A case report of simultaneous multiple intracerebral hematomas

A case of multiple spontaneous intracerebral hematomas is presented. A 67-year-old man with 7 years history of hypertension had sudden clumsiness in his right hand and an hour later dysarthria appeared. A CT scan taken 3 hours after the onset revealed two well demarcated high density areas in the left putamen and in the parietal subcortex. A diagnosis of multiple intracerebral hematomas was made. On neurological examination he was midly stuporous (13 points of Glasgow Coma Scale). Dysarthria, right hemiparesis and right extensor plantar response were seen. CT scan of 6 hours later disclosed the same findings as the previous study. He recovered well and neurologically free in a few days. On the following CT scans both hematomas were isodense 2 weeks later, and ring-like enhancement effect was noted. CT scan showed normal appearance 7 weeks later. On MRI using 0.5 T unit t-1 and t-2 weighted spin echo images of these hematomas also showed the similar chronological changes. The history, these CT and MRI studies suggest that two hematomas of this case occurred almost simultaneously in one cerebral hemisphere. No causative factors such as blood dyscrasias, AVM, angioma, septicemia, malignancies or sinus thrombosis was identified. We consider that a hypertensive intracerebral hematoma of the putamen was followed by the parietal intracerebral hematoma within a few hours, although amyloid angiopathy was not completely excluded because no cerebral biopsy of the lesion was performed.     

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.     

Metastatic brain tumors with simultaneous multiple cerebral hemorrhages: a case report

We encountered a case of multiple metastatic brain tumors with simultaneous multiple cerebral hemorrhages. A 45-year-old male suffered from sudden left hemiplegia and was admitted to our hospital. CT scans on admission revealed multiple cerebral hemorrhages with surrounding brain edema in the right frontal lobe, left frontal lobe, right occipital lobe and right basal ganglia. On full-body examination, renal cell carcinoma of the left kidney and multiple metastatic tumors in the lung, liver and vertebral body were identified. We continued conservative therapy, but the patient's condition worsened and he died 36 days later. The autopsy findings indicated that all hemorrhages had occurred in the necrotic tissue associated with the metastatic brain tumors. Simultaneous multiple cerebral hemorrhages caused by metastatic brain tumors are very rare, and the differential diagnosis of cerebral hemorrhage due to metastatic brain tumor and hypertensive cerebral hemorrhage is difficult. The present case indicates that metastatic brain tumor should be taken into consideration in cases with simultaneous multiple intracerebral hemorrhages.     

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.     

Intracerebral hemorrhage due to cerebral amyloid angiopathy. Case report

The case is presented of a 59-year-old man with cerebral amyloid angiopathy and three consecutive hemorrhages in the occipital lobes. The clinicopathological features and the relationship to Alzheimer's dementia are discussed. The correct treatment of intracerebral hemorrhage related to cerebral amyloid angiopathy is a matter of controversy.     

Three cases of acute interhemispheric subdural hematoma

Traumatic acute subdural hematomas over the convexity of the cerebral hemispheres are often encountered, but acute interhemispheric subdural hematomas are rare. Fourty-eight cases of acute subdural hematomas was admitted to our hospital between 1977 and 1986, and three cases of them (6%) were located in the interhemispheric subdural space. In this paper, these three cases are reported with 20 documented cases. Case 1: an 81-year-old female was admitted to our hospital because of headache, nausea and vomiting. She hit her occiput a week ago. CT scan demonstrated contusion in the right frontal lobe and a high density in the interhemispheric space of the right frontal region. Her complaints disappeared gradually by conservative therapy and she returned to her social life. Case 2: a 50-year-old male fell downstairs and hit his vertex. As he lost consciousness, he was admitted to our hospital. He was stuporous and had left-hemiparesis. Skull X-ray film showed fracture line extending from the right temporal bone to the left parietal bone across the midline. CT scan revealed intracerebral hematoma in both frontal lobe and right parietal lobe and subarachnoid hemorrhage in the basal cistern and Sylvian fissure of the right side. And interhemispheric subdural hematoma in the right parietal region was visualized. Angiography demonstrated a lateral displacement of the right callosomarginal artery and an avascular area between the falx and the callosomarginal artery. After admission his consciousness recovered and convulsion was controlled by drug. Left-hemiparesis was improved by conservative therapy and he was discharged on foot.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multiple intracerebral microhemorrhages associated with primary aldosteronism: a case report

