Recent Cyclones Causing an Increased Incidence of Intracranial Haemorrhage in India — A Cross-sectional Study

Background : Seasonal variations in the incidence of Intracerebral Haemorrhage (ICH) have been extensively evaluated in the studies conducted in various parts of the world. The prevalence per 100,000 person-years of spontaneous cerebral haemorrhage is regularly highest in the winter and lowest in the summer. However, these seasonal variations of ICH in India have not been comprehensively described in any published literature. Methodology : In this retrospective cross-sectional study, data of 15000 patients were collected from various State Government-owned Hospitals of India of the months April, May and June. The present study examined the association between temperature variations and spontaneous ICH incidence during recent severe Cyclonic Storms ‘Yaas’, and ‘Tauktae’ in India with the brain’s Computed Tomography (CT) scans. A CT brain persists in being the investigation of choice in the initial diagnosis of ICH, as it is readily available, accessible and fast. Results : During these Cyclones, there was a significant temperature drop associated with an increased incidence of ICH in the specified time. Conclusion : Sudden temperature drop during a Cyclone can cause spontaneous Hypertension, which causes rupture of arteries in the brain and results in Stroke. The Government, Physicians and the general public need to be made aware of such associations

Role of External Ventricular Drainage (EVD) in Treating Spontaneous Intraventricular Haemorrhage

Background: There is no consensus in the literature on the effects of the development of hydrocephalus on survival and disability after intracerebral haemorrhage (ICH) and the benefits of external ventricular drainage (EVD). This study is planned to describe the role of external ventricular drainage in treating patients of spontaneous, either primary or secondary, intraventricular haemorrhage with hydrocephalus.Material & Methods:A hospital based prospective interventional study was conducted in the Department of Neurosurgery of Dhaka Medical College Hospital, which is a tertiary level hospital, from April 2016 to September 2017.Total 42 patients of spontaneous intraventricular haemorrhage, either primary or secondary, with hydrocephalus were selected for this study. All the collected data were entered into IBM SPSS software, Version 24. For statistical analysis, paired t-test to compare the preoperative GCS with postoperative GCS at 24 hours was done.Results:Among 42 patients, age range was 26-75 years with the mean age 65.2 � 10.87 years. Male were 26 (61.9%) and female were 16 (38.1%). Male-Female ratio was 1.625:1. No patient needed conversion of EVD into VP shunt. EVD drain became blocked in 5 cases which were managed accordingly. 5 patients developed ventriculitis among which 2 patients died and rest 3 improved with antibiotics.Conclusions:The results of present study shows that EVD has a good role in the treatment of spontaneous IVH with hydrocephalus when ICH volume is low (<30ml) and modified Graeb Score is low (?10 found in this in this study. Preoperative higher GCS or initial improvement in GCS or initial improvement in GCS at 24 hours positively correlates with Glasgow outcome scale which is an indication of good function outcome.

