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Introduction: Endovascular treatment (EVT) is effective against acute cerebral large vessel occlusion (LVO). However, it has been associated with a high incidence of intracranial hemorrhage (ICH). Because the incidence of ICH and prognostic impact of ICH were not scrutinized in general patients, we investigated the impact of ICH after EVT on functional outcome at 90 days in patients with acute LVO. Methods: RESCUE-Japan Registry 2 was a multicenter registry that enrolled 2,420 consecutive patients with acute LVO within 24 h of onset. We analyzed 1,281 patients who received EVT and compared the functional outcomes between those with and without ICH (ICH and no-ICH groups, respectively) within 24 h after EVT. We explored the factors associated with ICH and prognostic impact of symptomatic ICH (SICH) among patients with ICH. We estimated the adjusted odds ratios (ORs) for good functional outcome as modified Rankin Scale scores 0–2 and mortality. We also explored the prognostic impact of symptomatic ICH (SICH) among patients with ICH. Results: ICH occurred in 333 patients (26.0%). Several factors such as perioperative edaravone, stent retriever, and baseline glucose were associated with development of ICH within 24 h. A good outcome was observed in 80 (24.0%) and 454 (47.9%) patients in the ICH and no-ICH groups, respectively, and the adjusted OR was 0.3 (95% confidence interval [CI] = 0.2–0.5, p < 0.0001). Incidence of mortality within 90 days was not significantly different between the groups (adjusted OR 1.2; 95% CI: 0.7–1.9, p = 0.5). SICH was observed in 36 (10.8%) of 333 patients with ICH, and the good outcomes were 8.3 and 25.9% in patients with SICH and asymptomatic ICH (AICH), respectively (p = 0.02). Mortality at 90 days was 30.6 and 7.1% in patients with SICH and AICH, respectively (p < 0.0001). Conclusions: The functional outcomes at 90 days were significantly worse in patients who developed ICH after receiving EVT for acute LVO, but the mortality was generally similar. [ABSTRACT FROM AUTHOR]

We report the case of a 38-year-old male with a previous history of severe cranial trauma and subsequent large subdural and subarachnoid hemorrhage on whom an emergent hematoma evacuation was performed with a good outcome and follow-up. Despite a good clinical evolution, the patient experienced a further intracranial hematoma 18 years after the trauma, with severe aphasia and mild right hemiparesis. After complete etiological study, two cranial pseudoaneurysms were observed in the cerebral angiography. Endovascular treatment was successfully completed, achieving full embolization without complications. No rebleeding was detected during follow-up. The patient had a good clinical outcome at 3 months and achieved complete recovery. Cranial pseudoaneurysm rupture is a rare cause of intracerebral hemorrhage, especially if the trauma occurs years before the bleeding. [ABSTRACT FROM AUTHOR]

Background: The incidence of non-traumatic intracranial haemorrhage among neonates is less than among adults. However, the outcomes are generally poor, with high rates of morbidity and mortality. Non-traumatic intracranial haemorrhage can cause a sudden increase in intracranial pressure, requiring emergency craniotomy for evacuation. Methods: We report 4 cases following craniotomy for non-traumatic acute intracranial haematoma in very young children. The surgical technique and postoperative course are discussed, with emphasis on dural repair to avoid resistant pseudomeningocele. Results: Despite successful management of the acutely raised intracranial pressure, all patients afterwards developed tense pseudomeningoceles and required formal dural repair. This led to a change in institutional practice and modifications to the surgical technique. Conclusion: The authors highlight the postoperative occurrence of resistant pseudomeningoceles in young children after clot evacuations and leaving the dura open. They describe the surgical procedures to avoid these pseudomeningoceles. [ABSTRACT FROM AUTHOR]

>bold<>italic/italic<>/bold< Hemorrhagic transformation (HT) is a major complication of acute ischemic stroke (AIS). Serum albumin is known for its neuroprotective effects and is a marker of improved AIS patient outcomes. However, it is not known whether there is a relationship between serum albumin and HT. >bold<>italic/italic<>/bold< AIS patients admitted to the Department of Neurology of West China Hospital from 2012 to 2016 were prospectively and consecutively enrolled. Baseline characteristics were collected. HT during hospitalization was diagnosed by brain imaging. Multivariate logistic regression analysis was performed to determine the relationship between serum albumin and HT. Confounding factors were identified by univariate analysis. Stratified logistic regression analysis was performed to identify effect modifiers. >bold<>italic/italic<>/bold< A total of 1996 AIS patients were recruited, of whom 135 (6.8%) developed HT. Serum albumin negatively correlated with HT. Patients in the upper serum albumin tertile (42.6–54.1 g/L) had a 46% lower risk of HT than patients in the lower tertile (19.3–39.1 g/L) after adjustment for potential confounders (OR 0.54, 95% CI 0.29–0.99, >italic/italic< = 0.04). Risk of HT decreased stepwise with higher serum albumin tertile (>italic/italic< for trend = 0.04). There was a significant interaction between serum albumin and age (>italic/italic< = 0.02), with no significant correlation between serum albumin and HT in patients over 60 years of age. >bold<>italic/italic<>/bold< Higher serum albumin is associated with lower HT risk in a dose-dependent manner in AIS patients younger than 60 years. [ABSTRACT FROM AUTHOR]

