无蛛网膜下腔出血的破裂脑动脉瘤

目的 总结无蛛网膜下腔出血(SAH)的破裂脑动脉瘤的诊治经验.方法 对15例在起病后2 d内首次CT或MRI上表现为脑内出血(ICH),和(或)脑室内出血(IVH)、硬脑膜下血肿(SDH)和壁间出血(IMH)而无SAH的破裂脑动脉瘤患者的临床表现、影像学检查结果 、治疗方法 和预后进行回顾性分析.结果 本组首次CT或MRI检查表现为ICH者3例、IVH合并ICH者6例、SDH者1例、IVH者1例、IMH者3例和等高混合密度者1例.其中动脉瘤位于大脑中动脉6例、前交通动脉4例、后交通动脉3例、大脑前动脉1例和小脑后下动脉1例.开颅手术夹闭动脉瘤13例,血管内栓塞2例.出院时GOS评分:恢复良好8例、中残3例、重残3例和植物生存1例.本组15例占同期破裂脑动脉瘤的3.8%.结论 破裂脑动脉瘤首次CT扫描可表现为单纯ICH,和(或)IVH、SDH、IMH而无SAH,与CT扫描时间、动脉瘤的部位和指向以及出血量有关.早期控制颅内高压、及时诊断和有效处理破裂动脉瘤,是改善预后的关键.     

Early diagnosis of intracranial hemorrhage in the newborn

A routine ultrasonographic (US) examination is essential for monitoring intraventricular hemorrhage (IVH) in very low-birth-weight newborn infants. The incidence of IVH was decreased by risk factor analysis using US. Subarachnoidal hemorrhage (SAH), subdural hemorrhage (SDH) and intraparenchymal hemorrhage (IPH) occurred more in mature infants who had difficult deliveries. Final diagnosis was established by cranial computed tomography (CT) or careful US examinations. Symptoms and signs of intracranial hemorrhage (ICH) were more non-specific than neurological. The possibility of ICH should always be considered and excluded by CT or US in the infants with nonspecific clinical manifestations.     

脑血管淀粉样变与高血压脑出血临床特征的研究

目的 比较颅内血管淀粉样变与高血压引起脑出血的临床、放射学和诊断的特点，对脑血管淀粉样变与高血压性脑出血的临床特征进行研究。方法 对41例急性颅内血管淀粉样变脑出血病人的临床资料(包括年龄、血肿部位、形状、大小、是否伴发蛛网膜下腔出血和脑室出血等)、放射学诊断和病理学结果等因素进行分析，并与42例高血压性脑出血病人进行对照，行统计学分析。结果 颅内血管淀粉样变出血组平均年龄明显高于高血压脑出血组，其出血主要位于脑叶的表面，呈分叶状或不规则状，易产生蛛网膜下腔出血和脑室出血，具有多发性和容易复发的特点。结论 颅内血管淀粉样变出血在临床和影像学上具有一定的特征，但确诊需要病理学的诊断。     

Cerebral blood flow velocity in preterm neonates

The postnatal changes of cerebral blood flow velocity in 35 preterm neonates with or without complications were measured with a bidirectional Doppler flow meter. In the cases without complications, the pulsatility index for the anterior cerebral artery (ACA-PI) was high shortly after birth, and gradually decreased after 6 hrs as that in normal term neonates. However ACA-PI showed large variations in the cases with respiratory distress. On the other hand, ACA-PI in the cases with subependymal hemorrhage (SEH) was low during the first 6 hrs after birth, and thereafter showed no significant changes. ACA-PI in the cases with intraventricular hemorrhage (IVH) was high during the first 6 hrs after birth and then decreased when IVH was found on ultrasound scanning. ACA-PI increased gradually with progression of post-hemorrhagic ventricular dilatation. The difference of high PI in IVH and low PI in SEH during the first few hrs after birth suggests that the pathogenesis of SEH may be different from the mechanism of intraventricular rupture from SEH. Low PI values in the infants with SEH may be related to intrapartum events, while the changing patterns of high to low PI in the infants with IVH suggest postnatal hemodynamic changes.     

