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A feared complication of ischemic cerebrovascular accident (CVA) is hemorrhagic transformation and it increases the length of hospital admissions, results in poor clinical outcomes and increases mortality. This study aims to identify risk factors of hemorrhagic transformation, discuss the pathogenesis of transformation and prognosis of the condition from original studies conducted within the past 10 years. PubMed and EMBASE are the major databases used. Eight articles met the inclusion criteria and are a mixture of retrospective and prospective studies. The sample size ranges from 32 to 1484 patients. Generally, the mechanism of hemorrhagic transformation identified involves the release of reactive oxygen species and metalloproteinase as a result of cerebral ischemia. Metalloproteinase further causes a breakdown of the extracellular matrix, thereby giving rise to the extravasation of cellular components. Some identified risk factors include: age, use of antithrombotic, the subtype of ischemic stroke, the severity of stroke and hypertension. Prognosis is linked to the type of hemorrhagic infarctions according to the European Cooperative Acute Stroke Study II (ECASS II) with patients with either hemorrhagic infarct type 2 (HI2) and parenchymal hematoma type 2 (PH2) having the worst functional outcome.

Background Cerebral venous sinus thromboses (CVSTs) are rare complications of neurosurgical interventions and their management remains controversial as most of cases appears clinically silent. Here, we analyzed our institutional series of patients with CVSTs evaluating clinical and neuroradiological characteristics, risk factors, and outcome. Materials and methods From the analysis of our institutional PACS, we collected a total of 59 patients showing postoperative CVSTs after supratentorial or infratentorial craniotomies. For every patient, we collected demographics and relevant clinical and laboratory data. Details on thrombosis trend were retrieved and compared along the serial radiological assessment. Results A supratentorial craniotomy was performed in 57.6% of cases, an infratentorial in 37.3%, while the remaining were a single cases of trans-sphenoidal and neck surgery (1.7%, respectively). A sinus infiltration was present in almost a quarter of patients, and in 52.5% of cases the thrombosed sinus was exposed during the craniotomy. Radiological signs of CVST were evident in 32.2% of patients, but only 8.5% of them developed a hemorrhagic infarct. CVST-related symptoms were complained by 13 patients (22%), but these were minor symptoms in about 90%, and only 10% experienced hemiparesis or impaired consciousness. The majority of patients (78%) remained completely asymptomatic along the follow-up. Risk factors for symptoms occurrence were interruption of preoperative anticoagulants, infratentorial sinuses involvement and evidence of vasogenic edema and venous infarction. Overall, a good outcome was observed in about 88% of patients at follow-up. Conclusions CVST is a complication of surgical approaches in proximity of dural venous sinuses. CVST usually does not show progression and courses uneventfully in the vast majority of cases. The systematic use of post-operative anticoagulants seems to not significantly influence its clinical and radiological outcome.

Background: Cross-sectional observational study was done in patients with non-traumatic, non-hypertensive intracerebral bleed undergoing cerebral angiography to study its different causes.Material & Methods:Patients with all age groups presenting to the emergency with acute non-traumatic intra-cerebral bleed undergoing cerebral angiography in our institution for a time period of 6 months with a total of 200 patients were included in the study. Data collected were analyzed with respect to causes, distribution of aneurysms. Suspected cases of hypertensive bleed were excluded from the study population.Results:Non-contrast computed tomographic images showed positive findings in the form of either intra-axial/extra-axial bleed or infarct in 95% of patients. However angiographic findings were positive in 52% of patients. Aneurysms were the most common positive angiographic findings (43% cases) with 95% of aneurysms were located in the circle of Willis. Majority of patients had solitary aneurysm while 6% had multiple aneurysms.Conclusions:Among all non-traumatic, non-hpertensive intracerebral bleed aneurysms accounts for majority of the causes. Other causes include intraparenchymal arterio-venous malformations, cerebral venous thrombosis with hemorrhagic infarct and dural arteriovenous malformations (AVM).