We have observed dot-like low intensity spots (a dot-like hemosiderin spot: dotHS) on T2*-weighted (T2*-w) MRI, subsequently diagnosed histologically as previous microbleeds associated with lipohyalinosis, amyloid angiopathy and cerebral small vessel disease (SVD) including an intracerebral hematoma (ICH) and a lacunar infarction. According to the literature, primary aldosteronism (PA), characterized by hypertension, is related to SVD. A 49-year-old female with a long history of untreated hypertension secondary to PA was admitted to our hospital for medical examinations on July 18th, 2000. She had the stepwise development of dementia, dysarthria and gait disturbance (right hemiparesis). CT and MRI demonstrated multiple lacunar infarctions. She was readmitted to our hospital on Jan 23rd, 2002. A neurological examination revealed right hemiparesis, dysarthria and consciousness disturbance. CT on admission demonstrated ICH in the left midbrain. Six days after the hemorrhage, T2*-w MRI showed thirty-two dotHSs in the basal ganglias and the cortical-subcortical regions. The incidence of ICH in patients with hypertension secondary to PA is reported to be higher than in patients with essential hypertension. Multiple dotHS may be associated with ICH, lacunar infarction, and severe microangiopathy related to hypertension secondary to PA.     

Diffuse axonal injury associated with multiple traumatic aneurysms of the distal anterior cerebral artery--case report.

A rare case of multiple traumatic aneurysms, arising from the distal anterior cerebral artery (ACA), associated with a diffuse axonal injury is presented. An 18-year-old male sustained a frontal impact injury in a traffic accident on February 19, 1988. He immediately lost consciousness and was transported to a local hospital where his Glasgow Coma Scale score was 6. A computed tomographic scan showed a traumatic subarachnoid hemorrhage extending from the corpus callosum to the left parietal lobe. With conservative treatment, he gradually regained consciousness and was referred to our hospital 12 days later. Skull x-rays revealed no fracture. A right common carotid angiogram revealed multiple aneurysmal dilatations on the right distal ACA. A left frontoparietal craniotomy was then performed to determine the nature of the aneurysmal dilatation, and to evacuate the intracerebral hematoma because his right hemiparesis persisted. Two aneurysmal dilatations on the distal ACA were tightly surrounded by clots and a hematoma extended from the corpus callosum to the parietal lobe. The ACA was trapped proximal and distal to the aneurysmal dilatations. The postoperative course was uneventful.     

Superficial temporal to superior cerebellar artery anastomosis for rostral brain stem infarction

The authors report a case of superficial temporal to superior cerebellar artery anastomosis (STA-SCA anastomosis) for progressing rostral brain stem infarction with an excellent result. Precise operative techniques were also described. A 47-year-old male was admitted to our hospital on November 9, 1984, because of sudden onset of dysarthria and ataxic gait. CT revealed a low density area in the pons. Left vertebral angiogram showed occlusion of the left vertebral artery just distal to the origin of the posterior inferior cerebellar artery (PICA). Arterial branch of the left cerebellar hemisphere were filled via the left PICA to the left SCA and anterior inferior cerebellar artery anastomosis. Right brachial angiogram showed the hypoplastic right vertebral artery which ended at the PICA. The rostral basilar artery, both posterior cerebral arteries (PCA's) and right SCA were filled through anastomosis from the right PICA. The posterior circulation was not filled by either of the carotid arteries. In spite of antiplatelet agglutination therapy, the patient had two more episodes of dysarthria, dysphagia, right hemiparesis and gait disturbance. Because of progressing stroke, STA-SCA anastomosis was carried out on the right side on February 27, 1985. During operation, the blood pressure was maintained above the level of 130 mmHg, and intravenous mannitol injection and spinal drainage were done to preserve the right temporal lobe from intracerebral hematoma and/or edema caused by retraction. Postoperatively, the patient has been free from new ischemic attack. He has only slight hemiparesis now eight months after operation. Right external carotid angiogram showed a patent STA-SCA bypass and good filling of SCA's and PCA's bilaterally.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cerebral amyloid angiopathy is difficult to diagnose in the intensive care unit

Cerebral amyloid angiopathy is a common cause of intracerebral haemorrhage in elderly patients. The diagnosis of cerebral amyloid angiopathy is based on the Boston criteria combining clinical and radiological criteria with no other cause of intracerebral haemorrhage. We describe the case of a 60-year-old female admitted to the intensive care unit for agitation and spatial disorientation. She had multiple intracerebral haematomas on brain CT scan. Typical cerebral microbleeds using MRI and the absence of other cause of intracerebral haemorrhage argued in favour of the diagnosis of cerebral amyloid angiopathy. The patient outcome was favourable with a discharge from the intensive care unit on day 16.     

