Types Of Intracranial Hemorrhage Research Articles

Hemorrhagic Manifestations of Reversible Cerebral Vasoconstriction Syndrome

Reversible cerebral vasoconstriction syndrome (RCVS), characterized by severe headaches and reversible constriction of cerebral arteries, may be associated with ischemic and hemorrhagic strokes. The aim of this study was to describe the frequency, patterns, and risk factors of intracranial hemorrhages in RCVS. We analyzed prospective data on 89 consecutive patients with RCVS, of which 8 were postpartum and 46 used vasoactive substances. Standard bivariate and multivariate statistical tests were applied to compare patients with and without hemorrhage. Thirty patients (34%), of which 5 were postpartum and 12 used vasoactive substances, developed at least 1 type of intracranial hemorrhage, including cortical subarachnoid (n = 27), intracerebral (n = 11), and subdural hemorrhage (n=2). Patients with hemorrhage had an older age (46.6 versus 41.6 years, P = 0.049) and were more frequently females (90% versus 51%, P = 0.0017) or were migrainers (43% versus 19%, P = 0.022) than those without hemorrhage. Multivariate testing identified 2 independent risk factors of hemorrhage in RCVS: female gender (OR, 4.05; 95% CI, 1.46 to 11.2) and migraine (OR, 2.34; 95% CI, 1.06 to 5.18). Patients with hemorrhage had a greater risk of persistent focal deficits (30% versus 2%, P = 0.0002), cerebral infarction (13% versus 2%, P = 0.039), posterior reversible encephalopathy syndrome (17% versus 3%, P = 0.041) at the acute stage, and of inability to resume normal activities at 6 months (27% versus 0%, P < 0.0001). In RCVS, women and migrainers seem to be at higher risk of intracranial hemorrhage. Overall, intracranial hemorrhages are frequent in RCVS and are associated with a more severe clinical spectrum.

Emergency decompressive craniectomy for trauma patients with Glasgow Coma Scale of 3 and bilateral fixed dilated pupils.

Trauma patients with Glasgow Coma Scale (GCS) of 3 and bilateral fixed dilated pupils (BFDP) usually have dismal outcome, and neurosurgeons are less likely to treat such patients aggressively. In this work, the authors assessed whether emergency decompressive craniectomy (EDC) can change the poor outcome of these patients. We reviewed all patients with GCS of 3 and BFDP admitted to our neurosurgical unit from January 2004 to January 2008. Injury data, prehospital times, findings on brain computed tomography (CT) scan, procedures, and outcomes were recorded. During this period, 21 patients were admitted with GCS of 3 and BFDP following traumatic brain injury (TBI). Brain CT scan showed diffuse brain edema in 17 patients (81%), and in 13 patients (62%) it showed different types of intracranial hemorrhage. All patients received conservative medical treatment. Urgent decompressive bifrontal craniectomy was performed in five patients at a mean of 4.6h (range 2-6h) from time of injury. Intracranial pressure (ICP) was recorded hourly by intraparenchymal sensor (Codman, Johnson & Johnson). Although decompressive craniectomy was effective in controlling ICP, all patients with GCS of 3 and BFDP died within 30days of trauma. Despite control of ICP following emergency decompressive craniectomy in patients with severe TBI, GCS of 3, and BFDP, this did not change the dismal outcome of these patients; on the contrary, it may increase the suffering for patients and their families and add unnecessary medical burden. We propose that these patients have irreversible severe brain insult.

Does Concomitant Epidural Hemorrhage and/or Traumatic Intracerebral Hemorrhage Influences on Outcome of Surgically Treated Acute Subdural Hemorrhage (SDH) Patient?

