Intracranial Haemorrhage Within the First two Years of Life

Summary. Summary. Background: Spontaneous intracranial haemorrhage is not common in infants, with differences from adults in both aetiology and severity. The infantile CNS is more vulnerable because of incomplete hydrovenous maturation. We analyzed infantile intracranial haemorrhage mainly caused by structural brain lesions and discuss specific aetiologies with regard to haemodynamic characteristics. Subjects and Methods: We reviewed 20 infants less than 2 years of age from a total of 328 neonates and infants with intracranial vascular lesions seen in our institution since 1985. Associated or causative lesions were arteriovenous malformation (AVM) in 6, dural sinus malformation (DSM) in 4, arteriovenous fistula (AVF) in 3, aneurysm in 2, developmental venous anomaly (DVA) in 1, vein of Galen malformation (VGAM) in 1, and others in 3. The locations of haematomas were intracerebral (ICH) in 8, combined ICH and intraventricular haemorrhage (IVH) in 5, IVH alone in 5, subarachnoid haemorrhage (SAH) in 1, and combined SDH and ICH in 1. Findings: Three patterns of haemorrhage were noted in high-flow vascular lesions such as AVM or AVF (n=9); haemorrhage at the site of nidus or fistula corresponding to nidal pseudoaneurysm in 4, regional venous hypertension with pial venous reflux in 3, global venous infarction causing multifocal haemorrhage in distant brain areas in 2. Aneurysmal bleeds were caused by dissecting aneurysms at the level of dural penetration of cranial vessels. One infant had haemorrhage near a DVA without evidence of cavernous malformation suggesting the possibility of venous ischaemia. IVH was associated with shunt operations in 4 infants with DSM, and SDH followed by ICH in a infant with VGAM. Interpretation: Spontaneous intracranial haemorrhage in infants and neonates is rare; it is associated with specific lesions which show some differences from their adult counterparts. The vein-related causes of hemorrhage are largely the pathophysiologic characteristics in this age group. Absence of hemorrhage in VGAM is remarkable in addition to occurrence of most hemorrhages after shunting.     

Intracerebral hematomas caused by aneurysm rupture. Experience with 67 cases

During a six-year period (1986–1992) 334 patients with subarachnoid hemorrhage (SAH) were admitted to the Department of Neurosurgery, Medical University of Lübeck, Germany. In 281 patients the SAH was caused by rupture of an intracranial arterial aneurysm, verified by angiography, postmortem examination, or at emergency operation without angiography. In 67 (23.8 %) of the 281 aneurysmal SAH patients the initial computerized tomography (CT) demonstrated an intracerebral hematoma (ICH). An ICH localized in the temporal lobe due to the rupture of a middle cerebral artery (MCA) aneurysm was found in 47 patients (70.2 %). Forty-three patients were considered for surgery with a surgical mortality of 8 (18.6 %). In the group of 19 ICH patients not operated upon, 16 individuals died (84.2%).We therefore advocate active surgical management of ICH patients: hematoma evacuation and aneurysm clipping at the same operation. Emergency surgery in younger patients (grade V) with temporal ICH suggesting the rupture of a MCA or internal carotid artery (ICA) aneurysm can be done without angiography.     

Fibrinolytic treatment of intraventricular haemorrhage preceding surgical repair of ruptured aneurysms and arteriovenous malformations

Previous studies have indicated that intraventricular administration of tissue-type plasminogen activator (TPA) might improve the prognosis of patients with intraventricular haemorrhage (IVH). In aneurysmal IVH, fibrinolytic treatment was always preceded by surgical repair of the aneurysm, since the risk of recurrent haemorrhage from a non-occluded aneurysm was estimated to be high. We reviewed a series of patients with IVH secondary to ruptured aneurysms (n = 4) or arteriovenous malformation (AVM; n = 1) who underwent emergency intraventricular administration of TPA before repair of the bleeding source. Fibrinolysis resulted in rapid decrease of haematoma volume and of ventricular dilatation, and prevented ventricular catheters from becoming obstructed. No intracranial haemorrhages or other complications occurred. The results suggest that the presence of recently ruptured aneurysms or AVM is not necessarily a contraindication for intraventricular administration of TPA. The potentially life saving benefits might outweigh the inherent risks of recurrent haemorrhage in carefully selected patients with massive IVH, in whom ventricular distension, periventricular brain compression, obstruction of CSF flow, and elevated ICP appear to be major determinants for the outcome.     