A case of posttraumatic vascular abnormality similar to dural arteriovenous malformation

A case of posttraumatic vascular abnormality similar to dural arteriovenous malformation is reported. A 21-year-old man was injured in the traffic accident and admitted to our hospital with comatose state. Bilateral carotid angiograms revealed no abnormal findings. Then, he was treated conservatively as a diagnosis of cerebral contusion. Nine years after the initial admission, he was fallen into comatose state suddenly and admitted to a local hospital. On the next day, he was transferred to our hospital. Neurological examination disclosed comatose state, right oculomotor palsy, and left hemiparesis. CT scan showed a crescent shaped high density area in the right subdural space, right temporal intracerebral high density area, and left frontal low density area, suggesting right acute subdural hematoma, right temporal intracerebral hematoma, and left frontal old cerebral contusion respectively. Right carotid angiogram revealed an abnormal vascularity in the right middle fossa, which was fed by the middle meningeal artery and drained into the superior sagittal sinus and the transverse sinus. Surgical treatment was performed immediately. Following the evacuation of intracerebral hematoma, the abnormal vascular mass suggesting a nidus of arteriovenous malformation was removed totally, that was attached to the dura mater. Pathological specimen showed large veins and arteries with thrombus, however, no characteristic feature of arteriovenous malformation. Then, this was thought to be an arteriovenous fistula between the branches of middle meningeal artery and the veins of fibroglial scar following by the cerebral contusion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Recurrent intracerebral hemorrhages in cerebral amyloid angiopathy: a case report

Cerebral amyloid angiopathy frequently causes recurrent intracerebral hemorrhages in elderly patients who do not have systemic hypertension. Surgery should be reserved for conditions which cannot be controlled by medical treatment. When surgery is needed, potential complications (such as bleeding near the operation site or remote area) should be kept in mind. A case study of a 66-year-old woman with cerebral amyloid angiopathy and recurrent intracerebral hemorrhages is presented.     

The early hemorrhage and development of a bacterial aneurysm after a cerebral ischemic attack caused by a septic embolism--a case report]

A 71-year-old female was admitted with the complaints of dysarthria and right hemiparesis. CT scan revealed subarachnoid hemorrhage in the left cerebral sulcus. The first angiography was performed 3 days after the onset and left carotid angiography revealed a small aneurysm arising from the left middle cerebral artery. After 3 weeks of antibiotic therapy, the second angiography showed the aneurysm to be clearly enlarged, so it was resected. The patient complained of marked dysarthria a day after the operation and CT scan revealed a new infarction in the right frontal lobe. The third angiography showed an aneurysm arising from the right middle cerebral artery and the fact that two peripheral arteries of the aneurysm had disappeared 3 weeks after the first operation. The second operation was performed and a bacterial aneurysm was resected. The patient left the hospital without any neurological deficits. Septic embolism is the most important complication of infective endocarditis and it is usually presented with subarachnoid hemorrhage and intracerebral hemorrhage caused by ruptured bacterial aneurysms. In this case the septic embolism occurred two times. At each time cerebral ischemic attacks were presented. The reason why this case presented with ischemic symptoms was suspected to be that embolisms occurred at the trifurcation of the distal middle cerebral arteries. We were able to detect a bacterial aneurysm angiographically 3 days after the ischemic attack and we suspected that a bacterial aneurysm had been able to develop within 3 days after the septic embolism.     

