Subcortical Hemorrhage Research Articles

Clinical features of elderly intracerebral hemorrhagic patients

Recently the proportion of elderly stroke patients has been increasing explosively. So it is meaningful to clarify the clinical features of old (≥75 years-old) intracerebral hemorrhagic patients. Twenty-five Saiseikai hospitals in Japan prospectively registered acute stroke patients within 7 days of onset in the Saiseikai Stroke Database from April 2014 to September 2018. The clinical backgrounds and outcomes of 1557 old intracerebral hemorrhagic patients were compared with those of 758 preold (65 to <75 years old) intracerebral hemorrhagic patients. In the old group, the comorbidities of hypertension (77.9 vs 82.6%), dyslipidemia (21.5 vs 26.0%), diabetes mellitus (16.8 vs 28.4%) and chronic kidney disease (8.4 vs 11.9%) were significantly lower. Female gender (59.3 vs 34.0%), current smoking (9.0 vs 2.9%), atrial fibrillation (15.1 vs 11.1%), congestive heart failure (8.1 vs 4.4%) and antithrombotic prescription before hemorrhage (34.1 vs 23.1%) were significantly more prevalent. The history of intracerebal hemorrhage (8.5 vs 9.0%) did not differ between the groups. The proportion with the subcortical hemorrhage (30.9 vs 23.9%) and the rate of mortality during admission (18.3 vs 11.9%) were significantly higher. Old intracerebral hemorrhagic patients had a higher prevalence of subcortical hemorrhage with less atherosclerotic risk factors and higher mortality compared with preold patients.

Minimally invasive evacuation of spontaneous supratentorial intracerebral hemorrhage by transcranial neuroendoscopic approach.

ObjectiveSpontaneous supratentorial intracerebral hemorrhage (SSICH) is one of the deadliest diseases, and neuroendoscopic surgery (NE) is a minimally invasive and promising treatment that might improve the functional recovery of patients. This study analyzed patient’s experience with this treatment in terms of safety, efficacy, and surgical technique.Patients and methodsForty-two patients with SSICHs treated by transcranial neuroendoscopic approach were retrospectively reviewed from June 2016 to July 2018 in our department. Patients were classified into four groups according to the main location of the hematoma on CT scans: Group A (basal ganglia hemorrhage), Group B (subcortical hemorrhage), Group C (thalamic hemorrhage), and Group D (intraventricular hemorrhage [IVH]). The clinical data were collected, and the outcomes were analyzed.ResultsAll procedures were successfully completed, and no patient died in the perioperative period. The average hematoma evacuation rate was 90.1%, and the highest hematoma evacuation rate was achieved in Group B which was 92.7%. No severe complications occurred, and the average GCS score improvement was 4.0 at discharge.ConclusionThese data suggest that evacuation hemorrhage by neuroendoscopy might be an effective and safe approach for SSICH. For better efficiency of this treatment, some details needed to be emphasized, such as setting up a good working channel, using of suction and bipolar forceps accurately.

Endoscopic Approach to Subcortical (Lobar) Hemorrhage.

Objective:To highlight the basic points of brain endoscopic procedure for Subcortical (Lobar) Hemorrhage to achieve repeatability and reproducibility in the results among the new brain endoscopic surgeons.Method:Sharing the experience of 10 years as an endoscopic surgeon to bring out the basic insight into the method, challenges, points which need special attention during the surgery and discussion of recent advancements in the endoscopic equipment for safe surgery.Conclusion:Procedure of endoscopic evacuation of brain hematoma is simple with learning curve. In the beginning new endoscopic surgeons should operate in the presence of experience surgeon. They should follow standard technique to achieve the good surgical outcome and uniformity in the result every time they perform the surgery.

Familial neuronal intranuclear inclusion disease complicated by subcortical hemorrhage

AbstractAn 80‐year‐old woman presented with loss of appetite. At age 78, she was diagnosed as familial neuronal intranuclear inclusion disease (NIID) based on (i) leukoencephalopathy with hyperintensities along the corticomedullary junction on diffusion‐weighted imaging (DWI) revealed by brain magnetic resonance imaging (MRI), (ii) skin biopsy samples showing ubiquitin‐positive intranuclear inclusions in adipocytes, and (iii) family history. Her cognitive function was preserved while apathy was apparent. However, on this admission, her cognitive function got worse. Afterward, the patient developed subcortical hemorrhage, and the risk for the hemorrhage was not identified. NIID might be associated with intracranial hemorrhage. In addition, brain MRI after the bleeding showed the rapid expansion of hyperintense lesions on DWI even in the frontal lobe where bleeding was irrelevant. Intracranial hemorrhage might have affected the enlarged hyperintense lesions.