Objective: In order to present statistical evaluation on the prognosis and surgical outcome of acute subdural hemorrhage (SDH), and concomitant epidural hemorrhage (EDH) and/or concomitant traumatic intracerebral hemorrage (T-ICH), we report the analysis of clinical findings and treatment results with literature. Methods: We retrospectively analyzed for 71 cases of 466 acute SDH cases that treated in Gyeoungsang National University Hospital from January 2006 to December 2008 by medical record. We analysed the age, gender, initial Glasgow Coma Scale (GCS) on admission, pupil light reflex, the time from emergency room to operation room, according to pastient’s Glasgow Outcome Scale (GOS). We used computed tomography (CT) scan to investigate the presence of concomitant EDH, T-ICH, presence of midline shifting. hemorrhage depth. We also took interest in effect of location of concomitant hemorrhage on patient's GOS. Results: There was stastistically significant correlation the age, GCS, pupil light reflex, concomitant bilateral hemorrhage unrelated with subtype with patient’s outcome (GOS) but other’s parameters (midline shifting, the time from emergency room to operation room) have no statistical significance correlation with patient’s outcome. Conclusion: This study showed that the factors like age, GCS on admission, and pupil light reflex were related to the prognosis of the patients with acute SDH, and involving bilateral hemorrhage, instead of unilateral, illustrated outcomes in any type of intracranial hemorrhage. We think that a futher study would be performed that includes amount of hemorrhage, location of hemorrhage, and a larger number of patients for statistical plausibility. (J Kor Neurotraumatol Soc 2010;6:27-32)

Prothrombin Complex Concentrates for Oral Anticoagulant Therapy-Related Intracranial Hemorrhage: A Review of the Literature

Warfarin-related intracranial hemorrhage carries a high mortality and poor neurological outcome. Rapid reversal of coagulopathy is a cornerstone of medical therapy to halt bleeding progression; however the optimal approach remains undefined. Prothrombin complex concentrates have promising features that may rapidly reverse coagulopathy, but remain relatively unstudied. We aim to review the literature regarding the use of prothrombin complex concentrates in patients with warfarin-related intracranial hemorrhage. A comprehensive review of the literature was conducted using PUBMED and Google Scholar databases to identify the use of PCC in patients with warfarin-related intracranial hemorrhage. The characteristics abstracted included the type of PCC, dosing, study design, type of intracranial hemorrhage, changes in the INR, and adverse effects. Prothrombin complex concentrates are heterogeneous in regards to factor concentration. PCC consistently reversed the INR in patients with intracranial hemorrhage. There is some evidence that PCC may reverse the INR more rapidly compared to fresh frozen plasma. Serious adverse effects were uncommon and included mainly thromboembolism. PCC has features which make it a promising therapy for patients with warfarin-related intracranial hemorrhage, and deserves more rigorous study in prospective-randomized controlled trials.

Sonographic stroke templates

This chapter provides arterial and venous stroke templates, designed with neonatal brain ultrasound as the viewpoint and adult stroke templates as the basis. Images change with maturation of the stages of infarction: swelling, necrosis, organisation and tissue loss. Adult templates permit recognition of well-delineated stroke types observed in the newborn brain. All circle of Willis arteries can be involved, as can their perforator branches. Middle cerebral artery (MCA) truncal stroke (anterior or posterior) is an important entity, with different prognosis than complete MCA stroke. Knowledge of these templates also aids in the definition of combinations of infarction (e.g. internal carotid artery stroke or pial plus perforator stroke) and of interarterial watershed injury. Venous templates, even if still under development around the time of birth, permit us to understand brain injury associated with sinus or deep vein thrombosis, especially several types of intracranial haemorrhage. Hindbrain stroke templates are scarcely applied to perinatal lesions.

MS03 BRAIN INJURIES

Blast injuries to the head and neck comprise various combinations of primary blast injury to the brain with brain swelling and all types of intracranial haemorrhage; open wounds with multiple metal and bone fragments in the brain; head and neck, cervical and facial vascular injury; skull base fractures with CSF leak; pharyngo‐laryngeal injury, acute airway compromise; facial and scalp burns, scalp defects; orbit and eye injuries; profound shock and multiple other systemic injuries. The principles of management include early tracheostomy, vigorous replacement of blood loss and correction of coagulopathy, nasal and wound packing, neck exploration and repair of carotid artery injury, early generous craniectomy, haematoma evacuation, removal of accessible fragments and debridement of devitalized cerebral tissue, ventriculostomy, duroplasty, and use of broad spectrum antibiotics. Repair of ocular injury or eye removal is often deferred. CT is required for planning the extent of the neurosurgery and CT angiography is useful when cervical vascular injury is suspected. The timing and extent of the neurosurgery must be balanced against the relative priorities of the other injuries and the state of physiological compromise. The surgery for these injuries is generally more extensive compared with what is described in the literature for penetrating brain injury from previous wars. The management of these complex head and neck injuries should be conducted by a multidisciplinary team of head and neck (ENT) surgeon, neurosurgeon, ophthalmologist, oral and maxillo‐facial surgeon and plastic/burns surgeon.

