Outcome of cerebral amyloid angiopathic brain haemorrhage

Background  Abnormal amyloid protein can be deposited in the wall of cerebral arteries leading to fragility and intracerebral haematoma in patients with cerebral amyloid angiopathy. Diagnosis can be done only histologically. The indication of surgically treating intracerebral haemorrhage caused by amyloid angiopathy is controversial. There are studies showing a high mortality and a high rate of recurrent bleeding. Others show almost no recurrent bleeding and a very low mortality and a third party states that even when recurrent intracerebral haemorrhage occurs, re-evacuation should be performed. In the present retrospective study a population of 99 patients suffering from cerebral amyloid angiopathy-related cerebral haemorrhage has been studied, to investigate the surgical outcome. Method  Ninety-nine patients were histologically diagnosed with cerebral amyloid angiopathy in our department from 1991–2004. The outcome has been established by the Glascow Outcome Score. Findings  It could be shown that intraventricular bleeding and age >75 years increased the mortality after operative evacuation. Recurrent bleeding occurred in 22% of patients. After re-evacuation at least half of the patients survived leading to the suggestion to re-operate a recurrent bleeding since patients have a chance to survive even when the Glascow Outcome Score is 3. The overall mortality in the observed population was 16% and 11% had a very good neurological recovery based on a Glascow Outcome Score of 4–5. The operative outcome in amyloid angiopathy related intracerebral haemorrhage is similar to this of intracerebral haemorrhage induced by other causes like hypertensive bleeding. Conclusions  Possible cerebral amyloid angiopathy is no contraindication for evacuation of brain-haematoma, and especially not in patients younger than 75 years old without an intraventricular haemorrhage.     

Hémorragie intracérébrale spontanée secondaire à un déficit congénital en facteur XIII

Deficiency of coagulation factor XIII is a rare anomaly. The risk of intracranial haemorrhage is particularly high at any age, either spontaneously or during minor trauma. We report a case of spontaneous intracerebral haemorrhage in a child carrying a known deficiency of factor XIII.     

Intracerebral hemorrhage due to cerebral amyloid angiopathy. Case report

The case is presented of a 59-year-old man with cerebral amyloid angiopathy and three consecutive hemorrhages in the occipital lobes. The clinicopathological features and the relationship to Alzheimer's dementia are discussed. The correct treatment of intracerebral hemorrhage related to cerebral amyloid angiopathy is a matter of controversy.     

Rôle délétère de l’hyperthermie en neuroréanimation

Fever is a secondary brain injury and may worsen neurological prognosis of neurological intensive care unit (NICU) patients. In response to an immunological threat, fever associates various physiological reactions, including hyperthermia. Its definition may vary but the most commonly used threshold is 37.5 °C. In animal studies, hyperthermia applied before, during or after cerebral ischemia may increase the volume of ischemic lesions. The mechanism of this effect may include increase in blood brain barrier permeability, increase in excitatory amino acid release and increase in free radical production. In NICU patients, fever is frequent, occurring in up to 20–30% of patients. Moreover, after haemorrhagic stroke, fever has been reported in 40–50% of patients. In half of the patients, fever may be related to an infectious cause but in more than 25% of patients, hyperthermia may be of central origin. After ischemic stroke, hyperthermia during the first 72 hours is associated with an increase in infarct size and increase in morbidity and mortality. This holds true also after subarachnoid haemorrhage. After traumatic brain injury, fever is not related to mortality but may increase morbidity. Whereas no causal link has been established between fever and unfavourable outcome, it seems reasonable to treat hyperthermia in patients suffering from brain injuries. In such patients, antipyretics have a moderate efficacy. In case of failure, they should be replaced by physical cooling techniques.     

