base pairs spanning 1q22, including SEMA4A, SLC25A44, and PMF1/PMF1-BGLAP were sequenced in 1,055 spontaneous ICH cases (534 lobar and 521 non-lobar) and 1,078 controls. Firth regression and Rare Variant Influential Filtering Tool analysis were used to analyze common and rare variants, respectively. Chromatin interaction analyses were performed using Hi-C, chromatin immunoprecipitation followed by sequencing, and chromatin interaction analysis with paired-end tag databases. Multivariable Mendelian randomization assessed whether alterations in gene-specific expression relative to regionally co-expressed genes at 1q22 could be causally related to ICH risk. Common and rare variant analyses prioritized variants in SEMA4A 5'-UTR and PMF1 intronic regions, overlapping with active promoter and enhancer regions based on ENCODE annotation. Hi-C data analysis determined that 1q22 is spatially organized in a single chromatin loop, and that the genes therein belong to the same topologically associating domain. Chromatin immunoprecipitation followed by sequencing and chromatin interaction analysis with paired-end tag data analysis highlighted the presence of long-range interactions between the SEMA4A-promoter and PMF1-enhancer regions prioritized by association testing. Multivariable Mendelian randomization analyses demonstrated that PMF1 overexpression could be causally related to non-lobar ICH risk. Altered promoter-enhancer interactions leading to PMF1 overexpression, potentially dysregulating polyamine catabolism, could explain demonstrated associations with non-lobar ICH risk at 1q22, offering a potential new target for prevention of ICH and cerebral small vessel disease. ANN NEUROL 2024;95:325-337.

A pediatric case of spontaneous intracerebral hemorrhage of unknown etiology

Pediatric ICH peaks in the first year of life especially in neonatal period with hematological abnormalities or structural vascular disorders such as arteriovenous malformations (AVM) or aneurysms. Imaging modality of choice is NCCT head. Urgent surgery when indicated should be performed early. To evaluate the causes of spontaneous ICH in paediatric patients and reviewing the literature. We have discussed the causes of spontaneous ICH in our paediatric patient and we have discussed the management provided to this patient. Taking a detailed history from the parents and the child is important for determining any history of head injury and bleeding episodes. Despite comprehensive evaluation, it may not be possible to determine the cause of ICH in some pediatric cases.

Extended reality platform for minimally invasive endoscopic evacuation of deep-seated intracerebral hemorrhage: illustrative case

BACKGROUNDExtended reality (XR) offers an interactive visualization platform that combines virtual reality (VR) for preoperative planning and augmented reality (AR) for intraoperative navigation overlay.OBSERVATIONSXR was used for treating a case of spontaneous intracerebral hemorrhage (ICH) requiring neurosurgical intervention to decompress a hemorrhage in the subcortical area involving the thalamus that was starting to compress the midbrain. The selected surgical technique was an endoscopic aspiration combined with neurosurgical navigation. Because of the deep-seated location of this ICH, a patient-specific 360XR model rendered using Surgical Theater was used for preoperative planning and intraoperative navigation to allow for enhanced visualization and understanding of the pathology and surrounding anatomy.LESSONSThe XR platform enabled visualization of critical structures near the ICH by extracting and highlighting the white matter tracts from magnetic resonance imaging (MRI) with tractography, which improved preoperative planning beyond using state-of-the-art neuronavigation techniques alone. Once the trajectory was set, the model was integrated with the neuronavigation system, and the planned approach was referenced throughout the procedure to evacuate the clots without further injuring the brain. The patient tolerated the procedure well and was doing well 11 months after his spontaneous ICH.

Spontaneous Intracerebral Hemorrhage (ICH) associated with pregnancy and SARS-CoV-2 infection: a case report

BackgroundCoronavirus Disease 2019 (COVID-19) is predominately known as a respiratory disease associated with pneumonia, acute respiratory distress syndrome and multiorgan failure. However, extra-pulmonary complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are increasingly being recognized. In this regard, some studies implied the hemostatic and vascular involvements in patients with SARS-CoV-2 infection.Case presentationWe describe a case of spontaneous Intracerebral Hemorrhage (ICH) in a pregnant patient with COVID-19 and history of cesarean section a week before the occurrence of ICH. The patient underwent emergent craniotomy with acceptable outcome. Hemorrhagic events, including ICH, may happen during COVID-19 infection with several possible mechanisms.ConclusionCOVID-19 patients, especially high-risk groups, are at a risk of intracranial hemorrhage. Therefore, close follow-up must be maintained and hemorrhagic events must be kept in mind in these cases.