ICH Score and Basal Plasma D-Dimer in Patients with Intracerebral Haemorrhage

Intracerebral haemorrhage constitutes 10-20 % of all strokes & remains without treatment of proven benefit & has higher risk of morbidity & mortality than cerebral infarction or subarachnoid bleed. Thus, these models may accurately predict outcome, and hence the purpose of this study is to define a clinical grading scale for patients with ICH which uses criteria that are predictive of outcome & that can be rapidly & accurately assessed at the time of presentation in emergency/casualty. Estimation of basal plasma D-dimer levels an indicator of systemic activation of coagulative & fibrinolytic system has shown to a powerful predictor of both early neurological worsening & mortality outcome & hence the present study is undertaken.METHODSThe study was carried out in the IPD of Department of General Medicine, Basaveshwara Teaching and General Hospital, Kalaburagi, attached to Mahadevappa Rampure Medical College. It is a cross sectional study conducted among 100 intracerebral bleed patients between November 2018 to November 2019 with simple random sampling procedure. Patients were followed up at the end of 1 month with telephone/letter/email.RESULTSThe mortality among patients who scored 0 of ICH scale was 0%, ICH score of 1 was 13.6 %, ICH score of 5 was 100 %. No patient scored 6. Higher the ICH score, higher is the mortality. Mortality among patients with D-Dimer value between 1500 – 5000 ng/ml is 55.2 %, and > 5000 ng/ml is 92.3 %. Above table indicates that higher the basal level of D-Dimer value higher is the mortality. Mortality among patients of either sex was equal i.e., 50 % between 8 - 15 days, and no deaths were noted between 15 - 30 days.CONCLUSIONSIntracerebral haemorrhage (ICH) has remained a serious disease despite recent improvements in management. So, efforts must be directed towards better understanding and modification of risk factors. The major risk factor in our study was hypertension. The other common risk factors were alcohol consumption and smoking. Thus, measures to ensure adequate control of hypertension/compliance of treatment among hypertensive, abstinence from alcohol and smoking may reduce the incidence of ICH. High initial plasma D-Dimer levels would indicate bad prognosis in ICH. In addition to diagnosis of ICH, CT Scan can also be used as a useful tool in assessing prognostic outcome of ICH, by using radiological parameters like larger volume of haematoma, presence of midline shift, intraventricular extension of haemorrhage and hydrocephalus which indicated bad prognosis i.e., using ICH score, higher the ICH score higher is the mortality.

Cerebral venous sinus thrombosis: review of cases in a single centre in Malaysia

@#Introduction: Cerebral venous sinus thrombosis (CVST) is a potentially fatal neurological condition. However, due to the non-specific clinical and radiological features of CVST, it can sometimes result in a delay in the diagnosis and subsequent management. The aim of this study was to evaluate the demography, risk factors and one-year outcome of CVST patients treated in Hospital Universiti Sains Malaysia. Methods: In this retrospective study, we reviewed the cases diagnosed with CVST admitted to our centre from January 2011 until November 2015. Results: A total of 15 patients were included in this review. The patterns of imaging findings as well as risk factors for CVST is discussed with a review of the literature and current management practices. One year followed-up showed full recovery (Glasgow Outcome Scale (GOS) of 5) in 10 cases (66.7%), whereas 4 cases (26.7%) with GOS of 4 (three cases with neurological deficits, and 1 case with mild symptom. There was one case of mortality in this study secondary to sepsis during hospitalisation. The presenting symptoms were mainly headache, focal neurology deficits, seizure and altered sensorium. Risk factors identified were oral contraceptive pills usage, chronic sinuses or ear infections, and obesity. Initial computed tomography (CT) scan showed various findings and haemorrhagic infarct was one of the common findings. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) revealed majority of the patients had occlusion at two or more venous sinus sites. No patients had new or recurrent intracranial haemorrhage following initiation of anticoagulation therapy. Conclusion: Thus it is considerable safe to start anticoagulation therapy in CVST patients including those with intracranial haemorrhage. We propose further neuroimaging to avoid missed diagnosis of CVST in patient presented with recent onset headache and CT evidence of unusual cerebral infarction.

Effectiveness Of Home Exercise Program With Modified Rood’s Approach On Muscle Strength In Post Cerebral Haemorrhagic Individuals Of Assam: A Randomized Trial

Background: Physical therapists are integral to the rehabilitation of patients of stroke, and home exercise program (HEP) prescription is a routine part of physical therapy care. Strength training is imperative in interventions for stroke patients. Various components of Rood’s Approach are effective in stroke rehabilitation, an aspect that has not been thoroughly explored as yet. Methods: A randomized controlled trial study was done at Gauhati Medical College & Hospital, Assam. The subjects were 236 hemorrhagic stroke patients who were randomly assigned into two groups. Both the groups were given a HEP consisting of routine physiotherapy exercises. Additionally, one group out of the two was also taught exercises based on the Rood’s approach, consisting of facilitation and inhibition techniques with the help of sensory stimulation and repetitive task-specific activity. The output was evaluated in terms of muscle strength using Manual Muscle Testing (MMT) after three months of intervention. Results: It was observed that HEP with Rood’s approach significantly improved (p<0.05) the muscle strength in shoulder flexors (p=0.038), shoulder extensors (p=0.003), shoulder abductors (p=0.033), shoulder adductors (p=0.018), elbow flexors (p=0.009), wrist flexors (p=0.044), finger flexors (p=0.011), hip flexors (p=0.007), hip extensors (p=0.015), hip adductors (p=0.00), knee flexors (p=0.00), ankle plantar flexors (p=0.00) and dorsi flexors (p=0.039). However, no improvements were observed for elbow extensors, wrist extensors, finger extensors, hip abductors and knee extensors. Conclusion:  Although it was observed that both the Groups improving their muscle strength, but HEP with Rood’s approach was found to be more effective in improving muscle strength.