Cerebral amyloid angiopathy complicated by multiple cerebral infarcts and intracerebral hemorrhages: case report

Recently, cerebral amyloid angiopathy is stressed as an unusual and infrequent cause of cerebral infarct or intracerebral hemorrhage. This report described a case of cerebral amyloid angiopathy complicated by multiple cerebral infarcts and multiple intracerebral hemorrhages. This 70-year-old man was admitted to our hospital on November 10, 1984 for evaluation of the gradual onset of dysarthria. Examination showed only slight dysarthria. There was no history of hypertension or dementia. A computed tomography (CT) showed enlarged ventricles with cortical atrophy and multiple low-density lesions, deep in the left frontal, left parietal, right parietal lobes, and in the both basal ganglias. The patient discharged from the hospital with only slight dysarthria. On November 20, 1984, he was admitted to our hospital again, because he was found unresponsive on the floor. He was somnolent but arousable. Examination showed disorientation, impairment of recent memory and impairment of calculation, A CT scan demonstrated three small intracerebral hemorrhages in the left frontal, right parietal lobes and left basal ganglia. On the fifth hospital day he deteriorated acutely, becoming semicomatose and hemiparetic on the right side. A repeated CT scan showed two new intracerebral hemorrhages in the left frontal lobe. Cerebral angiograms showed only minimal changes due to the occupying lesions in the above mentioned area. The hematomas was evacuated via left fronto-parietal craniotomy. The specimens removed with hematoma (stained with hematoxylin-eosin, Congo red and thioflavin T) showed extensive amyloid angiopathy. Postoperatively he made a good recovery, although he had residual mental dysfunctions. He expired by pneumonia on March 30, 1985.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lobar intracerebral hemorrhage. A clinical, radiographic, and pathological study of 29 consecutive operated cases with negative angiography.

The authors operated consecutively on 50 patients with lobar intracerebral hemorrhage during a prospectively designed study period from January, 1986, to March, 1990. They investigated the correlations between the underlying causes and the clinicoradiographic features in 29 patients who showed no angiographic vascular abnormalities, in order to elucidate the operative indication for such cases. Patients with ruptured saccular aneurysm or trauma were not included in this study. There were 15 males and 14 females, ranging in age from 7 to 76 years (mean 52.4 years). Histological diagnoses of the surgical specimens were as follows: vascular malformation in nine cases (arteriovenous malformation (AVM) in six and cavernous malformation in three), microaneurysm in 11, cerebral amyloid angiopathy in six, and brain tumor in two; in the remaining case the cause was not verified histologically. The underlying cause was determined in 96.5% of cases. The mean patient age was lowest in the cavernous malformation group (27.0 years), followed by the AVM (45.8 years), microaneurysm (59.8 years), and cerebral amyloid angiopathy (70.0 years) groups. Four patients with vascular malformation (three AVM's and one cavernous malformation) had previous episodes of bleeding at the same site, whereas none of those with microaneurysms or cerebral amyloid angiopathy had such episodes. On computerized tomography (CT) scans, the round to oval hematoma was related to the presence of an AVM or cavernous malformation in contrast to microaneurysms and cerebral amyloid angiopathy. Upon infusion of contrast material, variable enhancement was seen in five (two AVM's and three cavernous malformations) of the nine vascular malformations while no enhancement was noted in any patient with microaneurysm or cerebral amyloid angiopathy at the acute stage. Subarachnoid extension of the hematoma was associated with cerebral amyloid angiopathy significantly more frequently than with AVM's (p less than 0.05) and microaneurysms (p less than 0.01). The results suggest that clinicoradiographic pictures in cases with negative angiography are quite different among the three major pathological categories; namely, vascular malformation (AVM and cavernous malformation), microaneurysm, and cerebral amyloid angiopathy. It is suggested that the underlying etiology of a given lobar intracerebral hemorrhage with negative angiography may be predicted by a combination of patient age, history of previous bleeding at the same site, hematoma shape, and subarachnoid extension of the hematoma on CT scans. Based upon these findings, the authors discuss operative indications for such cases.     

