Traumatic Rupture of the Middle Cerebral Artery Followed by Acute Basal Subarachnoid Hemorrhage: Tailored Approach in Forensic Pathology by Aid of Post-mortem Angiographic Findings / 대한법의학회지

We present the case of a 23-year-old man who suddenly collapsed during a physical altercation with his friends while in a drunken state. The post-mortem computed tomography (CT) with angiography revealed acute basal subarachnoid hemorrhage with rupture of the left middle cerebral artery. On autopsy, the head, face, mandible and neck showed multifocal hemorrhages with fracture of the hyoid bone, and the pathologic findings of the brain was consistent with CT findings. However, the vascular rupture site was not observed macroscopically. On histologic examination, a microscopic focal rupture was identified at the proximal portion of the middle cerebral artery, and possibility of arteriopathy was considered. This case illustrates that other parts of intracerebral arteries (other than the vertebral arteries) can be the culprit of rupture in the case of traumatic basal subarachnoid hemorrhage, and the post-mortem angiographic findings can be helpful in targeting the site of vascular injury. Furthermore, meticulous sampling of intracranial vessels could help find the vascular rupture site and identify any histologic findings suspicious of arteriopathy. Therefore, we suggest that post-mortem angiography can be an effective and adjunctive tool for a tailored approach in finding the vascular injury, and that histologic examination of both the intracranial and extracranial arteries be important to medicolegally ensure the death of traumatic basal subarachnoid hemorrhage and to examine presence of arteriopathy as a predisposing factor.

Radiologic Findings and Patient Factors Associated with 30-Day Mortality after Surgical Evacuation of Subdural Hematoma in Patients Less Than 65 Years Old

OBJECTIVE: The purpose of this study is to evaluate the associations between 30-day mortality and various radiological and clinical factors in patients with traumatic acute subdural hematoma (SDH). During the 11-year study period, young patients who underwent surgery for SDH were followed for 30 days. Patients who died due to other medical comorbidities or other organ problems were not included in the study population. METHODS: From January 1, 2004 to December 31, 2014, 318 consecutive surgically-treated traumatic acute SDH patients were registered for the study. The Kaplan–Meier method was used to analyze 30-day survival rates. We also estimated the hazard ratios of various variables in order to identify the independent predictors of 30-day mortality. RESULTS: We observed a negative correlation between 30-day mortality and Glasgow coma scale score (per 1-point score increase) (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.52–0.70; p<0.001). In addition, use of antithrombotics (HR, 2.34; 95% CI, 1.27–4.33; p=0.008), history of diabetes mellitus (HR, 2.28; 95% CI, 1.20–4.32; p=0.015), and accompanying traumatic subarachnoid hemorrhage (hazard ratio, 2.13; 95% CI, 1.27–3.58; p=0.005) were positively associated with 30-day mortality. CONCLUSION: We found significant associations between short-term mortality after surgery for traumatic acute SDH and lower Glasgow Coma Scale scores, use of antithrombotics, history of diabetes mellitus, and accompanying traumatic subarachnoid hemorrhage at admission. We expect these findings to be helpful for selecting patients for surgical treatment of traumatic acute SDH, and for making accurate prognoses.

MRI evaluation of superficial siderosis of the central nervous system after traumatic subarachnoid hemorrhage / 实用放射学杂志

Objective To assess the diagnostic value of 3D-enhanced T2 ? weighted angiography (ESWAN )in evaluating superficial siderosis of the central nervous system (SS-CNS)after traumatic subarachnoid hemorrhage (tSAH).Methods ESWAN and GRE T2 ? WI sequence were performed on 30 patients with tSAH,detection rate and the number of distribution areas of SS-CNS were compared between the two sequences.A McNemar’s test and Wilcoxon signed-rank test were used to analyze the differences between T2 ? WI and ESWAN images sequences. Results In the tSAH group,29 of 30 patients (96.7%)showed SS-CNS on ESWAN images,the total number of SS-CNS regions was 134.Identified SS-CNS positive rate respectively was 95.8% (23/24)on ESWAN images and 66.7% (1 6/24)on T2 ? WI in 24 patients simultaneously perform ESWAN and T2 ? WI sequences.A McNemar ’s test showed that there was significant difference between the positive rates of two sequences in detecting the SS-CNS (χ2 =7.0,P <0.05).The number of SS-CNS regions on ESWAN images and T2 ? WI was 106 and 34 respectively.The Wilcoxon signed rank test showed that the number of SS-CNS regions difference between two sequences was significant (Z =-4.225,P <0.01).Conclusion Various degress of SS-CNS are detected in a majority of tSAH atients.ESWAN sequence is a reliable and efficient method for assessment of SS-CNS.