A rare presentation of snake bite

In India, doctor’s in casualty frequently get confronted with snake bite. A wide range of complications occur in snake bite. Intracerebral haemorrhage (ICH) is an unusual presentation following snake bite. Here authors discuss a patient presents with ICH after snake bite. Venom induced consumption coagulopathy is the most accepted theory behind intracerebral haemorrhage.

Hematoma intraparenquimatoso del sistema nervioso central asociado con dasatinib en el tratamiento de leucemia mieloide crónica en fase acelerada. Presentación de dos casos y revisión de la literatura / Intraparenchymal haematoma of the central nervous system associated with Dasatinib in the treatment of chronic myeloid leukaemia in accelerated phase. Presentation of two cases and review of literature

Resumen Se presentan dos casos clínicos de pacientes con leucemia mieloide crónica en fase acelerada, hospitalizados para inicio de terapia dirigida con inhibidores de tirosina cinasa (dasatinib). Posteriormente se determina la presencia de sangrado intraparenquimatoso a sistema nervioso central. Para finalizar, se revisa la literatura disponible a cerca de eventos adversos tipo sangrado asociados a dasatinib y los posibles condicionantes de este desenlace.

Abstract Two clinical cases are presented on patients with chronic myeloid leukaemia in accelerated phase, who were admitted to hospital for initiation of targeted therapy with tyrosine kinase inhibitors (Dasatinib). Intraparenchymal bleeding in the central nervous system was subsequently observed. A review was also made on the available literature on bleeding-related adverse events associated with Dasatinib and the possible determining factors of this outcome.

Evaluation by damped least-square algorithm on target identification ability of intracranial focal bidirectional electrical impedance perturbation / 医疗卫生装备

Objective To evaluate the effect of damped least-square algorithm on the identification of focal bidirectional electrical impedance perturbation in the intracranial area, and to analyze the influence of this kind of perturbation on the reconstruction quality of electrical impedance tomography. Methods Focal bidirectional electrical impedance perturbation was built based on the three-dimensional model and damped least-square algorithm was introduced into imaging. The position error and resolution were used to evaluate the imaging performance.Results When the focal electrical impedance perturbation existed,the target whose conductivity varied greatly or volume was large was more likely to be identified in the images while the target with smaller volume or variable conductivity presented in the reconstruction image was not obvious. It's pointed out that it may cause reconstruction images in some cases could not truly reflect the location and change information of the object of primary cerebral hemorrhage.At the same time,it affected the reconstruction precision,causing the position error and resolution with large fluctuation. Conclusion In reconstruction algorithm linearity correct matrix introduced for bidirectional electrical impedance perturbation contributes to enhancing the recognition of bidirectional perturbation, so that the characterization of the electrical impedance imaging can be augmented for clinical intracerebral hemorrhage.

