Post-traumatic intracerebral hematoma

The clinical and therapeutic features of 18 delayed traumatic intracerebral hematomas (DTICH) were compared with those of 84 primitive traumatic intracerebral hematomas in order to determine the origin of this complication. This retrospective study found that: DTICH usually occurs the first week after trauma, but could happen several weeks later; patients with skull fractures are at higher risk (p less than 0.01); osmotherapy as well as barbiturate therapy seem to have no influence on this complication; craniotomy (or craniectomy) appears to be a significant factor in the cause of DTICH (p less than 0.05). The pathogenesis of DTICH could be the evolution of delayed necrosis in vessel walls from the contused area which frequently bleed after the evacuation of an extracerebral hematoma. On the other hand the cause of a DTICH after conservative therapy remained unclear.     

Chronic expanding intracerebral hematoma

The cases of 10 normotensive patients with chronic intracerebral hematomas are reported. The patients' median age at diagnosis was 42 years. The median duration of symptoms was 22 days. Seizures were the presenting symptom in 50% of the cases. Computerized tomography almost consistently demonstrated ring-shaped lesions with mass effect and perifocal edema. Arteriography revealed that all but one of the lesions were avascular. All patients had superficial white matter lesions, mostly in the frontoparietal region. All patients were treated surgically. Most of the hematomas were encapsulated and contained blood in various stages of organization. The thick capsule consisted of an outer layer of collagenous tissue and an inner layer of granulation tissue. Occult cerebrovascular malformations were detected in two instances. There were two deaths, both related to recurrent postoperative hemorrhage. This entity can present much like a brain malignancy and should be considered in the differential diagnosis of ring-shaped lesions whatever the clinical presentation. Strategies of treatment are discussed.     

Multilocular encapsulated intracerebral hematoma

Encapsulated intracerebral hematoma is so rarely seen that only two cases have been reported, by Hirsh et al. Recently, we experienced a case of multilocular encapsulated intracerebral hematoma containing 9 to 10 capsules of different sizes. The capsules of the hematoma were easily dissected from the surrounding brain tissues and found to be grayish white in color, tough in hardness and 1 to 3 mm in thickness. The capsular contents ranged from very old to relatively new, which contents were hard on soft solid hematomas, liquid hematomas or xanthochromic fluid. These findings indicated the development of intracerebral hematomas with different chronic courses at different times. It is very interesting that the frequency of the convulsive seizure was almost consistent with the number of capsules. For etiology of multilocular intracerebral hematoma, either occult vascular malformation or bleeding from the sinusoidal channel layer of the capsules like that of chronic subdural hematoma is considered.     

Brain abscess following intracerebral hematoma

A 53-year-old man fully conscious was admitted with lt. hemiparesis due to a rt. putaminal hemorrhage. A phlebitis of superficial vein at lt. leg was noted on the 7th hospital day. Following administration of antibiotics, he was afebrile three days after. But local inflammation of phlebitis and leukocytosis continued for over one week. He had no sign of infection thereafter. Four months later, the hemiparesis exacerbated. CT scan revealed a cystic lesion with ring-like enhancement at the site of the hematoma. He was afebrile and had no sign of meningeal irritation. The patient underwent a stereotaxic aspiration of brown turbid pus. The culture from the aspirate was positive for staphylococcus, and histopathological examination of the excised specimen demonstrated a brain abscess with hemosiderin deposits. Follow-up CT scan revealed a progressive diminution in the size of the abs cess. We felt the hematoma represented an area of locus minoris resistentiae and that bacterial seeding of the hematoma from phlebitis resulted in brain abscess formation. Brain abscess formation should be considered as having possibly developed in patients with clinical deterioration after cerebral vascular disease.     

Delayed traumatic intracerebral hematoma.

Although delayed traumatic intracerebral hematomas (DTICHs) have been frequently reported since 1970, the time interval from trauma to hemorrhage and diagnosis has not been well defined. Eight patients with DITCH were found among 1,320 head-injured patients admitted to the neurosurgical service through the emergency department from March 1989 to March 1990. The mean time interval between initial and follow-up CT scan was 22 h. The mean time interval between initial trauma and diagnosis of DITCH was 24 h. One patient was diagnosed incidentally by magnetic resonance imaging. Three patients underwent operation and five patients were managed conservatively. Three patients died, resulting in a case mortality rate of 37.5%. The time interval for DTICHs' development and pitfalls in its diagnosis were discussed.     

