Thalamic hemorrhage. 30 cases studied: clinico-tomodensitometric correlations.

The clinico-tomographic correlations in 30 patients hospitalized for primary thalamic hemorrhage were studied. Arterial hypertension, observed in 90% of patients, represented the most important risk factor. Twenty-six subjects showed a sensory-motor hemisyndrome contralaterally to the lesion, nineteen showed alteration in level of consciousness from confusion to stupor and coma. Twelve subjects had poorly reactive pupils and eleven speech disturbances with involvement of the left thalamus. Seven patients died following hemorrhage; all subjects presented ventricular bleeding, severe disturbance of consciousness and arterial hypertension. On admission to hospital impairment of consciousness was the most significant unfavourable prognostic factor.     

Subarachnoid hemorrhage after thrombolytic therapy for acute myocardial infarction: A case report.

Intracranial hemorrhage is the most feared complication of thrombolytic therapy. This report describes a 42-year-old diabetic woman who presented with an acute myocardial infarction and sufferred a subarachnoid hemorrhage after receiving recombinant tissue plasminogen activator. This report discusses this important but very rare complication of thrombolytic therapy.     

Subarachnoid hemorrhage in neoplasms of the posterior cranial fossa. Description of 2 cases

The authors report on two cases of posterior cranial fossa tumours in which subarachnoid haemorrhage was the presenting sign. In both cases no evident focal signs were found which could suggest the presence of a space occupying intracranial lesion.     

Electrocardiographic findings in acute cerebrovascular hemorrhage. A prospective study of 70 patients.

Seventy patients with hemorrhagic stroke were prospectively evaluated regarding the electrocardiographic abnormalities observed within the first 48 hours of the ictus. Group I comprised 55 patients with spontaneous cerebral hemorrhage, and group II 15 patients with subarachnoid hemorrhage. Patients taking cardiac drugs (beta blockers, calcium-channel blockers, inotropic drugs) or with severe metabolic/electrolyte disturbances were excluded. The most common ECG abnormality was a prolonged Q-Tc interval: group I, 37 (67.2%); group II, 8 (53.3%). Only 4 (7.2% patients of group I and no patient of group II had a normal ECG. No relation was found between the site of the intracerebral hematoma and the occurrence of any particular ECG change. A prolonged Q-Tc may be related to the development of severe cardiac arrhythmias observed in some patients with acute cerebral hemorrhage.     

Correlation between clinical severity and extent of autonomic cardiovascular impairment in the acute phase of subarachnoid hemorrhage

Journal of Neurology - To assess associations between clinical severity and possible dysfunction of autonomic cardiovascular modulation within the acute phase after spontaneous subarachnoid...     

Neurogenic cardiac arrhythmias in acute intracranial increase in pressure (recurrent hemorrhage in subarachnoid hemorrhages)

Neurogenic cardiac arrhythmias during 5 cases of subarachnoid rebleeding in 4 patients were analyzed by using long-term ECG (Holter). The initial onset of rebleeding was characterized by an abrupt decrease of heart rate from 93.3 +/- 7.85 (beats/min) to 63.3 +/- 14.6 (beats/min). This was immediately followed by pronounced tachycardia of 163.0 +/- 20.9 (beats/min) and subsequently, alterations of the P wave, ST depression with an increase in T wave amplitude. Frequent premature ventricular contractions, couplets, and self-terminating episodes of ventricular tachycardia for 2-8 minutes were observed during 2 episodes of rebleeding, an idioventricular rhythm in one case. The ECG returned to normal in the 3 non-lethal cases. Pathogenetically, the initial heart rate decrease with varying P wave configuration can be explained through activation of the baroreceptor reflex. Elevated intracranial pressure causes a blood pressure increase thus stimulating the baroreceptors and consequently, the afferent and efferent tracts of the vagus nerve. The sympathicotonus appears to have a modulating effect.     