Predictors of Mortality in Spontaneous Intracerebral Hemorrhage Cases

Aim and objectives: This study was done with the aim of finding clinical and radiological correlation of patients with spontaneous intracerebral hemorrhage (SICH) and its correlation with 90-day mortality. The primary objective was to study the clinical, laboratory and radiological predictors of mortality in patients of intracerebral hemorrhage. The secondary objective was to compare 90-day mortality in patients with spontaneous intracerebral hemorrhage with that to coagulopathy related intra cerebral hemorrhage. Methods: This was a longitudinal, observational study carried out from June 2020 to June 2022 at Govt hospital situated in North India. The relevant history and clinical examination was done according to pre designed and pretested protocol. All patients underwent non-contrast computerized tomography imaging, their Glasgow coma scale score and intracerebral hemorrhage score were noted. For the sake of coagulopathy related intracerebral hemorrhage, the patients were classified as taking single antiplatelet, dual antiplatelet agents and oral anti-coagulant drugs. These patients were followed up daily during the hospital stay and regularly thereafter until 90 days. Functional outcome of patients was determined by modified Rankin's scale at 30 days and 90 days. The statistical analysis was done using SPSS software. Results: A total of 235 cases were studied. 202 patients were detected to have hypertension, out of which 25 (12.37%) deaths were recorded within 48hrs of admission, 77 (38.1%) and 85 (42%) of patients with hypertension had died at 30 days and 90 days respectively. Similarly, out of 40 diabetics in this cohort, 15 (37.5%) and 18 (45%) deaths occurred at 30 and 90 days. 97 out of 235 cases who consumed alcohol, 56 (57.7%) and 61 (62.9%) died at 30 and 90 days. Among 52 smokers in this study, 21 (40.4%) and 24 (46.2%) died at 30 and 90 days. Death at 30 and 90 days was significantly more among subjects with intracerebral hemorrhage score of 3 or more with P value of 0.001 and also in patients with GCS score less than 8. Higher mortality rates were seen among subjects with modified Rankin's scale (mRS) score 6 with P value of 0.001 at 30 days. Total number of coagulopathy related intracerebral hemorrhage cases were 99/235. On radiological correlation between spontaneous intracerebral hemorrhage and coagulopathy related intracerebral hemorrhage, this study did not find any strong correlation. The P value was 0.913 at 30 days and 0.961 at 90 days. Conclusion: This study found that comorbidities like hypertension and type 2 Diabetes mellitus were significant predictors of mortality in spontaneous intracerebral hemorrhage cases. The significant correlation was also found between consumption of alcohol and smoking with mortality in intracerebral hemorrhage cases. The 30 and 90-day mortality was significantly among subjects with ICH score 3 or more and also in patients with GCS score less than 8. Similarly, higher mortality is seen with higher modified Rankin score at 30 days. On radiological examination, the Intra cerebral bleed volume greater than 30 ml was greatest predictor of death. This study did not find coagulopathy as a strong predictor of mortality when compared with spontaneous modified Rankin score. Similarly, the location of intra cerebral bleed was not associated with higher mortality in this study.

Spontaneous Intracerebral Hemorrhage and Delayed Cerebral Vasospasm in a Patient with COVID-19 Infection

Introduction: The SARS-CoV-2 may cause vasculitis and thromboembolic events. We report on an unusual case of spontaneous intracerebral hemorrhage and delayed cerebral vasospasms in a patient with COVID-19. Case Presentation: A 65-year-old male was transferred to the emergency department due to a short period of unconsciousness. Twenty-two hours prior to presentation, the patient had a 39.5°C fever with breathing difficulties. Initial COVID-19 PCR was positive. While conscious and without any neurological impairment, a large right frontal intracerebral hemorrhage (ICH) was detected. A preoperative angiogram showed no pathological blood vessels or vasospasm. The patients had a generalized tonic-clonic seizure due to ICH progression, which led to an immediate microsurgical ICH removal. Thirteen days thereafter, the patient became unconscious again. Angiography revealed severe cerebral vasospasm (CV) that required repetitive percutaneous transluminal angioplasty (PTA) and intra-arterial nimodipine treatment. Conclusions: We present the first case of ICH and delayed vasospasm associated with COVID-19. In these patients, combined maximum surgical and endovascular therapy is needed.