Cerebral Vasospasm and Delayed Cerebral Ischemia in Intraventricular Hemorrhage

Background

Intracerebral hemorrhage (ICH) with intraventricular extension (IVH) is a devastating disease with a particular high mortality. In some aspects, IVH may resemble subarachnoid hemorrhage. The incidence and role of cerebral vasospasm in ICH with IVH are poorly understood. Here, we aimed to analyze the incidence and relationship of cerebral vasospasm to clinical characteristics, in-hospital mortality, and functional outcome at 3 months in patients suffering ICH with IVH.

Methods

Patients with ICH and IVH treated on a neurological intensive care unit were prospectively enrolled in a single-center observational study. Vasospasm was defined using established ultrasound criteria. Delayed cerebral ischemia (DCI) was defined as a new hypodensity on follow-up cranial CT. Functional outcome at 3 months was assessed using the modified Rankin Scale.

Results

129 patients with ICH and IVH were screened for the study. 62 patients entered the final analysis. The incidence of significant vasospasm was 37 %. A strong trend was found for the association between all cerebral vasospasm and DCI (P = 0.046). Early (up to 48 h) vasospasm was significantly associated with a DCI (P = 0.033). Overall mortality and outcome after 3 months did not differ between the groups.

Conclusion

Cerebral vasospasm seems to be a frequent complication after ICH with IVH and might be associated with DCI. Larger studies are warranted to confirm this hypothesis.     

Delayed hemorrhagic infarction. A cause of late neonatal germinal matrix and intraventricular hemorrhage

Although a single perinatal or postnatal event may be directly correlated to intraventricular hemorrhage (IVH) in some infants, in other infants IVH may be related to a series of insults. Asphyxia, hypotension, and a pressure-passive low cerebral blood flow (CBF) may lead to an infarction. Subsequent events known to cause sudden rises in the CBF may then produce a hemorrhage into damaged tissues. We report two cases of this proposed model for delayed hemorrhage into infarcted tissues, or late IVH. Both neonates were severely asphyxiated, and both experienced profound hypotension and a low CBF on the first postnatal day. Late IVH was found in both neonates; at 2 to 3 months of age, one neonate was found to have computed tomographic evidence for diffuse encephalomalacia, and the other neonate was noted to have an occipital porencephalic cyst.     

Intracranial hemorrhage in hypothermic low-birth-weight neonates

We studied periventricular/intraventricular type intracranial hemorrhage (ICH) by cranial ultrasonography in 82 low-birth-weight (LBW) newborn infants with admission hypothermia against the gestational-age-matched 82 normothermic neonates. The incidence of ICH was higher in the hypothermic infants during the 1st week of life (34/82 vs 20/82, P<0.02). Although the distribution of individual grades of ICH was not significantly different between the groups, the first ultrasound scan showed higher incidence of major ICH (grades 3 and 4) in the hypothermic infants. Most of the minor ICH (grades 1 and 2) after the first ultrasound appeared in infants who were small for their gestational age. Our data do not support the contention that admission hypothermia can precipitate the development of IVH in LBW infants. However, the detection of admission hypothermia in a LBW neonate should make one suspect the possibility of ICH and regard it as a manifestation of the severity of ICH rather than the cause. Most likely, this close relationship between hypothermia and neonatal ICH originates from perinatal asphyxia and the cumulative adverse effects of asphyxia-related events.     

Clinical discriminators of lobar and deep hemorrhages: the Stroke Data Bank.

Of the 1,805 patients with acute stroke enrolled in the Stroke Data Bank, 237 had parenchymatous hemorrhage. After excluding 34 secondary intracerebral and 31 infratentorial hemorrhage patients, a logistic regression analysis of the 172 patients with primary supratentorial intracerebral hemorrhage (ICH) elucidated clinical factors that distinguished the 65 patients with lobar hemorrhage (LH) from the 107 patients with deep hemorrhage (DH) located in the basal ganglia and thalamus. In LH, severe headache was more common than in DH, while hypertension and motor deficit were significantly less common. Patients with either LH or DH had a similar prognosis and mean Glasgow Coma Scale (GCS) scores, despite the hematoma volume measured on the initial CT being significantly greater for LH than DH. The presence of intraventricular extension (IVH) was more frequent in DH. The frequency of IVH increased with hematoma volume in LH, but remained constant for DH. Two CT variables (IVH and hematoma volume) that differed in these two hemorrhage groups were important predictors of coma (GCS less than or equal to 8) in a logistic regression model. Differences in the frequency of IVH may help explain why the degree of impairment in consciousness was similar in the two groups. Among patients with supratentorial ICH, location of the hematoma is related to both volume and IVH, which are important determinants of the level of consciousness.     

