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.     

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.     

T_1期高级别尿路上皮癌术后复发的影响因素分析

目的通过对T1期高级别尿路上皮癌患者的术后随访,了解影响这类患者复发的因素。方法回顾性分析78例T1期高级别尿路上皮癌患者,对其年龄、性别、肿瘤多发或单发、肿瘤大小、有无吸烟史等因素进行了χ^2检验及多因素分析。结果78例患者术后复发率34.6%（27/78）,术后2年内复发者19例。吸烟患者46例,均为男性,45.7%（21/46）出现术后复发。χ^2检验示肿瘤大小（P=0.012）和吸烟史（P=0.014）对肿瘤复发的影响有统计学差异,多因素分析示肿瘤数目（P=0.027）、肿瘤大小（P=0.018）和吸烟史（P〈0.001）有统计学差异。结论除了肿瘤数目、肿瘤大小是影响膀胱肿瘤患者预后的重要因素外,有吸烟史的T1期高级别尿路上皮癌患者可能更容易复发。     

The incidence of cerebral amyloid angiopathy in surgically treated intracranial hemorrhage in the Chinese population

Despite being widely accepted as an important cause of spontaneous intracranial hemorrhage (ICH), cerebral amyloid angiopathy (CAA) has seldom been studied in the Chinese population. The current study aims to investigate the incidence and features of CAA in surgically treated ICH patients in China. From May 2006 to April 2011, 974 patients admitted to 71 hospitals throughout China for acute spontaneous ICH were studied. Craniotomy for hematoma evacuation was performed. Brain tissue from the superficial side of the suspected residual hematoma cavity, as well as from the cortex and subcortex, was obtained. Congo Red stain and β-amyloid immunohistochemistry were used for the diagnosis. Each case was assigned a pathological severity score. Of the 974 involved patients, 37.7 % were identified with CAA of different degrees. CAA had positive correlation with age and was independent of sex. Most patients had mild CAA with only the superficial vessels involved in lobes instead of the basal ganglia; the patients ≥65 years had more severe pathological score of CAA than those <65 years and had more lobes and cerebellum involved than the latter. More than one third of the surgically treated Chinese ICH patients may have CAA of different degrees.     

微创幕上血肿抽吸引流术后患者死亡相关因素分析

目的探讨幕上脑出血患者行微创血肿抽吸引流术预后的影响因素。方法回顾性分析2009年1月~2013年1月我科采用微创颅内血肿抽吸引流术治疗的129例幕上脑出血患者的临床资料,并对可能影响其预后及死亡的相关因素进行单因素和多因素分析。结果术后死亡16例(12.4%)。单因素分析结果显示患者术前血肿体积(P=0.021或P=0.013)、GCS评分(P=0.011)、糖尿病史(P=0.045)及高血压病史(P=0.039)是影响预后的相关因素,多因素分析显示术前GCS评分(≤8)是患者术后死亡的独立危险因素。结论术前GCS评分≤8是预测幕上脑出血患者血肿抽吸引流术术后死亡风险的独立危险因素,应根据患者意识状态合理选择治疗方案。     

Are drains useful for lumbar disc surgery? A prospective, randomized clinical study

OBJECTIVE: In this prospective, observer-masked clinical study, we evaluated if insertion of a drain had a significant role in decreasing the existence and the size of postoperative epidural hematoma, which is believed to be a factor causing epidural fibrosis in patients undergoing lumbar discectomy. METHOD: Fifty patients undergoing lumbar disc surgery were randomly assigned to two groups: with or without insertion of a drain in the epidural space. A drain was inserted in 22 patients, whereas 28 were left without a drain. All patients were evaluated, by means of magnetic resonance imaging (MRI) on the first postoperative day, specifically looking for the existence and the size of epidural hematoma. The size of epidural hematoma was graded as none, minimal, moderate, or prominent. The patients were clinically examined preoperatively and at the follow-up of 6 months by Oswestry Disability Index and recurrence of pain. A follow-up MRI was repeated at 6 months, and the subsequent development of epidural fibrosis was evaluated. RESULTS: Epidural hematoma was detected in 36% of patients with a drain and in 89% of patients without a drain (P=0.000). There were significant less number of minimum, moderate, and prominent sized hematomas in the group with a drain (P=0.000). On the 6-month follow-up, epidural fibrosis was found in 58.3% of patients without a drain and in 31.6% of patients with a drain (P=0.08). Late clinical outcome (improvement in Oswestry Index and no recurrent pain) was better in the group with drain, but not statistically significant (P=0.4). CONCLUSIONS: Occurrence of hematoma in the epidural space is common after lumbar disc surgery even if meticulous hemostasis has been achieved. Insertion of a drain decreases both the incidence and the size of hematoma on the first postoperative day as detected by MRI. This may have practical implications for the prevention of significant postoperative fibrosis and obtaining better surgical outcome.     