Evaluation of spontaneous intracerebral hemorrhage by using CT image segmentation and volume assessment based on deep learning

Objective To evaluate the feasibility and accuracy of deep learning in CT image segmentation and further lesion-volume assessment of spontaneous intracerebral hemorrhage. Methods A total of 1 223 cases of spontaneous intracerebral hemorrhage including parenchymal hemorrhage, ventricular hemorrhage, subarachnoid hemorrhage and mixture hemorrhage, from April 2016 to April 2018 in Tianjin Medical University General Hospital, were retrospectively enrolled and analyzed. The patients were randomly divided into training set (905 cases), validation set (156 cases) and test set (162 cases), among each group, the number of parenchymal hemorrhage was 498, 107 and 100, respectively. The bleeding area manually outlined by physician was served as the reference standard to build the segmentation model and to evaluate the performance of the validation set. Patients were divided into 3 groups according to the volume calculated by reference standard. The volume of hematoma in group 1 was less than 5 ml, while group 2 was 5-25 ml, and group 3 was more than 25 ml. Comparison of the hematoma volume calculated by segmentation model and that calculated by ABC/2 formula was conducted in 97 simple intraparenchymal hemorrhage cases. Results In 162 cases of test set, the Dice coefficients of the segmentation model were 0.87, 0.85, 0.67 and 0.77 in parenchymal hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage and mixture hemorrhage, respectively. The estimated hematoma volume in the 97 intraparenchymal hemorrhage cases calculated by the segmentation model was (29.55±37.69) ml, and that calculated by the ABC/2 formula was (24.04±31.22) ml. Compared with reference standard, the absolute errors of three segmentation model were (0.52±0.54), (1.53±1.22) and (7.93±8.49) ml in group 1, 2 and 3 respectively. The absolute errors of the ABC/2 formula were (0.68±0.60), (3.16±2.90) and (19.31±17.23) ml in group 1, 2 and 3. Conclusion Deep learning based segmentation model improved detection of intraparenchymal hematoma volume, compared with ABC/2 formula. Key words: Deep learning; Image segmentation; Intracranial hemorrhage

Abstract 75: Predictors of Poor Outcome After Intracerebral Hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

Introduction: Intracerebral hemorrhage (ICH) is the most severe subtype of stroke with a high mortality rate and majority of survivors suffering significant disability. The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study prospectively recruited 1000 white, 1000 black and 1000 Hispanic spontaneous ICH cases. Herein, we report the main results of the predictors of 3 month outcome after ICH. Hypothesis: We hypothesized that ICH Score variables of age, ICH volume, ICH location, presence of intraventricular hemorrhage (IVH), and presenting Glasgow Coma Scale would predict long-term disability in addition to prior validation of mortality. Methods: Between 2010-2015, cases were prospectively recruited with uniform phenotype definitions, centralized neuroimaging review and with telephone follow-up at 3 months. Apolipoprotein E genotyping was performed centrally. Individual characteristics were screened for association under a logistic regression model, 90-day mRS ≥ 4 versus 0-3, and those meeting P<0.2 were entered into multivariate model building where the final model was determined by minimum AIC score. Analyses were repeated removing subjects with withdrawal of care. Results: The Table presents the prevalence/average of each variable entering the final multivariate model for association with poor (mRS 4-6) compared to good (mRS 0-3) outcome at 3 months. When analyses were repeated excluding withdrawal of care, overall Graeb (IVH) score fell out of the model (with presence of IVH replacing it) but the remaining variables were retained and in the same direction of effect. C-statistic for the multivariate model = 0.884 compared to 0.763 for ICH score alone (p=1.7E-22). Conclusion: ICH score elements were validated as predictive of 3 month outcome. Novel baseline characteristics such as white matter hyperintensity as well as subsequent clinical events that may affect outcomes were identified. Location specific results to be presented.

