Burr Hole Drainage : Could Be Another Treatment Option for Cerebrospinal Fluid Leakage after Unidentified Dural Tear during Spinal Surgery?

Authors report a rare case of acute intracranial subdural and intraventricular hemorrhage that were caused by intracranial hypotension resulted from cerebrospinal fluid leakage through an unidentified dural tear site during spinal surgery. The initial brain computed tomography image showed acute hemorrhages combined with preexisting asymptomatic chronic subdural hemorrhage. One burr hole was made over the right parietal skull to drain intracranial hemorrhages and subsequent drainage of cerebrospinal fluid induced by closure of the durotomy site. Among various methods to treat cerebrospinal fluid leakage through unidentified dural injury site, primary repair and spinal subarachnoid drainage are well known treatment options. The brain imaging study to diagnose intracranial hemorrhage should be taken before selecting the treatment method, especially for spinal subarachnoid drainage. Similar mechanism to its spinal counterpart, cranial cerebrospinal fluid drainage has not been mentioned in previous article and could be another treatment option to seal off an unidentified dural tear in particular case of drainage of intracranial hemorrhage is needed.     

出血性卒中的脑血流自动调节研究进展

脑血流自动调节 （cerebral autoregulation, CA） 是人体在一定血压或脑灌注压波动范围内维持脑血流量 （cerebral blood flow） 相对稳定的能力, 可避免脑组织发生高灌注或低灌注。 CA在出血性卒中中存在不同程度受损, 且与临床因素及预后密切相关。 对出血性卒中患者行CA监测不仅可评估临床预后, 还可为动脉血压及脑灌注压的管理提供参考信息。 本文主要就脑出血 （intracerebral hemorrhage, ICH） 和蛛网膜下腔出血 （subarachnoid hemorrhage, SAH） 的CA相关进展做一综述, 旨在探讨CA在上述疾病中的改变及其临床应用价值。     

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.     

Arterial spasm following perimesencephalic nonaneurysmal subarachnoid hemorrhage in a pediatric patient

Perimesencephalic nonaneurysmal hemorrhage is a benign form of subarachnoid hemorrhages. This entity is well recognized as a distinct type of subarachnoid hemorrhage in adults. However, perimesencephalic nonaneurysmal subarachnoid hemorrhage in pediatric patients is not well recognized. Angiographic changes such as vasospasm are uncommon in patients, especially in pediatric patients suffering from this type of hemorrhage. This case study reports a 12-year-old male who suffered from perimesencephalic nonaneurysmal subarachnoid hemorrhage. Cerebral carotid angiography performed on the tenth day of the posthemorrhagic period revealed severe vasospasm affecting the basilar artery. The patient, treated symptomatically, was discharged after improvement. One year later, magnetic resonance angiography revealed completely normal features.     

Cerebrovascular Complications of Methamphetamine Abuse

Objective  Methamphetamine is a stimulant widely abused in the United States. The objective of this study was to demonstrate an association of methamphetamine use and ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage and to further reveal the underlying vascular pathology using neuroimaging and pathology. Methods  This was a retrospective study based on medical chart review of admissions to the neurovascular service of a tertiary care medical center from January 2003 to July 2007. Cases included patients who used methamphetamine as documented by history or urine toxicology screening. Results  From 1,574 records, 30 cases were identified. The mean age of patients was 43 years and the discharge diagnoses included ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. All subarachnoid hemorrhages were aneurysmal with the majority of the aneurysms located in the anterior circulation. The majority of strokes were located in the anterior circulation. In many cases, radiologic imaging confirmed arterial stenoses in the vascular distribution of the stroke. One patient who presented with ischemic stroke had severe atherosclerosis of bilateral common, internal, and external carotid arteries. On pathology, there was no evidence of inflammation or necrosis to suggest vasculitis as a possible etiology. Conclusions  Methamphetamine use is associated with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, especially among young patients. We showed no evidence that the ischemic stroke associated with methamphetamine use is due to an inflammatory etiology but may be due to a process of accelerated atherosclerosis.     