Subarachnoid hemorrhage caused by pilocytic astrocytoma--case report

A 20-year-old woman presented with subarachnoid hemorrhage (SAH) in the frontal interhemispheric fissure, and a cystic lesion in the left frontal lobe. Cerebral angiography demonstrated no aneurysm or vascular abnormalities. T(1)-weighted magnetic resonance imaging with contrast medium revealed an enhanced lesion along the falx. The lesion and cyst were removed, and histological examination revealed a pilocytic astrocytoma. Spontaneous intracranial hemorrhage from pilocytic astrocytoma is rare, with only 15 reported cases mostly involving intratumoral hemorrhage in the parenchyma of hypothalamic and cerebellar tumors. SAH caused by cerebral hemisphere pilocytic astrocytoma is extremely rare. This case suggests that interhemispheric fissure SAH, not associated with aneurysm or abnormal vascularity, could originate from small, low-grade glioma in the superficial cerebral hemisphere.     

Intracerebral haematomas from aneurysm rupture: Their clinical significance

Summary Two series of patients (814 cases altogether) with ruptured intracranial aneurysms are analyzed in order to try to outline the clinical significance of space-occupying intracerebral haematomas (ICH) which may accompany SAH. In particular the question of whether intracerebral clots are or are not to be taken into account in planning emergency surgery is debated.From the reported series, it would appear that ICH after aneurysm rupture seldom lead to increasing intracranial hypertension warranting urgent surgery. This evolution was observed in approximately 5% of patients with expanding ICH. In 35% the intracerebral effusions were associated with irreversible lesions and in 20% the initial symptomatology definitely improved. Finally, in a relatively high percentage of cases (about 40%) ICH lacked of clinical significance.Brandtet al. [Brandt L, Sonesson B, Ljunggren B, Saveland H (1987), Ruptured middle cerebral artery aneurysm with intracerebral haemorrhage in younger patients appearing moribund: emergency operation, Neurosurgery 20, 925–929] have just reported 4 cases of huge ICH from ruptured MCA in young moribund patients successfully submitted to ultraemergency surgery, on the basis of CT alone without angiography. 3 patients survived with moderate disability. This report would indicate unsuspected therapeutic possibilities in some hyperacute cases. Unfortunately, the circumstances which had been given in the cases reported by Brandtet al. are seldom gathered.     

Intraventricular haemorrhage caused by aneurysms and angiomas

Summary More than 200 intraventricular haematomas (IVH) have been treated in the Homburg Neurosurgical University Clinic since computed tomography was available and facilitated the diagnosis.Among 200 consecutive cases, which are analysed and presented in this publication, there were 71 patients with subarachnoid haemorrhage (SAH)-58 of whom with angiographically and/or pathologically verified aneurysms-, and 21 cases with intraventricular angiomas. IVH without concomitant intracerebral haematoma (ICH) and without evidence of SAH is highly suggestive of intraventricular angioma.In our experience panangiography [if available digital subtraction angiography (DAS)] should be done as soon as possible in all cases of IVH. It is a precondition for early diagnosis and operative elimination of the source of bleeding, because the retrospective analysis of our material shows that rebleeding is by far the highest single risk factor in cases with IVH caused by aneurysms or angiomas.We therefore recommend early microsurgical occlusion of the aneurysms and exstirpation or intravascular embolisation of the angioma.The best survival rate (76%) was achieved in IVH cases caused by angiomas. In aneurysms with IVH the survival rate was 35%, in IVH caused by other diseases 37%. The worst prognosis occurs in SAH with IVH without proven aneurysm or angioma. The survival rate of this group was only 8%.     