Abstract WP333: Intracerebral Hemorrhage Volume and Location in Two Population-Based Studies: 1988 and 2008-2012

Objective: To compare two population-based studies of intracerebral hemorrhage (ICH), collected 20 to 24 years apart, with regard to hemorrhage volumes, location, and stroke risk factors. Methods: All cases of spontaneous ICH among adult residents of the primarily biracial Greater Cincinnati/Northern Kentucky (GCNK) region were ascertained for 1988 and 7/2008-12/2012. Subject information including age, sex, race, Glasgow Coma Scale, and baseline blood pressure were recorded, along with medical history and prescription of anticoagulant and antiplatelet medications. ICH location was defined as deep, lobar, brainstem, or cerebellar. ICH volume was calculated by the ABC/2 method. Results: There were 170 cases of ICH in 1988 and 1101 cases in 2008-2012 fulfilling inclusion criteria. There were no significant differences in mean age (71.2 vs. 70.5 years) or sex (57.7% vs. 51.6% female), but there was a higher proportion of blacks in 2008-2012 compared with 1988 (23.5 vs. 13.5%, P=0.0045). Among the 2008-2012 cases there was significantly less history of ischemic stroke and non-ischemic stroke, and there were no significant differences in history of hypertension, diabetes mellitus, and current smoking. The 2008-2012 cases were prescribed more anticoagulants and antiplatelets. The distribution of ICH location was similar between the two groups. The ICH volumes appear to be lower in 2008-2012 than for 1988 for all hemorrhage locations except the brainstem; however, statistical significance was reached only for deep ICH (Table 1). Conclusions: Although the distribution of ICH location was unchanged between 1988 and 2008-2012, deep ICH volume was smaller in the more recent study. This reduction in hemorrhage size occurred despite significantly more anticoagulant and antiplatelet medications in 2008-2012. More research is needed to investigate factors related to ICH size and trends over time.

Abstract WP327: CHADSVASC and HASBED Scores in Patients With Intracerebral Hemorrhage and Atrial Fibrillation

Background: Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (a-fib) are at risk for having future ischemic events after stopping anticoagulation. Risk calculators (CHA 2 DS 2 -VASc and HAS-BLED) have been validated to assess risk for ischemic stroke and for major bleeding in a-fib patients. We sought to compare the distribution of these scores among ICH patients with a-fib within a large biracial population. Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study included a population-based retrospective chart review of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky region between 7/2008 and 12/2012. CHA 2 DS 2 -VASc (risk of ischemic stroke) and HAS-BED (risk of bleeding with anticoagulation; minus “L” because “labile INR” was unavailable) scores were calculated for all ICH patients with a-fib who survived the hospital stay. Published risk coefficients for each score were used to calculate predicted ischemic and bleeding events within one year of onset. Results: Among 1186 cases of spontaneous ICH, 232 had a-fib, of which 123 patients were excluded due to inpatient death or discharge to hospice. Among the remaining 109 cases, 7-8 would be expected to have a major bleeding event (on anticoagulation), and about 6 patients would be expected to have an ischemic stroke within one year (off anticoagulation), with 73 of the 109 patients having higher risk for major bleeding than for ischemic stroke. The correlation between the two scores was weak (Spearman r=.220, p=.021). Discussion: Comparison of CHA 2 DS 2 -VASc and HAS-BED scores suggest a higher CHA 2 DS 2 -VASc threshold for considering anticoagulation is needed for ICH a-fib patients to balance their higher risk of major bleeding. Further evaluation of the consequences of ischemic stroke and major bleeding would be needed to better understand the best treatment strategies for our patients.