Background: Neurogenic pulmonary edema (NPE) is characterized by acute respiratory distress triggered by acute, severe compromise of the central nervous system (CNS). This review aims at summarizing and discussing recent and previous findings about the type and frequency of CNS triggers of NPE, pathogenesis, diagnosis, treatment, and outcome of patients experiencing NPE. Key Messages: NPE is diagnosed in the presence of pink, frothy sputum, pulmonary edema, bilateral opacities on X-ray, PaO2:PiO2 <200 mm Hg, acute CNS compromise with increased intra-cranial pressure, rapid resolution within 48–72 h, and the absence of alternative causes of respiratory distress. The most common cerebral triggers of NPE include enterovirus-71-associated brainstem encephalitis, subarachnoid bleeding, intracerebral bleeding, traumatic brain injury, epilepsy, ischemic stroke, intracranial/spinal surgery, multiple sclerosis, electroconvulsive therapy, subdural/epidural hematoma, intoxication, hypoxia, and hydrocephalus. Simultaneous treatment of CNS and pulmonary compromise is required. Cerebral treatment involves infectiologists, neurologists, and neurosurgeons. Pulmonary treatment is mainly supportive, but if ineffective, extracorporeal membrane oxygenation or thermodilution are alternative options. Applying intensive care measures, the outcome of NPE has improved. Summary: CNS-disease triggering NPE is more variegated than anticipated. Delineation of NPE from other pulmonary or cardiac conditions mimicking NPE is crucial to take appropriate measures and improve the outcome of these patients. [ABSTRACT FROM AUTHOR]

Hypertensive intracerebral hemorrhage (HICH) is a type of acute cerebrovascular disease with high rates of incidence, mortality, and disability, and is a cause of more frequent instances of secondary brain insult (SBI). In-depth study of the pathogenesis and pathophysiological mechanisms of SBI in HICH contributes to its clinical treatment and prognosis. This article presents a brief summary of the pathophysiological mechanism and treatment of SBI after HICH. [ABSTRACT FROM AUTHOR]

Background: Chronic antiplatelet therapy in the post-acute phase of non-cardioembolic ischemic stroke is limited by the risk of intracranial hemorrhage (ICH) complications. Methods: We developed an ICH risk score based on the PERFORM trial cohort (n = 19,100), which included patients with a noncardioembolic ischemic stroke or transient ischemic attack, and externally validated this score in one contemporary trial of very similar size and inclusion criteria, the PRoFESS trial (n = 20,332 patients). Outcome was ICH over 2 years. A Cox proportional-hazard regression analysis identified risk factors. Discrimination was quantified with c-statistics and calibration was assessed by comparing predicted and observed ICH risk in PERFORM and PRoFESS. Results: ICH occurred within 2 years in 263 (1.4%) patients in PERFORM trial and in 246 (1.2%) patients in PRoFESS trial. A 13-point score based on 9 items (Intracranial-B 2 LEED 3 S score -- low body mass index, blood pressure, lacune, elderly, Asian ethnicity, coronary artery or cerebrovascular disease history, dual antithrombotic agent or oral anticoagulant, gender) was derived from the PERFORM trial. In PERFORM, the observed 2-year ICH risk varied from 0.75% in low-risk (score ≤ 2) to 2.44% in high-risk patients (score ≥ 5) with an acceptable calibration but a low discrimination both in PERFORM (c-statistic 0.64, 95% CI 0.61-0.68) and on external validation in PRoFESS (0.58, 95% CI 0.55--0.62). Conclusion: The Intracranial-B2 LEED3 S score helps identify patients who are at a high risk of bleeding. However, other variables need to be identified to improve the score (e.g., microbleeds) (Clinical Trial Registration Information ISRCTN66157730). [ABSTRACT FROM AUTHOR]

We report a case of a 7-year-old child with a cranial deformity secondary to a craniotomy for an intracranial hematoma. He suffered from an acute epidural hematoma with a lineal fracture of the right temporal bone following a severe head injury. A large question mark-shaped skin flap with the periosteum and temporal muscle was created for a decompressive craniectomy; however, neither the acute epidural hematoma nor brain swelling was severe, and we performed a small craniotomy compared with the skin flap without a decompressive craniectomy. Eighteen months after the operation, he complained of skull deformity with a mild depression of the forehead. Axial and 3-dimensional computed tomography showed thinness and subsidence of the frontoparietal bone around the replaced bone flap, corresponding to the skin flap with the periosteum defect. We suggest that the periosteum defect following creation of the skin flap during surgery prevented normal growth of the skull, which caused the thinness and subsidence of the frontoparietal bone. Preservation and cooptation of the periosteum should be performed during neurological surgeries in babies and children to prevent skull deformity. [ABSTRACT FROM AUTHOR]

Background: Neutrophilia is associated with brain injury and is frequently accompanied by eosinopenia. Although eosinopenia is a poor prognostic indicator for various diseases, its significance in intracranial events has not been investigated. Methods: We retrospectively included 22 pediatric patients (≤18 years old) who experienced traumatic intracranial hemorrhage between 2002 and 2015. Patients were divided into two groups based on the presence or absence of eosinopenia on admission, i.e. the proportion of eosinophils to total white blood cells <1.0%. Results: The mean Glasgow Coma Scale score was marginally lower in the eosinopenia group (14.1 vs. 12.0, p = 0.06). The mean Glasgow Outcome Scale-Extended (GOSE) score was significantly lower in the eosinopenia group (7.5 vs. 5.7, p = 0.02), and the mean length of hospital stay tended to be longer in patients with eosinopenia (7.8 vs. 28.4, p = 0.10). In our multivariate logistic regression analysis, eosinopenia was the only significant risk factor for poor outcome (GOSE score 1-7, OR 29.7, p = 0.03) and prolonged hospital stay (>2 weeks, OR 7.1, p = 0.047). Conclusion: These results demonstrate the significance of eosinopenia as a novel prognostic factor in traumatic intracranial hemorrhage in children. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Few case reports of encapsulated intracranial hematoma (EIH) exist, and the mechanisms underlying the onset and enlargement of EIH remain unclear. Here, we report on a 39-yearold woman with an EIH that repeatedly hemorrhaged and swelled and was ultimately surgically removed. In June 2012, the patient visited her local doctor, complaining of headaches. A magnetic resonance imaging (MRI) scan identified a small hemorrhage of approximately 7 mm in her right basal ganglia, and a wait-and-see approach was adopted. Six months later, her headaches recurred. She was admitted to our department after MRI showed tumor lesions accompanying the intermittent hemorrhaging in the right basal ganglia. After admission, hemorrhaging was again observed, with symptoms progressing to left-sided hemiplegia and fluctuating consciousness; thus, a craniotomy was performed. No obvious abnormal blood vessels were observed on the preoperative cerebral angiography. We accessed the lesion using a transcortical approach via a right frontotemporal craniotomy and removed the subacute hematoma by extracting the encapsulated tumor as a single mass. Subsequent pathological examinations showed that the hematoma exhibited abnormal internal vascularization and was covered with a capsule formed from growing capillaries and accumulating collagen fibers, suggesting that it was an EIH. No lingering neurological symptoms were noted upon postoperative follow-up. This type of hematoma expands slowly and is asymptomatic, with reported cases consisting of patients that already have neurological deficits due to progressive hematoma growth. Our report is one of a few to provide a clinical picture of the initial stages that occur prior to hematoma encapsulation. [ABSTRACT FROM AUTHOR]