Association of cerebral arteriovenous malformation and cerebral aneurysm. Diagnosis and management

Summary Between 1979 and 1989, 7 patients were admitted, with cerebral arteriovenous malformations (AVM) and associated aneurysms (7% of the AVM patients and 2% of the aneurysm patients admitted during the same period). 6 of these patients were admitted because of an intracranial haemorrhage (in 3 of them the AVM, angiographically occult, was discovered at surgery). The last patient was referred for seizures.Preoperatively it was supposed that the haemorrhage was related to the aneurysm in 3 cases, and to the AVM in 3 cases. But surgery allowed one to correct this supposition. Haemorrhage was due to AVM rupture in all 6 cases, and no aneurysm had ruptured. Overall three situations were demonstrated in this series: aneurysm and occult AVM (3 cases); AVM and independent aneurysm in the same area (2 cases); large AVM and aneurysm on a feeding artery (2 cases). All 6 patients admitted for haemorrhage were operated upon, at one operation in 5 of them. Both the malformations were excluded in these six patients. For the patient admitted for seizure, intra-vascular embolization of the AVM was performed, the aneurysm was not treated. The pathogenesis of the association AVM-aneurysm is discussed. In the authors' opinion, haemodynamic relationship should be considered in two cases (large AVM and aneurysm on a feeding vessel). For the other 5 cases, both the AVM and the coexisting aneurysm may be the end-result of a common congenital vascular malformation syndrome.     

Intracerebral haemorrhage and drug abuse in young adults

The epidemic of abuse of the so-called 'designer drugs' amphetamine, cocaine and ecstasy--is fast replacing traditional aetiological factors as the largest cause of intracerebral haemorrhage among young adults. Traditional teaching is that these represent hypertensive haemorrhages. Recent reports, however, have indicated that these patients may harbour underlying vascular malformations. We review 13 patients with a positive history of drug abuse preceding the onset of intracerebral haemorrhage. These patients presented to the National Hospital for Neurology and Neurosurgery in central London over a 7-month period. Of the 13 patients (eight male, five female), average age 31 years (19-43) years), 10 were well enough to undergo cerebral angiography. Intracranial aneurysms were demonstrated in six patients and arteriovenous malformations in three patients. In only one of the patients was the angiogram normal. A further patient was subsequently shown to have a middle cerebral artery aneurysm at autopsy. The epidemiology, pharmacology and systemic effects of these drugs are considered. The mechanisms by which these compounds cause intracerebral complications and their influence on prognosis are discussed. The incidence of intracerebral haemorrhage (ICH), ischaemic cerebral infarctions and subarachnoid haemorrhage (SAH) following drug abuse is increasing. Contrary to historical opinion, drug-related ICH is frequently related to an underlying vascular malformation. Arteriography should be part of the evaluation of most young patients with nontraumatic ICH. A thorough history focusing on the use of illicit substances and toxicological screening of urine and serum should be part of the evaluation of any young patient with a stroke.     

Subarachnoid haemorrhage of unknown aetiology: what next?

Subarachnoid haemorrhage (SAH) is often associated with negative cerebral angiography. Following the exclusion of other causes, a patient may be suspected of harbouring an occult intracranial aneurysm, with risk of recurrent bleeding and death. These patients are often identified on the basis of clinical presentation and computed tomography (CT) findings, and require expeditious further investigation if morbidity and mortality are to be minimized. Currently available options include repeated cerebral angiography, surgical exploration, and the newer technologies of computed tomography angiography (CTA) and magnetic resonance angiography (MRA). We review these options, based on current literature, with particular emphasis on the expanding roles of CTA and MRA. A multimodality management protocol is proposed, with decisions based on clinical urgency, patient progress and the natural history of aneurysmal SAH, particularly vasospasm and aneurysm thrombosis.     

