Spontaneous intracerebral hemorrhage in cases of severe angiospasm following ruptured aneurysm--a pathological study.

Eleven patients with a history of moderate or severe angiospasm following ruptured cerebral aneurysm developed spontaneous intracerebral hemorrhage between 31 and 111 months after aneurysm surgery. In all cases, hemorrhage occurred in the ipsilateral hemisphere to the original aneurysm. In nine patients, the hematoma was surgically evacuated and bleeding perforating arteries were resected for histological examination. Computed tomographic scans showed the hematomas to be unusually extended compared to those after hypertensive intracerebral hemorrhage. The histological examination showed various degenerative changes in the elastic lamina and media of the perforating arteries, even though most patients were young and normotensive. These findings suggest that patients who have suffered severe cerebral angiospasm may have a higher risk for subsequent development of intracerebral hemorrhage than those without prior angiospasm.     

Three-dimensional computerized tomography angiography in patients with hyperacute intracerebral hemorrhage.

OBJECT: The authors confirm the usefulness of extravasation detected on three-dimensional computerized tomography (3D-CT) angiography in the diagnosis of continued hemorrhage and establishment of its cause in patients with acute intracerebral hemorrhage (ICH). METHODS: Thirty-one patients with acute ICH in whom noncontrast and 3D-CT angiography had been performed within 12 hours of the onset of hemorrhage and in whom conventional cerebral angiographic studies were obtained during the chronic stage were prospectively studied. Noncontrast CT scanning was repeated within 24 hours of the onset of ICH to evaluate hematoma enlargement. Findings indicating extravasation on 3D-CT angiography, including any abnormal area of high density on helical CT scanning, were observed in five patients; three of these demonstrated hematoma enlargement on follow-up CT studies. Thus, specificity was 60% (three correct predictions among five positives) and sensitivity was 100% (19 correct predictions among 19 negatives). Evidence of extravasation on 3D-CT angiography indicates that there is persistent hemorrhage and correlates with enlargement of the hematoma. Regarding the cause of hemorrhage, five cerebral aneurysms were visualized in four patients, and two diagnoses of moyamoya disease and one of unilateral moyamoya phenomenon were made with the aid of 3D-CT angiography. Emergency surgery was performed without conventional angiography in one patient who had an aneurysm, and it was clipped successfully. CONCLUSIONS: Overall, 3D-CT angiography was found to be valuable in the diagnosis of the cause of hemorrhage and in the detection of persistent hemorrhage in patients with acute ICH.     

Epileptic seizures in intracerebral hemorrhage: a clinical and prognostic study of 55 cases

Fifty-five cases of epileptic seizures associated with spontaneous intracerebral hemorrhage are reported. Seizures appeared as the first symptom in 23 patients, early (within two weeks after HI) in 18 and late (later than 2 weeks after HI) in 14. From the analysis of the observed cases we noticed that: 1) partial seizures were most frequent type (63%). These appeared mainly in cases with lobar hemorrhage above all; 2) development chronic epilepsy occurred frequently in the case of patients affected by late seizures. We compare our data with those reported in literature in order to highlight main factors which affect the onset and development of seizures associated with spontaneous intracerebral haemorrhage.     

Subarachnoid hemorrhage and negative angiography: clinical course and long-term follow-up

The aim of this study was to investigate the long-term natural history of nontraumatic angiogram-negative subarachnoid hemorrhage with typical pretruncal (P-SAH) and diffuse (D-SAH) pattern of hemorrhage. A retrospective review of 102 patients who experienced angiographically negative SAH at our institution was undertaken (11.6% of 882 spontaneous SAH). Follow-ups were obtained at 7.9 to 16 years. In the D-SAH group, 11 patients (13.9%) out of 79 had an aneurysm, and four (5.1%) had rebleeding episodes. In the P-SAH group, the second angiography was negative in all of the 23 cases, and no rebleeding episodes were recorded. The long-term follow-up confirms that P-SAH is a benign disease. A second angiography could not be necessary. D-SAH is probably due to an aneurysm that thrombose early after the bleeding. At short-term follow-up, the sack could frequently recanalize and rebleed, whereas a late follow-up shows that rebleeding is very rare.     