62 preterm infants of gestational age between 2837 wks are followed by Neonatology Unit Cerrahpaşa Medical School Istanbul University The infants were evaluated by cranial U S during their first week of them: 19 newborns revealed periventricular leuko malasia 2 had hemorrhagic infarct 6 had ventriculomegaly 1 had interhemispheric cyst and 2 of them were diagnosed as having 5th ventricle Amongst 10 infants having periventricular leukomalasia at one year of age two of them were neurologically handicapped Key words: Cranial Ultrasonography Periventricular Leukomalasid Ventriculomegaly Hemorrhagic Infarct, İ Ü Cerrahpaşa Tıp Fakültesi Yenidoğan Ünitesinde izlenen ve gestasyon yaşları 28 37 hafta arasında değişen 62 preterm bebeğin ilk bir hafta içinde yapılan kraniyal ultrasonografik incelemelerinde 19 olguda periventriküler lökomalazi 2 bebekte hemorajik infarkt 6 yenidoğanda ventriküler eklazi 1 olguda interhemisferik kist ve 2 bebekte de beşinci ventrikül saptandı Birinci yaşın sonunda 10 periventriküler lökomalazili bebeğin 2 sinde nörolojik sekel gözlendi Anahtar kelimeler: Kraniyal Ultrasonografi Periventriküler Lökomalazi Ventriküler Ektazi Hemorajik İnfarkt

A review of hemorrhagic transformation after brain ischemia is presented. The pathological, clinical and radiological aspects are discussed with respect to recent studies. The different pathophysiological mechanisms (reperfusion, vascular rupture, size of infarction, timing of constitution) are reviewed. The role of the utilization of antithrombotic (anticoagulant and thrombolytic) agents in the production of hemorrhagic infarct is presented, and we propose a new classification of hemorrhagic infarct, based on the CT scan patterns.

In ischemic stroke (IS) impairment of the blood–brain barrier (BBB) has an important role in the secondary deterioration of neurological function. BBB disruption is associated with ischemia-induced inflammation, brain edema formation, and hemorrhagic infarct transformation, but the underlying mechanisms are incompletely understood. Dysfunction of endothelial cells (EC) may play a central role in this process. Although neuronal NLR-family pyrin domain-containing protein 3 (NLRP3) inflammasome upregulation is an established trigger of inflammation in IS, the contribution of its expression in EC is unclear. We here used brain EC, exposed them to oxygen and glucose deprivation (OGD) in vitro, and analyzed their survival depending on inflammasome inhibition with the NLRP3-specific drug MCC950. During OGD, EC death could significantly be reduced when targeting NLRP3, concomitant with diminished endothelial NLRP3 expression. Furthermore, MCC950 led to reduced levels of Caspase 1 (p20) and activated Gasdermin D as markers for pyroptosis. Moreover, inflammasome inhibition reduced the secretion of pro-inflammatory chemokines, cytokines, and matrix metalloproteinase-9 (MMP9) in EC. In a translational approach, IS was induced in C57Bl/6 mice by 60 mins transient middle cerebral artery occlusion and 23 hours of reperfusion. Stroke volume, functional outcome, the BBB integrity, and—in good agreement with the in vitro results—MMP9 secretion as well as EC survival improved significantly in MCC950-treated mice. In conclusion, our results establish the NLRP3 inflammasome as a critical pathogenic effector of stroke-induced BBB disruption by activating inflammatory signaling cascades and pyroptosis in brain EC.

A case of fibromuscular dysplasia (FMD), presenting with a non-hemorrhagic infarct is reported. Positivity of anticardiolipin antibodies suggested an immune response. A 40-year-old man presented with sudden onset of stroke, preceded by similar ischemic attacks. Computed tomography (C1) of the brain showed a recent non-hemorrhagic infarct in the left middle cerebral artery (MCA) territory and an old right MCA territory infarct. Serum was positive for anticardiolipin antibodies. These above findings were confirmed at autopsy. A portion of the internal carotid artery and the middle cerebral arteries on both sides revealed features of FMD, with thrombosis. This case suggests an immune mechanism for FMD, hitherto unobserved in the cerebral circulation.

Cortical vein/venous sinus thrombosis (CVT) occurring in the context of a clinically isolated syndrome (CIS) is highly unusual. Our patient presented with dorsal cord demyelination and psoriasis. She developed severe headache post-lumbar puncture, which was followed by focal seizures. She had developed CVT with a hemorrhagic infarct in the left parietal region. Multiple factors, both patient related and as a consequence of treatment and management, may have contributed to this outcome. We aim to discuss the relevance of this rare finding with a brief review of literature.