Screening of risk groups for discovering intracranial aneurysms before rupture

In development of intracranial aneurysms contribute genetic factors together with smoking, hypertension, diabetes mellitus. Epidemiology studies suggest that as many as 5% of people harbour a cerebral aneurysm by age 75. Rupture of cerebral aneurysm is the most frequent cause of spontaneous subarachnoid haemorrhage (up to 80%.) Annual incidence of SAH is 10-14/100 000, but only 15-20% of aneurysms will rupture, and that will happen probably between 40-60 years. The morbidity and mortality of aneurismal subarachnoid (SAH) continues to be high. It is not possible to predict who has aneurysm and is it going to bleed or not, but it is possible to reveal high risk groups (polycystic kidney disease, Ehlers-Danlos sy, Marphan sy, family history of cerebral aneurysms, suspect de novo aneurysm formation in patients with prior history of cerebral aneurysm). Reviewing data from literature and reporting cases from each group with high risk, that have been screened and aneurysms discovered, authors wish to focus interest on this matter and propose screening program for these groups of patients. The mortality and morbidity in cases treated before rupture is significantly lower than after SAH, so screening programs could save many lives. According to our preliminara data, mostly based on control angiographies after 8-10 zears in patients previouslz operated for intracranial aneurysmas, from 15 angipgraphies 4 revealed new aneurysms (26% in 10 years period) with total number of 6 de novo formed aneurysms, which is not valid due to small number of patients but strongly suggests the importancy of screening program for risk groups.     

Acute subdural haematoma due to ruptured intracranial aneurysms

Acute spontaneous subdural haematoma (SDH) is rarely associated with rupture of intracranial saccular aneurysm. We report our experience with four cases of non-traumatic SDHs secondary to rupture of an intracranial aneurysm and discuss the diagnosis and management of this condition. We retrospectively reviewed of four cases of acute SDH due to cerebral aneurysm rupture confirmed by cerebral angiography and surgery. Patients were evaluated using the Glasgow Coma Scale (GCS) and subarachnoid grade of the World Federation of Neurosurgical Societies (WFNS) and outcome with the Glasgow Outcome Scale (GOS). Of the 232 patients with non-traumatic subarachnoid haemorrhage (SAH) treated between 1993 and 2002, only four patients (1.72%) presented SDH due to aneurysmal rupture. The SAH grade on admission was grade IV in one patient and V in the other three. In all cases the aneurysm was located in the posterior communicating artery. Spontaneous acute SDH secondary to aneurysm rupture has been rarely reported. We suggested that timely SDH removal and aneurysmal clipping surgery should be performed in such patients, including those in poor neurological condition.     

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.     

Subarachnoid hemorrhage of unknown origin. Longterm prognosis

Patients suffering subarachnoid hemorrhage in whom angiography does not initially show vascular malformation and CT scan rules out an intracranial tumor, have, reportedly, a good prognosis with a rate of recurrent hemorrhage of about 2–10% within a follow-up time of up to 15 years. Most authors denied indication for control angiography. In order to study the benefit of control angiography performed after 4-6 weeks, four-hundred eigthy-three patients with SAH but without ICH were reviewed, and the longterm clinical course of 98 patients with SAH of unknown origin treated in our department between 1976 and 1988 was investigated. Among 183 patients who underwent control angiography, a second angiography showed an aneurysm in 143. The third angiography was positive in a further 18 patients. Recurrent SAH occurred early only in patients who had undergone only one angiography. One patient died from intracerebral hemorrhage of unknown origin two years following SAH. These data support the need for control angiography in cases of SAH.     

Predicting the overall management outcome in patients with a subarachnoid hemorrhage accompanied by a massive intracerebral or full-packed intraventricular hemorrhage: a 15-year retrospective study

