Hypertrophic olivary degeneration following pontine haemorrhage: hypertensive crisis or cavernous haemangioma bleeding?

The clinical and magnetic resonance (MR) features of hypertrophic olivary degeneration are described, along with a rare but treatable cause of this entity-pontine cavernous haemangioma. Hypertrophic olivary degeneration occurs after focal lesions to the dentato-rubro-olivary pathway, typically following a pontine haemorrhage involving the ipsilateral central tegmental tract, the contralateral superior cerebellar peduncle, or the dentate nucleus. Clinically, there is palatal myoclonus and an uncontrollable tremor, presumably caused by loss of inhibitory control. On MR imaging, hypertrophic olivary degeneration is characterised by a non-enhancing T1 isointense, T2 hyperintense enlargement confined to the olivary nucleus. Typically, haemorrhages following a hypertensive crisis are responsible for hypertrophic olivary degeneration. However, in the three reported cases, imaging findings within the former bleeding cavity suggested a cavernous haemangioma as the source of the haemorrhage.     

Neurological complications of anticoagulants (author's transl)]

During a course of therapy by anticoagulants, 16 intracranial haemorrhages and 10 cerebral infarctions, were observed over a period of seven years. The intracranial haemorrhages include 11 subdural haematomas (four acute, seven chronic) and ive intracerebral haemorrhages, one of which resulted from the rupture of an arterial aneurysm. The anticoagulant therapy lasted in 12 cases for more than two years, and in four cases between twenty-four hours and two months. Monocoumarinics are most often the cause of the haemorrhages. The subdural haematomas are unpredictable and a traumatism was only observed in four cases. Three out of four patients with acute haematomas died, as well as two out of seven patients with chronic haematomas. Three out of four intracerebral haemorrhages occurred after ischemic cerebral accidents. The existence of a cerebral infarction counter-indicates the use of anticoagulants. The cerebral infarctions occurred five times during the anticoagulation therapy, and five times after stopping the treatment (from within a few days to a few weeks). Anticoagulation therapy, apart from infarction, is in general well supported and well supervised during the first weeks. Used for a long time, it may lead to very serious and often fatal complication, and must therefore be weighed against the advantages of the treatment.     

Supratentorial Intraparenchymal Haemorrhages during Spine Surgery

Intracranial haemorrhages are rare but potentially life-threatening complications of spine surgery. Most reported cases involved subdural or cerebellar haemorrhages; supratentorial parenchymal bleeding is very uncommon. We report a 28-year-old woman who underwent resection of a thoracic Ewing''s sarcoma, and developed fatal haemorrhages around her cerebral metastases during surgery. The clinical presentations, possible pathogenesis and potential preventive measures are discussed. Patients with disseminated metastases within the neural axis are at risks of intracranial complications during spine surgery. The presence of intracranial mass lesions should be considered as a relative contraindication to intradural spine surgery.     

Migraine associated bilateral intracerebral haemorrhages.

The authors report a case of bilateral basal ganglionic haemorrhages which occurred during an attack of classical migraine. The patient had a history of migraine associated with aura of neurological deficit for 10 years and a history of arterial hypertension for 20 years, which was treated with propranolol. Intracerebral haemorrhage during an attack of migraine is very rare and up to now the existence of true migraine-induced intracerebral haemorrhage has been controversial. Our case of bilateral occurrence of the haemorrhages supports the theory of the existence of migraine-induced damage of the wall of intraparenchymal vessels during vasoconstriction and focal ischaemia at the beginning of a migraine attack. Subsequent vessel rupture may occur during the following period of increased cerebral blood flow especially with coexisting arterial hypertension. The terminology of the syndrome of migraine associated with intracerebral haemorrhage is reviewed.     

Diagnostic problems in vertebral body hemangioma]

Vertebral haemangioma is a slowly growing benign tumour arising from blood vessels. Haemangioma of the vertebrae is usually asymptomatic. Neurological symptoms occur when haemangioma causes compression of nerve roots or spinal cord. In this paper a case of a 59 year-old woman with, vertebral body L2 haemangioma is reported. The signs and symptoms, modern imaging techniques (CT, MRI), differential diagnosis and treatment were discussed.     