A restricted subarachnoid hemorrhage in the cortical sulcus in cerebral amyloid angiopathy: could it be a warning sign?

BACKGROUND: Cerebral amyloid angiopathy is a well-known disease that is predominantly recognized in elderly people and repeatedly causes large subcortical hemorrhages. These hemorrhages may be derived from vessel wall weakness because of Abeta depositions in the wall of the cortical and leptomeningeal arteries. Although vessel ruptures in CAA have been thought to occur in cortical arteries, it was recently demonstrated that the primary hemorrhage occurs in the subarachnoid space, particularly the cerebral sulci, as a result of multiple ruptures of meningeal arteries in some cases of subcortical hematoma caused by CAA. CASE DESCRIPTION: Case patient 1 was a 74-year-old woman who presented with epileptic seizure. A restricted SAH in the right frontal lobe was observed on MRI. Thirty-three days later, left hemiparesis occurred suddenly and a huge subcortical hematoma was observed in the right frontal lobe on CT. The hematoma was removed, and the patient was pathologically diagnosed with amyloid angiopathy. Case patient 2 was a 73-year-old man who presented with epileptic seizure. A restricted SAH in the right frontal lobe was observed on MRI. Twenty days later, left hemiparesis occurred suddenly and a huge subcortical hematoma was observed in the right frontoparietal area on CT. Hematoma removal was performed on both patients, and they were diagnosed pathologically with amyloid angiopathy. CONCLUSIONS: We report on the cases of 2 patients with CAA who presented with epileptic seizure and were found to have a restricted subarachnoid hematoma in the cerebral sulcus on MRI before their subcortical hemorrhages occurred. Both cases were diagnosed pathologically. This demonstrated that vessel ruptures in CAA can occur in the subarachnoid space, particularly the cerebral sulci, as a result of ruptures of meningeal arteries. A restricted SAH on CT/MRI could be a warning sign of a huge subcortical hemorrhage in CAA.     

老年患者腹壁切口疝修补术后复发的危险因素探讨及风险列线图模型的建立

目的探讨老年患者腹壁切口疝修补术后复发的危险因素，并建立预测老年患者腹壁切口疝修补术后复发的风险列线图模型。 方法选取2014年1月至2019年12月于南京大学附属鼓楼医院进行诊治的260例行腹壁切口疝修补术老年患者作为研究对象，分析所选患者的临床资料，根据是否复发将所选患者分为复发组和正常组，采用Logistic回归分析筛选老年患者腹壁切口疝修补术后复发的危险因素，并建立老年患者腹壁切口疝修补术后复发的风险列线图模型。 结果260例腹壁切口疝修补术老年患者中术后复发患者36例（13.85%）。单因素分析结果显示，复发组和正常组患者性别、年龄、疝类型、疝部位、补片型号、固定补片、手术类型及饮酒史等资料差异均无统计学意义（P>0.05），而手术时间、医师水平、术后血肿、吸烟史及肥胖等资料差异均有统计学意义（P<0.05）。Logistic回归分析结果显示，手术时间≥120 min、医师水平、术后血肿、有吸烟史及肥胖等为老年患者腹壁切口疝修补术后复发的独立危险因素（P<0.05），均和老年患者腹壁切口疝修补术后复发高度相关。基于手术时间、医师水平、术后血肿、吸烟史及肥胖等老年患者腹壁切口疝修补术后复发的独立危险因素，建立预测老年患者腹壁切口疝修补术后复发的风险列线图模型，C-index指数为0.775（95% CI：0.728~0.823），预测值与实测值基本一致，说明本列线图的辨别力较好，列线图模型预测老年患者腹壁切口疝修补术后复发的受试者工作特征曲线显示，曲线下面积为0.807，表明本研究列线图的预测价值较高。 结论手术时间≥120 min、医师水平、术后血肿、有吸烟史及肥胖等为老年患者腹壁切口疝修补术后复发的独立危险因素，本研究所建立的列线图有助于预测老年患者腹壁切口疝修补术后复发的发生风险。     

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.     