Influence of Antiplatelet Pre-Treatment on the Risk of Symptomatic Intracranial Haemorrhage after Intravenous Thrombolysis

Background: The influence of antiplatelet agents (AP) in the development of a symptomatic intracranial haemorrhage (SICH) after intravenous rt-PA is not well known. We assessed the hypothesis that pre-treatment with AP may increase that risk. Methods: We studied data from consecutive patients with ischaemic stroke treated with intravenous rt-PA within the first 3 h after symptom onset. We recorded the antecedent of any AP therapy previous to thrombolysis. A follow-up CT was performed routinely 24–36 h after the infusion of rt-PA. Intracranial bleeding was categorized according to the criteria of the European Cooperative Acute Stroke Study II (ECASS II) into haemorrhagic infarction type 1 and 2 and parenchymal haemorrhage type 1 and 2. SICH was diagnosed if it was of the parenchymal haemorrhage type, occurred within the first 36 h and was associated with neurological deterioration. Results: Of a total of 605 patients, 137 (22.6%) were pre-treated with AP, most of them (n = 106) with aspirin. Any type of intracranial haemorrhage was observed in 119 patients (19.7%), without differences between the AP (18.4%) and the non-AP (20.2%) groups. Parenchymal haemorrhage was observed in 41 patients (8.5%) and SICH in 26 (4.3%). There was a non-significant rise in the frequency of SICH in the AP group compared with the non-AP group (6.6 vs. 3.6% p = 0.10). Conclusions: Pre-treatment with AP non-significantly increases the risk of SICH and therefore this antecedent should not be a contraindication for intravenous thrombolysis.

Recombinant activated factor VII for a warfarinised Jehovah’s Witness with an acute subdural haematoma

Recombinant activated factor VII (rFVIIa) (NovoSeven; Novo Nordisk A/S, Bagsvaerd, Denmark) is a haemostatic agent first developed for bleeding associated with haemophilia and trauma, but for which the indications continue to expand. Recent reports have suggested efficacy for various types of intracranial haemorrhage and for patients with abnormalities of coagulation. We report a warfarin-anticoagulated Jehovah’s Witness patient with an acute subdural haematoma for whom rFVIIa was used perioperatively. The haematoma was surgically evacuated without excessive blood loss and the patient eventually made a good recovery, returning to independent self-care.

Subdural and Primary Subarachnoid Hemorrhages: A Case Study

Subdural hemorrhage (SDH) and primary subarachnoid hemorrhage (SAH) are two forms of intracranial bleeding that can be encountered in infants. These events can be life threatening to the infant and devastating to his family. Neonatal nurses need to have an understanding of these unfortunate, yet not uncommon, types of intracranial hemorrhage. This article explains the etiology, the diagnosis, and the treatment of SDH and SAH, concluding

Postoperative Visual Recovery and Complications of Vitrectomy in Terson's Syndrome