Cases of cavernous hemangioma discovered in patients with post traumatic intracerebral hematoma]

Cavernous haemangioma has various forms. The cases with spontaneous intracerebral haemorrhage are most common, but post-traumatic intracerebral haematoma was not reported. The aim of this report is to present cases of cavernous haemangioma with unusual clinical course. In seven patients with post-traumatic intracerebral haematoma, fragments of histologically confirmed cavernous haemangioma tissue situated in the place of haematoma were found. In one case, delayed intracerebral haematoma twenty four hours after trauma and initial CT-scan was observed. On the initial CT-scan in this patient only traumatic changes in the brain without haematoma or tumour were present. In our cases, cavernous haemangioma was situated most frequently in frontal and temporal region, shown as haematoma usually 24 hours after trauma, mainly in men in age range 30-44 years with disorders of consciousness (GCS 11). As the result of operation, the majority of patients (6 out of 7) were discharged as self-independent. The authors reviewed the literature for cavernous haemangioma. The tumour may be present in any region of the brain including infratentorial region. The lesion is disclosed most frequently in children as spontaneous brain haemorrhage and rarely as seizures or intracranial hypertension. Final diagnosis is based on cerebral angiography or MRI. CT-scans are not typical and before the appearance of haematoma do not suggest the presence of tumour. Surgical removal of haematoma with tumour fragments is the main method of therapy, but radiation is possible in order to diminish the mass. The authors conclude that in each patient with post-traumatic intracerebral haematoma, the presence of cavernous haemangioma is possible.     

Retinal haemorrhage as a complication of gas encephalography and gas myelography. Prospective study using oxgen gas with a discussion of pathogenetic mechanisms.

Seventy patients, submitted to oxygen encephalography and oxygen myelography, were examined by retinal funduscopy to establish the incidence of intraocular haemorrhages, a complication reported to be frequent by other investigators. We did not discover any retinal haemorrhages. Pathogenetic factors influencing intracranial or intraocular venous pressure or both are discussed, particularly the effect due to different technical procedures during the examination, and the type of anaesthesia used.     

Tumoral spinal meningeal hemorrhage during anticoagulant treatment

Tumoral spinal meningeal haemorrhages are exceptional. A case during an anticoagulant treatment is reported. The tumor, an ependymoma of the filum terminale was smaller than usually.     

Spontaneous haematomyelia: a necropsy study.

Spontaneous haematomyelia (intramedullary spinal haematoma), is an uncommon event. Predisposing conditions have been reported including syringomyelia, pregnancy and delivery, angioma, spinal artery aneurysm, and haemophilia, but only rarely has a pathological evaluation been performed. Two such cases studied at necropsy are reported. In one case, the haematoma was restricted to the cervical spinal cord, while in the second case it extended from the medulla into the lowest thoracic cord segments. In both cases the haematomyelia was fatal. In the first case the clinical course was subacute, but in the other the course was more acute. Careful neuropathological examination showed no apparent cause for the haemorrhages.     

Intramedullary cavernous haemangioma.

A 35 years old male presented with episodic weakness of left upper limb followed by gradually progressive neurological deterioration. MRI revealed an intra medullary cervical cord angiomatous lesion. Histopathology revealed it to be cavernous haemangioma. A complete surgical removal of the haemangioma was carried out.     

Retinal haemorrhages in- head trauma resulting from falls: differential diagnosis with non-accidental trauma in patients younger than 2 years of age

INTRODUCTION: Falls are a common chief complaint among children seeking medical attention in emergency departments and are the leading cause of injuries requiring hospitalisation. Falls are also a frequent excuse to conceal cases of maltreatment in small children. Retinal haemorrhages could be a useful marker for their differential diagnosis. OBJECTIVE: This study aims to determine the prevalence and characteristics of retinal haemorrhages in children with head trauma resulting from a vertical fall. MATERIALS AND METHODS: This was a prospective study of children younger than 2 years of age admitted to the hospital with head trauma from a vertical fall. The circumstances of the falls and injuries were analysed. All children were evaluated by an ophthalmologist for retinal haemorrhage. RESULTS: One hundred fifty-four patients were included. Eighty-three percent of the falls were from a height equal to or less than 120 cm. The most common mechanism of injury was fall from a stroller followed by rolling off the bed. Sixteen children had evidence of intracranial injuries. Three patients had retinal haemorrhages (prevalence 1.9%; 95%CI, 0.4-5.6%), all unilateral, in association with severe epidural haematoma with a midline shift. The detection of retinal haemorrhages could be related to the presence of intracranial injury but not with the circumstances of the fall. DISCUSSION AND CONCLUSIONS: Any cranial injury from a vertical fall that produces severe epidural bleeding can also cause retinal haemorrhages, mainly unilateral. The finding of diffuse and bilateral retinal haemorrhages or their presence in the absence of this type of intracranial haemorrhage must continue to point out another cause different from the fall as origin of the traumatism, being necessary to exclude non-accidental trauma.     

Epidural extension of a lumbar vertebral haemangioma.

