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.     

Hypertensive intracerebral hematoma after aneurysmal subarachnoid hemorrhage

We report a patient with sequential intracerebral hematoma in bilateral basal ganglia after an aneurysmal subarachnoid hemorrhage. A 55-year-old woman presented with sudden loss of consciousness without a past history of hypertension. Subarachnoid hemorrhage secondary to a ruptured anterior communicating artery aneurysm was seen on initial CT and an intracerebral hematoma was observed in both basal ganglia 3 hours later on a follow-up CT scan. We suggest that delayed intracerebral hematoma may occur due to increased intracranial pressure caused by aneurysmal rupture and discuss the possible mechanisms of this occurrence.     

不同时间应用尼莫地平对脑出血血肿体积及脑水肿的影响

目的观察尼莫地平应用于脑出血的临床疗效。方法40例脑出血患者随机分为治疗组和对照组,治疗组分别在发病后12h、48h、5d时给予静滴尼莫地平8mg,共15d,对照组常规治疗。分别记录其在入院时、5d、15d的血肿体积及水肿带面积。结果尼莫地平可减轻脑出血水肿带出现程度;同时不增加再出血的几率。结论尼莫地平应用于脑出血有较好临床疗效,早期（12h内）疗效更佳。     

Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage

Introduction: Decompressive hemicraniectomy in large hemispheric infarctions has been reported to lower mortality and improve the unfavorable outcomes. Hematoma volume is a powerful predictor of 30-day mortality in patients with intracerebral hemorrhage (ICH). Hematoma volume adds to intracranial volume and may lead to life-threatening elevation of intracranial pressure. Methods: Records of 12 consecutive patients with hypertensive ICH treated with decompressive hemicraniectomy were reviewed. The data collected included Glasgow Coma Scale (GCS) score at admission and before surgery, ICH volume, ICH score, and a clinical grading scale for ICH that accurately risk-stratifies patients regarding 30-day mortality. Outcome was assessed as immediate mortality and modified Rankin Score (mRS) at the last follow-up. Results: Of the 12 patients with decompressive hemicraniectomy, 11 (92%) survived to discharge; of those 11, 6 (54.5%) had good functional outcome, defined as a mRS of 0 to 3 (mean follow-up: 17.13 months; range: 2–39 months). The mean age was 49.8 years (range: 19–76 years). Three of the 7 patients with pupillary abnormalities made a good recovery; of the 11 patients with intraventricular extensions (IVEs), 7 made a good recovery. The clinical finding (which was present in all 3 patients with mRS equal to 5 and which was not present in patients with mRS less than 5) was abnormal occulocephalic reflex. Of the 10 patients with an ICH score of 3,9 (90%) survived to discharge, 4 (44%) had good functional outcome (mRS: 1–3). Hematoma volume was 60 cm³ or greater in eight patients, four (50%) of whom had good functional outcome (mRS: 0–3). Conclusion: Decompressive hemicraniectomy with hematoma evacuation is life-saving and improves unfavorable outcomes in a select group of young patients with large right hemispherical ICH.     

Antiplatelet therapy and future intracerebral hemorrhage in hemodialysis patients with cerebral microbleeds

The use of antiplatelet drugs is thought to increase the risk for intracerebral hemorrhage (ICH) in patients with cerebral microbleeds (CMBs). However, hemodialysis (HD) patients have a high prevalence of CMBs and diverse pathologies that require antiplatelet therapy. In this study, we investigated whether the use of antiplatelet drugs increases the risk for ICH in HD patients with CMBs. Brain magnetic resonance imaging (MRI), including T2*-weighted MRI, was performed in 179 HD patients with no history of cerebrovascular events. CMBs were detected and patients were followed prospectively with a median follow-up period of 5.2 [1.4–6.2] years. To investigate whether the influence of antiplatelet therapy on the development of ICH differs in cases with and without CMBs, the inverse probability of treatment weighting method was used, including an interaction term between the presence or absence of CMBs and use of antiplatelet drugs. As a result, CMBs were detected in 45 patients (25.1%), and antiplatelet drugs were used in 66 patients (36.9%). When the effect of antiplatelet therapy on the incidence of ICH was modified by the presence of CMBs at baseline (P for interaction <0.001), the use of antiplatelet drugs was a significant risk factor for ICH in HD patients without CMBs, but not in HD patients with CMBs. Furthermore, the burden of CMBs significantly increased the risk for ICH, but the increase in this risk was slower in antiplatelet drug users as compared to non-antiplatelet drug users (P for interaction = 0.02). The influence of antiplatelet drugs on the development of ICH differed depending on the presence or absence of CMBs. In fact, the use of antiplatelet drugs did not increase the risk for ICH in HD patients with CMBs.     

