Exsanguinating hemorrhage from a caput medusae: cutaneous variceal bleeding.

We report the case of a 45-year-old female who presented to the emergency department with massive umbilical hemorrhage from a cutaneous varix. The patient had a long-standing history of alcohol-related liver disease and ascites. Her clinical course was complicated by coagulopathy and hemorrhagic shock, and she ultimately expired. Ectopic or nongastroesophageal bleeding constitutes a significant site of variceal hemorrhage. In this report we review the literature and explore methods of treatment.     

Terson's syndrome: Subarachnoid haemorrhage presenting as sudden visual loss

Subarachnoid haemorrhage is a condition that usually presents with headache and altered mental state. We report the case of a 50‐year‐old man with subarachnoid haemorrhage who presented with Terson's syndrome. This is a condition where there is retinal or vitreous haemorrhage secondary to subarachnoid or subdural haemorrhage.     

Massive pulmonary haemorrhage due to leptospirosis

A young man with leptospirosis developed massive pulmonary haemorrhage. This was remarkable both in its severity and in its occurrence early in the clinical course — before the onset or presence of jaundice, renal failure or of a serological diagnosis. It occurred in the absence of a coagulopathy or thrombocytopenia and presumably was a consequence of the capillary fragility characteristic of the disease — perhaps precipitated in this instance by mechanical ventilation.     

Atraumatic retroperitoneal haemorrhage in a hydronephrotic kidney secondary to transitional cell carcinoma

Retroperitoneal haemorrhage due to rupture of a hydronephrotic kidney has been described previously. There have only been two previous cases reporting retroperitoneal haemorrhage secondary to transitional cell carcinoma. We report two cases of spontaneous retroperitoneal haemorrhage in grossly hydronephrotic kidneys which had extensive transitional cell carcinoma present in the renal pelvis.     

Integrated major haemorrhage management in the retrieval setting: Damage control resuscitation from referral to receiving facility

Major haemorrhage is a leading cause of death in critically ill or injured patients requiring medical retrieval and presents significant clinical and logistic challenges irrespective of patient location, primary pathophysiology or mode of transport. It is essential that all care providers involved in the retrieval patient pathway, including referring hospitals, ambulance services, retrieval teams and tertiary receiving centres, adopt a common approach to the management of this complex patient group through the use of retrieval‐specific, integrated protocols. These should incorporate the latest clinical evidence base, recognise the differences between primary and inter‐facility missions and clearly define the roles and responsibilities of the retrieval clinical coordinator. By unifying the response across services, the aim is to facilitate seamless transition of care with ongoing damage control resuscitation from point of referral, during transfer and on arrival at the receiving centre.     

经阴道宫颈缝合治疗经阴道分娩的难治性产后出血

目的评估经阴道宫颈缝合术处理源于宫颈管的难治性产后出血的有效性和安全性。方法25例经阴道分娩的产后出血患者，元软产道损伤，经常规处理无效后经阴道行宫颈缝合术，用2／0可吸收线在宫颈前后唇近穹隆处间断缝合，该手术因阻断了子宫动脉下行支而发挥止血作用。结果所有患者均成功止血，无1例子宫切除术，无并发症发生，抢救成功率100％。该手术无需专门技术和特殊设备。结论经阴道宫颈缝合术处理源于宫颈管的产后出血是一项易操作、安全和高效的保守性手术技术，可避免部分子宫切除术。     