105例脑肿瘤卒中的临床诊治和病理基础

目的 总结脑肿瘤卒中的临床、病理特点，提高临床诊治水平。方法 对手术及病理证实的脑肿瘤卒中105例的临床资料进行回顾性分析。结果 垂体腺瘤49例，星形细胞瘤18例，转移瘤11例，少突胶质细胞瘤7例，多形性胶质母细胞瘤5例，髓母细胞瘤4例，脑膜瘤2例，桥小脑角神经鞘瘤2例，生殖细胞瘤2例，黑色素瘤2例，恶性淋巴瘤1例，室管膜瘤1例，脉络丛乳头状瘤1例。肿瘤卒中表现为颅内血肿、蛛网膜下腔出血或硬膜下血肿。结论 肿瘤的血管性变化是脑肿瘤卒中的摹础，CT扫描对于早期诊断和治疗有重要意义，脑肿瘤卒中易误诊，需与其他出血性疾病加以鉴别。     

The role of L-arginine metabolism in neurocritical care patients

Nitric oxide is an important mediator of vascular autoregulation and is involved in pathophysiological changes after acute neurological disorders.Nitric oxide is generated by nitric oxide synthases from the amino acid L-arginine.L-arginine can also serve as a substrate for arginases or lead to the generation of dimethylarginines,asymmetric dimethylarginine,and symmetric dimethylarginine,by methylation.Asymmetric dimethylarginine is an endogenous inhibitor of nitric oxide synthase and can lead to endothelial dysfunction.This review discusses the role of L-arginine metabolism in patients suffering from acute and critical neurological disorders often requiring neuro-intensive care treatment.Conditions addressed in this review include intracerebral hemorrhage,aneurysmal subarachnoid hemorrhage,and traumatic brain injury.Recent therapeutic advances in the field are described including current randomized controlled trials for traumatic brain injuries and hemorrhagic stroke.     

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。     

Subarachnoid Hemorrhage Presenting with Seizure due to Cerebrospinal Fluid Leakage after Spinal Surgery

Cerebrospinal fluid leakage may commonly occur during spinal surgeries and it may cause dural tears. These tears may result in hemorrhage in the entire compartments of the brain. Most common site of such hemorrhages are the veins in the cerebellar region. We report a case of hemorrhage, mimicking aneurysmal subarachnoid hemorrhage due to a cerebrospinal fluid leakage following lumbar spinal surgery and discuss the possible mechanisms of action.     

Anaplastic astrocytoma masquerading as hemorrhagic stroke

Although primary and metastatic brain tumors can cause intracranial hemorrhage, thalamic hemorrhage as the first presentation of an anaplastic astrocytoma has not been reported. We report a 47-year-old man who first presented with hypertensive hemorrhagic stroke. He improved with aggressive blood pressure control and recovered with minimal residual deficit within 10 days. This led to the initial misdiagnosis of uncontrolled hypertension as the cause of the stroke. He deteriorated rapidly 4 months later. A biopsy revealed an anaplastic astrocytoma. Misdiagnosis of tumor as stroke can occur in patients with vascular risk factors who do not have a previous history of neoplasia. Our case report is to heighten the awareness of the incidence of tumor apoplexy masquerading as stroke.     