BACKGROUND: Patients with a subarachnoid hemorrhage (SAH) accompanied by a massive intracerebral hemorrhage (ICH) or a full-packed intraventricular hemorrhage (IVH) have poor outcomes. We evaluated the clinical factors to predict the overall outcome in such patients. METHODS: Data on nontraumatic SAH patients were collected and classified into 3 groups: the pure SAH group (SAH accompanied with neither ICH nor IVH), the ICH group (SAH accompanied with a massive ICH; hematoma 30 mL), and the IVH group (SAH and all ventricles were full-packed with hematoma). One hundred seventy-nine patients were in the ICH group and 109 in the IVH group. We evaluated clinical factors, such as the Hunt & Hess (H&H) score on admission, age, sex, history, rebleeding ratio, and the computerized tomography findings (SAH score). RESULTS: The result of multivariate logistic regression analysis of clinical variables in the ICH group, good and intermediate H&H grades, younger age (<70), no rebleeding, and lower SAH score were associated with a favorable outcome. In the result of the multivariate logistic regression analysis of clinical variables in the IVH group, only a higher SAH score was associated with an unfavorable outcome. CONCLUSIONS: In the ICH group, factors that could be used to predict a favorable outcome included good and intermediate H&H scores (1, 2, and 3) on admission, younger age (<70), and a lower SAH score. In the IVH group, the main factor that could be used to predict a favorable outcome was a lower SAH score.     

Ruptured internal carotid artery bifurcation aneurysm presenting with only intracerebral hemorrhage without subarachnoid hemorrhage--case report

A 55-year-old man presented with intracerebral hemorrhage (ICH) without subarachnoid hemorrhage (SAH) manifesting as acute onset of consciousness disturbance and right hemiparesis. Computed tomography showed ICH mainly localized in the left putamen, but no evidence of SAH. Magnetic resonance angiography demonstrated a cerebral aneurysm originating from the bifurcation of the left internal carotid artery, which was considered to be responsible for the ICH. The patient underwent emergent intravascular surgery for coil embolization of the aneurysm, and his neurological symptoms gradually recovered with rehabilitation after surgery. Although ICH without SAH is a rare presentation of cerebral aneurysm, ruptured cerebral aneurysm should be considered as a potential cause of ICH. The localization and extent of ICH may be suggestive of latent cerebral aneurysm in such cases.     

Smaller cerebral aneurysms producing more extensive subarachnoid hemorrhage following rupture: a radiological investigation and discussion of theoretical determinants

OBJECT: The goal of this study was to determine the relationship between aneurysm size and the volume of subarachnoid hemorrhage (SAH). METHODS: One hundred consecutive patients who presented with acute SAH, which was diagnosed on the basis of a computerized tomography (CT) scan within 24 hours postictus and, subsequently, confirmed to be aneurysmal in origin by catheter angiography, were included in this study. The data were collected prospectively in 32 patients and retrospectively in 68. The volume of SAH on the admission CT scan was scored in a semiquantitative manner from 0 to 30, according to a previously published method. The mean aneurysm size was 8.3 mm (range 1-25 mm). The mean SAH volume score was 15 (range 0-30). Regression analysis revealed that a smaller aneurysm size correlated with a more extensive SAH (r(2) = 0.23, p < 0.0001). Other variables including patient sex and age, intraparenchymal or intraventricular hemorrhage, multiple aneurysms, history of hypertension, and aneurysm location were not statistically associated with a larger volume of SAH. CONCLUSIONS: Smaller cerebral aneurysm size is associated with a larger volume of SAH. The pathophysiological basis for this correlation remains speculative.     

Screening for brain aneurysm in the Familial Intracranial Aneurysm study: frequency and predictors of lesion detection

OBJECT: Approximately 20% of patients with an intracranial saccular aneurysm report a family history of intracranial aneurysm (IA) or subarachnoid hemorrhage. A better understanding of predictors of aneurysm detection in familial IA may allow more targeted aneurysm screening strategies. METHODS: The Familial Intracranial Aneurysm (FIA) study is a multicenter study, in which the primary objective is to define the susceptibility genes related to the formation of IA. First-degree relatives (FDRs) of those affected with IA are offered screening with magnetic resonance (MR) angiography if they were previously unaffected, are > or = 30 years of age, and have a history of smoking and/or hypertension. Independent predictors of aneurysm detection on MR angiography were determined using the generalized estimating equation version of logistic regression. RESULTS: Among the first 303 patients screened with MR angiography, 58 (19.1%) had at least 1 IA, including 24% of women and 11.7% of men. Ten (17.2%) of 58 affected patients had multiple aneurysms. Independent predictors of aneurysm detection included female sex (odds ratio [OR] 2.46, p = 0.001), pack-years of cigarette smoking (OR 3.24 for 20 pack-years of cigarette smoking compared with never having smoked, p < 0.001), and duration of hypertension (OR 1.26 comparing those with 10 years of hypertension to those with no hypertension, p = 0.006). CONCLUSIONS: In the FIA study, among the affected patients' FDRs who are > 30 years of age, those who are women or who have a history of smoking or hypertension are at increased risk of suffering an IA and should be strongly considered for screening.     

