Endovascular treatment of cerebral hemorrhage in a patient with a left ventricular assist device: report of a case

Cerebral hemorrhage is a common lethal complication associated with left ventricular assist device (LVAD) management. We performed cerebral angiography on patients with LVAD who developed cerebral hemorrhage and determined that ruptured aneurysms were the cause in some cases. Endovascular management of patients with LVAD can be a therapeutically useful approach for cerebral hemorrhage caused by aneurysm rupture.     

Neurologic complications of subarachnoid hemorrhage due to intracranial aneurysm rupture

The high rates of morbidity and mortality after subarachnoid hemorrhage due to spontaneous rupture of an intracranial aneurysm are mainly the result of neurologic complications. Sixty years after cerebral vasospasm was first described, this problem remains unsolved in spite of its highly adverse effect on prognosis after aneurysmatic rupture. Treatment is somewhat empirical, given that uncertainties remain in our understanding of the pathophysiology of this vascular complication, which involves structural and biochemical changes in the endothelium and smooth muscle of vessels. Vasospasm that is refractory to treatment leads to cerebral infarction. Prophylaxis, early diagnosis, and adequate treatment of neurologic complications are key elements in the management of vasospasm if neurologic damage, lengthy hospital stays, and increased use of health care resources are to be avoided. New approaches to early treatment of cerebral lesions and cortical ischemia in cases of subarachnoid hemorrhage due to aneurysm rupture should lead to more effective, specific management.     

Growth of occult arteriovenous malformation after cerebral hemorrhage demonstrated by serial magnetic resonance imaging--case report

A 19-year-old male presented with sudden onset of right hemiparesis caused by left cerebral hemorrhage. Cerebral angiography demonstrated no vascular abnormality, and the hematoma was removed surgically. At operation, no abnormal vascular lesion was found in the brain adjoining the hematoma. Two years later, magnetic resonance (MR) imaging demonstrated a few foci of flow voids adjacent to the hematoma cavity. Four years after the hemorrhage, MR imaging showed more extensive flow-void abnormalities that indicated growth of an occult arteriovenous malformation (AVM). Cerebral angiography indicated a definite AVM supplied mainly by branches of the middle cerebral artery. Total resection of this lesion was performed. The histological diagnosis was typical AVM. Immunohistochemistry with vascular endothelial growth factor showed staining in the walls of the abnormal vessels. Serial MR imaging is very useful for the diagnosis and management of occult AVMs.     

高血压脑出血术后脑梗死的防治

目的 探讨高血压腩出血术后脑梗死的原因及防治措施.方法 回顾性分析江苏徐州解放军第97医院神经外科61例高血压脑出血术后脑梗死患者的病历资料.结果 全组61例,死亡15例.按日常生活能力(ADL)分级标准:Ⅰ级10例,Ⅱ级11例,Ⅲ级14例,Ⅳ级8例,Ⅴ级3例.结论 脑出血术后脑梗死的发生与血肿挤压、血管痉挛、高血压病、术中操作及术后治疗相关.超早期手术、娴熟的手术技巧、高压氧治疗是防治脑出血后脑梗死的重要措施.     

Management of cerebral hemispherectomy in children

Surgical removal of a cerebral hemisphere may be undertaken in patients with intractable seizure disorders. Anesthetic management of such patients has not been reviewed in detail before. This study retrospectively analyzed hospital records of ten patients undergoing cerebral hemispherectomy at the Johns Hopkins Hospital between July 1983 and February 1988. Patient records were reviewed for diagnosis, physical characteristics, preoperative medications, anesthetic management, and postoperative course in the intensive care unit (ICU). Massive and sudden blood loss was a common finding in these patients, and during the intraoperative and postoperative periods, fluid resuscitation frequently was an ongoing process. In some patients, the blood loss exceeded one blood volume and was associated with coagulopathy, hypokalemia, and hypothermia. Urine output was elevated by a glucose-induced diuresis in some patients, giving misleading information as to intravascular volume status. Seizures and hemorrhage into the hemispherectomy cavity were management problems in the ICU. From this review, the authors conclude that blood loss may be marked and precipitous during surgical removal of a cerebral hemisphere. Monitoring of intra-arterial pressure and central venous pressure (CVP) is necessary for patient management during the intraoperative and postoperative periods. Intravenous (IV) access should allow rapid intravascular volume administration as it becomes necessary. Patients should remain intubated and observed closely during the immediate postoperative period due to difficulties with hemodynamic stability, seizures, and hemorrhage.     

Terson's syndrome: a reversible cause of blindness following subarachnoid hemorrhage.