Vertebral haemangiomas are relatively common, but those extending into the epidural space are rare. A 59-year-old man with severe lower back and right leg pain that did not resolve with conservative treatment was seen in an outpatient clinic. Magnetic resonance imaging of the lumbar spine identified an L3 vertebral corpus lesion with epidural extension. The diagnosis was unclear, so the patient underwent surgery. The pathologic diagnosis was capillary haemangioma, so angiography-guided embolization was performed postoperatively. Vertebral haemangioma must be considered when there is evidence of a vertebral corpus lesion with epidural extension on magnetic resonance imaging.     

Prevalence of stroke in Parkinson's disease: a postmortem study.

The results of previous epidemiological studies of the relationship between Parkinson's disease and stroke have been conflicting; some showing a reduced risk of ischaemic and haemorrhagic stroke during life, and others indicating an increased likelihood of stroke-related death. We compared the frequency of cerebral infarcts and haemorrhages at postmortem in 100 cases of pathologically verified idiopathic Parkinson's disease and 100 age-matched control brains. No significant differences were found in the numbers of infarcts or haemorrhages or stroke-related deaths between the two groups. Our findings do not indicate either a protective effect against stroke, or a greater susceptibility to death from stroke, in the population studied.     

Capillary haemangioma arising from the anterior choroidal artery

Background Capillary haemangioma of the central nervous system is extremely rare. Histologically proven cases developed in the dura mater and choroid plexus, or were typically intracranial extensions of an extra-cranial lesion.Features This report details a case that developed in the anterior choroidal artery of a newborn infant and manifested as a lethal intra-cerebral haemorrhage. Pathological criteria for the diagnosis of vascular malformations should be carefully investigated and the differential diagnoses of the present case are discussed.Prognosis Intracranial haemangioma presents a diagnostic challenge and the treatment of deep lesions remains problematic.     

Out of hospital antithrombotic prophylaxis after total hip replacement: low-molecular-weight heparin,warfarin, aspirin or nothing? A cost-effectiveness analysis

Several studies have suggested that after hip replacement the risk of deep vein thrombosis and subsequent pulmonary embolism (PE) may persist for some weeks. Antithrombotic prophylaxis, however, is generally stopped at hospital discharge. Using a Markov-based decision analysis, we measured the clinical and economical consequences of extending prophylaxis after hospital discharge up to 4 weeks and 6 weeks, using either low-molecular-weight heparin (LMWH), warfarin, or aspirin. In the reference strategy, antithrombotic prophylaxis was stopped at hospital discharge. Outcome measures included the number of PE prevented, major haemorrhages induced, overall costs in Euro (EUR) and specific costs generated by each PE prevented for all strategies. Extending prophylaxis up to 4 weeks after discharge was safe and cost saving for all prophylactic regimens, although LMWH was the most effective strategy. Our results were most sensitive to the rate of haemorrhages, the efficacy of treatment and its costs. Specifically, the number of PEs prevented exceeded that of haemorrhages induced if the efficacy of antithrombotic prophylaxis was > or = 40% (assuming a low rate of haemorrhages of 0.1% per week), and > or = 70% (assuming a high rate of haemorrhages of 0.25% per week). LMWH and warfarin remained cost saving unless their costs were more than doubled compared to that of baseline value. Although less effective than LMWH and warfarin, prophylaxis with aspirin was cost saving in all scenarios tested. Extending prophylaxis up to 6 weeks was also effective (the number of PEs prevented overwhelmed that of major haemorrhages induced), but only for the scenario of a low bleeding risk (0.1%/week). In this strategy, aspirin remained cost saving, while the costs for each PE prevented became high (EUR 10,000 to EUR 20,000) if the costs of LMWH and warfarin increased. After hip replacement, extending antithrombotic prophylaxis up to 4 weeks after hospital discharge is effective and cost saving. Although LMWH is the most effective strategy, warfarin, and to a lesser extent aspirin may be alternate options if ressources are a major concern. Extending prophylaxis up to 6 weeks is more risky in patients at high bleeding risk, and generates additional costs.     

Experimental amyotrophic lateral sclerosis in the guinea-pig

In guinea-pigs a diet which was deficient in ascorbic acid provoked neurogenic atrophy of the muscles, degeneration of the anterior horn motor cells and demyelination of the pyramidal tract. Muscles showed a decrease of cytochrome and cytochrome c oxidase. Subcutaneous haemorrhages were also found, particularly around the knee joints. The haemorrhages and the histopathology of the muscles and spinal cord were prevented by a high dosage of ascorbic acid. In animals with an ascorbic acid deficiency, histopathology of muscles and spinal cord were also prevented by L-cysteine, L-methionine and L-hydroxyproline. Subcutaneous haemorrhages were not prevented by these supplements.     