Intracerebral haemorrhage and postpartum cerebral angiopathy associated with the administration of sulprostone and norepinephrine

We report the case of a 29-year-old female who had developed a postpartum cerebral angiopathy (PCA) complicated by an intracerebral haematoma and convulsions, after a postpartum haemorrhage with sulprostone and norepinephrine infusion. PCA is an under diagnosed neurovascular pathology, responsible of reversible and non-specific symptoms. However, it can be complicated by haemorrhagic or ischemic stroke with vital or functional risks. As PCA is favored by vasoactive treatments, their administration in peripartum period, when it is imperative, should be strictly controlled.     

Recurrent intracerebral hemorrhages in cerebral amyloid angiopathy: a case report

Cerebral amyloid angiopathy frequently causes recurrent intracerebral hemorrhages in elderly patients who do not have systemic hypertension. Surgery should be reserved for conditions which cannot be controlled by medical treatment. When surgery is needed, potential complications (such as bleeding near the operation site or remote area) should be kept in mind. A case study of a 66-year-old woman with cerebral amyloid angiopathy and recurrent intracerebral hemorrhages is presented.     

Cerebral amyloid angiopathy presenting as multiple intracranial lesions on magnetic resonance imaging. Case report

Cerebral amyloid angiopathy is recognized as an important cause of spontaneous intracerebral hemorrhage in the elderly normotensive patient. Magnetic resonance (MR) imaging characteristics of this disease entity are rarely mentioned in the literature. The MR imaging findings of an elderly normotensive patient presenting with an acute spontaneous intracerebral hemorrhage secondary to amyloid angiopathy are reported and a brief review of amyloidosis is presented.     

Surgical experience with massive lobar haemorrhage caused by cerebral amyloid angiopathy

Summary Nineteen patients with massive lobar haemorrhage without angiographic lesions received direct or stereotactic surgery, and biopsy specimens were examined histologically. Ten patients (53%) were found to have vessels positive for Congo-red staining, and demonstrating amyloid angiopathy. In the patients with amyloid angiopathy, CT scan and surgical findings were investigated. Subarachnoid haemorrhage (9/10), irregularly shaped haematoma (9/10) and fluid-blood density level in the haematoma cavity (7/10) were frequently found on CT scan. The characteristic surgical findings in patients treated by direct surgery were subarachnoid haemorrhage adjacent to intracerebral haematoma (8/8) and the existence of a tangle of vessels in the haematoma cavity (4/8). Evacuation of haematomas was relatively easy, and difficulty of haemostasis was not encountered during surgery.     

Hémorragie cérébrale chez un enfant asthmatique ventilé : mécanismes multifactoriels

We report the case of a 7-year-old boy with acute status asthmaticus requiring mechanic ventilation in the pediatric intensive care unit. He developed a brain hemorrhage during the course of his illness. We discuss the mechanisms that may have precipitated this neurological complication.     

Multiple intracerebral hemorrhages due to cerebral amyloid angiopathy after head trauma

Cerebral amyloid angiopathy (CAA) is an important cause of intracerebral hemorrhage and ischemic cerebrovascular disease in some normotensive elderly patients. The diagnosis is made by proof of amyloid deposition in the vessel wall. A case of recurrent and multiple intracerebral hemorrhages due to cerebral amyloid angiopathy after head injury is reported. A 74-year-old female was referred to our hospital because of head injury. CT scan showed traumatic subarachnoid hemorrhage and intraventricular hematoma. Her consciousness was clear but slight disorientation was recognized. Conservative therapy was performed. During the course subcortical hemorrhages occurred five times and during the second one, right frontal and right parietal hemorrhages occurred simultaneously. Her consciousness deteriorated. The second subcortical hemorrhage was especially complicated by a ventriculoperitoneal shunt operation. A biopsy of the cortex was performed and pathological examination revealed amyloid deposition in the walls of small pial and cortical vessels. Occasional duplicated wall, obliterative intimal proliferation and disappearance of elastic lamina were recognized. The patient sank into a vegetative state due to recurrent and multiple hemorrhages. CAA results in two possibilities, hemorrhage and ischemic cerebrovascular disease. When lobar or subcortical hemorrhage is encountered in a normotensive elderly patient, the possibility of a CAA-related hemorrhage should be considered. The author carefully emphasizes that there is indication for neurosurgical treatment in CAA patients and proposes that therapy for ischemic cerebrovascular disease should be given special attention.     