Inflammatory Biomarkers and Their Value in Predicting Survival and Outcome among Patients with Spontaneous Intracerebral Haemorrhage

Background: Spontaneous intracerebral haemorrhage (SICH) has emerged as one of the most devastating forms of stroke in recent decades. This disease is noted to carry a 30-day mortality rate of approximately 45%. An increasing number of studies have implicated a complex immune-mediated and inflammation-mediated cascade of responses in the pathophysiology of SICH and the resultant neurologic outcome. Several clinical studies have demonstrated an association between inflammatory markers and outcome in patients with SICH. However, the exact relationship between serum biomarkers and functional outcomes amongst survivors has not been clearly elucidated. This study aimed to evaluate the changes in peripheral leukocyte count (WBC count) and C-reactive protein (CRP) levels in patients with SICH and to correlate these findings with survival and functional outcome. Methodology: A prospective, descriptive and correlational study was conducted at Sarawak General Hospital (SGH) over the span of two years (April 2013–April 2015). Patients aged between 30 years and 75 years with supratentorial intracerebral bleed secondary to uncontrolled hypertension were recruited in this study. Data pertaining to the demography, clinical and radiological parameters, peripheral WBC count and CRP levels were obtained. Mortality and functional outcomes were determined at 6 months post ictus. Patients were recruited following the fulfilment of exclusion and inclusion criteria, and all obtained data were analysed with the Statistical Package for Social Sciences (SPSS) for Windows version 21.0. Results: A total of 60 patients with a mean age of 56 years were recruited in this study. We found that approximately 16 patients were less than or equal to 50 years old (26.7%) and that 44 patients belonged to the older age group of above 50 years (73.3%). The Glasgow Coma Scale (GCS) score on admission ranged from 9 to 14/15 with a median value of 11/15. The mean clot volume was 20.1 cm3. The GCS score on admission and clot volume were significantly associated with the Glasgow Outcome Scale (GOS) at 6 months and overall survival (P < 0.05). The elevated WBC count and CRP level on admission and at 72 hours post admission were significantly associated with GOS at 6 months and overall survival (P < 0.05). Thus, the GCS score, clot volume, WBC count and CRP levels on admission and at 72 hours post admission can be used to predict functional outcome at 6 months and overall survival in patients with SICH. Conclusion: We could conclude via this study that for patients with SICH, the main determinants or predictors of functional outcome at 6 months and overall survival were noted to be the GCS score on admission, clot size, WBC count and CRP levels on admission and at 72 hours post admission.

Cerebral Amyloid Angiopathy: An Important Differential Diagnosis of Stroke in the Elderly

Cerebral amyloid angiopathy (CAA) accounts for approximately 10–20% of spontaneous intracerebral haemorrhage (ICH). This figure is thought to be higher in the elderly population. With the increasing life expectancy of our population, we anticipate that the prevalence of CAA- related ICH will increase in tandem. Although CAA-related ICH and hypertension-related ICH are distinct entities based on histopathology and imaging, the clinical presentation of the two conditions is similar. The use of brain computed tomography (CT) scans remain the ICH imaging modality of choice in Malaysia due to its availability, cost, and sensitivity in detecting acute bleeds. On the other hand, the use of brain magnetic resonance imaging (MRI) with susceptibility-weighted imaging (SWI) sequencing enables the clinician to determine the presence of chronic blood products in the brain, especially clinically silent microbleeds associated with CAA. However, the use of brain MRI scans in our country is limited and leads to a blurring of lines when differentiating between hypertension-related ICH and CAA-related ICH. How this misrepresentation affects the management of these conditions is unclear. In this study, we present two cases of ICH to illustrate this point and to serve as a springboard to question current practice and promote discussion.

Effects of anti-inflammatory active fraction from the tuber of Scirpus yagaraohwi on mice with intracerebral haemorrhage / 中国药学杂志

OBJECTIVE: To study the effects of anti-inflammatory active fraction (AF) from the tuber of Scirpus yagaraohwi in mice with intracerebral haemorrhage (ICH). METHODS: A 25 μL volume of autologous nonanticoagulated blood was collected from the tail artery of the mouse and then injected into the striatum using a syringe pump. Neurological deficits of the mouse was assessed 1, 3 and 5 days after ICH using a 28-point neurological deficit scale, and brain water content of the mouse cerebral tissues after ICH was measured at third day.The concentrations of pro-inflammatory cytokines in perihematoma tissues, including interleukin-6, interleukin-1β and tumor necrosis factor-α, were measured by ELISA assay. RESULTS: The results show that AF significantly reduced the neurological deficit scores and the brain water content after ICH. AF also markedly inhibited the levels of IL-6, IL-1β and TNF-α at first day and third day alter ICH. CONCLUSION: Anti-inflammatory active fraction of Scirpus yagaraohwi can improve the brain injury in mouse induced by ICH. The mechanism may involve decreased expression of pro-inflammatory cytokines of mouse after ICH.