Background: Epidural hematoma (EDH) is the most common form of intracranial bleeding following head trauma in pediatric patients. It may develop into a life-threatening pathology, requiring an immediate neurosurgical intervention. However, due to an increasing number of posttrauma CT scans most pediatric EDH patients can be treated conservatively, because of minor dimensions of the clot and the possibility of quick control scanning. Aim: Evaluation of distinct strategies in the treatment of EDH patients in our department between January 2007 and December 2012. Results: During this period a total number of 221 patients with EDH were enrolled in the study. Seventy-seven of them (35%) underwent surgical procedures. One hundred and forty-four patients (65%) were treated conservatively. The dominating age group among nonsurgical patients was 0-4 years (85 cases, 61% of the nonsurgical group). In most of these cases a small epidural blood collection with inconsiderable dynamics was observed. Twenty-one patients from this age group (20%) were treated operatively. Among older children (5-18 years) surgical treatment was implemented in 56 (49%) cases. Conclusions: (1) EDH may be successfully treated conservatively with the use of control CT scans. (2) Smaller blood clots dominate in younger patients. (3) Surgical intervention is required more commonly in older patients. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Thrombolytic treatment is of proven benefit in acute ischemic stroke. The term cerebral small vessel disease (SVD) refers to a group of pathological processes affecting the small arteries, arterioles, venules and capillaries of the brain, and encompasses both ischemic and hemorrhagic lesions. Lacunar stroke, an expression of SVD, is associated with an unfavorable long-term prognosis for an increased risk of death, recurrent stroke and cognitive dysfunction. Nonetheless, the efficacy and safety of intravenous thrombolysis in patients with lacunar stroke has been debated for two main reasons. First, among all ischemic stroke subtypes, lacunar strokes have been considered the most benign. Second, the efficacy of a pharmacological reperfusion has been questioned given the absence of a clear demonstration of thrombosis. Intracerebral hemorrhage (ICH) remains the most devastating and unpredictable complication related to thrombolysis, and neuroimaging evidence of SVD is nowadays recognized as one of the risk factors for thrombolysis-related ICH. Summary: This review is structured in two parts dealing with the questions whether or not patients with lacunar stroke or SVD should be treated with thrombolysis. In the first part, we revised the literature concerning the efficacy of thrombolysis in patients with acute lacunar stroke. We included two types of studies: those in which patients with lacunar stroke receiving recombinant human tissue plasminogen activator (rt-PA) were compared with lacunar stroke patients receiving placebo, and those in which a comparison was made among different stroke subtype patients treated with rt-PA. In the second part, we reviewed the available evidence on the risk of ICH in patients treated with thrombolysis for ischemic stroke and presenting with neuroimaging evidence of SVD such as white matter lesions (WML) and cerebral microbleeds. We further questioned the extent to which WML and microbleeds could be used as reliable predictors of ICH and the feasibility of their detection in an acute setting. Key Messages: The studies herein reviewed show that thrombolysis is an effective treatment in acute lacunar stroke, and that the presence of cerebral SVD increases the risk of ICH during thrombolysis but does not represent an absolute exclusion criterion. In the future, it can be assumed that the use of MRI on a routine basis might lead to a better quantitative definition of SVD and its correlates, permitting a step forward in thrombolysis decision making. © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The incidence of catastrophic head injury in American football is at a 30-year high; over 90% of these injuries are secondary to subdural hemorrhage (SDH). At the present time, it is unknown why the incidence of this devastating injury complex continues to rise. Because previous investigations have documented deficiencies in the process of equipment certification at youth and high-school levels, we sought to investigate the adequacy of headgear worn by two athletes who suffered contact-related SDH on the football field and presented to Vanderbilt Children's Hospital between 2009 and 2011. Helmets worn by the struck players at the time of collision (Medium Schutt Air Advantage 7888 and Large Schutt Air XP 7890) were obtained for formal biomechanical testing at a National Operating Committee on the Safety of Athletic Equipment (NOCSAE)-certified facility. Both helmets were found to be compliant with a modified version of the NOCSAE standard ND002-11m12. Based on the aforementioned tests, it can be concluded that headgear worn by both players who suffered SDH was not substandard, as defined by contemporary helmet quality assurance criteria. To the authors' knowledge, this is the first published report of helmet testing following sports-related helmeted collisions resulting in severe traumatic intracranial injuries. © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Purpose: One complication of thrombolysis is intracranial hemorrhage (ICH). We investigated whether treatment with tissue plasminogen activator (t-PA) for ischemic infarction results in a higher risk of ICH in patients with kidney dysfunction, who are predisposed to treatment complications due to their bleeding tendency. Methods: A total of 297 patients given thrombolytic therapy for ischemic stroke were classified into 2 groups on the basis of their estimated renal glomerular filtration rate (eGFR). The outcome measures included the incidence of ICH and modified Rankin scale scores at 1 month and 1 year. Results: ICH was more common in the renal dysfunction group (23 vs. 12.5%). Nevertheless, multivariate logistic regression showed that the odds of ICH were not high in the group with low eGFR. Also, eGFR values <60 ml/min/1.73 m2 did not predict the odds for functional dependence or death at 1 month and 1 year. Conclusion: After adjusting for confounding factors, the odds ratio for ICH was not higher in intravenous t-PA-treated stroke patients with renal dysfunction. A trend to the occurrence of ICH among these patients, however, was noted. Renal dysfunction does not predict the odds for functional dependence or death at 1 month and 1 year. © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Intravenous (IV) alteplase is not currently recommended in octogenarian patients, and the benefit/risk ratio of endovascular (intra-arterial, IA) therapy remains to be determined. The aim of this study was to determine the impact of a combined IV-IA approach in octogenarians. Methods: From a single-centre interventional study, we report age-specific outcomes of patients treated by a combined IV-IA thrombolytic approach. Patients ≥80 years with documented arterial occlusion treated by conventional IV thrombolysis constituted the control group. Results: Among 84 patients treated by the IV-IA approach, those ≥80 years (n = 25) had a similar rate of early neurological improvement to that of patients <80 years, whereas the 90-day favourable outcome rate was lower in octogenarians (adjusted odds ratio, OR, 0.21; 95% confidence interval, CI, 0.06-0.75). No difference in symptomatic intracranial haemorrhage was observed whereas a higher rate of 90-day mortality (adjusted OR, 3.27; 95% CI, 0.76-14.14) and asymptomatic intracranial haemorrhage (adjusted OR, 6.39; 95% CI, 1.54-26.63) were found in patients ≥80 years old. Among octogenarians, and compared to IV-thrombolysis-treated patients (n = 24), patients treated by the IV-IA approach had a higher rate of recanalization (76 vs. 33%, p = 0.003) associated with increased early neurological improvement (32 vs. 8%, p = 0.07). Although there was a higher rate of asymptomatic intracranial haemorrhage (44 vs. 8%, p = 0.005) observed in the IV-IA group, no difference existed in symptomatic intracranial haemorrhage rates and 90-day favourable outcome. Conclusion: The IV-IA approach in octogenarians was associated with lower efficacy at 3 months and higher mortality and asymptomatic haemorrhagic complications than in patients <80 years old. Definite recommendations cannot be given, but an endovascular approach may cause more harm than positive effects in patients over 80 years and should not be considered outside an approved protocol. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