High-grade Glioma Masquerading as a Small Cerebral Hemorrhage: A Case Report.

We report a rare case of a high-grade glioma masquerading as a small subcortical hemorrhage. A 71-year-old woman came to a local hospital with sudden right upper extremity numbness. Computed tomography revealed a small subcortical hemorrhage with faint perifocal edema in the left postcentral gyrus. Conservative treatment was initiated, and she was discharged from the hospital with no neurological deficits. Six months later after discharge, she suffered an acute partial seizure of the right upper extremity. Magnetic resonance imaging with gadolinium demonstrated a ring-enhancing mass surrounded by severe perifocal edema in the hemorrhagic scar. We performed complete resection of the tumor, and the histological diagnosis was anaplastic oligodendroglioma. The diagnosis of a high-grade glioma was delayed due to intratumoral hemorrhages mimicking a small subcortical hemorrhage; consequently, we suspected the hemorrhage was induced by cerebral amyloid angiopathy. It may be important to repeat radiological follow up, if necessary, and to maintain clinical observance of possible intracranial neoplasm, even when the hemorrhage is small, particularly when the cause of bleeding is unknown.

Clinical and neuropathologic analysis of intracerebral hemorrhage in patients with cerebral amyloid angiopathy

ObjectiveTo evaluate the clinical and histopathological features of elderly patients with subcortical intracerebral hemorrhage (ICH), and to analyze the presence of cerebral amyloid angiopathy (CAA) and Alzheimer’s disease (AD) type pathologic changes using amyloid beta (Aβ) and tau immunohistochemistry. Patients and methodsWe retrospectively analyzed cases satisfying the Boston criteria for CAA among patients with subcortical hemorrhage who underwent surgical removal by craniotomy at our hospital. Surgical specimens were subjected to hematoxylin and eosin (HE) staining as well as immunostaining. ResultsA total of 54 patients were included in this study, with a mean age of 74.5 years (range: 72.5–76.5 years, 95% confidence interval [CI]; 51% female). Of these 54 patients, 31 (57%) were hypertensive, 18 (33%) were undergoing antithrombotic therapy, and 12 (22%) had dementia. Strong immunoreactivity for Aβ40 in the cerebral vessels was observed in 30 patients (55.6%), and among these, 27 patients (90%) also showed strong immunoreactivity for Aβ42. Among the 54 patients, 25 (46%) exhibited AD characteristics, including Aβ-positive senile plaques and AT8-positive neurons. Multivariate analysis revealed that strong Aβ40 immunoreactivity in the cerebral vessels was associated with older patients, females, lack of high blood pressure, and the presence of AT8-positive neurons. ConclusionCAA patients with strong Aβ40 deposition in the cerebral vessels were associated with subcortical hemorrhage in our cohort. Future studies should investigate the pathomechanism of ICH in individuals with CAA.

Relationship Between Subcortical Hemorrhage Size and Characteristics of Dysphagia.

The subcortex is an important region in terms of swallowing function that passes fibers from the swallowing center to the cortex. However, studies on the relationship between the hemorrhage size and characteristics of dysphagia were lacking. In the present study, the relationship between subcortical hemorrhage size and characteristics of dysphagia was assessed in patients with subcortical hemorrhage. This study recruited retrospectively 49 subcortical hemorrhage patients with dysphagia. The hemorrhage size was measured and the clinical dysphagia scale (CDS) was used to evaluate the severity of dysphagia. The relationship between CDS score and hemorrhage size was analyzed. Subjects were divided into 2 groups according to average hemorrhage size of the subjects. The CDS scores of the 2 groups were compared and the relationship between each CDS item and hemorrhage size was analyzed. A significant positive correlation was observed between hemorrhage size and total CDS score. Also, a significant correlation was observed when patients over 70 years of age were excluded. The total CDS score in the large hemorrhage group was significantly higher than the CDS score in the small hemorrhage group. The CDS items including tracheostomy, lip sealing, tongue protrusion, laryngeal elevation, and reflex coughing were significantly correlated with hemorrhage size. In this study, the hemorrhage size in patients with subcortical hemorrhage correlated with the severity of dysphagia. In addition, the hemorrhage size was correlated with specific CDS items. These findings should be considered when treating subcortical hemorrhage patients with dysphagia in a clinical setting.

Frequency and characteristics of traumatic brain injury in restrained drivers involved in road traffic accidents.