Fatal Intracerebral Haemorrhage Following Carotid Endarterectomy in a Patient with Cerebral Amyloid Angiopathy

A 68-year-old man underwent carotid endarterectomy for symptomatic carotid artery stenosis. Immediately after surgery the patient suffered dramatic neurological deterioration, due to massive cerebral bleeding. Pathological examination revealed cerebral amyloid angiopathy. This condition is known to predispose to spontaneous, as well as anticoagulation induced, cerebral haemorrhage. Surgical intervention needing anticoagulation in elderly patients at risk for congophilic angiopathy should be performed with extreme caution.     

Amyloid angiopathy — a rare cause of intracerebral hemorrhage

The cerebral amyloid angiopathy (CAA), morphologically characterized by amyloid deposition in the vessel walls which are altered to rigid tubes, is a chronic disease of the cortical and meningeal vessels and can cause intracerebral hemorrhages (1,5% of all intracerebral bleedings). We report the course of five surgically treated patients with lobar space-occupying intracerebral hemorrhages and CAA confirmed by histological examination. All patients were elderly (74–84 years), in good condition, and self-providing before the hemorrhage. There were no signs of dementia of the Alzheimer's type. In four cases, CT showed a hematoma in the parietooccipital, and in one case in the temporo-parietal, region. After surgical evacuation, two patients recovered, one patient remained in bad condition, and two patients died from recurrent hemorrhage within two weeks. Spontaneous intracerebral hemorrhage of lobar localisation in an elderly patient strongly suggests CAA. The prognosis seems to be poor in cases with recurrent hemorrhage, the other patients presented an uneventful course, comparable with patients operated on for intracerebral bleeding of other origin. Further investigations are necessary to elucidate the prognosis of this entity.     

EEG en réanimation : quelles indications,quel matériel ?

There is a growing development of continuous EEG monitoring (cEEG) in the intensive care unit (ICU) management of neurological patients. Its main objective is the detection of epileptic seizures or status epilepticus because the sensitivity of standard short-duration EEG recording in the ICU is poor. The aim of monitoring is to allow rapid recognition and treatment of epileptic complications in order to decrease secondary insults to the brain and improve outcome. Several studies have demonstrated that a large proportion of patients has epileptic crisis after subarachnoid haemorrhage, stroke or brain trauma, without any clinical manifestation. The EEG feature has also demonstrated a prognosis value but its value for clinical management needs further studies. Another application of EEG in the ICU is monitoring depth of anaesthesia or barbiturate treatment. Due to artifacts contamination, this is possible only in deeply sedated of paralyzed patients. The impact or cEEG monitoring on clinical management and its indications have to be further defined.     

Primary intracerebral hemorrhage due to probable cerebral amyloid angiopathy complicated by brain abscess: case report

Cerebral amyloid angiopathy (CAA), in which deposition of amyloid within the arterial media and adventitia is the remarkable feature, causes spontaneous lober cerebral hemorrhage in elderly person, and some reports show the quite high occurrence rate of this entity among intracerebral hemorrhage in patents above 70 years old. Brain abscess resulting from intracerebral hemorrhage is rare. To our knowledge, no report of such hemorrhage which is caused by CAA has been published so far. We report a case of brain abscess, from which Stenotrophomonas maltophilia was isolated, following spontaneous non-hypertensive intracerebral hemorrhage caused by probable CAA, with a review of the relevant literature.     

Causes of early mortality after liver transplantation: a twenty-years single centre experience

Objective

To define the causes of mortality of patients who died within the first three months after a liver transplantation.