Purpose: To investigate the visual recovery and complications of vitrectomy in Terson's syndrome. Methods: A retrospective study was carried out on 11 eyes in 9 patients who had undergone pars plana vitrectomy for Terson's syndrome from October 2004 to June 2006. The factors assessed were age, gender, presence of hypertension, type of intracranial hemorrhage, preoperative and final visual acuity, time interval from intracranial hemorrhage (ICH) to vitrectomy, and any intraoperative and postoperative complications. Results: The average age of the subjects and the Interval from ICH to vitrectomy were 43.0±11.0 years and 3.25±3.48 months respectively. Binocular involvement was found in two of the nine patients, and fundus findings were severe vitreous opacity in all cases, while sub-ILM hemorrhage at the posterior pole was seen in five eyes. Intraoperative retinal break was recorded at the 10 o'clock sclerotomy site in five eyes, and four of these five eyes were associated with sub-ILM hemorrhage. One patient underwent a scleral buckling operation four months postoperatively due to rhegmatogenous retinal detachment associated with a retinal tear at the 2 o'clock sclerotomy site. Visual acuity improved in all cases postoperatively, and the final visual acuity was over 0.6 in seven eyes. Conclusions: We can expect from early surgery a relatively good prognosis of visual acuity and prevention of complications. Due to the possibility of retinal breaks at the sclerotomy sites, we should keep in mind that cautious handling of intraocular instrument and complete removal of vitreous base may be necessary.

Intracranial hemorrhage: ultrasound, CT and MRI findings

Intracranial hemorrhage is one of the most common causes of acute focal neurologic deficit in children and adults. Neuroimaging including ultrasonography (US), computer tomography (CT) and magnetic resonance imaging (MRI) is essential in the diagnosis of intracranial hemorrhage. Imaging findings should guide treatment. The highly variable appearance of an intracranial hemorrhage can be challenging. A thorough knowledge of hematoma evolution and US, CT and MR hematoma characteristics is mandatory for adequate interpretation of findings. The purpose of this review is (1) to summarize the imaging characteristics of intracranial hemorrhage on various imaging techniques and (2) to review the various types of intracranial hemorrhage, and their causes.

Primary intraventricular hemorrhage from dural arteriovenous fistula

Dural arteriovenous fistulas (AVFs) cause several types of intracranial hemorrhage, but rarely cause primary intraventricular hemorrhage (IVH). We report a 67-year-old man with sudden headache and a long history of a pulsatile bruit who developed intraventricular hemorrhage without any parenchymal hemorrhage. Cerebral angiogram revealed dural arteriovenous fistulas in transverse and sigmoid sinuses. Severe retrograde venous drainage seemed to have caused backward flow into the subependymal veins with their consequential rupture. Transvenous embolization was successful.

Risk, types, and severity of intracranial hemorrhage in patients with symptomatic carotid artery stenosis.

We sought to report the occurrence and risk factors of intracranial hemorrhage during long-term follow-up of patients with internal carotid artery stenosis, with and without carotid endarterectomy. From the prospective data of the North American Symptomatic Carotid Endarterectomy Trial, 3 types of intracranial hemorrhage were recognized: petechiae within infarction (PTI), intracerebral hematoma (ICH), and subarachnoid hemorrhage (SAH). The 30-day and 5-year risks of intracranial hemorrhage (PTI or ICH) were estimated from Kaplan-Meier event-free survival curves. Cox proportional-hazards regression modeling was used to identify risk factors. Of 1039 strokes that occurred in 749 of 2885 patients during an average follow-up of 5 years, there were 24 PTIs, 14 ICHs, and 1 SAH. The 5-year risk of intracranial hemorrhage was 1.7% in both medically and surgically treated patients, but the 30-day risk of 0.64% in surgically treated patients was 10 times higher than the risk of 0.07% in medically treated patients (P=0.01). Approximately 50% of all intracranial hemorrhages were either disabling or fatal, and ICHs were more likely to be fatal than PTIs. Old age, a history of hypertension, intermittent claudication and smoking, and infarct on brain images were risk factors for intracranial hemorrhage in medically treated patients, whereas diabetes mellitus was the sole risk factor in surgically treated patients. Intracranial hemorrhages are uncommon in patients with internal carotid artery stenosis but are associated with high mortality and morbidity. The risk factors for intracranial hemorrhage are different between medically and surgically treated patients.