大鼠脑出血模型血肿周围继发损害及超微结构变化研究

目的探讨脑出血所引发的血肿周围组织继发性损害的病理生理过程和可能机制。方法制备SD雄性大鼠脑出血模型，实验组分成1h、3h、12h、24h、48h、72h及7d7个小组；对照组分成3h、24h及72h3个小组，每组5只大鼠。每实验小组取2只大鼠，2％氯四氮唑(TTC)染色，进行大体组织病理演变观察。另取3只大鼠，在血肿周边区及同侧皮层区分别取脑组织在透射电子显微镜及光学显微镜下观察。结果TTC染色显示，血肿呈黑褐色，血肿周围未见白色梗死区。光镜下观察，血肿区与正常脑组织间有一周围区，其中可见组织疏松，细胞不同程度水肿，星形细胞肿胀，神经细胞变性、坏死，出血灶周边毛细血管增生伴炎细胞浸润。电镜观察可见，血肿周围组织早期星形细胞胞体和周边足突肿胀，神经细胞改变不明显。注血后24h，星形细胞肿胀明显，部分变性、坏死；神经细胞轻度变性，血脑屏障破坏。注血后72h，星形细胞高度肿胀，神经细胞变性。结论脑出血血肿周围脑组织发生病理、超微结构的改变，血肿周围脑组织产生继发性损害。     

Acute convexity subarachnoid haemorrhage: a cause of aura-like symptoms in the elderly

Late-life onset aura-like symptoms are not rare and can be potentially misdiagnosed as transient ischaemic attacks. The cause is often obscure. Four cases of recurrent aura-like symptoms are presented in whom acute convexity subarachnoid haemorrhage (SAH) contralateral to symptoms was demonstrated. Three experienced subsequent events or groups of events triggered by recurrent SAH. Negative diffusion-weighted imaging, normal electroencephalography and slow symptom march with complete resolution argued against ischaemic and epileptic causes. Aura-like symptoms in the elderly should be investigated with imaging modalities most sensitive for detecting subarachnoid blood, in particular gradient echo magnetic resonance imaging.     

Functional outcomes at 12 months for patients with traumatic brain injury,intracerebral haemorrhage and subarachnoid haemorrhage treated in an Australian neurocritical care unit: A prospective cohort study

BackgroundAcute severe brain injury is associated with significant morbidity and mortality. Patients and their families need accurate information regarding expected outcomes. Few studies have reported the long-term functional outcome of patients with acute severe brain injury treated in an Australian neurocritical care unit.ObjectiveThe objective of this study was to describe 12-month functional outcomes (using the extended Glasgow Outcome Scale) of patients with acute severe brain injury treated in an Australian neurocritical care unit.MethodsThis was a single-centre prospective cohort study. Patients with a diagnosis of traumatic brain injury, subarachnoid haemorrhage or intracranial haemorrhage admitted between 2015 and 2019 were enrolled.ResultsIn total, 915 participants were enrolled during the 51-month study period. Of the cohort, 403 (44%) were admitted after traumatic brain injury, 274 (30%) after subarachnoid haemorrhage and 238 (26%) after intracranial haemorrhage. The median duration of intensive care admission was 5 days (interquartile range: 2–13), 458 (50%) received invasive ventilation, 417 (46%) received vasopressor support and 286 (31%) received an external ventricular drain. At discharge from intensive care, 150 of 915 (16.4%) had died, and the in-hospital mortality was seen in 191 of 915 patients (20.9%). Favourable functional outcome, as defined by an extended Glasgow Outcome Scale score of 5–8, was reported in 358 of available 795 patients (45.0%) at six months and in 311 of 672 available patients (46.3%) at 12 months. Those with intracranial haemorrhage reported the highest rates of unfavourable outcomes with 112 of 166 patients (67.4%) at 12 months.ConclusionsIn this selected population, admission to a neurocritical care unit was associated with significant resource use. At 12 months after admission, almost half of those admitted to an Australian neurocritical unit with traumatic brain injury, subarachnoid haemorrhage and intracerebral haemorrhage report a good functional outcome.     

Isolated bilateral,large, basal ganglia haemorrhage following a traumatic brain injury: A case report

Traumatic basal ganglia haemorrhage is rarely seen in clinical practice. Bilateral basal ganglia hematoma without any other cerebral lesions due to trauma is extremely uncommon and has been reported only in a few cases. Although the mechanisms of this condition are unclear, haemorrhagic contusions are thought to arise as a consequence of a shearing strain on cranial blood vessels due to high-velocity forces at the time of the injury. Here we describe a 63-year-old female patient with an isolated bilateral, large, basal ganglia haemorrhage secondary to a road traffic accident. The patient was promptly diagnosed and conservatively treated and had fully recovered after two months.     