Terson's syndrome refers to the occurrence of vitreous hemorrhage with subarachnoid hemorrhage (SAH), usually due to a ruptured cerebral aneurysm. Although it is a well-described entity in the ophthalmological literature, it has been only rarely commented upon in the neurosurgical discussion of SAH. Fundus findings are reported in a prospective study of 22 consecutive patients with a computerized tomography- or lumbar puncture-proven diagnosis of SAH. Six of these patients had intraocular hemorrhage on initial examination. In four patients vitreous hemorrhage was evident on presentation (six of eight eyes). In the subsequent 12 days, vitreous hemorrhage developed in the additional two patients (three of four eyes) due to breakthrough bleeding from the original subhyaloid hemorrhages. The initial amount of intraocular hemorrhage did not correlate with the severity of SAH. Two of the six patients with intraocular hemorrhage died, whereas five of the 16 remaining SAH patients without intraocular hemorrhage died. Of the four survivors with intraocular hemorrhage, three showed gradual but significant improvement in their visual acuity by 6 months. The fourth underwent vitrectomy at 8 months after presentation and had a good visual result. With modern and aggressive medical and microsurgical management, Terson's syndrome should be recognized as an important reversible cause of blindness in patients surviving SAH.     

Asymptomatic intracerebral hemorrhage under strict blood pressure control due to postoperative cerebral hyperperfusion in a patient with moyamoya disease

We report a case of moyamoya disease manifesting as asymptomatic intracerebral hemorrhage due to postoperative cerebral hyperperfusion, despite the prophylactic intensive blood pressure control. This 35-year-old man initially suffered from right upper quadrantanopsia and was found to have cerebral infarction in the left occipital lobe due to moyamoya disease. He also manifested preoperatively a small intracerebral hemorrhage at the left caudate nucleus. The left cerebral hemisphere showed apparent hemodynamic compromise, thus he underwent left superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis with indirect pial synangiosis. He was subjected to prophylactic strict blood pressure control postoperatively to avoid hyperperfusion syndrome. The N-isopropyl-p-¹²³I-Iodoamphetamine SPECT (¹²³I-IMP-SPECT) 1 day after surgery showed intense increase in cerebral blood flow (CBF) at the site of the anastomosis, and further blood pressure lowering was attempted. He did not suffer from neurologic deterioration during the postoperative period, while computed tomography (CT) 7 days after surgery revealed asymptomatic intracerebral hematoma (ICH) at the subcortex under the site of the anastomosis. Cerebral hyperperfusion is a potential complication of revascularization surgery for moyamoya disease. Accurate diagnosis and proper management of hyperperfusion are essential to avoid deleterious neurologic event due to hyperperfusion.     

Extracranial-intracranial arterial bypass in the management of symptomatic vasospasm

Delayed neurologic deterioration from vasospasm remains the greatest cause of morbidity and mortality following subarachnoid hemorrhage. The authors performed superficial temporal artery-middle cerebral artery bypass in three patients with symptomatic vasospasm and studied its effects on cerebral hemodynamics. All three patients responded neurologically to the bypass procedure within 24 hours. The average cerebral blood flow in the region supplied by the spastic middle cerebral artery increased from 40 ml/100 g/min to 49 ml/100 g/min after bypass. Angiography disclosed dilatation of donor vessels during the peak of spasm, followed by their decrease in caliber coincident with alleviation of vasospasm. The authors conclude that superficial temporal artery-middle cerebral artery anastomosis for the management of symptomatic vasospasm can increase blood flow in the ischemic region supplied by the spastic artery. This management strategy may lower the incidence of death and disability from vasospasm after subarachnoid hemorrhage.     

Thrombosis of cortical vein: a case report

A 39-year-old woman presented with disturbed consciousness, left hemiparesis and headache. CT scan revealed subcortical hemorrhage in the right parietal region, which had lower density than usual intracerebral hemorrhage and was associated with irregular perifocal edema. Cerebral angiograms revealed narrowed cortical vein with irregular wall in the right parietal region, where delayed local blood flow into the deep cerebral veins through collateral vessels was noted. The diagnosis was subcortical hemorrhage due to thrombosis of cortical vein. Her symptoms and brain edema were progressive. To reduce intracranial pressure, evacuation of the hematoma was performed. The hematoma which existed 1cm under the right parietal cortex was about 20g in weight. She remarkably improved soon after operation. Frequency of sinovenous thrombosis has been reported to be about 10% of all cerebral ischemic diseases, however, localized venous thrombosis is rare among them. This is because it is not always symptomatic and it is difficult to make accurate diagnosis. Six cases of localized venous thrombosis were reviewed, in which accurate diagnosis were established by cerebral angiograms, CT scan and/or autopsy. Clinical and radiological features of this case were presented.     