Comparison of Maternal and Infant Outcomes Between Vacuum Extraction and Forceps Deliveries

The authors conducted a population-based historical cohort study in the Canadian province of Quebec to assess the maternal and infant outcomes associated with vacuum extraction and forceps deliveries. The study database contains information on 305,391 mother-infant dyads (linked by a common institutional code and hospital chart number) for singleton live vaginal births with a nonbreech presentation at the gestational age of 37 or more completed weeks and a birth weight between 2,500 and 4,000 g during fiscal years 1991/1992 to 1995/1996. Of the births, 31,015 were delivered by vacuum extraction, and 18,727 were delivered by forceps. Compared with delivery by forceps, the adjusted risk ratios for third-/fourth-degree perineal laceration, intracranial hemorrhage, subdural or cerebral hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, cephalhematoma, and neonatal in-hospital death were 0.48 (95% confidence interval: 0.45, 0.50), 1.28 (95% confidence interval: 0.73, 2.25), 0.97 (95% confidence interval: 0.49, 1.93), 0.99 (95% confidence interval: 0.16, 5.97), 5.44 (confidence interval: 1.26, 23.43), 2.02 (95% confidence interval: 1.89, 2.16), and 0.93 (95% confidence interval: 0.32, 2.70), respectively. The authors conclude that vacuum extraction causes less maternal trauma but may increase the risk of cephalhematoma and certain types of intracranial hemorrhage (e.g., subarachnoid hemorrhage).

Developmental outcome of infants with intracranial hemorrhage or ischemic stroke after treatment with extracorporeal membrane oxygenation in the newborn period

Back~,round. Extracorporeal membrane oxygenation (ECMO) is a technology that utilizes cardiopulmonary bypass to treat newborn infants with severe respiratory failure. The most serious complication of ECMO is the occurrence of intraeranial hemorrhage or ischemic stroke. This study was performed to compare the long term developmental outcome associated with these two types of perinatal brain injury after ECMO. Methods. Cognitive and motor skills were assessed using the Bayley Scales of Infant Development at 2 years of age (MDI= Mental Developmental Index, PDI=Psyehomotor Developmental Index). The Peabody Infant Motor Scales (DMQ=Developmental Motor Quotien0 was used to further evaluate gross motor (GM) and fine motor (FM) skills. (All scores: mean=100+_SD= 15) Results. 71 infants treated with ECMO over a five year period were evaluated at 2 years of age. 15% of these infants had some type of intracranial hemorrhage or ischemic stroke. Infants with a hemorrhage did not differ significantly in cognitive skills (MDI--89+ 16 versus 91• or motor skills (PDI--92• versus 86-2.17) from those infants without a hemorrhage or infarction. However, infants with an ischemic stroke had significantly lower scores than those infants without an infarction (MDI=63+16 versus 90• PDI=58• versus 87+17; p<.001 for both). Both gross and fine motor skills were severely delayed in these children (DMQ-GM= 48-&36 versus 88_-t.15, DMQ-FM=46+ 28 versus 75+12; p<.001 for both). Conclusions. These data indicate than an intraeranial hemorrhage alone does not necessarily predict poor cognitive or motor outcome in infants treated with ECMO. An ischemic stroke, however, is associated with poor developmental outcome. Improved bedside monitoring of cerebral blood flow and oxygen delivery is needed to be able to detect when ischemie damage is occurring during treatment with ECMO.

Complicaciones de la hemorragia intracraneal en recién nacidos a término

The incidence of various types of intracranial hemorrhage is different in full-term infants than those that occur in small premature infants. Consequently, the complications are for the most part different. The previous article described the types of hemorrhage occurring at term, as well as their signs and symptoms. This brief review will focus on the complications that may arise from these. Examples are given of superficially occurring hemorrhages and of those that arise deeper in the parenchyma of the brain. The actual bleed is the acute event that may become subacutely complicated by virtue of its position or by extension. This occurs as part of the natural process or as a result of injudicious intervention. There follow chronic complications: cerebral palsy, intellectual deficit and seizure disorder which remain for the patient's lifetime.

INTRACRANIAL HEMORRHAGE: DIAGNOSIS AND EMERGENCY MANAGEMENT

Intracranial hemorrhages are an important cause of acute neurologic disease presenting in the emergency setting. To optimize outcome, it is important that the physician quickly recognize intracranial hemorrhages. To minimize mortality and neurologic morbidity, it is often necessary to initiate urgent therapy in the emergency rooms and to obtain neurosurgical consultation in order to pursue early surgical therapy. This article discusses the recognition and early treatment of the various types of intracranial hemorrhages.