Surgical management of brain-stem cavernous malformations: report of 137 cases

BACKGROUND: With the improvement in neuroimaging and microsurgical techniques, brain stem cavernous malformations are no longer considered inoperable. Surgical indications for brainstem cavernoma are evolving, with better understanding of its natural history and decreasing surgical complications. METHODS: During 1986 through 1998, a series of 137 patients (4 patients each with two brain stem lesions, total number of lesions, 141) with brain stem cavernous malformations were treated microsurgically at Beijing Neurosurgery Institute. The age distribution, lesion location, and clinical presentations were analyzed. The bleeding rate, surgical indications and microsurgical techniques were also discussed. RESULTS: In our series, 92 of 137 cases (67.2%) suffered more than one hemorrhage. Female patients had a higher risk of recurrent hemorrhage than that of male patients. Unlike cavernomas malformations from other locations, repeated hemorrhages from brain stem malformations are much more common and usually lead to new neurologic deficits. Among all 137 surgically treated patients, there was no operative mortality. Ninety-nine patients (72.3%) either improved or remained clinically stable postoperatively. The size of the cavernoma/hematoma does not necessarily correlate with the surgical result. While the acute hematoma can facilitate the surgical dissection, longer clinical history with multiple hemorrhages often makes total surgical resection difficult, partially because of the firmer capsule that may not shrink or collapse after hematoma is released. Pathologically those capsules were associated with more hyaline degeneration, fibrous proliferation and even calcifications. During the follow-up period between 0.5 to 11 years in 129 cases, 115 patients (89.2%) have been working, studying, or doing house work. Three patients (2.3%) suffered recurrent hemorrhages. CONCLUSIONS: Surgical indications of brain stem cavernoma include (1) progressive neurologic deficits; (2) overt acute or subacute hemorrhage on MRI either inside or outside cavernous malformations with mass effect; (3) cavernoma/hematoma reaching brainstem surface (<2 mm brain tissue between cavernoma /hematoma and pial surface). Grave clinical presentations like coma, respiratory, or cardiac instability are not surgical contraindications. Emergent surgical evacuation may lead to satisfactory outcome. Repeated hemorrhages will worsen the pre-existing neurologic deficits and possibly make the surgical dissections more difficult. Patients with minimum, stable neurologic deficits and lesion/hematoma that has not reached the brain stem surface should be followed conservatively.     

非肌层浸润性膀胱尿路上皮癌预后的多因素Cox回归分析

目的:探讨影响非肌层浸润性膀胱尿路上皮癌(non-muscle invasive bladder cancer,NMIBC)预后的主要相关因素及其临床意义。方法:采用回顾性分析的方法,分析川北医学院附属医院2008年1月~2011年6月间收治的174例非肌层浸润性膀胱尿路上皮癌患者的临床病例资料。患者的临床病理特征(单因素)对肿瘤复发和进展风险的影响采用Kaplan-Meier法和log-rank检验评估。选择单因素分析有意义的变量分别对肿瘤复发、疾病进展进行Cox比例风险回归模型的多因素生存分析。结果:单因素分析表明患者年龄、肿瘤个数、肿瘤分期、分级、肿瘤生长部位、术后是否即刻灌注及既往复发情况七项因素与肿瘤复发显著相关(P0.05);肿瘤直径、肿瘤分期、分级、术后是否即刻灌注及既往复发情况五项因素与疾病进展相关(P0.05)。将上述各因素分别纳入Cox风险模型中得出各因素对肿瘤复发的相对危险度分别为:肿瘤分期(RR=2.041,P=0.046)、肿瘤分级(RR=1.548,P=0.037)、术后是否即刻灌注(RR=2.335,P=0.005)、既往复发情况(RR=1.484,P=0.048);各因素对疾病进展的相对危险度分别为:肿瘤分级(RR=3.019,P=0.006)、肿瘤直径(RR=5.062,P=0.005)、既往复发情况(RR=2.345,P=0.012)。结论:与非肌层浸润性膀胱尿路上皮癌术后复发密切相关的因素包括肿瘤分期、分级、术后是否即刻灌注及既往复发情况,而膀胱肿瘤的直径、分级及既往复发情况对患者肿瘤的进展影响最大。     