Evaluation of the Cerebral Function Monitor as a tool for neurophysiological surveillance in neonatal intensive care patients

BACKGROUND: Cerebral function in critically ill infants is difficult to assess and would certainly require continuous monitoring. Therefore, this study was performed to evaluate the Cerebral Function Monitor (CFM) as a tool for continuous neurophysiological surveillance in the Neonatal Intensive Care Unit (NICU). PATIENTS: A total of 40 neurological risk neonates were included in the study. They were classified on the basis of their primary diagnoses as infants with clinically manifest seizures, suspected seizure activity, intracranial hemorrhage (ICH) and hypoxic-ischemic encephalopathy (HIE). A group of 20 neurologically normal (preterm and full-term) infants served as controls. RESULTS AND CONCLUSION: All patients with seizures showed pathologic patterns in both the CFM and the conventional EEG tracings. The patients with ICH showed depressed amplitudes, an increase in discontinuous activity, and a high incidence of seizure activity. The patients with HIE were characterized by depressed activities correlating with the severity of the pathology. Our results indicate that the CFM is a very helpful tool for neurophysiological surveillance in high-risk neonates.     

Perinatal cerebral infarction

The diagnosis of perinatal cerebral infarction, although frequently suggested clinically, has been made most commonly at postmortem examination; few infants surviving stroke are reported in the literature. We evaluated 18 infants with perinatal cerebral infarction in a recent twelve-month interval. Seven were preterm neonates, 6 of whom had experienced neonatal intraventricular hemorrhage. Three full-term infants were thought to have experienced cerebral infarction in utero and had evidence of well-defined strokes on computed tomographic scans performed shortly after birth. Eight infants developed stroke at term. The most common cause of cerebral infarction in our series was perinatal asphyxia. Fourteen of the infants were seen with neonatal seizures. Fourteen of the 18 have died or are faring poorly at 4 to 12 months of age (corrected).     

Rare neonatal intracerebral hemorrhage

Intracranial hemorrhage in neonates is often found in either the subependymal area or the subdural space. The former is observed particularly in premature infants and is attributable to damage of the germinal matrix layer. The latter usually occurs in the vicinity of the falx and tentorium cerebri of full-term neonates and is thought to be caused by birth injury. Two cases of intracerebral hemorrhage in full-term newborn babies are reported. In both the hematoma was located at the left frontal area under the coronal suture. Angiograms revealed no causative signs, such as arteriovenous malformation, aneurysm or angioma. Observations on CT scans and during surgery led to the conclusion that the hemorrhages were caused by the moulding which forced the frontal bone to slip under the parietal bone at the coronal suture and then press on the fragile cerebral vasculature of the neonates, thus causing contusion.     

A priority treatment of the intraventricular hemorrhage (IVH) should be performed in the patients suffering intracerebral hemorrhage with large IVH

Background

In patients suffering from intracerebral hemorrhage (ICH) with ventricular hemorrhage (IVH), the IVH severity is thought to be associated with prognosis. Therefore, treating IVH may be a beneficial therapeutic target. In this study, by examining the associations among IVH severity, hydrocephalus, initial level of consciousness and prognosis, we attempted to identify which grade of IVH severity should be considered for surgical treatment.

Methods

One hundred twenty-nine patients with spontaneous supratentorial ICH treated in our hospital between 2005 and 2006 were screened in this study. Of these patients, 100 with an ICH volume less than 60 ml were categorized into either the ICH patients without IVH (no-IVH) group (n = 65) or the ICH patients with IVH (IVH) group (n = 35). The Karnofsky Performance Status (KPS) scale assessed at the time of discharge was employed as an outcome index, and a KPS score of ≤40 was defined as the bedridden state. Age, gender, hemorrhage location, volume of ICH, IVH grade (according to the Graeb score), acute hydrocephalus, surgical ICH removal, and ventricular drainage were selected for univariate analyses with logistic regression.