Dysautoregulation in patients with hypertensive intracerebral hemorrhage. A SPECT study

In patients with hypertensive intracerebral hemorrhage, changes in regional cerebral blood flow (rCBF) following drug-induced blood pressure reduction were examined by SPECT. Methods: The subjects were 68 patients with hypertensive intracerebral hemorrhage. The site of cerebral hemorrhage was the thalamus in 28 patients, and the putamen in 40 patients. RCBF was measured by SPECT using the ¹³³Xe inhalation method. To reduce blood pressure, trimethaphan camsilate (an autonomic ganglion blocker) and diltiazem hydrochloride (a calcium antagonist) were used. Results: 1. In the acute period, mean CBF declined as the mean arterial blood pressure declined by more than 20% in both the putaminal and the thalamic hemorrhage group (p<0.01). 2. During the chronic period, a greater reduction in blood pressure was needed to induce mean CBF reduction. 3. Neither of the two drugs significantly reduced the mean arterial blood pressure, but the group receiving trimethaphan demonstrated a 7. 7.5% decreased in CBF, group while the receiving diltiazem showed a 2.2 2.4% decrease (p<0.05). Conclusions: In patients with hypertensive intracerebral hemorrhage, a 20% or more drug-induced decrease in blood pressure resulted in a decrease in mean CBF. During the acute period of intracerebral hemorrhage, blood pressure showed reduced by 20%. Clinically, diltiazem was more effective than trimethaphan.     

Hypertensive intracerebral hemorrhage. Epidemiology and clinical pathology.

Hypertension is the major risk factor for intracerebral hemorrhage (ICH) and is present in about 50% of patients with ICH. Common clinical findings are focal neurologic deficits at onset, gradually progressive deterioration, and the presence of headache, vomiting, and depressed level of consciousness. The clinical syndromes of ICH at common locations are reviewed. CT scanning has dramatically changed our thinking about ICH and allowed better correlation of neurologic findings with lesions at various sites.     

Fibromatosis of the breast. A clinical and pathological study of 28 cases

The clinical and pathologic findings of 28 examples of fibromatosis of the breast not involving the deep fascia or chest wall are reported. Five of the 20 lesions treated by local excision recurred. Recurrences developed within a 4 to 8 month period following surgery in four of the five instances, and 6 years after surgery in one instance. One lesion recurred five times over a period of 3 years. None of the patients died from their disease, and none developed a metastasis. Those lesions that recurred had been inadequately excised initially, since surgical margins showed fibromatosis. Specific histological features, such as size, cellularity, atypia, and mitotic figures, were not helpful in predicting recurrence. Although local excision appears to have been adequate in the majority (75%) of the patients, the infiltrative nature of fibromatosis necessitates documentation of tissue margins in order to avoid the possibility of recurrence. The differential diagnosis includes benign reactive processes (such as keloid and nodular fasciitis), fibrous histiocytoma, low-grade spindle-cell (metaplastic) carcinoma, and fibrosarcoma.     

Two cases of cerebral aspergillosis with intracerebral hemorrhage

Two patients who had cerebral aspergillosis with massive intracerebral hemorrhage were presented. Case I was a 59-year-old woman who had slight mental retardation. There was swelling in the left forehead, from which mucosal cysts of frontal sinus had been removed 2 years before her admission. She had a diagnosis of subdural abscess and radical operation was performed. Aspergillus was found in the abscess histologically. Three months after the operation, CT scan revealed multiple abscess in bilateral frontal lobe. When she lost consciousness suddenly 4 months after the operation, CT scan showed a huge intracerebral hematoma. Case 2 was a 16-year-old girl who suffered from immunological dysfunction caused by more than 6 months antibiotics-steroid treatment for pneumonitis. She lost her consciousness after complaints of severe headache. CT scan showed a heterogeneous high density area with severe brain edema in the left temporal lobe. The removal of hematoma was performed immediately. The level of her consciousness improved, but she died of the complication of DIC and renal failure 14 days after the hemorrhage. Autopsy revealed a number of aspergillomas in lungs, kidneys, gastrointestinal tract, liver and pancreas. Marked necrosis and a number of aspergillus hyphae which invaded and penetrated the wall of cerebral vessels were found in the brain tissue. It was presumed that such a huge intracerebral hematoma was caused by direct invasion and penetration into the brain of aspergillus from the blood vessels. The diagnosis of cerebral aspergillosis is made mainly by the pathological examination of the tissue obtained at surgery or autopsy.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Souter-Strathclyde elbow arthroplasty. A clinical and radiological study of 525 consecutive cases