Near fatal haemorrhage 35 years after radiation for laryngeal cancer: emergency embolisation of a vertebral artery aneurysm

The authors report a rare case of a 75 year old man who presented 35 years after radiotherapy for carcinoma of the larynx, with catastrophic bleeding through the mouth. Both the time and mode of presentation were unusual. The patient required emergency sacrifice of the left vertebral artery to stop the bleeding. The literature has been reviewed.     

Functional outcome following thalamic haemorrhage: Relationship between motor and cognitive functions and ADL

Twenty-two patients with thalamic haemorrhage were examined to investigate the relationship between motor and cognitive function, and activities of daily living (ADL). Patients with unilateral spatial neglect had lower ADL scores on admission than patients without unilateral spatial neglect (Mean: 17.0 and 24.6, respectively; F= 4.38, df = 1, p < 0.05). Unilateral spatial neglect related to feeding, bowel control and transfer in Barthel index on admission. Patients with aphasia on admission had lower ADL at discharge than patients without aphasia on admission (Mean: 57.0 and 84.7, respectively; F= 7.70, df = 1, p ? 0.05). Aphasia related to the bathing, toilet, stair climbing, dressing, and ambulation in Barthel index on discharge. There was a significant difference between the severity of paresis in upper and lower limb on admission and ADL at discharge. The two-way repeated measures ANOVA showed a significant difference between severity of paresis in lower limb and ADL improvement. It can be suggested that the most important predictor of outcome was paresis in lower limb, and not aphasia or unilateral spatial neglect.     

Subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest: A prospective computed tomography study

Aim

Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can.

Methods

During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with “negative” CT finding.

Results

Brain CT scan was feasible with an average door-to-CT time of 40.0 min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01–0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01–0.61).

Conclusion

Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA.     

Headache as a warning symptom of impending aneurysmal subarachnoid haemorrhage

About half of the aneurysm patients admitted to neurosurgical departments experience warning symptoms in the form of minor bleeding episodes days or even several months before a major haemorrhage occurs. Headache is the most common symptom of this warning leak, occurring in 9 out of 10 patients. The onset of headache is sudden and is unusual in severity and location, being unlike any headache the patient has otherwise experienced. It is frequently accompanied by transient nausea, vomiting, visual disturbances or meningism. Medical advice may be sought by the patient but all too often the diagnostic importance of a warning headache is missed. It is misinterpreted as attacks of migraine, tension headache, the 'flu, sinusitis, or a "sprained neck". A more vigilant attention to the presence of a warning headache probably offers the greatest opportunity for altering the otherwise serious natural history of aneurysmal subarachnoid haemorrhage. If a warning headache is suspected, lumbar puncture is the examination of choice, once CT scanning has ruled out an intracranial mass lesion.     

Recombinant FVIIa in the management of intracerebral haemorrhage in severe thrombocytopenia unresponsive to platelet-enhancing treatment

Intracranial haemorrhage (ICH) is a dramatic and potentially life-threatening presentation of children with thrombocytopenia. Management is limited to supportive care. Recent evidence suggests that ongoing bleeding following the initial ICH may result in greater neurological morbidity and mortality. Haemostatic agents, including recombinant factor VIIa (rFVIIa), a product licensed for use in patients with haemophilia and inhibitors, may be helpful in reducing bleeding in children with refractory thrombocytopenia. We present the case of a 16-year-old girl with severe refractory immune thrombocytopenia, who presented with a major ICH and responded to treatment that included rFVIIa and platelet transfusions. The dose of rFVIIa was empirically chosen and based on reported cases in the literature. The case highlights a number of issues regarding off-label use of rFVIIa and demonstrates the need to prospectively collect accurate information on the off-label use of this new potentially useful medication.