非动脉瘤性自发性蛛网膜下腔出血分析

目的总结非动脉瘤性自发性蛛网膜下腔出血的临床特点。方法自发性SAH患者首次CTA和DSA均未发现动脉瘤和其他血管病变者,3～4周复查CTA或DSA,结果仍为阴性者诊断为非动脉瘤性SAH。分为中脑周围非动脉瘤性蛛网膜下腔出血(PMN)组和非中脑周围非动脉瘤性蛛网膜下腔出血(nPMN)组。结果 51例患者首次CTA和DSA未发现动脉瘤和其他血管病变,其中4例复查CTA或DSA发现动脉瘤,另有6例患者未复查即死亡。诊断为非动脉瘤性蛛网膜下腔出血共41例,其中PMN组29例,nPMN组12例。平均随访2.3年,两组均无死亡,全部的PMN病例和83.3%的nPMN病例预后良好。结论非中脑周围非动脉瘤性蛛网膜下腔出血(nPMN)临床过程和预后介于动脉瘤性SAH和PMNSAH之间,需要通过重复造影检查排除动脉瘤的可能。     

Caudate hemorrhage: clinical features, neuropsychological assessments and radiological findings

The nucleus caudatus is not a common location of spontaneous intracerebral hemorrhage. Twelve patients (8 men and 4 women) aged 38–76 years who had caudate hemorrhage between November 1, 1992 and March 31, 1994 were evaluated. These cases represented 2.1% of intracerebral hemorrhage cases at Neurological Institute, Veterans General Hospital-Taipei, Taiwan. Cerebral angiography was performed on eight patients. Six patients were evaluated by an extensive neuropsychological battery. The most frequent symptoms of caudate hemorrhage were headache and/or vomiting, and decreased consciousness. Clinical features were similar to those of subarachnoid hemorrhage. Angiography showed characteristic moyamoya disease in one patient but did not show an aneurysm or arteriovenous malformation in any patient. The etiology in most patients was hypertension. Neuropsychological assessments showed significant impairment in tasks of short-term and long-term memory and in verbal fluency as well as trends of impairment of orientation rather than of controls. Neurobehavioral symptoms probably resulted from interruption of the cortical-subcortical loops between the caudate nucleus and prefrontal cortex.     

动态测定出血性脑血管病患者血浆神经肽Y的临床意义

目的:动态观察脑出血(CH)及蛛网膜下腔出血(SAH)患者血浆神经肽Y(NPY)的水平变化,探讨NPY与出血性脑血管病发生、发展的关系。方法:采用放射免疫法测定了46例脑出血,30例SAH患者及28例健康人血浆NPY的含量。结果:CH和SAH患者血浆NPY水平均明显高于对照组(P<0.001)。发病24小时内即显著升高,4～7天达高峰,8～15天开始下降,15天后CH组仍维持较高水平。重型CH患者NPY水平显著高于轻型和中型。大面积出血组高于小面积出血组。SAH患者伴迟发性缺血性障碍(DID)组明显高于不伴DID组。结论:NPY可能在CH及SAH的发生及病理生理过程中起重要作用。     

Risk factors for acute symptomatic cerebral infarctions after spontaneous supratentorial intra-cerebral hemorrhage

Cerebral infarctions are unfavorable outcomes of spontaneous intra-cerebral hemorrhage (ICH). To date, there have been no reports on risk factors that are predictive of acute symptomatic cerebral infarctions. With the aim of determining the potential risk factors that are predictive of acute symptomatic cerebral infarctions in patients with spontaneous supratentorial ICH, we have retrospectively evaluated 212 hospitalized patients with spontaneous ICH and compared those who developed a complicated cerebral infarction with those who did not. Cerebral infarctions developed in 8.02% (17/212) of the patient cohort. Neuro-imaging findings between the two patient groups revealed that the presence of intra-ventricular hemorrhage (IVH), hydrocephalus, and the median value of intra-cranial hematoma on admission were significant factors, as well as neurosurgical intervention. However, the multiple logistic regression analysis revealed that only the presence of IVH had an odds ratio of 4.7 (95% confidence interval 0.06–0.75; p = 0.016) in patients with acute symptomatic infarctions. The results indicate that the presence of IVH may imply a danger of cerebrovascular complications when treating spontaneous supratentorial ICH during hospitalization. The frequency of acute symptomatic cerebral infarctions in patients with spontaneous supratentorial ICH is high (8%) and is associated with longer hospitalization and worse outcome.     

