Spontaneous intracerebral hematomas: study of 121 cases

Results are reported on the study of 121 patients committed by spontaneous intracerebral haematomas (HIE): mean age 53.4 years, 62.8% males, mean admission time of 36 hours (3 hours to 12 days) from onset; 63.5% were graded over 7 in the Glasgow scale and 81.9% were graded 3 or over in the Boterell scale. The HIE location was 45.5% in the basal ganglia, multilobar in 14.7%, lobar in 22.8%, brain stem in 4%, and cerebellum in 2%. The mean diameter was 46.6 mm (16-93) and mean area was 1422.9 mm2 (60-4818). CSF in 67 cases showed mean opening pressure of 234 mmH20 and mean protein content of 416.9 mg/dl. Treatment was conservative in 107 cases and surgical in 14; 55.8% cases survived. The majority of patients who died were graded 3 in the Boterell scale and below 9 in the Glasgow scale. It was found a statistical correlation between death and: low Glasgow and high Boterell scales grading, motor ocular nerve palsy, motor deficit, decerebration signs, bronchopneumonia, large diameter and area of hematomas. No statistical correlation was found regarding survival and treatment with dexamethasone, antifibrinolytics, anticonvulsants, antihypertensive drugs and diuretics. Use of mannitol, fall in the systolic blood pressure and surgical therapy increased the mortality rate. From 14 patients who underwent surgical drainage, 11 died. The main complication who lead to death was bronchopneumonia. A discussion is made on HIE pathogenesis, localization, present day incidence, clinical findings, death causes, size of hematomas and type of treatment used.     

Spontaneous intracerebral haemorrhage following evacuation of chronic subdural hematomas.

Spontaneous intracerebral haematoma (ICH) is an extremely unusual complication following the evacuation of a chronic subdural haematoma (CSDH). Good outcome is expected after the drainage of the CSDH and neurological deterioration is a cause for serious concern. Authors report three cases of spontaneous ICH away from the site of surgery following evacuation of a CSDH with a review of literature. Changes in cortical blood flow following decompression of a long standing CSDH may be responsible for the ICH.     

Occult infarct with acute hemorrhagic stroke in juvenile diabetic ketoacidosis

Diabetes ketoacidosis (DKA) is one of the common complications of type I insulin-dependent diabetes mellitus. Neurological deterioration during an episode of DKA is usually assumed to be caused by cerebral edema and cerebral vascular accidents. However, hemorrhagic stroke is a very rare complication of juvenile DKA. We describe a girl who had newly diagnosed insulin-dependent diabetes mellitus with juvenile DKA developed intracerebral hemorrhage.     

Indication for surgery in spontaneous intracerebral hematomas

Summary Indication for surgical treatment of spontaneous supratentorial intracerebral hemorrhage is discussed on the basis of 68 consecutively observed cases.The course of the symptoms is as important as the condition itself at the time of operation and location of the hematoma. These factors are considered together to form vital and relative indications for surgery which have different significance in the groups with vascular and tumour course (Table 4). This grouping indirectly also signifies the location of the hematoma. Some patients are already excluded from such an evaluation on a clinical basis (Table 3).The results will depend not only on the surgical treatment, but also on the selection of groups suitable for such treatment.     

Spontaneous spinal extradural hematomas.

We review three patients who presented with acute spontaneous spinal extradural hematomas (SSEH). We discuss the presentation, imaging and management strategies. All three patients were adult women with thoracic SSEH. All had motor weakness prior to surgery. One patient recovered completely, one partially recovered and one did not recover. SSEH, although rare, should be considered in cases of acute onset paraparesis. The diagnostic modality of choice is magnetic resonance imaging. Favourable outcome is related to aetiology, interval between the ictus and presentation, and the severity of the neurological deficits. Emergent surgical drainage is the treatment of choice.     

Spontaneous intracerebral hemorrhage

To determine the prognostic value of etiology and localization in spontaneous intracerebral hemorrhage, 896 patients with spontaneous intracerebral hemorrhage, as proven by CT, operation or autopsy, were retrospectively studied using univariate data analysis. Etiologies were hypertension in 63.5%, cerebrovascular malformations in 8.5% and abnormal hemostasis in 15% of the patients. In 23% no etiology was determined. Main localizations were cerebral lobes in 49.2%, basal ganglia in 34.4%, brain stem in 6.9%, cerebellum in 6.7% and primary intraventricular in 2.3% of the patients. Ventricular extension was present in 47.0%. A higher case fatality correlated with: 1) ventricular extension ( P <0.00001), 2) increasing age ( P =0.00005), 3) surgical treatment ( P =0.00010), 4) localization in basal ganglia ( P =0.0108) and 5) hypertension as only etiology ( P =0.01471). A lower case fatality was found in patients with cerebrovascular malformations ( P =0.00006) and when the hemorrhage was localized to the cerebral lobes ( P =0.0050). We conclude that etiology and localization are of prognostic value in spontaneous intracerebral hemorrhage.     

Spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (sICH) is defined as bleeding within the brain parenchyma, and occurs twice as commonly as subarachnoid hemorrhage, but is equally as deadly. Risk factors for sICH include hypertension, advanced age, leukoaraiosis, prior ICH, renal failure, use of anticoagulant drugs, and cerebral amyloid angiopathy. When a patient is clinically suspected of having sICH, head computed tomography scan is the standard diagnostic tool. However, newer magnetic resonance neuroimaging techniques may aid in determining the underlying pathology and aid in prognosis. Supportive care and blood pressure management are important in the care of patients with sICH. Ongoing research is aimed at determining a safe blood pressure goal that may also prevent expansion of hemorrhage. Hemostatic medications and neuroprotectants have thus far not shown clinical improvement. Although several neurosurgical trials have failed to demonstrate benefit for surgical evacuation of sICH, multiple research trials are ongoing investigating acute blood pressure control, deep or basal ganglionic hemorrhage evacuation via minimally invasive approach (MISTIE; http://mistietrial.com/default.aspx), lobar ICH evacuation (STICH; II http://research.ncl.ac.uk/stich/), and intraventricular thrombolysis with tissue plasminogen activator (tPA) (CLEAR III; http://biosgroup-johnshopkinsmedicine.health.officelive.com/default.aspx).     

CT导引下立体定向脑血肿抽吸术

目的评价CT导引下立体定向脑血肿抽吸术的临床应用价值。方法选择1989年10月～2001年11月入院治疗的脑血肿患者1020例,应用CJF型和Fischer2D型立体定向仪于CT导引下施行脑血肿抽吸治疗。根据CT扫描图像直接测算出脑血肿靶点的X,Y,Z轴坐标,标出靶点位置、抽吸针的行径和进针深度,确保抽吸针到达预定的靶点。1020例患者中基底节区血肿618例、丘脑血肿160例、脑叶血肿182例、小脑血肿6例、脑干血肿40例和脑室出血14例。结果686例患者血肿抽吸量>80%,248例为50%～80%,72例<50%,14例因血肿未液化难以抽出积血。手术后再次出血是主要并发症,发生率为1.17%。1020例中存活835例(81.9%),死亡185例(18.1%)。手术后1个月和3个月进行随访,评估患者预后。根据日常生活能力(activitiesofdailyliving,ADL)评价标准,在随访的819例中1～2级者450例(54.9%),3级者196例(23.9%),4级者131例(16.0%),5级者42例(5.1%)。结论CT导引下立体定向脑血肿抽吸术是一种创伤小、安全、精确和简便的治疗方法。     

Endoscopic treatment of the spontaneous intracerebral hematomas

BACKGROUND AND PURPOSE: Surgical evacuation of spontaneous intracerebral hematomas (ICH) performed in a traditional way usually increases primary brain tissue damage due to the hemorrhage. On the other hand, symptoms of the intracerebral pressure and secondary brain tissue destruction close to the hematoma are the basis for making a decision about surgical treatment. In order to limit surgical trauma we started research to evaluate the usefulness of endoscopic surgery in the treatment of ICH. MATERIAL AND METHODS: Twenty three cases were included in the study. Patients with consciousness disorders and/or focal neurological deficit and different systemic diseases were qualified for endoscopic evacuation. The diagnosis of hematoma was based on computed tomography (CT). ICHs were lobar and in certain cases they extended to the basal ganglia. All patients were operated on within one week from the onset of symptoms. Neuroendoscope was introduced to the hematoma cavity through the burr hole and the puncture of the cerebral surface over the hematoma. The hematoma was evacuated by fractionated rinsing. Bigger clots were fragmentized but those which were adjacent to the cavity wall were left. Postoperative assessment of the hematoma evacuation was based on CT performed immediately and in the second week after surgery. RESULTS: Total evacuation of the ICH was achieved in 6 patients, and its volume was reduced in 17 cases. Symptoms of brain edema resolved in all patients. A significant trend to reduce focal neurological deficits was observed: 16 patients improved and 3 remained unchanged. Four patients died. CONCLUSIONS: Endoscopic surgery allows a complete hematoma evacuation or reduction of its volume, reduces symptoms of brain edema and accelerates the improvement of focal neurological deficits.     

Brachial plexopathy in diabetic ketoacidosis

We report the clinical and electrodiagnostic findings of a 39-year-old patient who presented with severe, bilateral and asymmetrical, axon-loss brachial plexopathies occurring in the midst of diabetic ketoacidosis. This patient's unusual presentation is not consistent with the rare diabetic polyradiculopathy of the upper extremities usually occurring in association with diabetic amyotrophy.