We present the results of 525 primary Souter elbow arthroplasties undertaken in 406 patients between 1982 and 1997. There were 372 women and 34 men with a mean age of 57 years; 119 patients had a bilateral procedure. The elbows were affected by chronic inflammatory disease, usually rheumatoid arthritis, which had been present for a mean of 24.7 years (2 to 70). In about 30% the joints were grossly destroyed with significant loss of bone. In 179 elbows the ulnar components were metal-backed and retentive; in the remaining 346, with better bone stock, non-retentive, all-polyethylene prostheses were used. Because of complications, 108 further operations were required in 82 patients. During the early years the incidence of complications was higher. Dislocation was the indication for 30 further procedures in 26 patients. Thirty patients underwent 33 revision procedures for aseptic loosening, 12 had 29 operations because of deep infection, two for superficial infection, and 14 further operations were done for other reasons. The cumulative rate of success, without aseptic loosening, five and ten years after surgery, was 96% and 85%, respectively.     

Duodenal somatostatinoma. Anatomic/clinical study of 12 operated cases

STUDY AIM: Duodenal somatostatinomas (DS) are very rare neuro-endocrine tumours. The aim of this retrospective and multicentric study was to report the clinical and pathological characteristics of these neoplasms in a series of 12 patients and to compare them with the literature. PATIENTS AND METHODS: From 1987 to 1998, 12 patients were operated for a DS. There were seven women and five men ranging in age from 23 to 72 years (mean age: 56.6 years). Four patients had an associated von Recklinghausen's disease, one of them with multiple endocrine neoplasia (MEN type IIa) and medullary carcinoma of the thyroíd. The surgical procedures were pancreaticoduodenectomy (n = 8), small bowel resection (n = 2), inferior gastrectomy (n = 1) and gastrojejunostomy with hepatic metastases biopsies (n = 1). The tumour was mainly located on the 2nd duodenum (n = 10), with a mean size of 2.7 cm (ranging from 0.4 to 6 cm) and with a pancreatic invasion in three patients. A metastatic disease was present at the time of diagnosis in eight patients. There were, according to Capella's classification, two patients in the groups I and II, and ten patients in group III (83%), respectively. RESULTS: There was one postoperative death after a pancreaticoduodenectomy. Three patients secondarily died from tumoral progression. Eight patients were alive, with a mean follow-up of 84 months (ranging from 5 to 290 months), at the end-point of the study. CONCLUSION: Duodenal somatostatinomas are rare neuroendocrine, generally non-functioning, well-differentiated tumours with a low grade of malignancy. The association with the von Recklinghausen's disease is frequent. The clinical somatostatinoma syndrome with diabetes, diarrhea and biliary lithiasis is rare. The treatment is surgical even with a metastatic disease. The 5-year survival rate is better than those of the pancreatic somatostatinomas or the duodenal gastrinomas.     

Bronchioloalveolar carcinoma: clinical, radiographic, and pathological findings. Surgical results

BACKGROUND: Bronchioloalveolar carcinoma (BAC) remains one of the most controversial of lung cancer subtypes. METHODS: From 1980 to 1998, 374 resected patients for NSCLC were followed up in our department. Of the 147 cases histologically defined as adenocarcinoma, 34 were pure BAC. The records of these 34 patients were retrospectively reviewed in order to evaluate patient and tumor characteristics and to identify which variables had a prognostic impact on survival and recurrence rate. RESULTS: Patient age, sex, smoking habits and symptoms were not differentiating characteristics when related to radiographic presentation or to natural history. Mucinous cell-type (23.6% of cases) was more frequent with non-smokers, presence of a single nodule or mass and stage I. Favorable characteristics were: a) the prevalence of stage I and N0 cases (59% and 76.7% of cases, respectively) with a mean survival time of 66 and 77 months, respectively; and b) the radiographic presentation of a solitary pulmonary nodule or mass (76.4% of cases), that, independently of nodal involvement, showed a higher mean survival time (62 months). Independently significant adverse prognostic factors were: stage II-IV, lymph node involvement, and patient age over sixty years. The radiographic presence of multiple or satellite nodules was related to a significantly adverse prognosis (mean survival time: 18 months) by univariate analysis; this was not confirmed by multivariate analysis. CONCLUSIONS: In our experience BAC was the NSCLC subtype more frequently associated with a good outcome after resection; surgery should not to be denied also in patients with multiple nodules, when under sixty years of age and no lymph node involvement.     