The dilemma of discontinuation of anticoagulation therapy for patients with intracranial hemorrhage and mechanical heart valves.

Anticoagulant-related hemorrhage occurs with an incidence of approximately 1%/patient-year in mechanical heart valve recipients. Intracranial hemorrhage poses a difficult clinical choice; continuing anticoagulation therapy may enlarge the volume of the hemorrhage, early reinstitution of anticoagulation therapy may predispose patients to recurrence, and reversal of anticoagulation therapy may place patients at risk for systemic embolization involving the brain. The risk of embolization may also be greater for patients with atrial fibrillation, cage-ball valves in the mitral position, and reduced ventricular function. This dilemma exists because of a lack of data for a large series of patients. We reviewed the medical records and neuroimaging studies for a consecutive group of patients admitted with intracranial hemorrhage and mechanical heart valves. We reviewed neurological presenting data, cardiac risk factors for systemic embolization (atrial fibrillation, enlarged atrial chambers, reduced ventricular function, and the type and location of the metallic valve), and hospital management. We studied 39 patients with intracranial hemorrhage and mechanical heart valves (median age, 69 yr). Four patients had experienced previous transient ischemic attacks or minor strokes. The time from valve replacement to intracranial hemorrhage ranged from 2 months to 19 years (median, 6 yr). The type of intracranial hemorrhage was acute subdural hematoma (n = 20), lobar hematoma (n = 10), subarachnoid hemorrhage (n = 4), cerebellar hematoma (n = 3), or basal ganglionic hematoma (n = 2). Thirteen patients died within 2 days of admission. All 26 surviving patients received fresh frozen plasma and vitamin K. Fifteen patients underwent evacuation of acute subdural hematoma, and in one patient an anterior communicating aneurysm was clipped. The duration of discontinuation of anticoagulation therapy varied from 2 days to 3 months (median, 8 d). None of the patients developed transient ischemic attacks, ischemic strokes, valve thrombosis, or systemic embolization. No recurrence of intracranial hemorrhaging was observed during hospitalization and reinstitution of anticoagulation or antiplatelet agent administration. Temporary interruption of anticoagulation therapy seems safe for patients with intracranial hemorrhage and mechanical heart valves but without previous evidence of systemic embolization. For most patients, discontinuation for 1 to 2 weeks should be sufficient to observe the evolution of a parenchymal hematoma, to clip or coil a ruptured aneurysm, or to evacuate an acute subdural hematoma.

Histopathological study of major intracranial arteries in premature infants related to intracranial hemorrhage.

The incidence of various types of intracranial hemorrhage (ICH) and the microscopic appearance of the major intracranial arteries were investigated in 112 premature infants, and related to birth weight. In none of the premature newborns, regardless of the presence of ICH, did the intracranial arteries contain true elastic elements. The wall of the basilar artery was significantly thinner in all premature infants with any kind of ICH. Within each body-weight group those with ICH had intracranial arteries with fewer reticular fibers than did those without ICH. The density of the reticular fibers in the cerebral arteries of premature neonates without ICH did not seem to depend on maturity. The authors believe that the hypoplasia of the major intracranial arteries and the reticular fiber deficiency most probably involve the whole vascular system of the brain and may predispose to hemorrhage.

Correlation of early neurologic outcome and CT findings in neonatal brain hypoxia and injury.

Ninety cranial computed tomography scans were analyzed in 56 high risk neonates (30 premature and 26 term). Neurologic follow-up averaging 18 months in length was obtained. Four types of intracranial hemorrhage were seen: subdural (with three subtypes), germinal matrix--intraventricular, primary subarachnoid, and cerebellar. The four types differ in age of occurrence, mechanism, and prognosis. Mild periventricular low density was present in most of the neonates and did not correlate with future neurologic deficit. Severe periventricular leukomalacia (16%) and cortical low density zones (12%) at 40 weeks did correlate with abnormal motor and mental development.