Implications for the pathogenesis of aneurysm formation: metastatic choriocarcinoma with spontaneous splenic rupture. Case report and a review.

We report a case of ruptured intracranial aneurysm from metastatic choriocarcinoma in a patient presenting with intracerebral hemorrhage. Operative evacuation of the hematoma with clipping of a distal right middle cerebral artery aneurysm was performed. Postoperatively, the patient developed hypovolemic shock from spontaneous splenic rupture. Histopathologic examination of the cerebral aneurysm showed choriocarcinoma invading the vessel wall. Metastatic choriocarcinoma should be considered in the differential diagnosis of intracerebral or subarachnoid hemorrhage in women of child-bearing age.     

胎母输血综合征诊治进展

胎母输血综合征(FMH)发病隐匿,临床表现无特异性,不易做出早期诊断,常引起胎儿严重贫血、水肿,围产儿死亡率高。通过红细胞酸洗脱试验法(K-B试验)或流式细胞仪检测母体血中胎儿红细胞含量可以确诊并估计胎儿出血量,判断胎儿失血的严重程度。胎儿大脑中动脉超声检查及母血清甲胎蛋白检测可能有助于诊断FMH。终止妊娠是FMH的最终治疗方案,但需根据失血量以及胎龄决定个体化治疗。胎儿宫内输血技术的发展使大量胎母输血的孕妇继续妊娠成为可能。     

Management of a ruptured cerebral aneurysm in infancy.—Report of a case of a ten-month-old boy

A ten month old unconscious boy with hemiplegia (Hunt and Hess IV) was first admitted to a district hospital without a CT scanner or a neurosurgical service (Glasgow-Coma-Score 4, no pathological pupillary signs). Therefore he was transferred to the Pediatric Department of the University Hospital the same night. An emergency CT scan that night showed intracerebral and subarachnoid hemorrhage with enlarged ventricle (Fisher grade 5). Angiography was not available within reasonable time. Thus in the stage of progressively increasing clinical deterioration, still without pupillary signs, an external ventricular drainage was placed. Immediately after reduction of the cerebrospinal fluid volume, arterial hypertension was noticed—the right pupil was mydriatic and fixed. Without further apparative diagnosis an emergency craniotomy was performed for decompression under the suspicion of a secondary hemorrhage due to a rerupture of a middle cerebral artery aneurysm. A bleeding aneurysm of the right middle cerebral artery was found and clipped. A mass transfusion was necessary and a pulmonary air embolism occurred. The infant died in tabula. The histological specimens revealed disruption of the internal elastic membrane of both MCA. This emphasizes a congenital nature of the aneurysm. We conclude that cerebral arterial aneurysms have to be considered in the differential diagnosis of stroke-like symptoms in infancy and early childhood, although the incidence of reported cases is less than one case per year. Since no valid screening parameter is available, diagnosis is often made only after rupture of the aneurysm. This causes problems for emergency management. Infants and children with stroke or stroke-like symptoms should immediately be transferred to a hospital with a neurosurgical unit.     

颅内动脉瘤相关基因的研究进展

颅内动脉瘤是造成自发性蛛网膜下腔出血的首位原因，在脑血管意外中，仅次于脑血栓和高血压脑出血，是严重威胁人类生命健康的一种疾病。其发病机制包括遗传基因、脑血流动力学因素、血管因素等，其中遗传因素参与部分颅内动脉瘤的形成已经获得共识，而且动脉瘤常与某些遗传疾病伴发。文章综述了近年来发现的可能与颅内动脉瘤发病密切相关的易感基因，这些基因的确定对于动脉瘤从基因水平上进行筛选、诊断和治疗提供依据。     

Neoplastic cerebral aneurysm from metastatic gestational choriocarcinoma. Case report

This case of metastatic gestational choriocarcinoma presented as intracerebral hemorrhage from an atypical distal middle cerebral artery aneurysm. Operative evacuation of the intracerebral hematoma was undertaken and histopathological examination revealed choriocarcinoma invading the vessel wall. Neoplastic cerebral aneurysms are unusual, being reported in metastatic choriocarcinoma, cardiac myxoma, bronchogenic carcinoma, and undifferentiated carcinoma. Metastatic choriocarcinoma should be considered in the differential diagnosis of intracerebral hemorrhage in women of child-bearing age. Recent advances in treatment have resulted in a 75% cure rate for metastatic choriocarcinoma.     