Abstract 192: Anticoagulation Decision-Making in ICH Patients With Atrial Fibrillation: Quality-Adjusted Decision Model Outcomes

Background: While patients (pts) with atrial fibrillation (AF) face a risk of ischemic events, AF pts with intracerebral hemorrhage (ICH) are at increased risk of bleeding with anticoagulation (AC). Optimal decision-making must weigh the tradeoffs between these competing risks. Our goal was to analyze the impact of AC decisions on projected quality-adjusted life years (QALYs) pts with both ICH and AF within a population. Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study is a population-based evaluation of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky study region. The study period was 7/08-12/12. Pts with ICH and AF surviving the hospital stay were included. Medical history and demographics were entered into the Atrial Fibrillation Decision Support Tool, which is a 29-state Markov decision analytic model that projects patient-level QALYs for 7 thromboprophylaxis treatment strategies, using published event rates from CHADSVASC, HAS-B(L)ED, the Friberg ICH prediction model and clinical trials of anticoagulants (including warfarin and direct anticoagulants, DOACs), as well as published rates of outcomes for each possible event. Results: In the study period, there were 1186 cases of spontaneous ICH, 232 with a-fib, of which 123 were excluded because of inpatient death/discharge to hospice. Among the 109 cases, the aggregate net loss for AC was 16.9 QALYs; however there were 10 cases (9%) that gained > 0.1 QALYs with AC. The table displays a heat map showing aggregate gain/loss of QALYs with AC (compared with no treatment) for the cohort, displayed by their CHADSVASC and HASBED scores. Conclusion: We found that 91% of our ICH pts with AF would have either no change or a loss of QALYs with AC. However, given lower bleeding rates with DOACs, anticoagulation may be beneficial in a very select subset of AF pts with ICH. Thresholds for AC treatment should be considered carefully in this population.

Differences in Spontaneous Intracerebral Hemorrhage Cases between Urban and Rural Regions of Taiwan: Big Data Analytics of Government Open Data.

This study evaluated the differences in spontaneous intracerebral hemorrhage (sICH) between rural and urban areas of Taiwan with big data analysis. We used big data analytics and visualization tools to examine government open data, which included the residents’ health medical administrative data, economic status, educational status, and relevant information. The study subjects included sICH patients of Taipei region (29,741 cases) and Eastern Taiwan (4565 cases). The incidence of sICH per 100,000 population per year in Eastern Taiwan (71.3 cases) was significantly higher than that of the Taipei region (42.3 cases). The mean coverage area per hospital in Eastern Taiwan (452.4 km2) was significantly larger than the Taipei region (24 km2). The residents educational level in the Taipei region was significantly higher than that in Eastern Taiwan. The mean hospital length of stay in the Taipei region (17.9 days) was significantly greater than that in Eastern Taiwan (16.3 days) (p < 0.001). There were no significant differences in other medical profiles between two areas. Distance and educational barriers were two possible reasons for the higher incidence of sICH in the rural area of Eastern Taiwan. Further studies are necessary in order to understand these phenomena in greater depth.

リバーロキサバン内服中に発症した脳内出血の3例

リバーロキサバン内服中に発症した脳内出血の3例

The Striate Artery, Hematoma, and Spot Sign on Coronal Images of Computed Tomography Angiography in Putaminal Intracerebral Hemorrhage

A spot sign is a bright spot on computed tomography angiography source images, which is predictive of hematoma growth in spontaneous intracerebral hemorrhage, although the cause of the spot sign is unclear. Our aim was to investigate the spot sign seen on computed tomography angiography and a striate artery, which is a presumed site of intracerebral hemorrhage bleeding origin in the putamen. In consecutive cases of spontaneous intracerebral hemorrhage in the putamen, spot signs and striate arteries were evaluated. Coronal reformat images of computed tomography angiography were created to visualize the striate arteries. Acute deterioration, defined as hematoma enlargement, emergency hematoma removal, or death within the day of admission, was reviewed. Of the 141 patients undergoing computed tomography angiography, 15 of the 30 patients (50%) who had spot signs showed an intrahematoma striate artery (termed spot and tail sign), which was a linear density extending from the middle cerebral artery toward the spot sign. Acute deterioration occurred more frequently in patients who had a spot and tail sign compared with patients who had spot signs without intrahematoma striate arteries (P<0.05). Multivariate analysis revealed that hematoma volume, spot signs, and intrahematoma striate arteries were independent predictors of acute deterioration (P<0.05). The presence of a spot and tail sign, assumed to indicate active bleeding from the striate artery, could be a more sensitive predictor of acute deterioration than the presence of a simple spot sign.