Destructive hydrocephalus: a proposed new category

A case is reported with hydrocephalus subsequent to neonatal intraventricular and intracerebral hemorrhage. Hydrocephalus was diagnosed as obstructive, secondary to subarachnoid hemorrhage. However, the lateral ventricle in the hemisphere in which the intracerebral hemorrhage occurred dilated much more than that in the contralateral hemisphere. Hydrocephalus occurring in regions of the brain that have suffered destructive changes from a cause other than that of the hydrocephalus, as in this reported case, is proposed as a new category, (destruction hydrocephalus). It is to be distinguished from hydrocephalus with dilated ventricles due simply to increased intraventricular pressure. In destructive hydrocephalus dilatation of the ventricles occurs irregularly and rapidly, leading to secondary cerebral destruction. Therefore, treatment to prevent the progressive cerebral damage is required immediately.     

The AGTR1 gene A1166C polymorphism as a risk factor and outcome predictor of primary intracerebral and aneurysmal subarachnoid hemorrhages

Associations between the angiotensin II type 1 receptor (AGTR1) gene A1166C polymorphism and hypertension, aortic abdominal aneurysms (as a risk factor) as well as cardiovascular disorders (as a risk factor and an outcome predictor) have been demonstrated. We aimed to investigate the role of this polymorphism as risk factors and outcome predictors in primary intracerebral hemorrhage (PICH) and aneurysmal subarachnoid hemorrhage (aSAH).We have prospectively recruited 1078 Polish participants to the study: 261 PICH patients, 392 aSAH patients, and 425 unrelated control subjects. The A1166C AGTR1 gene polymorphism was studied using the tetra-primer ARMS-PCR method. Allele and genotype frequencies were compared with other ethnically different populations.The A1166C polymorphism was not associated with the risk of PICH or aSAH. Among the aSAH patients the AA genotype was associated with a good outcome, defined by a Glasgow Outcome Scale of 4 or 5 (p < 0.02). The distribution of A1166C genotypes in our cohort did not differ from other white or other populations of European descent.In conclusion, we found an association between the A1166C AGTR1 polymorphism and outcome of aSAH patients, but not with the risk of PICH or aSAH.     

高血压性脑出血破入脑室患者血中超敏C-反应蛋白水平与病情和早期转归的关系

目的探讨高血压性脑出血破入脑室患者血中超敏C-反应蛋白水平及其与病情和早期转归的关系。方法设健康体检者为对照,检测同期入院的高血压性脑出血破入脑室系统患者及高血压性脑出血病人入院和第4周血中的超敏C-反应蛋白水平,评定高血压性脑出血破入脑室患者治疗前后神经功能缺损评分及疗效。结果与对照组相比,2组患者hs-CRP均增高(P<0.01),脑出血破入脑室患者与未破入脑室患者有显著差异(P<0.05),破入脑室患者未好转组与好转组间hs-CRP差异显著。结论高血压性脑出血破入脑室患者血中超敏C-反应蛋白水平与病情相关,对其早期转归有一定的提示作用。     

微创软通道手术治疗高血压性小脑出血的临床分析

目的 探讨微创软通道置管引流术治疗中等量高血压性小脑出血的效果。方法 选取中等量小脑出血(出血量10～20 mL)患者作为研究对象,对61例中等量小脑血肿患者分为微创软通道置管引流组(n=33)和小骨窗开颅组(n=28),比较2组近期(治疗后3周)和远期(治疗后6个月)格拉斯哥预后评分(GOS)、日常生活能力Barthel评分(BI)等指标以及并发症发生率。结果 软通道置管引流组和小骨窗开颅组近期及远期疗效均无显著差异(P>0.05),但后者颅内感染、肺部感染等并发症发生率以及手术时间和平均住院时间明显高于前者(P<0.05)。结论 对于中等量小脑出血(10～20 mL)患者微创软通道置管引流术是一种安全而有效、简便快捷的治疗方法。     

高血压脑出血合并上消化道出血临床分析

目的 探讨高血压脑出血的出血部位、出血量与消化道出血发生率及预后的关系.方法 对96例脑出血患者的临床表现、出血部位、出血量、血糖、治疗方法 进行分析.结果 上消化道出血发生率分别为壳核出血组36.46%, 丘脑出血组32.29%,脑干出血组13.54%,脑叶出血组17.71%.高血压脑出血合并上消化道出血组病死率为43.75%.结论 脑出血合并上消化道出血常见丘脑、脑干等部位病变,且出血量大者发生率高,脑出血并上消化道出血提示预后不良,病死率高.     