60 year old diabetic and hypertensive female presented to casualty with right hemiplegia and hemianesthesia with lower motor neuron type of facial nerve palsy and loss of pain, temperature on left side of the face. She had difculty adduction and abduction on left eye with horizontal nystagmus in the contralateral eye when abducted while vertical movements were preserved. MRI brain was done which showed acute focal non hemorrhagic infarct in the left hemi pons along with partial basilar artery thrombosis. Hence a diagnosis of foville syndrome with inter nuclear opthalmoplegia was made. Classically foville syndrome is characterised by ipsilateral sixth nerve palsy, lower motor neuron facial nerve palsy, fth sensory nuclear palsy along with contralateral hemiparesis and hemisensory loss. The patient was started on single antiplatelet along with high intensity statin. On follow up after 3 months patients power improved.

INTRODUCTION: Non-dysraphic intradural spinal cord lipomas are rare, and true intramedullary cervical-thoracic lipomas are extremely rare. Spinal lipomas usually present with chronic, progressive myelopathic features. Unlike dysraphic lipomas, which are usually located in the lumbo-sacral region, non-dysraphic lipomas are usually located in the cervical or thoracic spine. CASE PRESENTATION: We present an unusual case of a 21-year-old female who presented with four months of severe back pain, progressive spasticity, and weakness in the lower limbs. Magnetic resonance imaging (MRI) revealed a T1- and T2-hyperintense lesion between D4 and D6. DISCUSSION: This fatty intramedullary lesion had undergone evolution and a possible hemorrhagic infarct and cord compression. The patient underwent an urgent dorsal laminoplasty and total resection of this lesion, which histopathology indicated was a fibrous lipoma. Total resection is possible in such cases if a micro-surgical technique that includes neurophysiological monitoring is used.

25-year-old woman with paroxysmal nocturnal hemoglobinuria was admitted to the hospital because of headache, progressing right hemiparesis and speech disorders. Several days later patient lost consciousness. Cerebrospinal fluid was xanthochromic with increased pleocytosis and protein level. CT-scan revealed ischemic area with hemorrhagic focus within left cerebral hemisphere. Patient died 3 weeks after the admission. Brain section revealed hemorrhagic infarct in the cortex of the left parietal lobe, thrombosis of the superior sagittal sinus and "respiratory brain" changes. Microscopic examination revealed meningeal venous thrombosis, hemorrhagic infarct, vasculitis, abundant accumulation of bacteria within blood vessels, and other pathological changes such as petechiae, perivascular exudates and small, round areas composed of acellular fibrillary network. There were no macrophages and GFAP-positive astrocytes in any of these areas. Authors suggest that weak cell reactivity may be connected with alterations in cell membranes, mainly low phosphatidylinositol (GPI) content.

Neonatal cerebral sinus venous thrombosis (CSVT) causes high morbidity and mortality. Factors associated with either favorable or unfavorable long-term outcomes have not been clearly established. This study aimed to determine the factors involved in long-term neurological outcomes in patients with neonatal CSVT.This was a retrospective cohort study of patients with neonatal CSVT at a single institution. Clinical factors associated with long-term neurological outcomes were examined.A total of 67 patients met study inclusion criteria for radiologically confirmed neonatal CSVT. The mean patient follow-up duration was four years (range one week to 16 years, median six years). We observed a favorable neurological outcome defined by a pediatric stroke outcome measures (PSOM) score of 0 to 0.5 in 26 (53%) of osurviving patients at follow-up. An unfavorable neurological outcome as defined by PSOM score0.5 was observed in 23 survivors (47%). Death was reported in 18 (27%) patients, of which 10 patients died due to direct complications of CSVT. Congential heart disease and genetic disease were associated with significantly increased odds for all-cause death. Cardiorespiratory failure and altered mental status during the initial neurological examination were significantly associated with increased odds of death due to CSVT. Among surviving patients, higher PSOM scores were associated with premature birth (i.e., gestational age 37 weeks), traumatic birth, site of thrombosis in the straight sinus, site of thrombosis in the internal cerebral veins, and hemorrhagic infarct. In contrast, lower PSOM scores were associated with a normal neurological examination at presentation, thrombosis in only superficial sinuses, and hemorrhage without infarct. There was no statistically significant association between the type and duration of CSVT treatment.The major factors influencing outcome of neonates following CSVT included comorbid medical conditions, abnormal neurological examination at presentation, location of venous thrombosis, and type of cerebral injury. These results can help guide further studies in neonatal CSVT aiming to decrease morbidity and mortality with the goal of improving long-term neurological outcomes.