Independent predictors of recurrence of chronic subdural hematoma: results of multivariate analysis performed using a logistic regression model

OBJECT: The authors attempted to determine independent predictors that contribute to the recurrence of chronic subdural hematoma (CSDH). METHODS: A total of 105 consecutive patients who underwent surgery for CSDH were included in this study. Eleven patients underwent a repeated operation because the CSDH recurred. Univariate and multivariate analyses were performed to assess the relationships among various variables and CSDH recurrence. Finally, four variables were found to be independently associated with the recurrence of CSDH: 1) absence of a multiplicity of hematoma cavities on CT scans; 2) presence of a history of seizure; 3) width of the hematoma; and 4) absence of a history of diabetes mellitus (DM). CONCLUSIONS: As previously reported, the width of the hematoma is related to the incidence of CSDH recurrence. In this study, the lack of a multiplicity of hematoma cavities was the favorite predictor of CSDH recurrence. In addition, histories of seizure and no past DM are closely related to the incidence of CSDH recurrence.     

胶质瘤患者中癫痫发作影响因素及其与痫性再发的关系

目的 分析胶质瘤患者癫痫发作的影响因素,并探讨致痫发作因素与术后痫性再发之间的关系.方法 回顾性分析郑州大学第五附属医院2012年1月-2015年12月收治的95例胶质瘤患者资料,将其分为两组,其中伴有癫痫发作组54例,无癫痫发作组41例,所有患者均行肿瘤切除术,对伴有癫痫发作者寻找癫痫病灶并作切除,术后通过电话或患者来院复查进行随访并记录痫性再发情况,术后随访时间为2012年2月-2016年12月.整理并分析患者的临床资料,探讨胶质瘤患者痫性发作的影响因素以及致痫性发作相关因素与术后痫性再发的关系,对致痫性发作相关因素采用x2检验和多因素Logistic回归模型;致痫性发作相关因素与术后痫性再发之间的关系行x2检验.结果 Logistic回归模型显示瘤周水肿带＞2 cm(OR =6.905,95％ CI:2.787 ～ 17.106)及肿瘤低病理级别(OR=5.032,95％CI:1.696～14.931)是致痫性发作的独立危险因素,通过随访发现术后有16例患者(癫痫发作组13例,无癫痫发作组3例)于不同时间出现痫性再发作,水肿带与癫痫发作组和无癫痫发作组患者术后痫性再发有关(x2依次为2.940,3.049,均P ＜0.05),病理分级与癫痫发作组术后痫性再发有关(x2=4.774,P＜0.05),而与无癫痫发作组术后痫性再发无关(x2 =0.060,P ＞0.05).术前癫痫史与术后痫性再发有关(x2=4.672,P＜0.05).结论 瘤周水肿带＞2 cm、肿瘤低病理级别是导致胶质瘤患者癫痫发作以及术后痫性再发的危险因素,积极处理相关因素,有望降低癫痫发作,尤其对伴有癫痫发作的胶质瘤患者,应格外关注.     

Grading and operative indication for hypertensive cerebellar hemorrhage

Fifty six patients with hypertensive cerebellar hemorrhage diagnosed by CT scan were hospitalized from November 1976 up to June 1984. The 35 male and 21 female patients ranged in age from 24 to 84 years, and 39 of them were operated on. The important factors related to prognosis of cerebellar hemorrhage were level of consciousness, size of hematoma on CT scan, and massive ventricular hemorrhage resulting in obstruction of the ventricular system. We classified the patient with cerebellar hemorrhage into 5 grades, according to the severity of these factors. Grade I indicates cerebellar signs without disturbance of consciousness and size of hematoma less than 25 mm measured by CT scan. Grade II indicates disturbance of consciousness (stupor), or progressive neurological deficits, and size of hematoma less than 50 mm without acute hydrocephalus. Grade III reveals disturbance of consciousness (stupor-semicoma), and size of hematoma less than 50 mm with acute hydrocephalus. Grade IV reveals severe disturbance of consciousness (semicoma), and size of hematoma less than 50 mm with massive ventricular hemorrhage. Grade V exhibits deep coma, and more than 50 mm diameter of hematoma. The prognosis of all of 9 patients in Grade I was good, Eleven out of 13 patients (85%) in Grade II and all of 9 patients in Grade III were alive. Fourteen out of 19 patients (74%) in Grade IV and all of 6 patients in Grade V expired in spite of operation. The patients of Grade I should be treated by conservative therapy. The patients of Grade II, Grade III, and Grade IV should be managed surgically. Surgical treatment for Grade V is not advisable.     