A prospective long-term study of return to work after nontraumatic nonaneurysmal subarachnoid hemorrhage

Patients generally have a good prognosis and develop only occasional neurological complications after nontraumatic, nonaneurysmal subarachnoid hemorrhage (SAH). This prospective long-term study investigated the normal return to work of patients who had experienced nontraumatic nonaneurysmal SAH. From June 2001 to June 2004, all patients presenting with nonaneurysmal nontraumatic SAH were asked to participate in this study. The population was divided in two groups: perimesencephalic (pSAH) and nonperimesencephalic pattern (npSAH). All patients underwent a battery of neuropsychological tests and completed psychological questionnaires assessing their general cognitive and language functions, memory and construction ability, attention, anxiety and depression, and quality of life. The patients were interviewed at the hospital, and neuropsychological assessments were conducted regularly for 7 years. The cognitive assessment after 7 years revealed a statistically significant difference between the pSAH and npSAH groups with respect to the activation and elaboration speed of attention as well as long-term non-verbal memory. Nine patients could not return to their former jobs after nonaneurysmal SAH. Although nontraumatic nonaneurysmal subarachnoid hemorrhage is typically a pathology with an excellent prognosis, there is evidence that this event may influence working life for a long time.     

Angioma of the choroid plexus: Personal experience of 42 cases and a review of the literature

Only 127 cases have been reported of choroidal angiomas, including the 42 examples cited in the present paper. The mean age of the 42 subjects examined in the present series was 15 years and the median was 1 month. The lateral ventricle was the most common location. Bilateral angiomas comprised 40% of lesions in the lateral ventricle, which is strikingly more common than in previous reports (8%). Most patients presented with signs and symptoms of intraventricular or subarachnoid hemorrhage. The lesion, however, was found accidentally in 15 cases (36%), particularly in the perinatal period. Associated developmental malformations were observed in 25 instances (59%), which often involved the cardiovascular system. The median age of 30 years of patients with choroid plexus angioma in the literature is significantly (P < 0.005) higher than that in the present study. Of 85 cases of choroidal angioma reported in the literature, only three cases (4%) were encountered accidentally. It is suggested that careful examination of the choroid plexus will increase the diagnosis of choroidal angiomas and that hemangiomas should be searched for in the choriod plexus in cases of intraventricular hemorrhage as well as in instances of developmental malformations, particularly those affecting the cardiovascular system.     

Dynamic evolution of D-dimer level in cerebrospinal fluid predicts poor outcome in patients with spontaneous intracerebral hemorrhage combined with intraventricular hemorrhage

The risk of mortality in patients with intracerebral hemorrhage (ICH) significantly increases when complicated by intraventricular hemorrhage (IVH). We hypothesize that serial measurement of cerebrospinal fluid (CSF) D-dimer levels in patients with both ICH and IVH may serve as an early marker of IVH severity. We performed a prospective study of 43 consecutive ICH patients combined with IVH and external ventricular drainage placement admitted in our institution from 2005–2006. IVH severity (Graeb score) and fibrinolytic activity were evaluated continuously for 7 days using CT scans and CSF D-dimer levels. The primary outcome was 30 day mortality. Overall 30 day mortality was 26% (n = 11), with eight deaths (72.7%) after 3 days (D3). Graeb score and CSF D-dimer on admission (D0) were not significantly different between survivors and non-survivors. The temporal profiles of both parameters were distinctly different, with a downward trend in survivors and an upward trend in non-survivors. A mortality rate of 54% was observed between D0–D3 when both scores increased during this interval. In contrast, the mortality was only 4% when both measures decreased during this interval. Early phase (D0–D3) CSF D-dimer or Graeb score change demonstrated high sensitivity of 88% and specificity of 81% when predicting 30 day mortality. Early phase CSF D-dimer change in patients with both ICH and IVH is accurate in predicting mortality and may be utilized as a cost-effective surrogate indicator of IVH severity. Serial monitoring of CSF D-dimer dynamic changes is useful for early identification of patients with hematoma progression and poor outcome.     