Cerebrovascular complications in cancer patients

Coagulation disorders are common in cancer patients. In patients with solid tumors, a low-grade activated coagulation can result in systemic and cerebral arterial or venous thrombosis. Cancer treatments may also contribute to this coagulopathy, which usually, but not exclusively, occurs in the setting of advanced malignant disease. There may be TIAs or cerebral infarctions. Because of the widespread distribution of cerebral thromboses, there may be a superimposed encephalopathy; sometimes this is the only sign. Concurrent systemic thrombosis is present in many patients and is a useful clue to the diagnosis. In cerebral venous occlusion, the initial symptom is usually a headache. Except for cerebral intravascular coagulation that is unassociated with NBTE, neuriomaging studies usually demonstrate one or more parenchymal infarctions. MRI or MRV may demonstrate venous thrombosis. The laboratory evidence of coagulopathy is difficult to distinguish from the asymptomatic coagulopathy that often accompanies advanced cancer, and the test results must be interpreted cautiously. NBTE can be diagnosed by transesophageal echocardiography. There is no established treatment for the thrombotic coagulopathy associated with cancer, but anticoagulation should be considered. In leukemia and lymphoma, the coagulopathy is typically acute DIC that can lead to systemic and brain hemorrhages. It is especially common in acute myelogenous leukemias. The clinical signs of cerebral hemorrhage are fulminant and may be fatal. The bleeding usually occurs in the brain or subdural compartment, and rarely in the subarachnoid space. The diagnosis can be suspected by the clinical setting and by systemic thrombosis or hemorrhage. It can be established by examination of the peripheral smear, the platelet count, and tests of coagulation function. Therapy of acute DIC is controversial and should be individualized for the clinical setting. Cerebrovascular disorders can complicate metastatic or primary tumor in the brain, skull, dura, or leptomeninges. The clinical signs of infarction are indistinguishable from other causes of stroke, except that tumor-related venous occlusion will usually first produce signs of increased intracranial pressure. The diagnosis of tumor-related infarction can usually be established by neuroimaging studies that show infarction and may show extracerebral sites of tumor. CSF examination is useful in diagnosing leptomeningeal metastasis. A search for lung or cardiac tumor should be performed when embolic tumor infarction is suspected. Primary or metastatic tumors in the brain or dura may hemorrhage, producing the initial clinical signs of the brain tumor or a change in chronic signs induced by the tumor. There are helpful clues to a neoplastic hemorrhage on brain CT or MRI scans. The brain hemorrhage may require evacuation and the underlying tumor will usually require additional antineoplastic treatment. Hyperleukocytosis (extreme elevation of the cell count) in acute myelogenous leukemia is a less common cause of brain hemorrhage in recent years because of improved methods to lower the cell count. Cerebral arterial or venous thrombosis is sometimes the result of cancer therapy. The attribution of thrombosis to chemotherapy in many published cases is only speculative, because carefully conducted prospective studies that include investigation for other thrombotic causes are not available. The best-known associations with thrombosis are L-asparaginase, which is typically used in the induction therapy of acute lymphocytic leukemia, and combination hormonal therapy and chemotherapy for breast cancer. Radiation to the head and neck, typically administered for head and neck epithelial cancers or lymphoma, may result in delayed carotid atherosclerosis. The distribution of stenosis or occlusion is within the radiation portal and is typically more extensive than is atherosclerosis that develops in the absence of radiation. Small clinical series suggest that surgical treatment is equally effective as in nonirradiated carotid atherosclerosis. In children, the cerebral vessels can be affected by brain radiation resulting in stenosis or occlusion. Brain hemorrhages can result from chemotherapy effects on the hemostatic system or a microangiopathic anemia. Hemorrhages from radiation-induced vascular abnormalities are rare. Opportunistic infections, especially fungal infections, can complicate cancer or its treatment. Septic cerebral emboli may result in focal cerebral signs, seizures, or encephalopathy. Sometimes there is an associated hemorrhagic vasculitis or cerebritis. Rarely, mycotic aneurysms may bleed. A high index of suspicion is needed to diagnose fungal infection because of the difficulty in culturing the organism from the blood or CSF. A clinician can usually establish the cause of stroke in the cancer patient by performing a careful review of the clinical setting--including the type and extent of cancer and the type of antineoplastic therapy--in which the stroke occurred. Systemic thrombosis, embolism, or hemorrhage can be a clue to the cause, and appropriate neuroimaging and coagulation studies to aid in the diagnosis are available. Therapy may ameliorate symptoms or prevent further episodes. The identification of one of these unusual stroke syndromes that leads to the diagnosis of an occult and treatable cancer can be particularly rewarding.     