Repeated intracerebral hemorrhage associated with impaired platelet aggregation--report of two cases.

The authors report two cases of hypertensive intracerebral hemorrhage (ICH) repeated at the same site within 1 or 2 days causing death in a 53-year-old male and a 48-year-old female. In both cases, platelet aggregation was significantly impaired. Acquired platelet dysfunction may be important in the expansion of hemorrhage in patients with repeated hypertensive ICH. In such cases administration of normal platelets may be required to prevent devastating hemorrhage.     

Risks and benefits of CT angiography in spontaneous intracerebral hemorrhage

Background

Few studies have examined the risk of computed tomography angiography (CTA) during the acute phase of spontaneous intracerebral hemorrhage (ICH), while the benefits of CTA in ICH have been well-documented. The present study investigated both the benefits of identifying spot signs, which are supposed to indicate hematoma enlargement after admission, and risks of CTA performed during the acute phase of ICH.

Methods

We retrospectively assessed 323 consecutive patients with spontaneous ICHs admitted to our hospital between April 2009 and March 2012 and who underwent CTA on admission.

Results

In 80 patients (24.7 %), spot signs were demonstrated on CTA source images. Multivariate analysis revealed two independent factors correlated with presence of the spot sign: age and hematoma volume (p?<?0.05 each). The presence of spot sign was associated with unfavorable outcomes at discharge and hematoma growth after admission (p?<?0.05 each). Adverse events related to CTA occurred in 17 patients (5.2 %), including transient renal dysfunction in 16 patients and allergy to contrast medium in one patient. All adverse events completely resolved within 1 week.

Conclusions

Presence of the spot sign indicated the possibility of hematoma growth and unfavorable outcomes. A small number of adverse events occurred in association with CTA, but without any permanent deficits. Given the potential benefits and risks, we believe that CTA performed at admission in all patients with ICH is beneficial to improve the outcomes.     

Comparative study of traumatic and spontaneous intracerebral hemorrhage.

OBJECT: Spontaneous intracerebral hemorrhage (SICH) and traumatic intracerebral hemorrhage (TICH) are common disorders. The authors planned to study how these two types of hemorrhage behave pathologically and clinically to gain further insight into their causes, pathogeneses, indications for surgical intervention, and prognoses. METHODS: Prospectively filled databases of demographic, clinical, radiological, and outcome details have been maintained for all patients admitted to the Regional Neurosciences Centre with head injury since 1987 and with SICH since 1993. Of the 5686 patients whose case information was included in the head-injury database, 90 were found to suffer from an isolated intracerebral hemorrhage (ICH) as the only major abnormality observed on computerized tomography scans (subdural and extradural hematomas were excluded). Case details on these 90 patients and the 440 patients from the SICH database were extracted and analyzed using a statistical software program. The median age of patients with TICH was lower than the median age of patients with SICH (51 years compared with 65 years, respectively), but it was much higher than the median age of the entire head-injury group (21 years). Among patients younger than 45 years of age, 0.8% of patients who experienced trauma suffered from an ICH compared with 4.3% of patients older than 45 years of age. Irrespective of intervention, much better outcomes were achieved by patients with TICH compared with those with SICH (67% favorable outcomes compared with 24% in patients with SICH). Following trauma, there was no significant relationship between the severity of injury and the development of ICH. At presentation the median Glasgow Coma Scale (GCS) score for both groups was 13. Younger age and higher GCS score at presentation were strongly related to a favorable outcome for both types of hemorrhage. There was no significant difference in patient age, presenting GCS score, or outcomes of patients who underwent surgery compared with those who did not for either type of hemorrhage. No conclusions can be drawn about the efficacy of surgery from such observational studies. CONCLUSIONS: On the basis of these data the authors suggest that TICH and SICH have different features: TICH affects a slightly younger age group and carries a much better prognosis compared with SICH. In addition, indications for surgical intervention are not well defined for either type of hemorrhage. Practice is subjective and inconsistent. The International Surgical Trial in Intracerebral Haemorrhage may resolve the dilemma for SICH. A similar trial in which surgery is compared with conservative management should be considered for cases of TICH.