Intracranial hemorrhage

The initial and exclusive use of MRI in patients with a stroke syndrome is feasible, probably cost-effective, and even time saving when considering its potential wealth of information. MRI may be the diagnostic tool of choice in patients with all stages of stroke, especially in the hyperacute assessment of ICH, and could be equivalent to CT and CTA in SAH diagnosis. The authors’ aim is to provide a comprehensive review about the potential role of MRI in evaluating ICH and SAH. Emerging applications, such as the assessment of microbleeds as a risk factor for secondary hemorrhage after thrombolysis and perihemorrhagic ischemic changes as a potential marker for patients likely to benefit from hematoma evacuation, are reviewed.     

持续腰大池引流治疗不同原因的颅内出血

目的探讨持续腰大池引流对颅内出血性疾病的治疗效果。方法回顾我院2008年7月至2010年4月外伤性蛛网膜下腔出血、开颅术后蛛网膜下腔积血、脑室内出血(包括高血压脑出血破入脑室)患者共85例持续腰大池引流治疗过程。结果所有患者颅内出血均于持续腰大池引流4～18 d内消失,取得较好效果。结论持续腰大池引流是治疗多种颅内出血性疾病的安全、有效、微创的方法,值得广泛推广。     

Poor-grade subarachnoid hemorrhage patients: The use of nimodipine and other optional treatments

Abstract

The use of calcium antagonists has been advocated as decreasing morbidity and mortality in patients with subarachnoid hemorrhage (SAH) following aneurysm rupture. Results reported from open or placebocontrolled studies show a wide variation with regard to outcome. The immediate clipping of an aneurysm as soon as diagnosed accompanied or not by removal of expansive hematomas, drainage of CSF obstructions, decompressive craniectomy and the employment of individual variation in the critical intensive care schema, may eventually influence the outcome of patients in a bad clinical condition (Hunt and Hess Grade IV and V). The aim of this paper is to analyze which patients should profit from a differential treatment on a literature review and own experience-based data. [Neurol Res 1999; 21: 649-652]     

Posthemorrhagic hydrocephalus development after germinal matrix hemorrhage: Established mechanisms and proposed pathways

In addition to being the leading cause of morbidity and mortality in premature infants, germinal matrix hemorrhage (GMH) is also the leading cause of acquired infantile hydrocephalus. The pathophysiology of posthemorrhagic hydrocephalus (PHH) development after GMH is complex and vaguely understood, although evidence suggests fibrosis and gliosis in the periventricular and subarachnoid spaces disrupts normal cerebrospinal fluid (CSF) dynamics. Theories explaining general hydrocephalus etiology have substantially evolved from the original bulk flow theory developed by Dr. Dandy over a century ago. Current clinical and experimental evidence supports a new hydrodynamic theory for hydrocephalus development involving redistribution of vascular pulsations and disruption of Starling forces in the brain microcirculation. In this review, we discuss CSF flow dynamics, history and development of theoretical hydrocephalus pathophysiology, and GMH epidemiology and etiology as it relates to PHH development. We highlight known mechanisms and propose new avenues that will further elucidate GMH pathophysiology, specifically related to hydrocephalus.     

Neurovascular complications of cocaine

Use of cocaine in the USA, has reached epidemic proportions since 1983, when "crack" was introduced, its higher potency compared with cocaine HCl has been associated with a tremendous increase in the incidence of strokes. This study reports our experience with 55 cases of neurovascular events (25 ischemic and 30 hemorrhagic) related to cocaine use in 54 patients. Only 15 patients had other risk factors for stroke. Twenty six patients smoked "crack", 10 snorted cocaine and 12 injected it intravenously. Strokes occurred within 3 h of cocaine use in 15 patients with infarcts and 17 with hemorrhages. Ten infarcts occurred after an overnight binge. Of the hemorrhage group 9 were subarachnoid, 16 intracerebral (8 basal ganglia, 7 hemispheric and one brain stem) and 5 intraventricular. Computerized tomography (CT) showed an aneurysm of the anterior communicating artery, as well as one of the vein of Galen. Four aneurysms and 3 AVMs were identified on angiography. CT revealed 15 infarcts; it was normal in 7 patients with pure motor hemiparesis and in 3 with findings consistent with anterior spinal artery infarction. Several mechanisms may be responsible for the cerebrovascular complications. A sudden rise in systemic arterial pressure may cause hemorrhages, frequently in association with an underlying aneurysm or AVM. Vasospasm, arteritis, myocardial infarction with cardiac arrhythmias and increased platelet aggregation may provoke infarcts.     