Results

Elderly patients, IVH volume, acute hydrocephalus, and poor initial level of consciousness were significantly associated with an unfavorable prognosis in the IVH group. Poor level of consciousness was significantly dependent on acute hydrocephalus, and significantly more occurrences of acute hydrocephalus were found in patients with a high IVH volume (Graeb score ≥6) than in patients with low to moderate IVH volume (Graeb score ≤6).

Conclusions

IVH severity influenced the occurrence of acute hydrocephalus and initial level of consciousness, which was significantly associated with prognosis. Our results suggest that priority treatment of the IVH should be given to those ICH patients with IVH admitted with a Graeb score of 6 or more.     

Perinatal brain injuries and subsequent epilepsy: a study on intraventricular hemorrhage in preterm infants and hypoxic-ischemic encephalopathy in full-term infants

The clinical course of symptomatic epilepsy caused by intraventricular hemorrhage (IVH) in 7 preterm infants and hypoxic-ischemic encephalopathy (HIE) in 9 full-term infants were followed up for more than 2 years and 6 months. West syndrome was the first manifestation of epilepsy in 10 cases (IVH: 4, HIE: 6), and all 16 patients had severe neuropsychiatric deficits. Comparing with children without epilepsy, IVH grades III and IV, mechanical ventilation for more than 6 days and neonatal convulsions in the patients with IVH, and mechanical ventilation and neonatal convulsions in the patients with HIE, were significantly related to the risk of subsequent epilepsy. These findings suggest that the degree of brain injuries may be predictive of the development of epilepsy during infancy and early childhood in the patients with IVH or HIE.     

Risk factors for acute symptomatic cerebral infarctions after spontaneous supratentorial intra-cerebral hemorrhage

Cerebral infarctions are unfavorable outcomes of spontaneous intra-cerebral hemorrhage (ICH). To date, there have been no reports on risk factors that are predictive of acute symptomatic cerebral infarctions. With the aim of determining the potential risk factors that are predictive of acute symptomatic cerebral infarctions in patients with spontaneous supratentorial ICH, we have retrospectively evaluated 212 hospitalized patients with spontaneous ICH and compared those who developed a complicated cerebral infarction with those who did not. Cerebral infarctions developed in 8.02% (17/212) of the patient cohort. Neuro-imaging findings between the two patient groups revealed that the presence of intra-ventricular hemorrhage (IVH), hydrocephalus, and the median value of intra-cranial hematoma on admission were significant factors, as well as neurosurgical intervention. However, the multiple logistic regression analysis revealed that only the presence of IVH had an odds ratio of 4.7 (95% confidence interval 0.06–0.75; p = 0.016) in patients with acute symptomatic infarctions. The results indicate that the presence of IVH may imply a danger of cerebrovascular complications when treating spontaneous supratentorial ICH during hospitalization. The frequency of acute symptomatic cerebral infarctions in patients with spontaneous supratentorial ICH is high (8%) and is associated with longer hospitalization and worse outcome.     

White Matter Lesion Severity is Associated with Intraventricular Hemorrhage in Spontaneous Intracerebral Hemorrhage

Background: Intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability in intracerebral hemorrhage (ICH). A prior report identified an increased risk of IVH with greater WML burden but did not control for location of ICH. We sought to determine whether a higher degree of WML is associated with a higher risk of IVH after controlling for ICH location. Methods: Utilizing the patient population from 2 large ICH studies; the Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study and the Ethnic/Racial Variations of Intracerebral Hemorrhage study, we graded WML using the Van Swieten Scale (0-1 for mild, 2 for moderate, and 3-4 for severe WML) and presence or absence of IVH in baseline CT scans. We used multivariable regression models to adjust for relevant covariates. Results: Among 3023 ICH patients, 1260 (41.7%) had presence of IVH. In patients with IVH, the proportion of severe WML (28.6%) was higher compared with patients without IVH (21.8%) (P < .0001). Multivariable analysis demonstrated that moderate-severe WML, deep ICH, and increasing ICH volume were independently associated with presence of IVH. We found an increased risk of IVH with moderate-severe WML (OR = 1.38; 95%Cl 1.03-1.86, P = .0328) in the subset of lobar hemorrhages. Conclusions: Moderate to severe WML is a risk for IVH. Even in lobar ICH hemorrhages, severe WML leads to an independent increased risk for ventricular rupture.     