Simultaneous multiple hypertensive intracerebral hematoma

Hypertensive intracerebral hemorrhage (HIH) occurring simultaneously in different locations is rare. We encountered 11 such cases between January 1990 and November 2002. The diagnosis of all 11 cases was established by computed tomography, and the location of the hematomas was: cerebellum and basal ganglia in 5 cases, pons and basal ganglia in 4, and subcortex and basal ganglia in 2. Our patients were analyzed with respect to clinical characteristics, pathogenesis of multiple hematomas, and indication of operation. These patients represented 1% of all 1,069 patients we encountered with HIH. As past history, there were no characteristic disorders except hypertension. There were no characteristic initial symptoms suggesting that hemorrhage had occurred simultaneously. Both supra- and infra-tentorial hematomas were observed in 80% of the patients, and the size of the multiple hematomas was proportional in principle. Cerebellar hematomas were often mild, and pontine hematomas were often severe. The outcome in those patients whose neurological grading was 1 to 3 was good with conservative therapy or surgical treatment. The severity, treatment methods, and outcomes in these patients were similar to those in patients with single HIH, which suggests only a slight influence of multiple lesions on outcome. As for the possible mechanism of simultaneous multiple hemorrhages, we speculated that bleeding occurred simultaneously in the different regions, or that the initial bleeding was followed after a short time by secondary bleeding due to high intracranial pressure and circulatory disturbance. In patients with cerebellar hematoma, initial symptoms suggested the development of secondary hemorrhage after primary hemorrhage. The surgical treatment for multiple hematomas should be determined by the location and maximum axis of the hematoma. We proposed that cerebellar hematomas should be removed if the supra-tentorial hematoma is small.     

Chronic encapsulated intracerebral hematoma associated with cavernous angioma--case report

An 80-year-old male presented with a chronic encapsulated intracerebral hematoma (CEIH) with surrounding edema under the right frontal lobe manifesting as slow exacerbation of disturbance of orientation and gait. He had a history of cerebral infarction with an asymptomatic cavernous angioma in the right frontal lobe. The CEIH was diagnosed as bleeding from the cavernous angioma, and surgical removal was performed. The hematoma was chronic and covered by a thick capsule. In addition, mass tissue covered with the organized hematoma was found near the capsule, which was excised and found to be a cavernous angioma. CEIH is a special type of intracerebral hemorrhage, and bleeding from a cavernous angioma is occasionally seen. CEIH should be considered in the case of a hemorrhagic intracranial lesion with a chronic, progressive course with capsule formation and edema around the lesion. The source of bleeding is unknown in about half of the reported cases, and occult vascular malformation may be involved, necessitating care in diagnosis.     

外伤性颅内血肿手术后并发迟发性血肿分析

目的分析外伤性颅内血肿手术后并发迟发性颅内血肿,探讨其与诸多因素的关系。方法回顾性调查1994年1月至2002年12月期,间本院收住的764例外伤性颅内血肿手术病人熏术后并发迟发性颅内血肿共98例,对其年龄、受伤机制、血肿厚度与中线移位的关系、血肿量、血肿部位、脑挫裂伤、手术时机以及术后骨窗的压力与发生迟发性血肿的关系,进行研究分析。结果诸多因素与并发迟发性血肿之间的存在相关关系。结论迟发性颅内血肿是颅脑外伤手术后较常见和严重的并发症,对其的发生应有足够的预见性,早期诊治是降低其死亡率和致残率的关键。     

Fibrinolytic activity in experimental intracerebral hematoma

In an attempt to investigate the role of tissue fibrinolytic activity in the resolution of intracerebral hematoma, an experimental model of intracerebral hematoma was developed in the rat. The fibrinolytic activity was studied using a histochemical fibrin slide technique. A total of 59 adult male rats were studied. Twenty-nine rats were used for developing the intracerebral hematoma model via injection of autologous whole blood into the left frontal lobe; in the remaining 30 rats, the intracerebral hematomas were studied sequentially. Intracerebral hematoma formation was unsuccessful in six (21%) of 29 rats. Four rats died in the immediate postoperative period and two showed no intraparenchymal clot. Intense fibrinolytic activity was demonstrated in the blood vessel walls of the normal brain, especially in the meninges, choroid plexus, and ependymal cell layer. In the initial stages of hematoma resolution, fibrinolytic activity was not seen in the hematoma or parenchyma except in the preexisting blood vessels. However, 3 to 5 days later, fibrinolytic activity was observed in the capillary buds surrounding the hematoma and among the infiltrating mononuclear cells. This activity increased for 7 to 10 days following formation of the hematoma and decreased after 21 to 28 days. It is concluded that tissue fibrinolytic activity associated with newly formed blood vessels appears to be important in lysis of intracerebral hematomas.     

Conservative treatment of traumatic intracerebral hematoma

In the previous report, it was insisted that traumatic intracerebral hematoma should be regarded as a variety of cerebral confusion and that conservative treatment would be therapy of choice in these situations. Adversely, unjudicious operation would sometimes result in more expansion of hematoma by untamponade effect of decompressive craniectomy. In the present investigation, it was attempted to provide therapeutic policy in the management of traumatic intracerebral hematoma. Consecutive thirty two cases of traumatic intracerebral hematomas were selected for this study. Those cases with other hematoma such as epidural or subdural hematoma were excluded. These 32 cases were divided into two groups, operative (15 cases) and non-operative (17 cases). Whether to be operated or not was arbitrarily decided by the surgeons who were faced to the patients. Disturbance of consciousness of the patients were divided into three categories, namely severe (III-100 to 200 level), moderate (II-10 to 30 level), and mild (I-1 to 3 level). They were 8 cases, 5 cases, 1 case in operative cases and 6 cases, 10 cases, 1 case in non-operative cases respectively. Mortality rates were 13.3% (2 cases) in operative cases and none in non-operative ones. Concerning the patients of severely disturbed consciousness, there were no difference in their final outcomes between the two groups. On the other hand, 7 out of 10 cases of moderately disturbed consciousness recovered completely without operation, whereas all operative cases of the same category were, more or less, handicapped.     