Aneurysms in relatives of patients with subarachnoid hemorrhage: frequency and risk factors. MARS Study Group. Magnetic Resonance Angiography in Relatives of patients with Subarachnoid hemorrhage.

OBJECTIVE: To evaluate the frequency and identify risk factors of unruptured aneurysms in first-degree relatives of patients with sporadic subarachnoid hemorrhage (SAH). BACKGROUND: First-degree relatives (parents, siblings, and children) of patients with SAH have a three to seven times increased risk of SAH. METHODS: Magnetic resonance angiography (MRA) was performed in 626 first-degree relatives of a consecutive series of 193 index patients with "sporadic" SAH (participation rate, 78% of eligible relatives). The authors recorded demographic and medical data, and performed blood pressure measurements and blood tests (cholesterol, high-density lipid cholesterol, triglycerides, apoprotein A1, lipoprotein a, glucose). RESULTS: Aneurysms were found in 25 of 626 relatives (4.0%; 95% CI, 2.6 to 5.8%), and 6 relatives had multiple aneurysms. Index patients with multiple aneurysms and a younger age had a higher risk of aneurysms in relatives. Siblings of index patients had a four times higher risk than children. In screened relatives female sex, increasing age, polycystic kidney disease, hypertension, and elevated levels of cholesterol and glucose tended to be associated with a higher risk of aneurysms. No increase in risk was conferred by smoking or alcohol use, or by a previous family history of SAH or of atherosclerosis. CONCLUSIONS: First-degree relatives of index patients with sporadic subarachnoid hemorrhage have a 4.0% chance of intracranial aneurysms. Being a sibling of the index patient is the most important risk factor. Risk factors for general atherosclerosis (hypertension, smoking, hypercholesterolemia, high levels of blood triglycerides, lipoprotein a, and apoprotein A1) and use of alcohol do not increase the risk of intracranial aneurysms significantly in these relatives.     

Subarachnoid hemorrhage in the rat: cerebral blood flow and glucose metabolism during the late phase of cerebral vasospasm

A double-isotope technique for the simultaneous measurement of CBF and CMRglu was applied to a subarachnoid hemorrhage (SAH) model in the rat. Cisternal injection of 0.07 ml blood caused a rather uniform 20% reduction in CBF together with an increase in glucose utilization of 30% during the late phase of vasospasm. In one-third of the SAH animals, there were focal areas where the flow was lowered to 30% of the control values and the glucose uptake increased to approximately 250% of control. We suggest that blood in the subarachnoid space via a neural mechanism induces the global flow and metabolic changes, and that the foci are caused by vasospasm superimposed on the global flow and metabolic changes. In the double-isotope autoradiographic technique, [14C]iodoantipyrine and [3H]deoxyglucose were used for CBF and CMRglu measurements, respectively, in the same animal. In half of the sections, the [14C]iodoantipyrine was extracted using 2,2-dimethoxypropane before the section was placed on a 3H- and 14C-sensitive film. The other sections were placed on x-ray film with an emulsion insensitive to 3H. The validity of the double-isotope method was tested by comparing the data with those obtained in animals receiving a single isotope. The CBF and metabolic values obtained in the two groups were similar.     

Correlation of cardiac arrhythmias with brainstem compression in patients with intracerebral hemorrhage

Neurogenically caused cardiac arrhythmias and their correlation to lesions within the central nervous system were examined prospectively in 54 patients with spontaneous intracerebral hemorrhage. All patients were examined neurologically daily for 3 weeks, with special attention given to signs of brainstem compression resulting from transtentorial herniation. Electrocardiograms were continuously recorded over an average of 5 days. A significant correlation was established between the clinical manifestations of brainstem compression and sinus arrhythmias, multifocal premature ventricular contractions, couplets, and ventricular tachycardias. An explanation for this correlation may be found in the localization of the autonomous cardiovascular centers in the hypothalamus and brainstem. Transtentorial herniation frequently leads to a bilateral lesion of these structures. However, the cardiac arrhythmias are only a partial phenomenon within a complex cardiovascular reaction.     