Acute Promyelocytic Leukemia in a 17yr Male presenting as Intracerebral Haemorrhage.

Acute promyelocytic leukemia (APML), once highly fatal, has emerged as the most curable subtype of acute myeloid leukemia in adults. Early mortality most often is due to a severe catastrophic bleeding, often intracerebral in location. Here we report a 17year male patient presented with status epilepticus having high leukocyte count (3,28,000/mm3) and low platelet count(34,000/mm3).Peripheral blood & bone marrow was showing good no. of atypical promyelocytes. CT scan of brain revealed an intracerebral haemorrhage with laboratory profile of prolonged prothrombin time and activated partial thromboplastin time, the presence of Ddimer and decreased fibrinogen concentration. The patient was diagnosed as Acute Promyelocytic Leukemia with Intracerebral haemorrhage. The patient died on the same day. APML is the notorious subtype of acute myeloid leukemia which causes fatal intracranial haemorrhage which has high mortality and morbidity. Clinically significant coagulopathy is present in 70%– 80% of APML patients at the time of diagnosis. Early detection and aggressive correction of coagulopathy may prevent the catastrophic event. Prompt image study for locations and types of ICH can predict outcomes.

Analysis of risk factor and intervention of intracranial hemorrhage in the premature infants / 重庆医学

Objective To explore the risk factors and seek effective intervention of intracranial hemorrhage in the premature in-fants .Methods Clinical data of the premature infants in our hospital from January 2009 to December 2013 was retrospectively ana-lysed and single factor analysis of 20 relevant factors was done for cases with intracerebral haemorrhage and without intracerebral haemorrhage .Logistic regression analysis were done for some influence factors of intracranial hemorrhage .Results 1 726 cases of premature babies were included in the study ,including 264 cases of intracranial hemorrhage .Logistic regression analysis results shown that the neonatal transport network and integrated active transport models are protective factors of intracranial hemorrhage in the premature infant .We found that basic-level hospital transport was an independent risk factor .Between January 2009 and De-cember 2011 ,142 of 714 premature infants were intracranial hemorrhage ,including 88 cases from 348 patients transported from bas-ic-level hospital ,the incidence of intracranial hemorrhage was 25 .29% ,and compared with the incidence of intracranial hemorrhage (14 .75% ) of our hospital ,the difference was statistically significant (P<0 .05) .From January 2012 ,we established perfect neonatal transport network and implementation of comprehensive active transport model .122 of 1 012 premature infants were intracranial hemorrhage ,including 75 cases of 490 patients from basic-level hospitals .The incidence was statistically significant different com-pared with the incidence of intracranial hemorrhage(9 .00% ) transported from our hospital(P<0 .05) .The incidence of intracranial hemorrhage in the premature infants transported from basic-level hospitals were statistically different before and after neonatal transport network and comprehensive active transport model was established (P<0 .01) .Conclusion It will effectively reduce the incidence of intracranial hemorrhage in the premature infant by establishing the perfect regional neonatal three-level network trans-port system and comprehensive active transport models .

Functional outcome at 6 months in surgical treatment of spontaneous supratentorial intracerebral haemorrhage