大鼠脑出血后血肿周围组织线粒体功能变化的研究

目的:研究大鼠脑出血后脑组织线粒体功能的变化。方法:以50 μL鼠尾血注入大鼠尾状核制作大鼠脑出血模型,注血后分别于12 h及1、3、7 d处死大鼠,断头,取血肿周围脑组织,测定不同时相点血肿周围组织线粒体功能(琥珀酸脱氢酶活性、呼吸控制率)。结果:出血后12 h线粒体呼吸控制率及琥珀酸脱氢酶活性无明显变化,1 d后呼吸控制率较对照组下降,3 d时线粒体呼吸控制率及琥珀酸脱氢酶活性均较对照组下降,出血后7 d线粒体琥珀酸脱氢酶活性、呼吸控制率则较对照组明显下降(P<0.01)。结论:脑出血早期(尤其在12 h之内)血肿周围组织线粒体功能无明显下降,晚期则明显受损。     

Diagnostic/prognostic significance of photo-evoked eyelid microvibration in neonates with intracranial hemorrhage

Photo-evoked eyelid microvibration (PEMV) was recorded in neonates with intracranial hemorrhage in order to determine whether it serves as a useful indicator of clinical course and also prognosis. Although the latency of PEMV was prolonged or absent in the acute stage of ICH, it returned to a normal range in these subjects with the improvement of symptoms. Three infants whose PEMV were still prolonged in the convalescent stage developed mental retardation or cerebral palsy. PEMV may be a useful predictor of the prognosis of neonatal ICH and its prolongation may signal later neurological sequelae.     

Neonatal Intracranial Ischemia and Hemorrhage : Role of Cranial Sonography and CT Scanning

Objective

To evaluate the role of cranial sonography and computed tomography in the diagnosis of neonatal intracranial hemorrhage and hypoxic-ischemic injury in an Indian set-up.

Methods

The study included 100 neonates who underwent cranial sonography and computed tomography (CT) in the first month of life for suspected intracranial ischemia and hemorrhage. Two observers rated the images for possible intracranial lesions and a kappa statistic for interobserver agreement was calculated.

Results

There was no significant difference in the kappa values of CT and ultrasonography (USG) for the diagnosis of germinal matrix hemorrhage/intraventricular hemorrhage (GMH/IVH) and periventricular leucomalacia (PVL) and both showed good interobserver agreement. USG, however detected more cases of GMH/IVH (24 cases) and PVL (19) cases than CT (22 cases and 16 cases of IVH and PVL, respectively). CT had significantly better interobserver agreement for the diagnosis of hypoxic ischemic injury (HII) in term infants and also detected more cases (33) as compared to USG (18). CT also detected 6 cases of extraaxial hemorrhages as compared to 1 detected by USG.

Conclusion

USG is better modality for imaging preterm neonates with suspected IVH or PVL. However, USG is unreliable in the imaging of term newborns with suspected HII where CT or magnetic resonance image scan is a better modality.     

Neurodevelopmental assessment of very low birth weight neonates: effect of germinal matrix and intraventricular hemorrhage

During a recent 36-month interval, all neonates of less than or equal to 1250 gram birth weight who were admitted to our Newborn Special Care Unit and survived the first 36 postnatal hours underwent either computed tomography or echoencephalography or both for the assessment of neonatal germinal matrix hemorrhage and intraventricular hemorrhage. Seventy of the 164 long-term surviving infants experienced neonatal germinal matrix and/or intraventricular hemorrhage (GMH/IVH Group), whereas 94 infants had studies that were negative (Non-hemorrhage Group). Serial neurodevelopmental assessments were performed on 142 (87%) of the 164 long-term surviving infants; these assessments included the Bayley Scales of Infant Development at 3, 6, 12, and 18 months (corrected age) and the Stanford-Binet and Peabody Picture Vocabulary examinations at 30 months (corrected age). At 30 months (corrected age), the incidence of major neurologic abnormalities was extremely low in both the GMH/IVH and the Non-hemorrhage groups. In addition, although there were few survivors of the more severe grades of intraventricular hemorrhage, we could detect no difference between the developmental scores of the GMH/IVH and the Non-hemorrhage Group infants.