Extents of White Matter Lesions and Increased Intraventricular Extension of Intracerebral Hemorrhage

To determine whether the extent of white matter lesions on a CT scan of acute intracerebral hemorrhage patients is associated with the prevalence and severity of intraventricular extension of hemorrhage. A post hoc analysis of Acute Brain Bleeding Analysis-IntraCerebral Hemorrhage cohort, a nationwide prospective cohort of acute intracerebral hemorrhage patients (total number of cohort subjects, 1,604). Spontaneous intracerebral hemorrhage patients (n = 1,262). None. The authors analyzed CT scan images taken within 48 hours after stroke onset. Extent of white matter lesions, volume of intracerebral hemorrhage, presence of intraventricular extension of hemorrhage, and intraventricular extension of hemorrhage score (approximation of intraventricular extension of hemorrhage volume) were measured using CT scans, and demographic, laboratory, clinical, and mortality data were also gathered through review of medical records and retrieval from the governmental statistical archive. The frequency of intraventricular extension of hemorrhage in our population was 27.2% (343 subjects). The proportion of extensive white matter lesions in intraventricular extension of hemorrhage subjects (33.8%) was higher than that of non-intraventricular extension of hemorrhage cases (16.3%; p < 0.01). Multivariable analysis showed that mild (odds ratio, 1.48; 95% confidence interval 1.05- 0.09; p < 0.01) and extensive (odds ratio, 2.73; 95% confidence interval 1.88-3.98; p < 0.01) white matter lesions were significantly associated with the presence of intraventricular extension of hemorrhage in spontaneous intracerebral hemorrhage patients. The estimated mean of the intraventricular extension of hemorrhage score from the extensive white matter lesions group (9.09 ± 0.76) was significantly higher than that of the no white matter lesions group (6.72 ± 0.78; p < 0.01 from analyses of covariances) after adjustment for relevant covariates. We documented that the severity of white matter lesions is related to the occurrence and amount of intraventricular extension of hemorrhage in spontaneous intracerebral hemorrhage cases.

Comparison of Spontaneous Intracerebral Hemorrhage Treatment in Germany Between 1999 and 2009

The aim of our study was to examine surgical practice in the therapy of spontaneous intracerebral hemorrhage in Germany over a period of 10 years. In 1999 and 2009 a questionnaire with 10 different cases of spontaneous intracerebral hemorrhage was sent to all neurosurgical centers in Germany. It included a cranial CT as well as a case description. The question asked if a conservative or surgical procedure was most suitable. When choosing surgery, the participants could decide between large open approach or microsurgery as well as stereotactic aspiration or external ventricular drainage. In 1999, 85 of 121 (70%) and in 2009 111 of 125 (89%) questionnaires could be evaluated. The results of the questionnaires from 1999 and 2009 showed no difference in the decision for or against a surgical procedure, except for a move toward conservative treatment in 1 patient with a massive spontaneous intracerebral hemorrhage. In 2 cases of isolated basal ganglia bleeding, a conservative approach was chosen by approximately 98% of the participants both in 1999 and in 2009. In all other cases of spontaneous intracerebral hemorrhage, in particular when the patient was in poor clinical condition, the decision was very heterogeneous. Despite new studies, there were no significant differences regarding the decision for or against a surgical procedure in 1999 and 2009. Although clearly unfavorable prognostic factors are known, many patients still undergo a surgical procedure. It appears that at least spontaneous intracerebral hemorrhage in the area of the basal ganglia is a unique domain of conservative treatment.