While seatbelt is an important device protecting drivers from traumatic brain injury (TBI), it has rarely been reported how often and in what circumstances restrained drivers sustain TBI after road traffic accident (RTA). Whole-body computed tomography (WBCT) for blunt trauma patients may provide a unique opportunity to investigate the frequency and characteristics of TBI sustained by restrained drivers. A single-center, retrospective observational study was conducted using prospectively acquired data. Between January 2013 and December 2017, 409 restrained drivers (284 men/125 women, mean age of 45.0 ± 19.1years) whose vehicle had been severely damaged in RTAs underwent WBCT for evaluation of injuries. Multivariate regression analysis was performed to identify variables predictive of TBI. Influence of collision patterns (frontal, lateral or rollover) on the frequency and severity of TBI was evaluated. Relationship between collision patterns and CT findings was also reviewed. Thirty-one restrained drivers (7.6%) sustained TBI after RTA. The distribution of Glasgow Coma Scale (GCS) scores among the 31 drivers was 15 in 9, 13-14 in 9, 9-12 in 4, and ≤ 8 in 9, indicating that the majority of TBIs were classifiable as mild. The frequency of TBI in alert and oriented drivers, i.e., those with a GCS score of 15, was 2.9%. Multivariate regression analysis showed that both altered mental status (OR, 4.933; 95% CI, 1.135-21.431) and loss of consciousness (OR, 6.492; 95% CI, 1.669-25.249) were associated with TBI. The frequency of TBI tended to be higher in drivers with rollover collision than those with frontal collision (6 vs. 13%, p = 0.07). Interhemispheric acute subdural hematoma and subcortical petechial hemorrhage seemed to be characteristic CT findings in drivers with frontal and lateral collision, respectively. The key finding of this study, i.e., that (1) TBI was observed in 7.6% of restrained drivers with severe vehicular damage, may provide useful information to neurosurgeons who take care of RTA victims. The majority of the TBIs were mild without need for neurosurgical intervention. While association may exist between type of collision and type of brain injury, further studies with prospective design are warranted.

An autopsy case of amyloid β-related angiitis with cognitive impairment, multiple infarcts and subcortical hemorrhage

A 76-year-old female presented with cognitive impairment and multiple brain infarcts and died of massive subcortical cerebral hemorrhage. A premortem clinical diagnosis was not possible. She did not show apparent microbleeds on brain images during her lifetime. An autopsy revealed vasculitis at various stages with amyloid β deposition and granulomatous reaction in cortical and leptomeningeal arteries, although almost vasculitic processes were in the healing stage, suggestive of the inactive stage of the disease process. Affected vessels were strictly limited to the brain. The final pathological diagnosis of the autopsy was amyloid β-related angiitis. Genotype analyses of ApoE revealed ApoE ε3/ε3 genotype, low risk for Alzheimer's disease. On retrospective examination, the titer of anti-amyloid β autoantibody in cerebrospinal fluid was rather high in our case, but the exact clinical significance remains unknown. Since microbleeds on brain images are diagnostic findings in patients with cerebral amyloid angiopathy-associated conditions, it is very difficult to make an accurate diagnosis of amyloid β-related angiitis without typical microbleeds or open brain biopsy like our case.

P98. CSF NFL – A new biomarker for neurodegeneration in CSVD?

Background Cerebrospinal fluid (CSF) neurofilament light chain (NfL) has emerged as a putative biomarker of neuroaxonal injury in various neurodegenerative diseases. Particularly, patients suffering from amyotrophic lateral sclerosis (ALS) display significantly elevated levels. We here aimed to compare CSF NfL between patients diagnosed to have cerebral small vessel disease (CSVD) and those exhibiting ALS. Supposing there to be some shared mechanisms of white matter injury we suspected to find similarly increased CSF NfL levels across the diagnostic groups. Methods Our analysis comprised (i) n = 22 patients with CSVD, defined according to the detectability of subcortical and cortical cerebral microbleeds and/or intracerebral hemorrhages (ICH), (ii) n = 39 patients diagnosed to have definite, probable or probable laboratory-supported ALS according to the El Escorial criteria and (iii) n = 31 hospital- and community-based control subjects. All cases were matched for age and sex, and all of them had CSF NfL levels available. In CSVD, cerebral MRIs were rated for the number of (i) cerebral microbleeds, (ii) enlarged perivascular spaces, (iii) lacunes and, for the existence of (a) cortical superficial siderosis and (b) white matter hyperintensities (WMH). WMH have thereby been assessed in a semiquantitative manner according to the Fazeka’s visual rating scale ranging from 0 to 3 and according to the existence of different patterns (multiple subcortical spots, peri-basal ganglia WMH, anterior subcortical patches, posterior subcortical patches). ANOVA was conducted with CSF NfL as dependent variable and group as a fixed factor; for subgroup comparisons Bonferroni adjusted post hoc analysis was performed. In CSVD, bivariate correlations and Mann–Whitney U test were calculated to relate CSF NfL levels to the various MRI measures. P-values £ 0.05 were deemed to be statistically significant. Results When considering the whole cohort CSF NfL levels were not related to age or sex. Analysis revealed a significant group effect (F(2) = 10.5, p ρ = 0.4, p = 0.04, one-tailed). Higher CSF NfL concentrations were, moreover, related to the existence of peri-basal ganglia WMH (Z = 1.9, p = 0.06 [trend-level]). Discussion Our data demonstrate that CSF NfL could serve as a biomarker for neuroaxonal injury in CSVD subjects, revealing similarly elevated concentrations as those found in ALS. In CSVD CSF NfL thereby seems to reflect the extent and patterns of white matter damage, as expected.