Surgical treatment of spontaneous intracranial hemorrhage in patients with cancer: Analysis of prognostic factors

BackgroundIntracranial hemorrhage (ICH) is the most common cerebrovascular event in patients with cancer. We sought to evaluate the outcomes of surgical treatment for ICH and to determine possible pre-operative outcome predictors.MethodsWe retrospectively reviewed surgical procedures for the treatment of ICH in patients with cancer. Analysis included clinical and radiological findings of the patients. Primary endpoints were survival and mortality in index hospitalization.ResultsNinety-four emergency neurosurgeries were performed for ICH in 88 different patients with cancer over ten years. 51 patients had chronic subdural hematomas (CSDH: 54.3%), 35 with intraparenchymal hemorrhage (37.2%), 6 with acute subdural hematoma (ASDH: 6.4%), and only 2 with epidural hemorrhages (2.1%). Median patient follow-up was 63 days (IQR = 482.2). 71 patients (75.5%) died at follow-up, with a median survival of 33 days. Overall 30-day mortality was 38.3%; 27.5% for patients with CSDH. Lower survival was associated to higher absolute leucocyte count (HR 1.06; 95%CI 1.04–1.09), higher aPTT ratio (HR 3.02; 95% CI 1.01–9.08), higher serum CRP (HR 1.01; 95%CI 1.01–1.01), and unresponsive pupils (each unresponsive pupil - HR 2.65; 95%CI 1.50–4.68).ConclusionOutcomes following surgical treatment of ICH in patients with cancer impose significant morbidity and mortality. Type of hematoma, altered pupillary reflexes, coagulopathies, and increased inflammatory response were predictors of mortality for any type of ICH.     

高血压性脑干出血预后因素分析

目的探讨高血压性脑干出血预后相关的因素。方法回顾性分析57例高血压性脑干出血病人的临床资料,采用Kaplan—Meier法计算生存期及进行生存分析。以随访GOS评分为预后的判断指标,使用Fisher精确概率检验进行单因素分析,二分类Logistic回归作多冈素分析。结果单因素分析显示：入院时GCS评分、脑干血量及并发症是影响脑干出血预后的因素（P〈0．05）;其中人院时GCS评分13～15分,腑十出血量≤5ml及无并发症的病人预后较好。多因素分析显示：GCS评分和行发症是高血压性脑十出血预后相关的独立凶素（P〈0．05）。GCS评分越低,病人生存时间越短;有并发症者明显较无行发症者预后差。结论发病时GCS评分、出血量和并发症是影响病人预后的重要因素。     

Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature

Severe intraventricular hemorrhage caused by extension from subarachnoid hemorrhage or intracerebral hemorrhage leads to hydrocephalus and often to poor outcome. We conducted a systematic review to compare conservative treatment, extraventricular drainage, and extraventricular drainage combined with fibrinolysis. We carried out a search in Medline of the literature between January 1966 and December 1998 and an additional hand-search from January 1990 to December 1998. Pharmaceutical companies were contacted to gather unpublished data. We reviewed the reference lists of all relevant articles. Two authors independently assessed eligibility of the studies and extracted data on characteristics of study design, patients, and treatment. Patients with primary intraventricular hemorrhage were excluded. Main outcome measures were death and poor outcome (defined as death or dependency) at the end of follow-up. No randomized clinical trial has yet been conducted so far, and we therefore reviewed only observational studies. The case fatality rate for conservative treatment (ten studies) was 78%. For extraventricular drainage (seven studies) it was 58% [relative risk versus conservative treatment (RR) 0.74; 95% confidence interval (CI) 0.55-0.99]. For extraventricular drainage with fibrinolytic agents (five studies) the case fatality rate was 6% (RR 0.08; 95% CI 0.02-0.24). The poor outcome rate for conservative treatment was 90%, that for extraventricular drainage 89% (RR 0.98; 95% CI 0.75-1.30) and that for extraventricular drainage with fibrinolytic agents 34% (RR 0.38; 95% CI 0.21-0.68). All RR values remained essentially the same after adjusting for age, sex, World Federation of Neurological Surgeons scale, study design, and year of publication for the studies that provided these data. Outcome is thus poor in patients with intraventricular extension of subarachnoid or intracerebral hemorrhage. This meta-analysis suggests that treatment with ventricular drainage combined with fibrinolytics may improve outcome for such patients, although this impression is derived only from an indirect comparison between observational studies. A randomized clinical trial is warranted.