Opportunity of forensic medical identification for simple traumatic subarachnoid hemorrhage / 复旦学报（医学版）

Objective To investigate the identification time and attention issue for simple traumatic subarachnoid hemorrhage (STSAH).Methods A total of 51 cases of STSAH from Center of Forensic Science,Siping Policy Security Bureau during 2014 to 2016 were analyzed retrospectively.Statistical methods used for sex,age,bleeding site,injury style and treatment outcome in forensic medical identification.Results In 46 cases of STSAH,high-density shadow in bleeding site narrowed gradually with regular change by CT scan,meanwhile clinical features disappeared gradually after longer treatment and was given the recognition in clinical identification.In addition,5 cases of STSAH had no obvious change 14 days after the injury confirmed by repeated CT,which were not given the recognition by forensic medical identification.Conclusions Early evaluation of injury degree in STSAH cases was carefully made to ensure the reliability of forensic medical identification;meantime false positive results could be avoided by follow-up CT scan.

Clinical Observation of Shuxuening Injection in the Adjunctive Treatment of Traumatic Subarachnoid Hemorrhage / 中国药房

OBJECTIVE:To observe clinical efficacy and safety of Shuxuening injection in the adjunctive treatment of traumat-ic subarachnoid hemorrhage. METHODS:96 patients with traumatic subarachnoid hemorrhage were randomly divided into control group and observation group with 48 patients in each group. Control group was given Tranexamic acid injection,Nimodipine injec-tion and Citicoline injection,daily lumbar punctrive and determined intracranial pressure and drained cerebrospinal fluid via lumbar puncture;observation group was additionally given Shuxuening injection 20 ml added into 5% Glucose injection 250 ml,ivgtt,qd. Both group were treated for consecutive 2 weeks. Clinical efficacy of 2 groups were observed,and GCS and MCA were also ob-served before and after treatment;ADR of 2 groups were recorded. RESULTS:Excellent rate of observation group(60.42%)was significantly higher than that of control group(31.25%),with statistical significance(P0.05);7 and 14 days after treatment, GCS of 2 groups increased significantly while MCA decreased significantly,and the observation group was better than the control group,with statistical significance (P<0.05). The incidence of cerebral vasospasm,cerebral infarction and cerebral hemorrhage were 8.33%,4.17%and 4.17%in observation group,and those of control group were 16.67%,12.50%and 16.67%;the observa-tion group was significantly lower than the control group,with statistical significance(P<0.05). CONCLUSIONS:Shuxuening in-jection shows significant therapeutic efficacy in the adjunctive treatment of traumatic subarachnoid hemorrhage,with low incidence of ADR.

Demonstration of Traumatic Subarachnoid Hemorrhage from the Anterior Choroidal Artery

We present a case of angiographically confirmed transection of the cisternal segment of the anterior choroidal artery (AChA) associated with a severe head trauma in a 15-year old boy. The initial brain computed tomography scan revealed a diffuse subarachnoid hemorrhage (SAH) and pneumocephalus with multiple skull fractures. Subsequent cerebral angiography clearly demonstrated a complete transection of the AChA at its origin with a massive extravasation of contrast medium as a jet trajectory creating a plume. We speculate that severe blunt traumatic force stretched and tore the left AChA between the internal carotid artery and the optic tract. In a simulation of the patient's brain using a fresh-frozen male cadaver, the AChA is shown to be vulnerable to stretching injury as the ipsilateral optic tract is retracted. We conclude that the arterial injury like an AChA rupture should be considered in the differential diagnosis of severe traumatic SAH.