Clinical analysis on spontaneous intracerebral hemorrhage in childhood, a report of 85 cases

Objective To investigate the characteristics,clinical manifestation,surgical treatment and prognosis of spontaneous intracerebral hemorrhage ( SIH ) in childhood.Method During a 5 - year period from 2004 to 2009,85 cases of spontaneous intracerebral hemorrhage in children( ≤ 14 years of age) were studies retrospectively.Results The main reason of spontaneous intracranial hemorrhage in children was cerebral arteriovenous malformation( AVM ) (84.7％ ),then Moyamoya disease (MMD) (8.2％ ),and aneurysm was rare(3.5％ ).Bleeding sites were mostly located in the brain parenchyma,supratentorial cases more than infratentorial. Headache,vomiting as initial symptoms were more common. DSA was the gold standard for diagnosis of cerebrovascular disease.Hematoma removal and lesion resection was the effective treatment.Conclusions AVM is the most important cause of spontaneous intracranial hemorrhage in childhood,surgical resection is the preferred method which can achieve good results. Key words: Cerebral hemorrhage; Intracranial arteriovenous malformations; Child; Neurosurgical procedures

Do-not-resuscitate orders and predictive models after intracerebral hemorrhage

To quantify the accuracy of commonly used intracerebral hemorrhage (ICH) predictive models in ICH patients with and without early do-not-resuscitate orders (DNR). Spontaneous ICH cases (n = 487) from the Brain Attack Surveillance in Corpus Christi study (2000-2003) and the University of California, San Francisco (June 2001-May 2004) were included. Three models (the ICH Score, the Cincinnati model, and the ICH grading scale [ICH-GS]) were compared to observed 30-day mortality with a chi(2) goodness-of-fit test first overall and then stratified by early DNR orders. Median age was 71 years, 49% were female, median Glasgow Coma Scale score was 12, median ICH volume was 13 cm(3), and 35% had early DNR orders. Overall observed 30-day mortality was 42.7% (95% confidence interval [CI] 38.3-47.1), with the average model-predicted 30-day mortality for the ICH Score, Cincinnati model, and ICH-GS at 39.9% (p = 0.005), 40.4% (p = 0.007), and 53.9% (p < 0.001). However, for patients with early DNR orders, the observed 30-day mortality was 83.5% (95% CI 78.0-89.1), with the models predicting mortality of 64.8% (p < 0.001), 57.2% (p < 0.001), and 77.8% (p = 0.02). For patients without early DNR orders, the observed 30-day mortality was 20.8% (95% CI 16.5-25.7), with the models predicting mortality of 26.6% (p = 0.05), 31.4% (p < 0.001), and 41.1% (p < 0.001). ICH prognostic model performance is substantially impacted when stratifying by early DNR status, possibly giving a false sense of model accuracy when DNR status is not considered. Clinicians should be cautious when applying these predictive models to individual patients.

The Spot Sign in Intracerebral Hemorrhage: The Importance of Looking for Contrast Extravasation

Background: The ‘spot sign’ is a bright spot on computerized tomography angiography (CTA) source images predictive of hematoma growth. Contrast extravasation (CE) is seen on routine head CT following CTA as pooling of contrast within the hematoma. Our aim was to re-evaluate the predictive value of both the spot sign and CE and measure the reliability of scoring them. Methods: Consecutive cases of spontaneous intracerebral hemorrhage (ICH) presenting within 4 h. The presence of a ‘spot’ and CE, ICH and intraventricular hemorrhage volume at baseline and on follow-up scans were assessed. Clinical outcome was captured using the modified Rankin Scale on hospital discharge. Results: We identified 28 patients with a mean age of 56.8 years, median ICH volume of 19 ml, and median NIH Stroke Scale score on admission of 17.5. 11/27 (40.7%) had a positive spot and 13/22 (59.1%) had CE. Interrater reliability was 0.812 (95% CI 0.57–0.91, p < 0.001) for the spot sign and 0.952 (95% CI 0.89–0.98, p < 0.001) for CE. ICH volume increased in 16/28 (57.1%) patients. Both the spot sign and CE were associated with ICH growth (p < 0.001) and poor outcome (p < 0.001). Conclusions: In ICH patients, the presence of the spot sign or CE is highly correlated with early ICH growth. In our experience, CE is a more sensitive predictor of ICH growth with a better negative predictive value than the spot sign; CE is more consistently identified even by experienced clinicians. Postcontrast CT should be done routinely after CTA in patients presenting with ICH within 4 h. Patients who are CE-positive may be candidates for hemostatic therapies or early surgical intervention.