To investigate the clinical features of infancy traumatic brain injury (TBI) and the prognostic value of the Trauma Infant Neurologic Score (TINS), infants <2 years of age with TBI who were admitted from 2000 to 2007 were retrospectively studied. Fifty-six patients with a mean age of 13.3 ± 6.5 months (range = 2-24) were identified. The clinical diagnoses, in terms of the severest injury, included scalp hematomas (n = 2), skull bone fractures (n = 3), epidural hematomas (n = 21), subdural hematomas (n = 14), cerebral contusion and laceration (n = 4), intracerebral hematomas (n = 7), traumatic subarachnoid hemorrhage (n = 2), diffuse axonal injury (n = 2) and diffuse brain swelling (n = 1). The most common clinical presentations were vomiting (66.1%), paleness (55.4%), irritability (37.3%), pupillary abnormalities (35.7%) and altered consciousness (32.1%). The mechanism of injury included falls (n = 41), vehicle accident (n = 9), abuse (n = 4) and unknown (n = 2). The TINS score ranged from 1 to 10 with a mean of 3.6 (SD = 2.4) in the whole patient cohort. The Children's Coma Scores (CCS) on admission were 13-15 (n = 31), 9-12 (n = 7) and 3-8 (n = 18). Thirty-nine of the infants were operated on and the other 17 infants were treated nonsurgically. Forty-eight patients (86%) were followed up for a period of 1-8 years (mean = 4.4) after discharge. In the followed-up patient cohort, the mean TINS score at admission was 3.8 ± 2.5. The total clinical outcome, according to the Glasgow Outcome Scale (GOS), was: 37 (77.1%) good recovery, 4 (8.3%) moderately disabled, 1 (2.1%) vegetative and 6 (12.5%) dead. For those who were operated on the outcome was: 25 (78.1%) good recovery, 4 (12.5%) moderately disabled and 3 (9.4%) dead, and for those who were not operated on: 12 (75.0%) good recovery, 1 (6.3%) vegetative and 3 (25.0%) dead. At two years of follow-up, the GOS included 34 (73.9%) good recovery, 3 (6.5%) moderately disabled, 2 (4.3%) severely disabled, 1 (2.2%) vegetative and 6 (13.0%) dead. Statistical tests revealed that the TINS scores were highly associated with the GOS. Higher TINS scores resulted in worse clinical outcome. The CCS scores were also to some degree associated with the GOS score. However, the CCS score on admission was not as discriminating as TINS, predicting only the best and worst outcome in our series. Our study showed that the clinical features of TBI in infants were different from those seen in adults regarding both the distribution of the pathology type and the clinical presenting symptoms. We found that the TINS scoring system is useful for predicting prognosis and outcome in infancy TBI and suggest that it could be routinely used in the infantile population. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine the incidence and clinical correlation of intracranial hemorrhages (ICHs) detected by 3-tesla gradient echo T2*-weighted images after intravenous recombinant tissue plasminogen activator (rt-PA) administration. Methods: We included 43 consecutive patients with anterior-circulation ischemia who underwent MRI studies before and after thrombolysis. Each hemorrhage was classified as a hemorrhagic infarction (HI) or parenchymal hemorrhage (PH) according to the European Cooperative Acute Stroke Study definition. The clinical outcome was defined as an improvement (≥4-point reduction) or deterioration (≥4-point increase) based on a comparison between the initial and the 30-day NIHSS scores. Results: The incidence of ICHs was 58%, and the HI rate was 52%; both were higher than the rates reported in the literature. Most of the patients with HI improved clinically, and these patients had second MRAs that showed recanalization. None of the patients with PH demonstrated improvement. Conclusions: Three-tesla MRI may reveal a higher frequency of HI type hemorrhages than lower-field MRIs, and HI may be a predictor of good recovery by reflecting the presence of recanalization. The rate of PH in our study was low compared to other studies, probably due to the lower dosage of rt-PA. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Intracranial hemorrhage (ICH) is a rare but major cause of death in immune thrombocytopenic purpura (ITP). The authors reviewed data of 1,840 patient with ITP, from 5 pediatric hematology centers in Egypt from 1997 to 2007, to study the incidence and risk factors of ICH. Ten cases of ICH were identified with a median age at presentation of 7.5 years; 4 patients had acute ITP, 2 persistent and 4 chronic. The platelet count was <10 × 109/l in 7 cases, and only 1 patient had a history of head trauma. Seven children were on treatment prior to or at the time of occurrence of ICH and all were treated by pharmacotherapy. Two children died shortly afterwards due to late referral to a specialized center. Our results suggest that treatment does not prevent ICH and that it can occur at any time during the course of the disease. Delayed referral can be considered a risk factor for unfavorable outcome of ICH, highlighting the importance of teaching sessions for patients and their parents to minimize subsequent morbidity and mortality of ICH in children with ITP. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Intracranial intra-arterial calcifications (ICAC) are a common finding on head CT examinations, but their significance is not known. The aim of this study is to determine if a relationship exists between ICAC on head CT and the presence of a high-grade atherosclerotic stenosis on cerebral angiography. Methods: This was a retrospective study of 108 consecutive patients admitted to the stroke service at Parkland Hospital in Dallas, Tex., USA. Each patient had undergone a head CT and catheter-based angiographic study to meet the inclusion criteria. Demographic information was recorded along with CT imaging data in regards to the amount of calcification. Angiographic images were reviewed independently, and a comparison was made to determine if calcification was predictive of finding a high-grade stenosis on angiography. Results: A total of 108 consecutive patients with a mean age of 56 ± 12 years were studied. Of the 540 vessels studied, 65 (12%) were found to have a stenosis of ≥50% on angiography, and 71 (13.1%) were found to have a calcium grade of 3 or 4 on head CT. ICAC appeared to be more common in the anterior circulation compared to the posterior circulation. Patients with grade 3 or 4 calcification of an intracranial vessel on head CT were more likely to have a stenosis of ≥50% on cerebral angiography. Conclusions: The presence of ICAC on head CT appears to correlate with the presence of an underlying intracranial stenosis on angiography. Further study is required to validate these preliminary findings. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The outcomes after stroke vary considerably between countries, yet the extent of the variation after intracerebral hemorrhage (ICH) remains unknown. This study examines differences in outcomes after ICH in a recent multinational trial, and explores the effect of differences in patient severity and case management for the variations observed. Methods: Factor Seven for Acute Hemorrhagic Stroke was a randomized, multinational, double-blind, placebo-controlled trial conducted between May 2005 and February 2007 at 122 sites in 22 countries. We investigated differences in baseline patient characteristics, case management and clinical outcomes across the 14 highest recruiting countries. Between-country differences in mortality and functional outcomes were examined using regression analysis while adjusting for differences in observed patient severity (case mix) and case management. Results: Eight hundred and one patients had complete data on baseline characteristics, case management and clinical outcomes and were recruited in a country that contributed ≥20 patients to the trial. Significant differences were observed between the countries in unadjusted mortality rates (p = 0.001) and functional outcomes (p = 0.001) at 90 days after ICH onset. When first adjusting for differences in case mix, and secondly differences in case management, the differences in outcomes remained significant, yet the variation between countries was reduced with each level of adjustment. Significant determinants of mortality were age, baseline ICH and intraventricular hemorrhage volume, baseline neurological deficit, smoking status, use of mechanical ventilation, total length of hospital stay, reduction in blood pressure between 1 and 20% during the first 24 h of admission and edema management. Poor functional outcomes were also determined by age, baseline ICH volume and baseline neurological deficit as well as neurosurgical procedures performed and sedation during the first 5 days of admission. Conclusion: Significant global differences exist in the clinical outcomes after ICH, even after comprehensively adjusting for differences in case mix and case management. This is most likely due to unmeasured variation in case mix and case management. Similar research is encouraged in data sets of other multinational stroke trials to further investigate country-level and regional differences in clinical outcomes. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objective: The aim of this investigation was to determine the factors influencing acute intracerebral hemorrhage severity on admission and clinical outcomes at discharge. Methods: Sixty acute stroke hospitals throughout Japan participated in the Japan Standard Stroke Registry Study (JSSRS), documenting the in-hospital course of 16,630 consecutive patients with acute stroke from January 2001 to March 2004. We identified 2,840 adult patients from the JSSRS who had intracerebral hemorrhage. Results: Intracerebral hemorrhage severity on admission was strongly related to age, previous stroke history, and hemorrhage size in a monotone fashion [χ2(9) = 374.5, p < 0.0001]. Drinking history was also predictive of intracerebral hemorrhage severity on admission, but the association was not monotone. Interestingly, intracerebral hemorrhage severity on admission was increased in nondrinking and heavy drinking compared to mild drinking (p < 0.05). Unsuccessful outcome (modified Rankin scale score = 3–6) was related to age, previous stroke history, hemorrhage size, and intracerebral hemorrhage severity on admission [χ2(9) = 830.4, p < 0.0001]. Mortality was related to hemorrhage size, intraventricular hemorrhage, intracerebral hemorrhage severity on admission, and surgical operation [χ2(7) = 540.4, p < 0.0001]. Conclusion: We could find four varied factors associated with intracerebral hemorrhage severity and its outcomes. Interestingly, intracerebral hemorrhage severity tended to be greater in nondrinking and heavy drinking than mild drinking. Additionally, surgical operation decreased intracerebral hemorrhage mortality. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Fetal/neonatal alloimmune thrombocytopenia (NAIT) results from fetomaternal mismatch for human platelet alloantigens leading to antibody-mediated destruction of fetal platelets. This is one of the most common causes of severe thrombocytopenia in the newborn with an incidence of 1/800–1,000. In the most severe cases, NAIT may result in intracranial hemorrhage and may lead to death or neurologic sequelae. We report a case of fetal hydrocephalus caused by NAIT and discuss the importance of making an accurate prenatal diagnosis to improve the management of the current pregnancy and the outcome of subsequent pregnancies. Screening of female siblings of affected cases is recommended in order to detect at-risk individuals. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