Solitary spinal epidural cavernous haemangioma presenting as acute epidural haematoma

This report describes a case of solitary spinal epidural cavernous haemangioma presenting as an acute epiduralhaematoma. The patient is a 50 year old diabetic female with right brachalgia and hemiparesis. Magnetic resonance imaging (MRI) demonstrated the presence of a cervical spinal epidural haematoma. The patient underwent laminectomy and total removal of the haematoma and the accompanying vascular tissue. The diagnosis of cavernous haernangioma was proven by histological examination. Because the source of bleeding in most cases of spontaneous spinal epidural haematoma is usually obscure, the authors emphasise the possibility that a small cavernous haemangioma can be one of the bleeding sources in some of these cases.     

Repeated thalamic haemorrhage: case report and review of the literature

Recurrence of thalamic haemorrhage has rarely been reported. A 70-year-old woman had recurrent thalamic haemorrhage five-times during a period of 6 years. The first, second and fifth haemorrhages were located in the right thalamic region, and the third and fourth haemorrhages in the left thalamic region. Cranial computed tomography and magnetic resonance imaging revealed no abnormal lesion. After the first, second, and third haemorrhage with medical treatments, the patient recovered her functional ability or was at least capable of self-care at home. However, after the fourth and fifth haemorrhage, with medical therapy the patient's prognosis was severe disability. In this case, systemic blood pressure was normalized without antihypertensive agents after the first attack. However, there was an episode of sudden hypertension at each attack. Although the mechanism of rebleeding has not been clarified, rebleeding might be associated with changes of cerebral circulation following the previous haemorrhage.     

Cerebrovascular diseases in childhood--etiology, clinical aspects and prognosis

Over a period of nine years we observed 52 children with acute neurological symptoms which were caused by a cerebrovascular disease. Fourteen patients had congenital vascular malformations, most frequently AV-angiomas (9 patients). A Sturge-Weber-Syndrome and a venous angioma were found in two cases and one patient had an aneurysm of the middle cerebral artery. Thirty-eight patients had acquired cerebrovascular diseases such as ischaemic infarctions (22), intracranial haemorrhages without vascular malformations (14) and thromboses of the dural sinus (2). The cerebral infraction was a complication of a congenital heart disease in 8 children, two others suffered from chronic renal insufficiency and were on haemodialysis. Two children had a trauma of the internal carotid artery and in one patient a large haemorrhagic infarct was caused by hypernatremic dehydration. In 9 patients (6 females, 3 males) no obvious aetiology of the infarct could be found. However, in most of these cases a nonspecific febrile illness preceded the neurological manifestations. The thrombosis of the dural sinus occurred in a 6-week old previously healthy infant and in a 3-year old boy as a complication of a nephrotic syndrome. Intracranial haemorrhages (without cerebrovascular malformations) occurred in 14 patients, mainly as a complication of haematological diseases (acute lymphatic leukaemia, severe aplastic anaemia, haemophilia A, lupus erythematodes). Four children had spontaneous intracerebral haemorrhages without obvious causes. The prognosis for survival was good in children with infarcts, but persisting neurological deficits were more severe than in children with haemorrhages. At the acute stage the lethality was higher in children with intracranial haemorrhages.     

Subdural haematoma and non-accidental head injury in children

PATIENTS AND METHODS: In this retrospective study, 36 children referred to paediatric neurology and neurosurgery during April 1995-June 1998 with a diagnosis of subdural haematoma (SDH) were studied. Nine were accidental secondary to witnessed trauma and 4 were iatrogenic. Non-accidental head injury (NAHI) was suspected in the remaining 23 children. RESULTS: After a full clinical, radiological and social assessment, NAHI was diagnosed in 14, lateral sinus thrombosis in 1, 2 were accepted as accidental and 6 remained unexplained. In the NAHI group (n=14), 12 were between 4 and 16 weeks of age, 12 (85%) had retinal haemorrhages and skeletal surveys showed evidence of additional injury in 8. Computerised tomography (CT) brain scans showed bilateral SDH in 11, and 6 had inter-hemispheric bleeding along with loss of grey-white differentiation. Eleven had magnetic resonance imaging (MRI), which yielded additional information in 7. Seven required intensive care, and 2 died. Twelve had surgical aspiration. In the group with no satisfactory explanation for SDH ( n=6); 5 had neonatal problems, all except 1 were older than 5 months of age and not as ill with bilateral, old SDH. All but 1 had skeletal surveys, which were normal, and eye examination showed no retinal haemorrhages. A social services enquiry was non-contributory. CONCLUSIONS: SDH is frequently traumatic whether accidental or non-accidental. SDH due to NAHI tends to present before 4 months of age with an inconsistent history; the patients are more seriously ill and have other findings, such as fractures and retinal haemorrhages. A small subgroup of patients was identified who had isolated, old SDH and in whom full investigation remained inconclusive. A consistent, comprehensive approach needs to be maintained in all cases with the essential backup of detailed neuro-imaging including MRI.