Neurosurgical treatment of traumatic intracerebral hematoma

From January 1st to August 31st 2002 yr., Neurosurgical department of the Trauma Center, Clinical Center of Serbia, has operated 43 patients with posttraumatic intracerebral haemathoma (PTIH). From that number, 9 patients survived and 34 died. Only 4 patients with acute PTIH were in terminal state of incarceration and in spite they were operated immediately, all died. Other 39 patients have delayed PTIH where secondary CT cerebral scans showed the development of posttraumatic intracerebral haematoma that has not been verified at the incipient scanner. Indication for repeated CT scan was found for 19 patients for their focal or general neurological deterioration. 20 patients had no delayed neurological disturbances. Survivors were younger, in lower grade of coma and were mostly with temporal localisation of haemathoma.     

Nonsurgical management of spontaneous intracerebral hematoma

This report describes our experience with the use of osmotic diuretics, governed by continuous monitoring of intracranial pressure (ICP), as the primary treatment for 12 consecutive patients suffering from an acute, supratentorial intracerebral hematoma. In all cases the hematoma, as shown by computed tomographic scan, had a long axis of greater than 4.0 cm. ICP and cerebral perfusion pressure were successfully maintained within the assigned limits in all patients, and in none was surgical evacuation required. There was one death during the 6-month follow-up period. With appropriate weighting to differences in admission status, statistical comparison of the patient outcome in the present series with that reported by McKissock et al. suggests that ICP monitoring can improve the outcome of conservatively (and perhaps surgically) treated patients.     

Clinical analysis of the patients with hemodialysis associated with intracerebral hematoma

We treated 64 hemodialysis patients with cerebral hemorrhage over an 18-year period between 1986 and 2003. Clinical features, prognostic factors, and therapeutic strategy were reviewed in these cases. Thirty of the cases were in the 13-year period between 1986 and 1998, and 34 cases, in the 5-year period between 1999 and 2003. In recent years, the incidence of cerebral hemorrhage has risen with the increase in the number of hemodialysis patients. There were 21 patients with at least a 10-year history of hemodialysis. The underlying cause of renal failure was diabetic nephropathy in 25 patients and glomerulonephritis in 24 patients. The most frequent sites of bleeding were the basal ganglia and thalamus, the cerebellum being involved in only one patient. Many patients had severe bleeding with hematomas greater than 61 ml. Outcome assessment by the Glasgow Outcome Scale showed 24 patients with good recovery, 8 with moderate disability, 4 with severe disability, and 28 who died. Good recovery was seen more often in patients in their 50s and 60s, whereas death occurred more often in patients aged 70 and older. Although there is now less morbidity than previously, the prognosis is not uniformly favorable in all cases. Factors associated with a poorer prognosis included mixed hemorrhage, hematomas greater than 61 ml, and age 70 and older. Hematoma size and age were particularly important prognostic factors. Improved management and prognosis in these patients requires acute intensive treatment similar to that for hypertensive cerebral hemorrhage.     

Calcified chronic subdural hematoma with intracerebral rupture forming a subcortical hematoma. A case report

We report a calcified chronic subdural hematoma which ruptured intracerebrally forming an acute subcortical hematoma in the frontal lobe in a 59-year-old woman with long-standing liver cirrhosis. Both hematoma cavities communicated each other through a small defect within the inner membrane of the subdural hematoma. The content of both hematomas was identical and was of a clay-like clot. The inner membrane around this communication consisted of thick, very vascular granulation tissue with many hemosiderin deposits and was tightly adherent to the cortex. We speculated that a fresh bleeding into the granulation tissue resulted in formation of a subcortical hematoma through a rupture of the inner membrane. Disseminated intravascular coagulation likely played an important role in this unusual condition.     

慢性扩展性脑内血肿18例临床分析

目的 总结慢性扩展性脑内血肿的诊断与治疗经验。方法 对18例慢性扩展性脑内血肿的临床资料进行回顾性分析。结果 多数病变术前误诊为脑肿瘤。术后15例痊愈，2例重残，1例死亡。结论 脑内有包膜的占位性病变应考虑慢性扩展性脑内血肿的可能，最后诊断需手术及病理证实。     

Congenital astrocytoma presenting with intracerebral hematoma. Case report.

A massive left intracerebral hematoma was surgically evacuated from a 2-week-old infant. Pathological examination showed that the hemorrhage had developed within a fibrillary astrocytoma. Neonatal intracerebral hemorrhage should raise the question of congenital tumor because such a hemorrhage in this age group is rarely the result of trauma, bleeding diathesis, or vascular malformation.