We report a case of prenatally diagnosed intracranial hemorrhage and hydrops in the fetus of a mother with a past history of surgical and medical treatment for gastric lymphoma and having high platelet counts thereafter. To the best of our knowledge, such a complication of maternal thrombocythemia has not been described in the literature. In our opinion, the possible pathophysiology of the disease is based on placental insufficiency due to infarctions and related fetal platelet dysfunction, leading to intracranial hemorrhage with subsequent hydrops fetalis. The trigger in this event appears to be trauma to the maternal abdomen. Certain measures for high-risk mothers such as avoidance of trauma to the abdomen and platelet-lowering medications like interferon-α may be useful for preventing such fetal complications. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Subependymal germinal matrix with intraventricular hemorrhage (GMIVH) is a common complication associated with delivery in preterm neonates but has rarely been observed in the fetus. Clinical and neuroradiological findings of 5 patients who were diagnosed as having fetal GMIVH with prenatal ultrasonographic examinations (US) and MRI, and postnatal MRI were reviewed retrospectively. During a seemingly uneventful pregnancy, fetal GMIVH occurred at approximately 30–33 weeks of gestation, with the absence of any known factor predisposing to fetal hemorrhage. Routine obstetric US revealed an intraventricular lesion in the enlarged ventricles. Prenatal MRI clearly demonstrated parenchymal change such as intracerebral hematoma adjacent to the subependymal and intraventricular hematoma, and periventricular leukomalacia as well as GMIVH. Although patients without parenchymal destruction (hemosiderin deposit alone) had a favorable neurodevelopmental outcome, encephalomalacia and periventricular leukomalacia contributed to long-term neurodevelopmental deficits. Evaluating parenchymal damage with prenatal MRI can therefore help to predict neurodevelopmental prognosis of the fetus with GMIVH. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background/Aims: Central but also peripheral IGF-1 is suggested to play a role in the initiation of puberty as it directly affects GnRH synthesis and release. A possible intermediate in the effects of IGF-1 on puberty might be the adiposity-signaling hormone leptin, whose plasma levels are decreased in food-restricted (FR) rats. Methods: IGF-1 was chronically centrally infused in 23-day-old prepubertal female rats which were either normally fed or 30% FR, and the effects on time of vaginal opening (VO) and plasma leptin levels were monitored. Results: FR treatment postponed time of VO and decreased plasma leptin levels. In normally fed rats centrally infused with IGF-1, time of VO was found to be postponed to the same extent as FR treatment did. The IGF-1 infusion did not affect plasma leptin levels in normally fed animals but increased leptin levels in the FR group compared to controls. Daily food intake was equal between all groups but body weight course was lower in FR rats. IGF-1 treatment did not significantly affect food intake or body weight course. Conclusion: FR treatment delays the moment of vaginal opening to the same extent as observed in normally fed rats that were centrally infused with IGF-1. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