高血压脑出血患者血肿灶周组织形态学观察

目的 观察高血压脑出血患者急性期血肿周围组织的病理变化.方法 将28例高血压脑出血患者微创技术治疗时吸出的脑组织进行HE和刚果红染色.结果 光镜下可见大片出血病灶和点状出血,部分小动脉玻璃样变性及粟粒型动脉瘤;血管周围可见嗜中性粒细胞渗出,血管腔内充血,脑组织水肿,神经胶质细胞及神经元均有不同程度的坏死.同时通过CT影像学改变进行对比观察血肿发生部位与病理变化关系.结论自发性的高血压性脑出血及脑动脉扩张与动脉血管发生玻璃样变性有关,少数与动脉急性坏死、微动脉瘤、细动脉粥样硬化、淀粉样变性有关.通过CT进一步证实高血压动脉硬化性脑出血部位以基底节最为常见,而血管淀粉样变性导致的脑出血主要以脑叶为主.     

口服抗凝药相关性脑内出血的治疗探讨

目的探讨口服抗凝药相关性脑出血的临床特点和治疗方法。方法回顾性分析36例口服抗凝药相关性脑出血患者的临床资料,所有患者入院后均常规纠正凝血功能障碍,包括静脉输注维生素K和新鲜冷冻血浆。16例行开颅血肿清除,13例行定向血肿穿刺引流,5例仅行脑室外引流,2例保守治疗。结果出院时按GOS评分评定预后,预后良好4例,中残3例,重残6例,植物生存4例,死亡19例。结论口服抗凝药相关性脑出血病情进展快,再出血率和死亡率高。早期纠正凝血功能障碍及清除血肿,防止再出血是治疗的关键。     

超早期小骨窗经侧裂入路微侵袭治疗基底节血肿

目的探讨超早期小骨窗经侧裂入路微侵袭治疗基底节血肿的效果。方法对53例基底节血肿的病人采取侧裂投影直切口,小骨窗经侧裂入路手术清除血肿。结果术后10h意识状况：42例神志清楚,7例较术前好转,4例无改善;24内复查CT,残余血肿量与术前比较。血肿清除80%以上有40例,50～80%者有9例,50%以下和超过原血肿量共3例,术后72h复查CT,脑水肿引起的占位效应与传统手术相比非常轻微;死亡7例,死亡率达13.21%;术后3～6个月随访,按ADL分级进行测评：Ⅰ级4例（7.55%）;Ⅱ级11例（20.75%）;Ⅲ级22例（41.51%）;Ⅳ级7例（13.21%）;Ⅴ级2例（3.77%）。结论超早期小骨窗经侧裂入路有视野好便于彻底清除血肿、创伤小、对脑组织损伤轻微和手术时间短等优点;术后脑水肿轻微,病人恢复快,明显提高预后。     

Managing the therapeutic dilemma: patients with spontaneous intracerebral hemorrhage and urgent need for anticoagulation

Physicians face a therapeutic dilemma in patients with acute hemorrhagic stroke requiring long-term, high-intensity anticoagulants because this treatment increases the risk of intracranial hemorrhage (ICH) 8- to 11-fold. We retrospectively studied 15 patients with ICH which occurred under anticoagulation with phenprocoumon, with an international normalized ratio (INR) of 2.5–6.5 on admission. Hemispheric, thalamic, cerebellar, intraventricular, or subarachnoid hemorrhage without aneurysm occurred. Absolute indications for anticoagulation were double, mitral, or aortic valve replacement, combined mitral valve failure with atrial fibrillation and atrial enlargement, internal carotid artery-jugular vein graft, frequently recurring deep vein thrombosis with risk of pulmonary embolism, and severe nontreatable ischemic heart disease. As soon as the diagnosis of ICH was established, INR normalization was attempted in all patients by administration of prothrombin complex, fresh frozen plasma, or vitamin K. After giving phenprocoumon antagonists (and neurosurgical therapy in four patients) heparin administration was started. Nine patients received full-dose intravenous and six low-dose subcutaneous heparin. The following observations were made: (a) All patients with effective, full-dose heparin treatment with a 1.5- to 2-fold elevation in partial thromboplastin time after normalization of the INR were discharged without complication. (b) Three of four of the patients with only incomplete correction of the INR (> 1.35) experienced relevant rebleeding within 3 days (all patients with an INR higher than 1.5), two of whom were on full-dose heparin. (c) Three of seven of the patients with normalized INR and without significant PTT elevation developed severe cerebral embolism. Although our data are based on a retrospective analysis, they support treatment with intravenous heparin (partial thromboplastin time 1.5–2 times baseline value) after normalization of the INR in patients with an ICH and an urgent need for anticoagulation. Received: 1 September 1999/Received in revised form: 28 October 1999/Accepted: 19 November 1999     