Symptomatic inferior cavernous sinus artery aneurysm associated with cerebral arteriovenous malformation

A 50-year-old man presented with a symptomatic aneurysm arising from the right inferior cavernous sinus artery (ICSA) associated with a cerebral arteriovenous malformation (AVM) manifesting as a 3-month history of progressive right abducens nerve palsy. Cerebral angiography demonstrated a high-flow AVM and a saccular aneurysm arising from the right ICSA acting as a meningeal feeder. The symptom was thought to be attributable to aneurysmal mass effect rather than the AVM. The aneurysm was successfully treated with endovascular embolization and the symptom improved gradually. Hemodynamic stress in the ICSA may have resulted in the development of the aneurysm of the ICSA. Meningeal artery aneurysm presenting with cranial nerve palsy is extremely uncommon. The present case illustrates the need for detailed evaluation of the external carotid artery and internal carotid artery vasculature in patients with cerebral AVMs.     

Distal anterior choroidal artery aneurysm associated with an arteriovenous malformation. Intraoperative localization and treatment

BACKGROUND

Distal anterior choroidal artery aneurysms are rare. The outcome of patients with distal anterior choroidal artery aneurysms has been poor, and the treatment of such aneurysms is surgically challenging.

CASE DESCRIPTION

The authors describe the case of an 8-year-old girl with a ruptured distal anterior choroidal artery aneurysm associated with an arteriovenous malformation (AVM). The patient experienced sudden onset of headache and vomiting. Computed tomography revealed an intraventricular haemorrhage, and cerebral angiography demonstrated an aneurysm arising from the distal portion of the right anterior choroidal artery. The patient also had an AVM in the ipsilateral temporal lobe fed by the branches of the middle cerebral artery. A right frontotemporal craniotomy was performed with the aid of intraoperative angiography to eliminate both the AVM and the aneurysm. Intraoperative angiography was helpful in confirming the complete removal of the AVM and in accurate localization of the small and deeply placed distal anterior choroidal artery aneurysm. Both the AVM and the aneurysm were successfully treated and the patient was discharged without any neurological deficits.

CONCLUSION

This case is the youngest reported patient with a distal anterior choroidal artery aneurysm. This report is also the first to describe an association of such an aneurysm with an AVM. The etiology of the aneurysm formation in this case and surgical strategy for deeply placed vascular lesions are discussed.     

Acute subdural hematoma without subarachnoid hemorrhage caused by ruptured A1-A2 junction aneurysm. Case report

A 54-year-old man was admitted to our hospital with complaint of sudden headache. The patient had suffered two episodes of transient headache before admission. Computed tomography (CT) revealed acute subdural hematoma (ASDH) on the right side of the cerebral convexity with bilateral extension along the tentorium cerebelli without signs of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH). Three-dimensional CT angiography and conventional cerebral angiography revealed a left A1-A2 junction aneurysm. Neck clipping of the aneurysm was performed. The aneurysm extended inferiorly, with the dome embedded in the chiasmatic cistern and tightly adhered to the arachnoid membrane. There was no evidence of hematoma in the subarachnoid space. The patient was discharged without neurological deficit. Ruptured aneurysms resulting in ASDH without SAH or ICH are very rare. Radiological investigation such as three-dimensional CT angiography should be performed to find the causative aneurysm in a patient with ASDH with a history of repeated headaches and without traumatic signs or episodes, and the appropriate treatment should be planned with expediency.