This article represents the recommendations for the management of spontaneous intracerebral haemorrhage of the European Stroke Initiative (EUSI). These recommendations are endorsed by the 3 European societies which are represented in the EUSI: the European Stroke Council, the European Neurological Society and the European Federation of Neurological Societies. [ABSTRACT FROM AUTHOR]

Background: Intracranial haemorrhage (ICH) is the type of stroke associated with the highest death rate, and about 30% of ICH occurs in patients on antithrombotic treatment. This study relates clinical presentations and outcome of ICH patients on oral anticoagulant (OA) or antiplatelet (AP) therapy admitted to 33 Italian emergency departments (ED). Methods: Consecutive patients were enrolled after cranial computed tomography (CT). Primary outcome was the Modified Rankin Scale (MRS) score at 3 months of follow-up. Common descriptive statistics were computed after stratification for traumatic or spontaneous ICH and identification of the anatomical location of bleeding. Multivariate logistic regression was used to assess predictors of death. Results: We recruited 434 patients on AP therapy and 232 on OA. There were 432 spontaneous and 234 traumatic ICH patients. The proportions of AP and OA patients undergoing neurosurgery were 21.8 and 19.4%, respectively, while <30% underwent procoagulant medical treatment. At the 3-month follow-up, the case fatality rate was 42.0%, while disability or death (MRS 3-6) was 68.1%. The odds ratio for death in OA versus AP patients was 2.63 (95% CI 1.73-4.00) in the whole population and 2.80 (95% CI 1.77-4.41) in intraparenchymal event patients. Glasgow Coma Scale, age, spontaneous event and anticoagulant use were found to be predictors of death both in traumatic and spontaneous events. Conclusion: This study confirms the high prevalence of death or disability in OA and AP patients with ICH. As far as the determinants of mortality and disability are concerned, the results of this study might be useful in the clinical management and allocation of resources in the ED setting. The observed low use of procoagulant therapy highlights the need for ED educational programmes to heighten the awareness of available and effective haemostatic treatments. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the respective value of 5 MR sequences to distinguish between stroke patients with and without acute intracerebral hemorrhage (ICH). Methods: MR images obtained ≤6 h after stroke onset of 86 patients (43 ICH, 43 non-ICH) were reviewed by 3 observers who looked for signs of acute ICH on each image set [T1 and T2 gradient echo (GRE), FLAIR, T2-EPI and DWI], presented separately. Results: For the identification of ICH, intraobserver and interobserver concordance were at least κ = 0.95 for all sequences. Of all interpretations, 7 (0.4%) were erroneous, with sensitivity and specificity of FLAIR, T2-EPI and DWI reaching 100%; GRE sensitivity and specificity were 100% and 95–97.5%, respectively; T1 sensitivity and specificity were 97.3–100% and 97.4–100%, respectively. All 4 patients misclassified on one pulse sequence were correctly classified on all the other sequences. Conclusion: In the setting of acute stroke, each of the 5 studied sequences enables ICH and non-ICH patients to be distinguished with high sensitivity and specificity. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Malignancy potential of pleomorphic xanthoastrocytomas (PXAs) has rather been an underestimated reality. We report the case of a 13-year-old boy who presented with signs of increased intracranial pressure. The child had been epileptic since the age of 2. Computed tomography and magnetic resonance scans revealed a huge left frontal mass. At surgery, a subtotal excision was accomplished. Histopathological diagnosis was anaplastic PXA (grade III; WHO, 2000). The tumor showed an increased mitotic index and minimal endothelial proliferation. The patient died 3.5 months later due to a fatal intracranial hemorrhage. A review of the entire PXA literature revealed 15 well-documented cases of PXA with subsequent malignant transformation and 11 cases of primary anaplastic PXA. The prognosis was grim for both subsets of patients. Anaplastic PXAs clearly represent the transition between the original PXA concept and lipidized giant-cell glioblastoma. Copyright © 2004 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background and Purpose: Intracranial hemorrhage (ICH) constitutes an important subtype of stroke. In a prior study, we found that the city of Changsha, People’s Republic of China, not only had a high incidence of stroke, but also had almost the highest incidence of cerebral hemorrhage. To provide information for preventing and managing ICH, we undertook this study supervising and determining the annual first-ever average incidence of cerebral hemorrhage from 1986 to 2000 in Changsha. Methods: In January 1986, people from 6 well-defined communes in the Kai-fu district in Changsha were selected as the study population. Since 1991, we added another 18 well-defined communes of the same district. Data on these residents were obtained from the census register of the local administrative office. Persons who had a history of stroke were excluded from our study at the beginning. Every year, we checked up on the population and carried out door-to-door inquiries to verify the new cases of ICH and stroke. If the patients were diagnosed in hospital, as many as possible were examined with CT and/or MRI. The incidence rate adjusted to the World population in 1985 for age and sex, as well as the prevalence of risk factors were calculated. Results: An accumulative total of 551,163 people were supervised in 15 years (from 1986 to 2000); the annual average incidences of stroke and ICH were 236.6/100,000 (adjusted rate: 154.7) and 131.0/100,000 (adjusted rate: 73.1), respectively. From 1986 to 2000, the total annual average rate of stroke confirmed by CT and/or MRI in Changsha was 70.8%, and for ICH it was 64.7%. The incidences of stroke and ICH confirmed by image analysis were 167.5 (adjusted rate: 110.8) and 84.7 (adjusted rate: 55.1), respectively. The mean annual mortality rate of ICH was 78.3/100,000 (adjusted rate: 49.3) and that of stroke was 124.5/100,000 (adjusted rate: 97.0). The percentage of ICH among stroke cases was 55.4%. Among patients with ICH, 79.8% had hypertension, 30.6% had cardiovascular disease, 7.6% had diabetes mellitus, and 12.5% had an abnormal high level of lipid. Among patients with other subtypes of stroke apart from ICH, the percentages were 76.6, 40.6, 15.5, and 22.5%. Conclusions: The incidence of ICH in Changsha is very high, so is the proportion of ICH among all stroke cases. Changsha is an area with a high incidence of ICH in the world. Hypertension is the prominent risk factor. The study demonstrated the importance of ICH as a significant subtype of stroke.Copyright © 2004 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background and Purpose: Chronic alcohol intake is considered to be a risk factor for spontaneous intracranial hemorrhage (SICH). However, there is a lack of objective data in this field. The aim was to assess its role in hemorrhagic stroke objectively and to evaluate its correlation with the elevation of γ-glutamyltransferase (GGT) plasma levels. The reliability of patients’ anamnestic data concerning alcohol intake was also assessed. Methods: Laboratory assessment of the plasma carbohydrate-deficient transferrin (CDT) level was performed in 105 SICH patients and in a control group of 105 patients with dorsalgia. All patients were treated at the Clinic of Neurology, Faculty Hospital, Olomouc, Czech Republic. GGT plasma level values and anamnestic data concerning alcohol consumption were also analyzed. χ2 tests were applied when assessing statistical significance. Results: The CDT test was positive in 25.7% of SICH patients versus 7.6% of control group subjects (p = 0.0008). GGT plasma levels were elevated in 44.4% of SICH patients with a positive CDT test versus 25.6% of patients with a negative one. The GGT test is not reliable in the detection of alcohol intake when compared with the CDT test (p = 0.71). Only 13.0% of SICH patients with a positive CDT test (subgroup 1) stated regular and high consumption of all types of alcoholic beverages. Another 26.1% of these patients stated regular daily consumption of more than 1 liter, and 47.8% of them stated less than 1 liter of beer, with uncertain data concerning wine and spirits intake. Thirteen percent of subgroup 1 patients denied alcohol consumption altogether. Conclusions: Chronic alcohol consumption is at least one of several risk factors in one fourth of SICH patients in the Olomouc region of the Czech Republic. The CDT test is the most sensitive method to diagnose chronic alcohol consumption, and it is superior to the examination of GGT and the evaluation of patients’ anamnestic data. [ABSTRACT FROM AUTHOR]