Environmental dependency syndrome (Lhermitte) after left frontal subcortical hemorrhage

Environmental dependency syndrome (Lhermitte) after left frontal subcortical hemorrhage

Validating the Use of Prophylactic Antiepileptic Drugs in Patients with Subcortical Intracranial Hemorrhage in a Large Urban Hospital. (P6.333)

Validating the Use of Prophylactic Antiepileptic Drugs in Patients with Subcortical Intracranial Hemorrhage in a Large Urban Hospital. (P6.333)

Incidence of EEG seizures in patients with intraparenchymal hemorrhage re-veals a significant role for subcortical hemorrhages in epileptogenicity. (P5.286)

Incidence of EEG seizures in patients with intraparenchymal hemorrhage re-veals a significant role for subcortical hemorrhages in epileptogenicity. (P5.286)

Complement Activation in Capillary Cerebral Amyloid Angiopathy

Background: Cerebral amyloid angiopathy (CAA) is classified as type 1 with capillary amyloid β (Aβ) or type 2 without capillary Aβ. While it is known that CAA activates complement, an inflammatory mediator, there is no information on the relationship between capillary Aβ and complement activation. Methods: We evaluated 34 autopsy brains, including 22 with CAA and 12 with other neurodegenerative diseases. We assessed the vascular density of CAA by analyzing the expression of complement (C1q, C3d, C6, C5b-9), macrophage scavenger receptor (MSR), and apolipoprotein E (ApoE). Results: Capillary immunostaining for C1q, C3d, MSR, and ApoE was identified almost exclusively in CAA-type1 brains. There was intense expression of C1q, C3d, MSR, and ApoE, as well as weaker expression of C5b-9 and C6 in the arteries/ arterioles of both CAA subtypes, but not in control brains. C5b-9 and C6 were preferentially expressed in arteries/arterioles with subcortical hemorrhage or cortical superficial siderosis. Triple immunofluorescence revealed that C1q, C3d, and ApoE were colocalized with Aβ in CAA brain capillaries. Conclusion: Complement, MSR, and ApoE were only coexpressed in the presence of Aβ accumulation in capillaries, suggesting a role for complement activation in the propagation of Aβ. Additionally, C5b-9 expression may be associated with hemorrhagic brain injury in CAA.

Abstract WP343: EEG Seizures in Patients With Intraparenchymal Hemorrhage Reveals a Significant Role for Subcortical Hemorrhages in Epileptogenicity

Introduction: Patients with intra-parenchymal (IPH) have seizures detected on continuous EEG (cEEG) monitoring, but data that define seizure risk in IPH patients is limited. Methods: A retrospective chart review of 110 consecutive patients that had ICH on CT or MRI imaging and cEEG monitoring from January 2013 to December 2014 was completed. Patients with isolated cerebellar or brainstem hemorrhages were excluded. Primary aim was to examine the incidence of seizures and abnormal EEG patterns in patients with IPH, particularly those patients with deep IPH. Secondary aim was to examine time from EEG placement to first seizure Results: Median age was 73 [IQR 83-60]. 25 (22.73%) of the 110 patients had an abnormal EEG, defined as the presence of periodic lateralized epileptiform discharges (PLEDS) and/or seizures. 40 (36.36%) had subcortical white matter or thalamic or basal ganglia IPH +/- IVH. 5 (12.5%) of these 40 patients had EEG seizures. 66 (60%) patients had cortical IPH +/- IVH. 11 (16.67%) of these 66 patients had seizures. [OR=0.71, CI=0.23 to 2.23, p=0.56]. 4 patients had both deep and cortical IPH and were excluded. A total of 18 (16.36% of the 110) patients had EEG seizures. Of these 18 patients, 5 (27.78%) patients had deep IPH +/- IVH, defined as subcortical white matter, thalamic or basal ganglia IPH. 11 (61.11%) of the 18 had cortical hemorrhage +/- IVH. 2 (10.5 %) additional patients had both cortical and deep IPH. Additionally, of the 25 patients with abnormal EEG, 7(28%) patients had deep IPH +/- IVH 15(60%) of the 25 patients had cortical hemorrhage +/- IVH. Thus 17.5% of patients with deep IPH and 22.7% of patients with cortical IPH had abnormal cEEG.[OR=0.55, CI=0.20 to 1.48, p=0.23]. Average time for EEG placement from admission was 6 hours and 9 minutes. Average time from EEG placement to first seizure was 7 hours and 4 minutes. Discussion: Subcortical IPH is common and can lead to seizure risk. Our results show that a significant portion of the patients with IPH and seizures on cEEG monitoring had subcortical hemorrhages. They accounted for 28% of cases with seizures and abnormal EEG as well as for 13% of all the patients with subcortical ICHs. This data suggests that patients with supratentorial IPH should be evaluated for subclinical seizures.