Cesárea urgente y craneotomía en una paciente con rotura de una malformación arteriovenosa cerebral

The intracerebral hemorrhage in pregnancy is a rare event, but can have catastrophic consequences for both mother and fetus. The management of non-ruptured arteriovenous malformations in pregnancy is not free of controversy in the current literature, as there is the possibility of spontaneous bleeding and becoming a true emergency. We report the case of a pregnant patient of 35 weeks with a diagnosis of a cerebral arteriovenous malformation, who developed a sudden onset of headache, generalized tonic-clonic seizures, loss of consciousness, and hemiparesis with radiological images of an intracranial hematoma with a mass effect, and signs of herniation. The multidisciplinary management is discussed, emphasizing perioperative cesarean approach plus craniotomy and drainage of the hematoma, and subsequent management in intensive care, and definitive management by neuroradiology, with a successful outcome.     

A case of subacute subarachnoid hemorrhage without xanthochromic cerebrospinal fluid--usefulness of emergent MRI

We reported a case of subacute subarachnoid hemorrhage with watery clear cerebrospinal fluid. Emergent magnetic resonance image was useful not only for diagnosis by fluid attenuated inversion recovery image but also for evaluation of cerebral ischemia and vasospasm by magnetic resonance angiography, diffusion weighted image and perfusion weighted image. A 50-year-old man presented disturbance of consciousness and dysarthria. Neither computed tomographic scan nor cerebrospinal fluid study could diagnose subarachnoid hemorrhage clearly. However, emergent fluid attenuated inversion recovery image showed the show subarachnoid hemorrhage as high signal intensity. Diffusion weighted image showed multiple, round hypersignals both in the white and gray matter. In the area with diffusion hypersignal, the apparent diffusion coefficient value was 0.57 x 10(3) mm2/sec. Perfusion weighted image showed normal cerebral blood volume but prolonged mean transit time in the territory of the right middle cerebral artery. Magnetic resonance angiography revealed an aneurysm at the anterior communicating artery and severe vasospasm on the bilateral anterior cerebral artery, the right middle cerebral artery. Thus we are able to diagnose subarachnoid hemorrhage due to a ruptured anterior communicating artery aneurysm. The hyperintensity of the diffusion weighted image and the fluid attenuated inversion recovery image was caused by cerebral ischemia from vasospasm. After conservative therapy during the period of vasospasm, successful surgical clipping was performed with full clinical recovery.     

平板3D-DSA在颅内动脉瘤诊断和介入治疗中的价值

目的评估平板探测器三维数字减影血管造影（3D-DSA）技术在颅内动脉瘤诊断和介入治疗中的应用价值。方法对51例蛛网膜下腔出血的患者进行常规全脑血管DSA检查后,再行旋转DSA采集数据,利用工作站进行三维重建。分析3D-DSA与常规DSA对颅内动脉瘤显示的差异,评价3D-DSA对介入栓塞治疗的指导意义。结果常规DSA检出脑动脉瘤34例,经应用旋转DSA及三维重建后检出46例,其中35例进行介入血管内栓塞治疗,栓塞效果良好,11例行手术夹闭治疗。结论3D-DSA可显著提高颅内动脉瘤的检出率,能够直观清楚地显示动脉瘤详细全面的解剖信息,指导制定治疗计划,在脑动脉瘤的诊断和介入治疗中具有重要的价值。     

Rupture of middle cerebral artery aneurysm in a neonate: case report and review of the literature

Intracranial hemorrhage because of rupture of a cerebral aneurysm is extremely rare in the neonatal period. Delayed diagnosis contributes to high mortality and morbidity.The authors report an extremely rare case of a middle cerebral artery aneurysm diagnosed and treated shortly after birth. Extensive review of the literature is presented. The patient died 4 years after surgery.     

Pseudo-subarachnoid hemorrhage in a patient with hypoxic encephalopathy

The authors report an unusual case of diffuse subarachnoid hemorrhage on brain computed tomography (CT) scan in a patient with post-resuscitation anoxic encephalopathy. A 42-year-old woman suffered both respiratory and cardiac arrest, associated with hypoxic encephalopathy, which occurred during a visit to our gynecology clinic. CT examination was performed the next day, which revealed a hyperdensity in the basal cisterns with a diffuse cerebral edema. Lumbar puncture was applied for diagnosis. No yellow coloration or red cells were observed in the cerebrospinal fluid. Nineteen days after treatment, the CT examination revealed features of a subarachnoid hemorrhage with a significantly increased cerebral edema. The patient died two months later. This clinical case illustrates that hypoxic encephalopathy can mimic diffuse subarachnoid hemorrhage on CT scan.