We performed a retrospective analysis of 79 patients with cerebral sinus venous thrombosis, who were treated with a fixed regimen of dose-adjusted intravenous heparin, to determine predictors of a fatal course. The parameters investigated were the state of consciousness and the presence of intracranial haemorrhage (ICH) at the start of heparin treatment, involvement of the internal venous system, mean delay from initial symptom to stupor or coma and from initial symptom to hospital admission, focal neurological deficits, mean intracranial circulation time (ICT) on conventional angiography, and age and sex distribution. Mortality rate was 10% in this series (8/79). There was a strong link between the outcome and the level of vigilance: 53% of the patients with stupor or coma at the start of the heparin therapy died (8/15), whereas all of the 64 patients with no more than mildly impaired vigilance survived (p < 0.00001). Furthermore, mean age and mean ICT were significantly higher in the group of patients who died. There was a statistical trend (p = 0.056) for ICH to be more frequent in cases with fatal outcome, but there was reason to assume that ICH represented an epiphenomenon of a severe course rather than an independent predictor. Other investigated parameters were not linked with a fatal outcome. [ABSTRACT FROM AUTHOR]

Hemophilia is a rare disorder, and an uncommon cause of intracranial hemorrhage in neonates. We present 2 patients with hemophilia A, who presented with massive subdural hemorrhages on day 5 and day 4 postpartum. Both were taken urgently to surgery without a diagnosis of hemophilia being established. Neither patient had a family history of hemophilia, and both were born following difficult deliveries. The activated partial thromboplastin time (APTT) was normal in patient No. 1 (subsequent factor VIII level 10%). In patient No. 2, the APTT was slightly prolonged, but initially interpreted as being within the normal range for age (subsequent factor VII level of <1%). Patient 1 rebled, required a second operation, and had a poor outcome. Patient 2 was given prophylactic fresh frozen plasma, and made a good recovery. Factor VIII assay should be performed in all term male babies presenting with intracranial hemorrhage. In urgent circumstances, prophylactic clotting therapy should be administered during surgery to prevent postoperative bleeding in an undiagnosed hemophiliac.Copyright © 2001 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Massive intracranial hemorrhage, no history of trauma and radiographic findings that were initially interpreted as linear parietal fractures raised the possibility of nonaccidental trauma in 2 infants. Both had severe coagulopathy, 1 due to hemorrhagic disease of the newborn (vitamin K deficiency) and the other due to disseminated herpes simplex virus infection. Both infants died. At autopsy, the parietal bone abnormalities were not fractures, but proved to be an anomalous suture in 1 and a connective tissue fissure in the other.Copyright © 2001 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Rapid resolution of acute subdural hematoma is rare. Delayed traumatic intracerebral hematomas following medical or surgical treatment of increased intracranial pressure have also been reported. Coexistence of a quickly resolving acute subdural hematoma and a delayed traumatic intracerebral hemorrhage has not been reported before. A 13-month-old boy was admitted to our emergency department after a car accident. On CT, a thin acute subdural hematoma on the right frontotemporal region and a small epidural hematoma on the left frontal region could be seen. On 24-hour follow-up CT, the right subdural hematoma was found to be less dense but larger than it had been before. At 36 h after hospitalization, CT showed that the right acute subdural hematoma had completely disappeared; however, a delayed traumatic intracerebral hematoma on the left occipital region was identified. We think that the mechanism involved in the development of a delayed intracerebral hematoma in our case was similar to the one causing delayed traumatic intracerebral hematoma after treatment for increased intracranial pressure. Copyright © 2004 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Electrocardiographic (ECG) changes and wall motion abnormalities of the left ventricle have been observed in patients with severe intracranial hemorrhage. However, ECG evidence of an acute myocardial infarction in this setting is extremely rare but may have important therapeutic consequences. We report the case of a 45-year-old female who became unconscious with respiratory insufficiency after an endoscopic retrograde cholangiopancreaticoscopy with ECG changes consistent of an inferior myocardial infarction with right ventricular involvement. Immediate coronary angiography revealed normal coronaries; however, left ventricular angiography showed extensive wall motion abnormalities predominantly in the anteroseptal region. Immediate cranial computer tomography demonstrated massive intracranial bleeding. Intracranial hemorrhage can be associated in the initial phase with ECG evidence of an acute myocardial infarction. This has to be taken into consideration in the setting of unexplained loss of consciousness or nonresponsiveness of a patient. A rapid diagnostic evaluation has to be initiated to rule out a myocardial infarction and to diagnose intracranial hemorrhage before the use of thrombolytic or anticoagulant therapy.Copyright © 2001 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

In this article the author discusses the study by Ziai and colleagues which compares urokinase (UK) and placebo for the treatment of intraventricular hemorrhage (IVH) in a randomized controlled trial. It notes that the other objective of the study is to determine the association between IVH and intracranial hemorrhage (ICH). It mentions that the result of the study emphasizes that UK or placebo administration for IVH is not associated with ICH elevation.

The article compares the treatment results of stroke patients treated with intravenous Alteplase (rt-PA) ≤80 years with patients older that 80-year-old. It uses the observational data from the Arbeitsgruppe Schlaganfall (ASH) Stroke Database in Germany as of 2003 to 2004. The evaluation shows that elderly patients did not suffer more often intracranial hemorrhage than young patients treated with rt-PA.

Postcraniotomy complications include various types of intracranial hematomas and systemic complications like cardiac and renal failure. This is a report of a patient who underwent a reexploration of a previous craniotomy and then went into status epilepticus, which was controlled, but the patient developed acute renal failure and then a delayed extradural hematoma. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Copyright © 2004 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]