Primary intracerebral hemorrhage in Izumo City, Japan: incidence rates and outcome in relation to the site of hemorrhage

OBJECTIVE: The aim of this community-based study was to investigate the incidence rates and outcome of primary intracerebral hemorrhage (ICH) in relation to the site of hemorrhage. METHODS: The subjects were 350 patients with primary first-ever ICH who were treated during the 8-year period 1991 to 1998 in Izumo City, Japan. RESULTS: The crude and age- and sex-adjusted incidence rates for all types of ICH were 52 and 47 per 100,000 population, respectively, for all ages. The most common site of ICH was the putamen (120 patients, 34%), followed by the thalamus (115, 33%), lobar areas (53, 15%), brainstem (30, 9%), cerebellum (25, 7%), and caudate nucleus (7, 2%). The crude and age- and sex-adjusted annual incidence rates per 100,000 population were 18 and 16 for putaminal, 17 and 15 for thalamic, 8 and 7 for lobar, 4 and 3 for cerebellar, 4 and 4 for brainstem, and 1 and 1 for caudate hemorrhages, respectively. The Glasgow Coma Scale scores on admission were best in patients with cerebellar hemorrhage and worst in those with brainstem hemorrhage. Surgery was performed for 34% of putaminal, 9% of thalamic, 14% of caudate, 21% of lobar, and 32% of cerebellar hemorrhages but not for brainstem hemorrhages. The 30-day case fatality rate was 11% for putaminal, 9% for thalamic, 14% for caudate, 11% for lobar, 0% for cerebellar, and 53% for brainstem hemorrhages. When patients with ICH were analyzed as a whole, the overall survival rates at 30 days, 3 months, and 3 years were 87, 83, and 73%, respectively. Both the short-term and long-term outcomes after ICH were directly related to the site of hemorrhage and the severity of bleeding, which was assessed by the hematoma volume and Glasgow Coma Scale score. Overall, 190 (54%) of 350 patients had a favorable outcome, and 55 (16%) had died at discharge. CONCLUSION: Marked differences were observed in the incidence rates and outcome of primary ICH in relation to the site of hemorrhage. The differences in outcome were primarily a result of differences in the severity of bleeding for each ICH subtype.     

Emergency craniotomy for intraparenchymal massive hematoma after embolization of supratentorial arteriovenous malformations

OBJECTIVE: We sought to evaluate the efficacy of emergency craniotomy for patients with massive hematoma secondary to endovascular embolization of supratentorial arteriovenous malformations (AVMs) and to investigate relevant factors affecting outcome. METHODS: Within the past 15 years, 605 patients with intracranial AVMs have undergone 1066 endovascular embolizations at our institution. Of these, 24 patients experienced intracranial hemorrhage during or after the procedure. Fourteen patients were demonstrated to have massive intraparenchymal hematomas and deteriorated to a comatose state (Glasgow Come Scale score < or =6). Twelve patients underwent craniotomy within 170 minutes of being diagnosed with intraparenchymal hemorrhage. The surgical procedures performed were hematoma evacuation with total (6 patients) or partial (2 patients) resection of the AVM or hematoma evacuation only (4 patients). The clinical records of these 12 patients were analyzed retrospectively. RESULTS: Nine patients recovered to a favorable condition (good recovery, four patients; moderately disabled, five patients), one patient remained in a persistent vegetative state, and two patients died. The interval between hemorrhage and emergency craniotomy was significantly shorter in patients with favorable outcomes than in those with poor clinical outcomes. Advanced age and a larger volume of intraoperative blood loss were the factors relevant to poor outcome. Temporal lobe location of the AVM and incomplete embolization tended to correlate to poor clinical outcome, but this correlation was not statistically significant. The sizes of the AVM and the hematoma did not correlate to patient outcome. There was no difference in outcomes with regard to the surgical procedure performed. CONCLUSION: In patients with massive postembolization hematomas, emergency craniotomy should be performed as soon as possible to achieve a favorable outcome. Cooperation among interventional neuroradiologists, intensive care physicians, and neurosurgeons is essential to manage AVM patients with critical postembolization hemorrhage. There is no need to persist in performing simultaneous total resection of the AVM at the emergency craniotomy.     