A prospective cohort study was done to evaluate the role of surgery in patients with spontaneous supratentorial intracerebral haemorrhage (SICH) and to identify predictors of outcome including the use of invasive regional cortical cerebral blood flow (rCoBF) and microdialysis. Surgery consisted of craniotomy or decompressive craniectomy. The ventriculostomy for intracranial pressure (ICP) monitoring and drainage and regional cortical cerebral blood flow (rCoBF) and microdialysis were performed in all subjects. Pre and post operative information on subjects were collected. The study end points was functional outcome at 6 months based on a dichotomised Glasgow Outcome Scale (GOS).The selected clinical, radiological, biochemical and treatment factors that may influence the functional outcome were analysed for their significance. A total of 36 patients were recruited with 27(75%) patients had Glasgow Coma Score (GCS) between 5 to 8 on admission and 9(25%) were admitted with GCS of 9. At 6 months, 86 % had a poor or unfavourable outcome (GOS I-III) and 14% had good or favourable outcome (GOS IV-V). The mortality rate at 6 months was 55%. Univariate analysis for the functional outcome identified 2 significant variables, the midline shift (p=0.013) and mean lactate:pyruvate ratio (p=0.038). Multivariate analysis identified midline shift as the single significant independent predictor of functional outcome (p=0.013).Despite aggressive regional cortical cerebral blood flow (rCoBF) and microdialysis study for detection of early ischemia, surgical treatment for spontaneous intracerebral haemorrhage only benefited a small number of patients in terms of favourable outcome (14%) and in the majority of patients (86%), the outcome was unfavourable. Patients with midline shift > 5mm has almost 21 times higher chances (adj) OR 20.8 of being associated with poor outcome (GOS I-III).

Best time of mini-traumatic operation to treat hypertensive intracerebral haemorrhage in internal capsule / 中国医师进修杂志

Objective To investigate the best time of mini-traumatic operation to treat hypertensive intracerebral haemorrhage in internal capsule. Methods Sixty-four patients were divided into treatment group and control group according to operative time. Patients who were treated with mini-traumatic operation within 6 hours were as treatment group, those treated with mini-traumatic operation beyond 6 hours were as control group. Results Twelve of 40 patients in treatment group were cured, 16 became better, 5 had no effect, 7 were dead, and the effective rate was 70.00%. Five of 24 patients in control group were cured, 6 became better, 5 had no effect, 8 were dead, and the effective rate was 45.83%. Conclusion The effect of mini-traumatic operation to treat hypertensive intracerebral haemorrhage in internal capsule within 6 hours is clearly better than that beyond 6 hours.

Secondary injury to perihematoma in intracerebral haemorrhage rats / 中国康复理论与实践

@#ObjectiveTo study possible mechanism through investigating the pathological and ultrastructural characters of secondary injury to perihematoma in intracerebral haemorrhage (ICH) rats.MethodsSprague Dawley male rats were subjected to ICH models. They were randomly divided into test group and control group. The rats in the test group were divided into 7 subgroups at 1h,3h,12h,24h,48h,72h and 7d after ICH; while those in control group were divided into 3 subgroups at 3h,24h,72h after saline injection. Each subgroup contained 5 rats. 2 rats from each group were stained by 2% triphenyltetrazolium chloride(TTC) to observe the pathological change.3 rats were picked up from each group to do optical microscope and electric microscope investigation on perihematoma tissue and ipsilateral cortex.ResultsHematoma tissue was demonstrated as black brown by TTC staining, no white infarcted area was detected around hematoma. In addition, there was a transitional zone between hematoma and normal tissue under microscopy; the involved tissue looked loose with varied edematous cells. Astrocytes appeared swollen and neural cells looked degenerated and necrosis. Meanwhile, capillary hyperplasia around hematoma with foot plate swollen were detected, no remarkable neural cells change was observed. 24 h after blood injection, astrocytes started to swell, part of them became degenerated and necrosis. Neural cells appeared mild degenerated and blood brain barrier were destroyed. 72 h after ICH, astrocytes showed highly swollen with neural cells degenerated.ConclusionSecondary injury to perihematoma has been identified and the pathological and ultrastructural changes have been observed.

Some opinions of the haematologic and biochemical tests for intracerebral haemorrhage in patients with hypertension

In a study in 90 patients with primary hypertensive intracerebral hemorrhage in Friendship Hospital from August 1998 to May 2000. We found that white blood cell were 64.5% when the patients admitted to hospital. The increase of cholesterol is 53.4%; triglycerid is 63.3%. This is rich factor of primary hypertensive intracerebral hemorrhage. The author suggested the above mentioned clinic signs give the early diagnose, fast indication and blood test.