Impairment of abstract attitude in a patient with subcortical hemorrhage in the posterior-inferior area of the left temporal lobe

Impairment of abstract attitude in a patient with subcortical hemorrhage in the posterior-inferior area of the left temporal lobe

発症急性期に液性成分が急速増大し開頭術を要した頭頂葉皮質下出血の3 例

発症急性期に液性成分が急速増大し開頭術を要した頭頂葉皮質下出血の3 例

Hemorrhagic Adult Unilateral Moyamoya Disease with Multiple Unruptured Intracranial Aneurysms: A Case Report

Adult unilateral moyamoya disease with intracranial aneurysm is frequently reported in the literature, but there is much variation in its treatment. In this case report, we describe the time course and treatment regimen of a patient with moyamoya disease and review the literature regarding moyamoya disease with intracranial aneurysm. A 64-year-old man had untreated intracranial aneurysm and unilateral moyamoya disease for 10 years. He presented with sudden-onset right hemiparesis and aphasia due to a subcortical hemorrhage. He was admitted to the local neurosurgical unit, and upon resolution of symptoms, he was admitted to our hospital. A cerebral angiogram revealed the champagne bottleneck sign of the left carotid artery and obliteration of the top of the left intracranial carotid artery with a moyamoya phenomenon. Two unruptured intracranial aneurysms were identified in the anterior communicating artery(Acom A) and the right intracranial carotid artery(C3). We performed superficial temporal artery-middle cerebral artery anastomosis followed by aneurysmal neck clipping of the Acom A aneurysm. Postoperative imaging showed no new ischemic damage and improved cerebral blood flow. Although the patient experienced temporal worsening of aphasia, his function recovered a few months later and he was able to resume his normal daily life activities. The combination of direct bypass surgery and aneurysmal neck clipping might be a therapeutic option for hemorrhagic unilateral moyamoya disease with unruptured intracranial aneurysm.

Speech error analysis in isolated Apraxia of Speech may reveal subtypes: evidence from two stroke case studies

Speech error analysis in isolated Apraxia of Speech may reveal subtypes: evidence from two stroke case studies

Neurological involvement and characterization in acquired hemophagocytic lymphohistiocytosis in adulthood

ObjectiveTo describe the neurological and neuroradiological features of acquired hemophagocytic lymphohistiocytosis (HLH) in adulthood by reporting a series of cases. MethodsTen consecutive patients who were diagnosed with HLH at Medstar Georgetown University Hospital and Walter Reed National Military Medical Center were evaluated for neurological involvement. All underwent clinical neurological evaluation, and when indicated CSF analysis and MR imaging of the brain. Data were gathered and analyzed retrospectively. ResultsSeven of the ten patients with HLH had neurological involvement. Mean age at onset was 50 (range: 21 to 73). Four patients were males. Prominent clinical features included mild to severe encephalopathy and seizures. Other findings included hemiparesis and spastic tetraparesis. Neuroimaging revealed a wide spectrum of abnormalities including cortical and subcortical edema, gadolinium enhancement, hemorrhage, and diffusion restriction. Basal ganglia involvement was present in four out of seven patients. Three patients died due to multisystem organ failure, and the other patients displayed varying degrees of recovery. ConclusionsThe neurological features of acquired HLH in adults have not been previously reported. These seven patients demonstrate the spectrum of neurological involvement that can occur. The diagnosis of HLH should be considered in patients who are systemically ill with unexplained fevers and hyperferritinemia who have evidence of inflammation in the CNS.