Type of study

Retrospective, observational, and single centre study.

Patients and methods

Between March 1989 and July 2010, all patients who died within three months after a liver transplantation were included. Demographic characteristics, preoperative and peroperative data, donor characteristics, postoperative complications and causes of mortality were collected.

Results

Among the 788 performed liver transplantations, 76 patients died in intensive care unit (11%). The main indications of liver transplantation were alcoholic cirrhosis (30%), hepatitis C (28%), hepatocarcinoma (15%), primitive or secondary biliary cirrhosis (10%). Fifty percent of the patients were categorized as Child C. The main causes of death were non-function or dysfunction with retransplantation contra-indication graft (18%), sepsis (18%), neurological complications (12%), hemorrhagic shock (13%), (9%), multiorgan failures (5%), cardiac complications (6%).

Conclusion

In this study, the main causes of mortality were infectious, neurological and hemorrhagic. These results emphasize the necessity for better control of sepsis, haemorrhage and immunosupressors.     

Aspects of stroke management including subarachnoid haemorrhage

The present review focuses on some aspects of stroke management and covers important clinical studies and studies in basic research published during the past year. It is subdivided in three sections. First, we focus on ischaemic stroke and discuss some new insights into the genetics of ischaemic stroke, intensive stroke care including cerebral thrombolysis, and neuroprotective treatment. Secondly, new insights into the risk factors and outcome of primary and iatrogenic intracerebral haemorrhage are discussed. Finally, we review in the section on subarachnoid haemorrhage literature on the further development of endovascular treatment of cerebral aneurysms, and research into the causes of vasospasms and secondary cerebral ischaemia.     

Neurosurgical and immunological implications of primary cerebral amyloid (congophilic) angiopathy

Two cases of histologically documented primary cerebral amyloid complicated by spontaneous intracerebral hematoma are reported. The neurosurgical implications of this disease are reviewed briefly. Immunological studies in one patient, believed to be a rare survivor of an intracerebral hemorrhage from nonfamilial primary cerebral amyloid angiopathy, demonstrated an increased percentage of B cells within both the cerebrospinal fluid (CSF) and the blood compartments. Hypofunction of CSF concanavalin A-activated suppressor cells with respect to B and T cell targets was shown. The blood suppressor cells from the patient were similar to those of an age-matched control. Compartmental central nervous system suppressor cell dysfunction resulting in B cell activation could play a role in facilitating amyloid deposits in the brain. The mechanisms responsible for the compartmental and limited suppressor cell dysfunction are unknown.     

A case report of simultaneous multiple intracerebral hematomas

A case of multiple spontaneous intracerebral hematomas is presented. A 67-year-old man with 7 years history of hypertension had sudden clumsiness in his right hand and an hour later dysarthria appeared. A CT scan taken 3 hours after the onset revealed two well demarcated high density areas in the left putamen and in the parietal subcortex. A diagnosis of multiple intracerebral hematomas was made. On neurological examination he was midly stuporous (13 points of Glasgow Coma Scale). Dysarthria, right hemiparesis and right extensor plantar response were seen. CT scan of 6 hours later disclosed the same findings as the previous study. He recovered well and neurologically free in a few days. On the following CT scans both hematomas were isodense 2 weeks later, and ring-like enhancement effect was noted. CT scan showed normal appearance 7 weeks later. On MRI using 0.5 T unit t-1 and t-2 weighted spin echo images of these hematomas also showed the similar chronological changes. The history, these CT and MRI studies suggest that two hematomas of this case occurred almost simultaneously in one cerebral hemisphere. No causative factors such as blood dyscrasias, AVM, angioma, septicemia, malignancies or sinus thrombosis was identified. We consider that a hypertensive intracerebral hematoma of the putamen was followed by the parietal intracerebral hematoma within a few hours, although amyloid angiopathy was not completely excluded because no cerebral biopsy of the lesion was performed.