Background: High altitude, an extremely rare cause of cortical venous thrombosis (CVT) has no literature review available signifying the relation between two as per date. The aim of this study is to establish the relation of exposure to high altitude and occurrence of CVT in properly acclimatised healthy individuals exposed to high altitude having no pre-existing morbidities.Methods: An observational type of prospective study was conducted at a tertiary care centre in North India. Patients who were sent back from a high-altitude area with CNS symptoms (headache to coma) were included in the study. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV), blood investigations including complete blood count and D-dimer were done as routine examinations in all these patients. MRI and MRV findings were recorded and analyzed for features of CVT.Results: Twenty-eight patients with an average age of 31.5 years (23-51 years) were included in the study. All patients had CNS symptoms; with headache being the common symptom. In the patients of CVT, there were MRI features of parenchymal infarct in 7 (25%), hemorrhagic infarct in 11 (41.6%), subarachnoid hemorrhage in 7 (25%) and mass effect in 3 (8.4%) patients. MRV revealed involvement of multiple sinus involvement more common than single sinus involvement, of which most commonly involved sinuses were Superior sagittal sinus and transverse sinuses. D-Dimer levels were significantly raised in 23 (83%) patients.Conclusions: High altitude though a rare cause, can be the single most important contributory factor in the development of CVT in healthy acclimatised individuals with no predisposing factors. The physicians dealing with such patients at high altitude should be well aware of the scenario as early diagnosis via imaging and prompt management can drastically reduce mortality in this potentially lethal but treatable conditions.

Background and Purpose: To determine factors associated with fluid-attenuated inversion recovery (FLAIR) hyperintense arteries (FLAIR-HAs) on magnetic resonance imaging and their prognostic significance in thrombolysis-treated patients with acute ischemic stroke from the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study) trial alteplase-dose arm. Methods: Patients with acute ischemic stroke (N=293) with brain magnetic resonance imaging (FLAIR and diffusion-weighted imaging sequences) scanned Results: Prior atrial fibrillation, LVO, large infarct volume, and anterior circulation infarction were independently associated with FLAIR-HAs. The rate of modified Rankin Scale scores 0 to 1 was numerically lower in patients with FLAIR-HAs versus without (69/152 [45.4%] versus 75/131 [57.3%]), as was the subset of LVO (37/93 [39.8%] versus 9/16 [56.3%]), but not in those without LVO (25/36 [69.4%] versus 60/106 [56.6%]). After adjustment for covariables, FLAIR-HAs were independently associated with increased primary outcome (adjusted odds ratio [95% CI]: overall 4.14 [1.63–10.50]; with LVO 4.92 [0.87–27.86]; no LVO 6.16 [1.57–24.14]) despite an increased risk of hemorrhagic infarct (4.77 [1.12–20.26]). Conclusions: FLAIR-HAs are more frequent in acute ischemic stroke with cardioembolic features and indicate potential for a favorable prognosis in thrombolysis-treated patients possibly mediated by LVO. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01422616.

Evaluate the prevalence of Labbe vein thrombosis (LVT) and its liability for the lesions observed in the case of associated ipsilateral transverse sinus thrombosis (TST). MRI findings of 58 consecutive patients (≥ 18 years) with acute LVT and TST (group 1) were compared with those of 149 patients with acute TST-no LVT (group 2) observed during the same period. The prevalence of LVT was 15.2%. Group 1: TST extended to sigmoid sinus in 94.8%, resulting in complete sinuses occlusion. Any lesion was observed in 81% within LV territory: swelling (n = 5, 8.6%), edema (n = 9; 15.5%), non-hemorrhagic Infarct (n = 1; 1.7%), multiple temporal lobe hemorrhages (n = 31; 53.5%), temporal lobe hematoma (n = 13; 22.4%), and pericerebral hemorrhages (n = 28; 50%). The hemorrhagic lesions were not related to dominant TST or to extensive venous thrombosis. There was a prevalence of left TST- LVT (n = 32; 55.2%) and a higher prevalence of hemorrhagic lesions in this subset (59.4%). Risk factors were also associated (p = 0.03). Group 2: the TST resulted in an occlusion of the TS: (i) complete (n = 16; 10.7%); (ii) incomplete (n = 97; 82.8%); and (iii) segmental, involving the TS before (n = 32; 21.5%) or after (n = 10; 6.7%) LV ending within the TS. No parenchymal/pericerebral lesions were associated. This study shows a strong association between the following: (i) the extent of thrombosis in the TS and the presence of LVT (p