Childhood cerebrovascular diseases not associated with vascular malformations

Of 76 patients in the pediatric age group suffering from cerebrovascular diseases treated in the years 1970–1983, 26 patients (34%) did not harbor intracranial vascular malformations (aneurysms or arterovenous malformations). Two groups of patients were identified: (a) those suffering from a spontaneous intracranial hemorrhage (16 cases); (b) those suffering from an ischemic stroke (10 cases). Of those with spontaneous intracranial hemorrhage, 10 patients underwent surgery and evacuation of the hematoma. In 2 cases the hematoma was located in the posterior fossa, in 1 case in the upper brain stem, and in 3 cases in the basal ganglia; in the remainder the hematoma was supratentorial. Two patients died soon after the hemorrhage. Eight of the surviving patients completely recovered. In those with ischemic stroke, none suffered from congenital heart disease, a well-known predisposing factor. In this second group 1 patient died and 9 survived. Only one patient showed complete recovery. The data indicate that a hemorrhagic stroke is more common than an ischemic stroke in a child presenting with acute onset of hemiparesis and/or loss of conciousness: thus the value of CT scan as the first diagnostic procedure is clear, owing to the possibility of emergency surgical treatment. In children with ischemic strokes, a complete laboratory/clinical evaluation should be undertaken in order to exclude preexisting heart disease, coagulation disorders or lipoprotein abnormalities, and less common systemic diseases.     

Frequent Hemorrhagic Lesions in Cerebral Toxoplasmosis in AIDS Patients

Cerebral toxoplasmosis is a frequent complication in immunosuppressed patients such as AIDS (acquired immunodeficiency syndrome). Frequently, lesions are located deep in the brain which are inaccessible for biopsy making rapid diagnosis dependent on accurate interpretation of neuroimaging findings. The commonest cranial CT findings reported in toxoplasmosis are ring enhancing hypodense lesions in basal ganglia or cortical gray matter. Hemorrhage has only rarely been described and is usually seen following antitoxoplasma treatment. We reviewed the records of 11 AIDS patients with cerebral toxoplasmosis and found multiple hemorrhagic cerebral, cerebellar, or brain stem lesions in 7 of 11 patients. Six patients had hemorrhage at the time of initial clinical presentation and one developed hemorrhage following 2 weeks of antitoxoplasma treatment. We conclude that hemorrhagic lesions are frequently found on cranial MRI scans in cerebral toxoplasmosis. AIDS patients presenting with hemorrhagic cerebral lesions should be considered for a trial of presumptive antitoxoplasma treatment.     

Stroke in Saudi Arabian young adults: a study of 120 cases

One hundred and twenty cases of stroke occurring in Saudi Arabian subjects aged 15 to 45 years are reviewed. These constituted 12.7% of a group of 946 stroke patients. Males outnumbered females (76/44). The frequency of intracranial hemorrhage, including subarachnoid hemorrhage, was slightly lower than cerebral infarction (41.5 vs 58.5%). The causes of large cerebral infarction were as follows: atherosclerosis 17 (28%), cardiac embolism 12 (19.5%), uncommon and uncertain causes 21 (34.5%). Some unusual causes were encountered such as dissecting arterial aneurysm due to popular healing manoeuvres or to traditional dance, retrograde embolism from a thoracic outlet syndrome or embolism from a fibroelastoma of the mitral valve chorda. Lacunar cerebral infarction was diagnosed in nine cases. Hypertension (25.5%) and arteriovenous malformations (20.5%) were the main causes of cerebral hemorrhage; all subarachnoid hemorrhages except one were due to berry aneurysms. The cause was undetermined in 16% of cerebral infarction and 26% of intracranial hemorrhage. The high frequency of stroke in young Saudi Arabian adults is probably a reflection of the demographic structure of the predominantly young Saudi society. The observed causes were relatively similar to those in industrial societies. Contrary to other developing countries infectious disease no longer seems to be an important cause of stroke. Drug abuse, which is becoming an important cause in Western societies, was encountered in only two of our cases.     