Subarachnoid hemorrhage of unknown origin and the basilar artery configuration.

It is unclear whether the configuration of the basilar artery (BA) in patients with subarachnoid hemorrhage (SAH) of unknown origin is comparable to that in normal subjects or whether there are differences which may help to identify the origin. We studied the BA configuration in 57 patients with SAH of unknown origin (10%), who were identified in a prospectively collected series of 549 SAH patients consecutively admitted to our service over a 9-year period. There were 30 patients (53%) with non-perimesencephalic SAH and 27 with perimesencephalic SAH (47%). According to a standardized algorithm we determined, on straight anteroposterior digital subtraction angiography (DSA), the width of the proximal BA segment at the origin of the anterior inferior cerebellar artery and the width of the most distal BA segment between the superior cerebellar arteries and the posterior cerebral arteries. Based on these measurements we calculated the distal-proximal BA ratios and compared them to the ratios obtained in a control group of 31 patients who had DSA for reasons other than aneurysmal SAH. The mean ratio in patients with non-perimesencephalic SAH of unknown origin was 1.150 (range: 1.080-1.230). In patients with perimesencephalic SAH of unknown origin it was 1.156 (range: 1.120-1.250). In the control group the mean ratio was 1.163 (range: 1.125-1.200). There are no variations in the configurations of the BA which could possibly explain the cause of this type of SAH or clarify the origin of hemorrhage.     

Central neural control of blood pressure and cardiac arrhythmias during subarachnoid hemorrhage in rats

Sudden death may follow subarachnoid hemorrhage which indicates involvement of neural mechanisms connected with the cardiovascular system. Since various regions of the brain mediate blood pressure and heart rate changes, these parameters and heart rhythm could be affected due to a subarachnoid hemorrhage near the circle of Willis which surrounds the hypothalamus, the highest center for autonomic control. To investigate this in the control group, intracranial pressure, blood pressure, and electrocardiogram were measured before and after a simulated subarachnoid hemorrhage; blood pressure and electrocardiogram were measured following midcollicular lesions in the decerebrate group both before and after a subarachnoid hemorrhage. The results demonstrate that an increase in systemic arterial blood pressure and premature ventricular contractions (with respect to unlesioned group, p less than 0.04) are mediated by forebrain areas and require the integrity of neuroanatomical connections with structures that are caudal to the midbrain. Since bradycardia and other electrocardiographic abnormalities could still be produced after midcollicular lesioning it is suggested that they can be mediated via the brainstem only without involvement of more rostral areas and may occur due to increased intracranial pressure.     

Cardiac arrhythmias and sudden death in subarachnoid hemorrhage.

Life-threatening cardiac arrhythmias can occur in patients with subarachnoid hemorrhage secondary to rupture of intracranial aneurysms. The arrhythmias are secondary to acute dysfunction of the central nervous system and possibly to sudden increase in intracranial pressure. The autonomic nervous system is the mediator in the production of these disorders. The clinical significance of these rhythm disorders is discussed, particularly in regard to the sudden, unexpected death seen in this type of patient. The possible mechanisms of production are analyzed and their therapeutic implications are stressed.     

Electrocardiographic changes in subarachnoid hemorrhage secondary to cerebral aneurysm. Report of 70 cases

Electrocardiographic (ECG) alterations in the course of sub-arachnoid hemorrhage (SAH) have frequently been reported. The most frequent anomalies reported were lengthening of the QT interval, very negative or positive deep T waves, elevation or depression of the ST segment and the presence of U waves. We report 70 cases of SAH secondary to rupture of intracranial aneurysm (part of a larger group of 150) with ECG changes. We review the literature with particular regard to discussion of the possible pathogenesis of ECG changes and to the way they may affect the general clinical course.