神经内镜锁孔入路与传统开颅术治疗颅内血肿的对比研究

目的研究评价神经内镜锁孔入路清除颅内血肿的临床疗效及安全性。方法回顾性分析21例颅内出血患者采用神经内镜治疗的临床资料,另随机选择同期30例采用传统开颅显微镜下血肿清除术治疗颅内血肿患者作为对照组。以病死率、血肿量,血肿清除率、感染率、GCS评分、mRS评分、GOS评分等作为疗效指标。结果神经内镜组血肿清除率明显高于传统手术治疗组,两组差异具有明显统计学意义,且神经内镜组术后感染率低于对照组。两组在病死率、GOS评分、出院时GCS评分、6个月mRS评分方面差异均无统计学意义。而神经内镜组患者术后恢复良好率(GOS≥4)明显高于对照组,差异具有统计学意义。结论神经内镜经锁孔入路治疗颅内血肿临床疗效满意,具有较高的血肿清除率,明显降低术后感染发生率,显著提高患者术后的神经功能恢复。     

Blood pressure surge precedes intracerebral hemorrhage

Introduction: Most patients with acute intracerebral hemorrhage (ICH) have very high blood pressure (BP) on presentation, but it is unclear whether such pressure elevation is the cause or a consequence of the ICH. This controversy could be clarified by determining the exact temporal relationship between the BP elevation and the onset of the ICH. Several case reports have attributed ICH to specific situations in which the BP was inferred to be high. Unfortunately, those cases lacked continuous monitoring of BP and neurological exam. Methods: Single case observation in a University-based tertiary medical center. Results: A neurologically intact 64-year-old woman whose BP and neurological status were monitored during admission to a medical intensive care unit. The patient suddenly developed a decreased level of consciousness and a right hemispheric syndrome 3.5 hours after demonstrating systolic BP values in the range 200 mmHg. An unenhanced computed tomography scan of the brain demonstrated a right ICH. Conclusion: In this monitored case, the BP surge clearly preceded the onset of neurological symptoms by 3.5 hours, supporting the view that the acute BP elevation was the cause of ICH. An erratum to this article is available at .     

高血压脑出血患者早期强化降压对血肿扩大的影响

目的 探讨高血压脑出血(ICH)患者早期强化降压治疗对血肿扩大的影响.方法 选择入院时血压＞180/110 mmHg的ICH患者256例,随机分为强化降压组(A组,128例)及指南标准降压组(B组,128例),分别给予强化降压及指南标准降压治疗;观察24 h后两组血肿体积的变化和入院时及21 d时美国国立卫生研究院卒中量表(NIHSS)情况.结果 A组治疗前及24 h后血肿平均体积为(20.5±2.76)ml和(23.3±2.32)ml,血肿扩大11例(8.59%);B组血肿平均体积为(20.2±2.87)ml和(26.5±2.48)ml,血肿扩大29例(22.66%),两组血肿扩大率的比较差异有统计学意义(P＜0.01);A组入院时及治疗21 d时NIH-SS评分分别为(26.5±7.42)分及(16.5±9.26)分;B组分别为(25.8±7.93)分及(19.7±10.40)分;两组发病21 d时比较差异有统计学意义(P＜0.05).结论 高血压ICH早期强化降压治疗对控制血肿扩大有益.     

自发性脑室内血肿的外科手术治疗

目的 总结自发性脑室内血肿的手术治疗。方法 回顾性分析手术治疗的35例自发性脑室内血肿患者的临床资料。结果 手术治疗的35例自发性脑室内血肿患者恢复良好27例，植物生存3例，死亡5例。结论 局麻下一侧或双侧侧脑室穿刺置管＋尿激酶注入溶解持续引流是一种简便、易行、有效的治疗自发性脑室内血肿的方法。     