The Saudi Stroke Data Bank Analysis of the first 1000 cases

OBJECTIVES: To determine the types of stroke, their risk factors and their most likely causes in Saudi patients. METHODS: Data on stroke cases admitted to 2 major hospitals in Saudi Arabia since 1982 were collected retrospectively up to 1991 then prospectively since then. By January 1995, the number of cases with first-ever-stroke stored in our Saudi Stroke Data Bank reached 1280. This article describes the findings in the first 1000 Saudi patients investigated by brain computed tomography. RESULTS: Males (68%) outnumbered females. There was no significant difference between the retrospective cases and the prospective ones in relation to the types of stroke or the risk factors. Ischemic strokes accounted for 76% of the cases and one third of them were lacunar infarcts. Most of the hemorrhagic strokes were intracerebral hemorrhages (ICHs) and only 2% of all strokes were subarachnoid hemorrhages (SAHs). Hypertension (52%), diabetes mellitus (41%) and cardiac disorders were common risk factors. The commonest causes of cerebral infarcts were atherosclerosis 36%, hypertensive and/or diabetic arteriolopathy 24% and cardiac embolisms 19%. Hypertensive arteriolopathy accounted for two-thirds of the cerebral hemorrhages. Strokes related to small artery disease, i.e. lacunar infarcts and ICHs accounted for 47% of the cases. CONCLUSION: The overall distribution of stroke types in Saudis is not very different from that reported in western studies, except for the low frequency of SAH. However, the important role of small artery disease in stroke pathogenesis and the high number of diabetic patients are quite distinctive.     

中风后癫痫的临床研究

本文报告３６例中风后癫痫发作的临床和ＣＴ资料。通过回顾性病历复习和随访发现，中风后癫痫的发生率占同期住院中风患者的５．２６％，以蛛网膜下腔出血和脑栓塞发生癫痫比率最高，分别为１５％和１２．５％。癫痫发作与ＣＴ所见病灶分布密切相关，皮质病灶较皮质下病灶更易发生病病。癫痫发作可发生于中风后任何时期，但早期癫痫以出血性中风多见，而迟发性癫痫则更多见于脑梗塞患者。     

Clinico-epidemiologic study of stroke in Akita, Japan

An analysis was performed of 2,168 consecutive stroke patients who were examined by computed tomography and entered into a hospital-based stroke registry in Akita Prefecture, Japan. The occurrence of cerebral hemorrhage, cerebral infarction, and subarachnoid hemorrhage was 30, 55, and 14%, respectively. Age-specific rates of subarachnoid hemorrhage were higher in women than men; other types of stroke showed a preponderance in men. Total strokes increased in the winter; this seasonal difference was confined to cerebral hemorrhage. Putaminal hemorrhages predominated in the younger age groups; thalamic hemorrhage and cerebellar hemorrhage were predominant in the older age groups. The increased accuracy of the diagnosis of stroke subtypes by the use of computed tomography in this study is in contrast to other community-based epidemiologic studies that have relied solely on clinical diagnosis. This increased accuracy is seen to be the reason that new ratios of stroke subtype incidence have been identified.     

病理证实的淀粉样脑血管病26例临床分析

目的 总结26例尸检证实的淀粉样脑血管病的临床资料特点,以提高对本病的认识和诊断水平.方法 回顾性分析我院1983--1999年收治的经尸检证实的26例淀粉样脑血管病患者,总结其既往史、临床表现、实验室检查等临床资料.结果 26例淀粉样脑血管病中男17例,女9例,年龄45 ～78岁,有高血压病史者8例(30.7％),糖尿病病史者6例(23.1％).2例患者(7.6％)正服用抗凝或扰血小板剂,均为多发脑叶出血.26例中脑出血20例,其中单发脑叶出血2例,多灶性脑叶出血8例,壳核出血5例,丘脑及小脑出血各2例,脑干出血1例.蛛网膜下腔出血2例,出血性脑梗死、基底节区梗死、椎基底动脉闭塞及硬膜下血肿各1例.20例淀粉样脑血管病脑出血患者临床表现为头痛、肢体瘫痪、昏迷、抽搐等.结论 淀粉样脑血管病临床上常以脑血管病表现形式起病,伴有或不伴有高血压.脑叶出血是淀粉样脑血管病最常见临床表现,但少数也可见基底节、小脑和脑干出血.淀粉样脑血管病也可表现为脑梗死、蛛网膜下腔出血.抗凝剂(如华法林)及抗血小板药物(如阿司匹林)的应用对淀粉样脑血管病脑出血可能具有一定的促发作用.     