---

Sommario Alterazioni elettrocardiografiche in corso di emorragia subaracnoidea sono state frequentemente descritte in letteratura. Le anomalie più frequentemente segnalate sono state: allungamento dell'intervallo QT, presenza di onde T profonde e ampiamente positive o negative, sopraslivellamento o sottoslivellamento del tratto ST e presenza di onde U. Gli autori riportano 70 casi di emorragia subaracnoidea secondaria a rottura di aneurisma intracranico (facenti parte di una più ampia casistica di 150 individui) associata ad anomalie elettrocardiografiche. La letteratura sull'argomento viene accuratamente analizzata con particolare riguardo per la discussione della possibile patogenesi delle anomalie elettrocardiografiche e per l'influenza che tali anomalie hanno sul decorso clinico dei pazienti.

     

Subarachnoid and intra-cerebral hemorrhage in young adults: Rare and underdiagnosed

Objectives

Convexity subarachnoid and intra-cerebral hemorrhages, in patients aged < 50 years, are always a diagnostic challenge. This condition is characterized by acute headaches with or without neurological symptoms and/or seizures, and by the radiological demonstration of subarachnoid and/or intra-cerebral hemorrhages and, more rarely, by the association of ischemic events.

Patients and methods

In a prospective series of 30 consecutive patients (median age 31 years; 22 women) with a subarachnoid and intra-cerebral hemorrhages, 19 were diagnosed with reversible cerebral vasoconstriction syndrome (RCVS), 7 with cerebral venous sinus thrombosis (CVST), and 4 with a bleeding mycotic aneurysm (MA).

Results

RCVS appeared spontaneously in 16 patients and was related to the postpartum period in three cases. Subarachnoid hemorrhage (SAH) was demonstrated in 24 patients as follows: 18 cases were in cortical areas, 4 were in the polygon of Willis, one was inter-hemispheric, and one was inter-hemispheric/intra-cerebral. A convexity pure intra-cerebral hemorrhage (ICH) was recorded in 6 cases. Among the 7 patients suffering from CVST, the superior sagittal sinus was involved in 4 cases, the transverse sinuses (TS) in 2, and the TS plus sigmoid sinus (SS) in one.

Conclusion

The three most common causes in this series were RCVS, followed by CVST and bleeding from MA. Because of atypical clinical or radiological presentations, this large spectrum of etiologies can cause diagnostic difficulties. Therefore, careful analysis is needed to ensure correct and prompt diagnosis and to avoid any dangerous delays in management.     

Nontraumatic cerebral hemorrhage in the young: A study of 107 cases.

Background: Reports on intracerebral hemorrhage (ICH) in the young are rare, and information on the cause and prognosis of ICH in this age-group is sparse. Methods: All cases of ICH admitted to three major hospitals in Saudi Arabia over a 15-year period were retrospectively reviewed. Patients aged between 6 months and 45 years at stroke onset were studied. Pooling of our data with those published from other centers was used for final analysis. Results: One hundred seven cases (69 male, 38 female), including 12 children younger than 10, were analyzed. The causes of hemorrhage were as follows: arteriovenous malformations (AVMs), 23%; systemic hypertension, 20%; blood dyscrasias, 16%; berry aneurysms, 8%; other causes, 7%. No cause was found in 26%. Sixty-two percent of the ICHs were lobar and 3% multiple. Early death rate was high (27%). Twelve percent of the patients were lost to follow-up, and only 26% returned to a state of complete autonomy. Conclusion: The pooling of the causative data from our cases and the 253 others reported in the literature showed that even before 45 years of age systemic hypertension is the leading cause of ICH. It accounts for approximately 30% of the cases, with AVMs (20%) being next. The pooled overall early mortality rate is approximately 20%, and only one third of the patients return to independent living.     

A pathological survey of 41 cases of acute intrinsic spinal cord disease.

A pathological survey of 41 cases collected in a neuropathological laboratory over a number of years is presented. The cases described had predominant spinal cord diseases, acute and subacute onset, and no evidence of compression, trauma or meningeal infection. The cases were classified on pathological and clinical grounds, and the features of each group are discussed.