A case of familial cerebral cavernous angioma and review of Japanese cases

We present one pedigree of familial cerebral cavernous angioma (FCCA). Case 1 was a 52-year-old male with right hemiplegia. When he was 37 years old, a left occipital lesion was excised and histologically diagnosed as cavernous angioma. MR image showed many cavernous angiomas in the right temporal lobe, the right paraventriclar white matter, the right frontal lobe, the left basal ganglia, and the left parietal lobe. Stereotactic radiosurgery was undertaken for all the lesions. Although the size of each lesion was unchanged, neither hemorrhage nor neurological deterioration were recognized after radiosurgery. Case 2 was a 24-year-old male, a son of the patient in case 1. He has manifested tonic-clonic type epilepsy since the age of 2. MR image showed cavernous angiomas in the pons, the right frontal, and the left intra-Sylvian regions, and many paraventricular cysts with rims indication of previous hemorrhages. Two de novo lesions were observed on subsequent annual MR screening. Surgical excision for the left intra-Sylvian lesion and stereotactic radiosurgery for all lesions were undertaken. Histological diagnosis was cavernous angioma. In the literature, there were 17 pedigrees and 37 cases of FCCA in Japan. The incidence of both multiple lesions and hemorrhage were less than in found in Spanish or French cases. Stereotactic radiosurgery is considered an useful treatment for FCCA, because lesions are multiple and de novo lesions occur.     

An autopsy case of extraneural metastases of giant cell glioblastoma with intracerebral hemorrhage

We report a case in which a 71-year-old man with a giant cell glioblastoma who had a spontaneous intracerebral hematoma including subarachnoid hemorrhage and extraneural multiple metastases followed by the craniotomy 9 months later. He had complained of nausea and vomiting on 20, October, 1981 and admitted to the Ohara hospital. For that reason, he was admitted to our hospital on 29, October, 1981 and a CT scan showed a large subcortical high dence mass accompanied by adjacent edema in the right frontal lobe. Gradually he got worse with Korsakoff's syndrome and motor weakness of the left side. Total removal of the hematoma and adjacent tissue by transcortical route on 24, November, 1981 was performed, followed by 60Co radiation therapy to the local area, chemotherapy and immunotherapy. The surgical specimen showed typical features of giant cell glioblastoma with intratumoral hemorrhage. After 9 months of the operation, he had complained of the subcutaneous tumor in the supraclavicular region and swelling of the right arm. After the second admission on 30, August, 1982, a biopsy of the tumor revealed malignant tumor cells resembling intracerebral giant cell glioblastoma. He died on 29, November, 1982. At autopsy, extraneural metastases were revealed at some lymph nodes, organs and bones. However, a primary tumor was not found in the other organs. Lymph node: cervical, supraclavicular, mediastinal, bronchial, pancreaticoduodenal, hepatic hilus, mesenteric, retroperitoneal, and parastomach. Organ: esophagus, Ileum, jejunum, adrenal gland and kidney. Bone: vertebra (thoraco-lumbar), sternum, rib. Positive reaction to GFA protein antibody was demonstrated in the tumor cells in the periphery of the surgical specimen of the brain tumor.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multiple Cerebral Arteriovenous Malformations (AVMs) Associated with Spinal AVM

Summary  The co-existence of multiple cerebral arteriovenous malformations (AVMs) and a spinal AVM is extremely rare. A 22-year-old man suddenly developed severe headache. Computed tomography (CT) scan showed intracerebral haemorrhage in the left occipital lobe. Cerebral angiography revealed eight AVMs; four were in the right frontal lobe and two each were in the right temporal and left occipital lobe, respectively. A huge high-flow spinal AVM was found incidentally. He had no other vascular lesions such as hereditary haemorrhagic telangiectasia. A left occipital craniotomy was performed and the ruptured left occipital AVMs were removed. Further therapeutic treatment was refused. To our knowledge, except for one autopsy case, this is the first reported patient with multiple cerebral AVMs with a spinal AVM. We discuss the characteristics of this case and review reported cases with cerebral and spinal AVMs.     