神经内镜微创手术与开颅血肿清除术治疗高血压脑出血疗效比较

目的 探讨神经内镜微创手术与开颅血肿清除术治疗高血压脑出血的疗效。方法 连续收集同一术者手术病例120例,分成开颅手术组和神经内镜手术组,每组60例。通过手术时间、血肿清除率、术后GCS、NICU滞留时间、术后并发症的出现和术后3个月GOS,比较两组手术疗效。结果 所有120名患者接受持续随访,随访时间大于3个月。内镜手术组和开颅组2组病例术前临床资料无明显差异(P0.05);手术时间内镜组为(1.5±0.4)h,开颅组为(3.9±0.6)h(P0.01);血肿清除率内镜组为95.84%±2.72%,开颅组为87.48%±7.84%(P0.01);术后第1、3、7天GCS评分内镜组分别为:10(6,12),12(8,13),13(10,13),开颅组分别为6(5,9),7(5,11),8(5,12()P均0.01);NICU滞留时间内镜组为(3.55±4.21)d,开颅组为(9.10±4.72)d(P0.01);术后并发症内镜组无颅内感染病例,坠积性肺炎5例;开颅组颅内感染6例,坠积性肺炎41例,内镜组优于开颅组(P均0.05);术后3个月GOS评分,内镜组3(3,4),开颅组2(2,3)(P0.01)。结论 神经内镜手术治疗高血压脑出血具有微创高效的特点,是治疗脑出血的有效方式,多个方面优于开颅血肿清除术,值得临床推广。     

Massive intracerebral hemorrhage caused by a cavernous malformation

We present a rare case of massive intracerebral hemorrhage resulting from a small, superficially-located supratentorial cavernous malformation, or cavernoma. These lesions rarely lead to massive, life-threatening intracerebral hemorrhages. A 17-year-old female presented with a 3-week history of declining mental status. Brain computed tomography and magnetic resonance imaging revealed a sizable intracranial hemorrhage, within the right occipital region, associated with a small nodule at the hematoma's posterior margin. An emergency operation removed the entire hematoma and nodule. Histological examination of the nodule was compatible with a diagnosis of cavernous malformation. The patient's post-operative course was uneventful.     

自发性脑出血的再出血随访分析

对首次脑出血存活者出院后进行２８－８８个月的随访，结果显示，在随访期２７．７％的存活者，经历了一次或次再出血。在正常血压病人出血部位被认为是血管淀粉样变的好部位。     

MRS对微创血肿清除术后的评估研究

目的观察脑出血患者保守治疗及微创血肿清除术治疗后的磁共振波谱(MRS)表现,探讨血肿周围脑组织改变及微创血肿清除术的临床价值。方法将20例高血压性脑出血患者随机分为2组,微创血肿清除手术组(微创组)和保守治疗组(对照组)各10例,所有病例均于发病后9～11d行常规MR及MRS检查。结果对照组血肿周围NAA/Cr值与对侧相应区的NAA/Cr值有显著性差异(P<0.01),前者较后者降低(12.6±7.4)%,其中4例可见到明确的乳酸峰;微创组血肿周围NAA/Cr值与对侧相对应区的NAA/Cr值亦有显著性差异(P<0.05),前者较后者降低(7.4±6.8)%;微创组血肿周围NAA/Cr值与对照组有显著性差异(P<0.05)。结论血肿周围NAA/Cr降低反映了血肿周围神经元损伤;微创血肿清除术能改善脑出血后的脑水肿形成。     

再发脑出血的临床研究

目的探讨再发脑出血的临床特点和危险因素。方法回顾性分析54例再发脑出血患者的临床资料,并与同期住院的首发脑出血患者进行比较。结果54例患者62次再发,再发间隔时间为(3.7±3.5)年,34.4%在1年以内再发。再发类型以基底节-基底节最多见,其次为基底节-丘脑和基底节-脑叶,多在对侧再发,很少在同一部位再发。与首发患者相比,再发脑出血患者多有高血压病,病程较长且控制不良。多变量logistic分析显示高血压病程与再发脑出血正相关,首次发病年龄与再发脑出血负相关。结论脑出血后3年以内再发危险性较大,积极控制高血压有助于防止脑出血再发。     

脑出血患者血清瘦素浓度及意义

目的 分析脑出血患者血清瘦素浓度的变化,探讨瘦素与脑出血的关联。方法 对86例脑出血患者和58例对照者进行瘦素、空腹胰岛素等的检测,并进行比较。结果 （1）脑出血组与对照组相比胰岛素敏感指数（ISI）降低（P〈0．01）,男性患者瘦素水平高于对照组（P〈0．01）。（2）脑出血组与对照组相比收缩压和舒张压水平均升高（P〈0．01）。（3）脑出血患者血清瘦素水平与ISI呈负相关（P〈0．05）。（4）男性患者中高瘦素-高血压水平（收缩压或舒张压）的联合作用与增加脑出血的危险强烈相关。结论 脑出血患者存在胰岛素抵抗;男性脑出血患者的瘦素水平升高,高瘦素-高血压水平的联合作用增加发生脑出血的危险。