外伤后颅内进展性出血性损伤106例分析

目的探讨颅脑损伤后进展性出血性损伤（PHI）的发生及影响预后的相关因素。方法对2007年颅脑损伤后出现PHI的106例患者的临床资料进行回顾性分析,并与同期无PHI患者进行对照研究。结果颅脑损伤后是否出现PHI与患者的年龄是否超过50岁（P〈0．05）、血浆纤维蛋白原水平是否低于2g／L（P〈0．01）及有无蛛网膜下腔出血（SAH）（P〈0．05）密切相关。PHI患者的预后与年龄是否超过50岁（P〈0．01）、血浆纤维蛋白原水平是否低于2g／L（P〈0．01）、有无SAH（P〈0．01）及入院时的GCS评分（P〈0．01）密切相关。结论PHI最常出现于颅脑伤后12h内,好发于着力点的对冲部位,以额颞部为主,与患者的年龄、血浆纤维蛋白原水平及是否伴有SAH等因素密切相关;其预后与患者的年龄是否超过50岁、入院时GCS评分、血浆纤维蛋白原水平是否低于正常及是否伴有SAH密切相关。     

出血型烟雾病患者72例的损伤模式

目的 探讨成年人出血型烟雾病(moyamoya disease,MMD)病灶分布模式.方法 从南京脑卒中注册系统中提取2004年1月至2010年2月间以出血事件为首发症状的成年人MMD住院患者72例.按出血原发部位的不同将患者分为4组:非丘脑性脑实质出血(脑叶和纹状体出血)、丘脑出血、原发脑室出血和自发蛛网膜下腔出血(subarachnoid hemorrhage,SAH).所有患者均行脑血管造影检查,根据造影结果 ,按改良的Morioka分级标准将出血侧脉络膜前动脉和后交通动脉(anterior choroidal artery and posterior communicating artery,AChA-PComA)分为3级:"正常或轻度扩张"、"极度扩张和延长"及"未显影".分析出血病灶分布模式与AChA-PComA分级的关系.结果 在AChA-PComA正常或轻度扩张阶段,非丘脑性脑实质出血的比例最大(51.6%,16/31;Z=-3.266,P=0.001),且以纹状体出血最为常见(22.6%,7/31);在AChA-PComA极度扩张和延长阶段,脑室出血所占比例最大(58.8%,20/34;Z=-2.696,P=0.008);另外,后循环SAH同侧的AChA-PComA级别较前循环的高(Z=-4.655,P＜0.01);在AChA-PComA近端未显影阶段,后循环动脉瘤破裂相关的SAH是此阶段惟一的出血亚型(9.7%,7/72;x2=42.999,P＜0.01).结论 成年人出血型MMD脑卒中不同亚型与AChA-PComA形态有关,其造影显像特点可预测出血部位.

Abstract：

Objective To study the lesion patterns of hemorrhagic type of moyamoya disease (MMD) in adults. Methods Seventy-two consecutive cases of hemorrhagic type of MMD, confirmed by digital cerebral angiography in Jinling hospital between January 2004 and February 2010, were retrieved from the Nanjing Stroke Registry Program. MMD patients were classified according to the hemorrhagic sites into 4 types: non-thalamic parenchymal, thalamic, primary ventricular and subarachnoid. The ipsilateral anterior choroidal artery and posterior communicating artery (AChA-PComA) were evaluated by the modified Morioka's 3-points grading system: normal or mild to moderate dilation, severe dilation with abnormal extension and non-visualization. The relationship between lesion patterns and the angiographic findings was analyzed. Results In the stage of normal or mild to moderate dilation of AChA-PComA, non-thalamic parenchymal hemorrhage was the more frequent type (51.6%, 16/31 ;Z = -3.266,P =0.001 ), and there was a high incidence of intrastriatal hemorrhage occurred (22.6%, 7/31 ). In the stage of severe dilation with abnormal extension, intraventricular hemorrhage was most common ( 58.8%, 20/34 ;Z = -2.696 ,P =0.008). In addition, posterior circulation subarachnoid hemorrhage (SAH) was associated with a higher grade of AChA-PComA than anterior circulation SAH (Z = -4.655 ,P ＜ 0.01 ). Furthermore, posterior circulation SAH was the only type of SAH in the stage of non-visualization(9.7% ,7/72; x2 =42.999,P ＜0.01 ). Conclusion In adult patients with MMD, different subtypes of hemorrhagic stroke were associated with angiographic changes of AChA-PComA, and the angiographic characteristics may predict the location of hemorrhage.