Clinical factors of recurrent chronic subdural hematoma

The clinical, radiological, and operative factors of recurrent chronic subdural hematoma (CSDH) were retrospectively analyzed in 116 patients with CSDH in 134 hemispheres, treated by one burr hole surgery. The correlation of recurrence was evaluated with personal and clinical factors such as age, sex, history of head injury, and interval from onset of initial symptoms to hospitalization; laboratory findings such as bleeding tendency and liver function; computed tomography (CT) findings such as hematoma density and brain atrophy; and operative findings such as additional procedures and postoperative residual air. The recurrence group (RG) included 10 hemispheres (7.5%) in 10 patients (8.6%). The interval from onset of symptoms to hospitalization was significantly shorter in the RG than in the nonrecurrence group (NRG). Headache was more frequently seen in the RG than in the NRG. Density of hematoma on CT was classified into five types: Low, iso, and high density, niveau, and mixed, and the incidence of recurrence was 0%, 2.3%, 17.2%, 12.5%, and 6.5%, respectively. Larger amounts of residual air in the postoperative hematoma cavity were associated with recurrence of CSDH. CSDH that progresses rapidly in the acute stage and appears as high density on preoperative CT is associated with a high incidence of recurrence. Intraoperative air invasion to the hematoma cavity should be avoided to prevent recurrence.     

急性外伤性颅内血肿开颅血肿清除术后迟发血肿相关因素的Logistic回归分析

目的研究急性外伤性颅内血肿开颅血肿清除术后迟发血肿的相关因素。方法收集记录271例急性外伤性颅内血肿开颅手术治疗患者的临床资料．对相关因素进行二分类单因素及多因素Logistic回归分析。结果52例患者术后迟发血肿。单因素回归分析得到持续昏迷、Babinski征阳性、颅骨骨折等12个变量有统计学意义（P〈0．05）．多因素回归分析得到血浆凝血酶时间（P=0．027,OR=1．154）、Babinski征阳性（P=0．000,OR=4．107）、颅骨骨折（P=0．000,OR=4．980）为术后迟发血肿的危险因素,手术时机（P=0．016,OR=0．91）为保护因素。结论对入院时Babinski征阳性、血浆凝血酶时间明显延长、合并颅骨骨折且早期急诊手术治疗的重型颅脑损伤患者在术后早期需警惕迟发血肺的发生。     

Intrapleural instillation of quinacrine for treatment of recurrent spontaneous pneumothorax.

We used intrapleural instillation of quinacrine hydrochloride in 20 patients (Group A) with recurrent spontaneous pneumothorax (one bilateral) and compared their clinical course with 19 patients who underwent thoracotomy and scarification or pleurectomy (Group B) and 63 patients treated by tube thoracostomy alone (Group C). In Group A, there was one complication of treatment, a pneumothorax immediately following tube removal, which necessitated repeat tube thoracostomy, and there was one late ipsilateral recurrence 2 years after treatment. These 20 patients with 21 recurrent spontaneous pneumothoraces treated with intrapleurally administered quinacrine have been followed for from 6 months to more than 4 years with only one late recurrence on the treated side. Eight patients in Group B had postoperative complications: 2 patients who had had pleurectomy required reoperation for postoperative bleeding; lobar pneumonia developed in 3; 1 had lack of total expansion of the lung; an intrathoracic hematoma developed in 1; and an ipsilateral pneumothorax necessitating tube thoracostomy developed in 1. In Group C, the rate of recurrence of pneumothorax was 23% during the first year following treatment. Intrapleural instillation of quinacrine is a simple, low-risk, reliable, and effective treatment for recurrent spontaneous pneumothorax, and is equally as effective as thoracotomy and scarification.