A case of metastatic intracerebral malignant schwannoma]

A 53 year old male complaining of headache and left hemiparesis was referred to our hospital on November 11, '89. He had no evidence of von Recklinghausen's disease. He had been operated on because of a well circumscribed tumor in the left paravertebral muscle on July 11, '87, and metastasis in the lower lobe of the left lung on April 20, '88. The pathological diagnosis of both the primary and the metastatic lung tumor was malignant peripheral nerve sheath tumor showing peripheral cell differentiation (malignant schwannoma). Contrast enhanced CT demonstrated an irregularly enhanced mass in the right parietal lobe just before admission. On the night of admission November 12, '89, he suddenly had severe headache and this progressed to hemiparesis. Repeat CT examination was done immediately and revealed intratumoral hemorrhage. On November 19, '89, the tumor was totally removed. His symptoms disappeared postoperatively. The pathological findings of the tumor were the same as those made previously. The patient received radiotherapy to the brain (local 50 Gy and whole brain 30 Gy) and chemotherapy with nitrosourea (MCNU 150mg). He was discharged without neurological deficits. However he had two operations to remove metastatic tumors in the soft tissue of the hip on January 12, and August 17, '90. A very rare case of metastatic intracerebral malignant schwannoma is reported, and the literature on this point is reviewed.     

Pediatric blunt carotid injury--case report

A 5-year-old boy was struck by a pickup truck, and admitted with Glasgow Coma Scale score of 14. Initial computed tomography (CT) showed no evidence of intracerebral lesions except for a skull fracture. Repeat CT 5 hours later showed hyperdense middle cerebral artery (MCA) sign, but he did not show any focal signs. Eighteen hours after the accident, he developed left hemiparesis. CT revealed a fresh infarction in the right MCA territory, associated with definite hyperdense MCA sign. He was immediately transferred to our hospital for further evaluation. Emergent angiography revealed a rat tail-shaped occlusion of the right internal carotid artery at the C-3 level. Cross-filling of the right MCA territory was insufficient for collateral circulation. He was treated conservatively because of the significant risk of hemorrhagic change from the established infarction. His hemiparesis improved gradually, and he was discharged on foot. Hyperdense MCA sign in a child is an important clinical sign for the early detection of cerebral ischemia after blunt carotid injury, before any focal signs appear.     

Acute subdural hematoma after intra-arterial thrombolysis for acute ischemic stroke--case report

A 79-year-old man with a cardiac pacemaker for bradycardia fell down and presented with sudden onset of right hemiplegia and aphasia. Initial computed tomography (CT) showed no cerebral infarction but angiography revealed occlusion of the left middle cerebral artery (MCA). Local intra-arterial thrombolysis with tissue plasminogen activator (tPA; tisokinase, 1,600,000 units) was performed 3 hours after the onset, and the MCA was partially recanalized. Further administration of tPA was suspended because of nosebleed. However, the patient's neurological findings did not improve. His consciousness gradually deteriorated to coma and quadriplegia with dilation of the left pupil 2.5 hours after thrombolysis. CT disclosed marked mass effect with a left acute subdural hematoma and a small intracerebral hematoma in the left frontal lobe. He underwent urgent craniotomy and removal of the subdural hematoma. The subdural hematoma originated in a frontal cerebral contusion. He died of severe brain edema 2 days after surgery. Acute subdural hematoma is a very rare complication of intra-arterial thrombolysis. Presumably he had suffered head trauma at the first onset. Evidence of head trauma should be considered a contraindication for the use of thrombolytic agents in a patient with acute stroke.     

A case of glioblastoma in which early diagnosis was difficult by MRI

The authors report a case of glioblastoma in which MR images with Gd-DTPA enhancement changed rapidly during the early stage. A 61 year-old male presented with sudden right facial spasm and dysarthria. However, both a plain and an enhanced CT failed to demonstrate any abnormal lesions. On the other hand, T2 weighted MR image revealed a well circumscribed high intensity lesion in the left frontal lobe without mass effect. This lesion could not be differentiated from cerebral infarction, since no contrast enhanced lesion was able to be observed in T1 weighted MR image with Gd-DTPA. His symptoms gradually became aggravated and at 3 months from the onset, MR image with Gd-DTPA disclosed a small enhanced lesion in the left frontal lobe near the cortical surface. After 6 months from the onset, he suffered from right hemiparesis and motor aphasia. The MR image with Gd-DTPA at this time showed a large enhanced lesion in the left frontal lobe with mass effect. He was admitted to our hospital, and subtotal removal of the tumor and intraoperative radiation was carried out. The patient did well postoperatively without additional neurological deficit, and then he received additional radiation therapy. It should be noted that Gd-DTPA enhanced MR image might fail to reveal the lesion of glioblastoma in its early stage, while T1 weighted image discloses only the gyral swelling.