A preliminary study on cerebral vasospasm patients with traumatic subarachnoid hemorrhage / 中华急诊医学杂志

Objective To analyze the incidence of cerebral vasospasm (CVS) in patients with traumatic subarachnoid hemorrhage(t-SAH), time windows of CVS as well as the risk factors. Method A total of 98 patients,with t -SAH admitted from June 2007 to December 2008, were enrolled for this prospective study. The hemodynamics of middle cerebral artery (MCA) in these patients was monitored with trancranial Doppler (TCD) daily for 7 days after admission and on the 14th day of hospital stay. The incidence of cerebral vasospasm (CVS) in patients with traumatic subarachnoid hemorrhage (t-SAH) ,time windows of CVS as well as the risk factors were analyzed. Results Of them, 41 patients (41.8%) had CVS. The flow velocity of MCA in patients with GCS≤ 8 was significantly higher than that in patients with GCS≥9. Classified by t-SAH cumulative blood Hijdra method, 2(4.44%) of 45 patients(45.9%)with scores 6 or less,9 (29.0%)of 31 patients (37.8%) with scores 6～ 13,and 8 (36.4%) of 22 patients (20.0%)with scores 13 or more had CVS. Severe CVS occurred in 13 (35. 1% )of 37 surgical patients (37.8%), and local cerebral infarction occurred in four surgical patients after symptomatic treatment. The flow velocity of the MCA was significantly higher in surgical patients than that in non-surgical patients 3 days after admission. Conclusions The severity of original trauma, bleeding, location of t-SAH and operation are the major risk factors to lead to CVS in patients with t-SAH. Attention should he paid to those risk factors during the treatment of patients with t-SAH.

Subarachnoid hemorrhage misdiagnosed as acute subdural hematoma / 中国综合临床

Objective To explore the features of subarachnoid hemorrhage (SAH) manifested as crescentshaped high density changes on brain CT.Methods The clinical data of 32 eases of tSAH similar to acute subdural hematoma ASDH were retrospectively analyzed.Results 2 cases of 3 receiving operation procedure were cured and 1 was slightly disabled.28 cases of 29 receiving non-operation treatment were cured and l was slightly disabled. Conclusion Because sometimes tSAH is featured as crescent-shaped high density image on brain CT,which will have a better effect through non.operation,so it is easily misdiagnosed as ASDH.

Analysis of Traumatic Subarachnoid Hemorrhage due to Blunt Force Trauma on Facial Region / 대한법의학회지

Traumatic subarachnoid hemorrhage (T-SAH) is said to be typically occurred in a young, healthy, but intoxicated man who receives a minor blow, immediately collapses, and dies within minutes. Sixteen forensic cases of T-SAH were analysed in the point of time of collapse, blood alcohol level, injured site, vascular rupture sites, and sentenced servitude. Majority of the cases (12 cases) were autopsied in the department of Kyungpook National University. Two cases of National Institute of Scientific Investigation, South District Office and 1 case of Jeju National University were added. Autopsy was not done in one case. There were 14 male and 2 female victims. The peak age were their forties (7 cases) and under twenties (7 cases). The time of incident was most often at night. The survival time from the time of trauma until death indicates that 62.5% (10 victims) died immediately from the assault, 12.5% (2 victims) died within 30 minutes. Blood alcohol was detected in 11 cases (68.8%), and mean blood alcohol level was 0.16% (0.08-0.22%). The damage was generated to the facial region, especially around the jaw and below the ears (7 cases), and temporal areas (4 cases). Bleeding foci were detected in 7 cases; basilar artery (2 cases), left vertebral artery (2 cases), and right vertebral artery (3 cases). Meticulous autopsy techniques for identifying the vascular rupture sites are required. The author conclude that tremendous emphasis must be placed on the fact that fatal T-SAH can occur due to minor facial trauma and social campaign for alerting people to the danger of T-SAH is needed.

Comparison of Computed Tomography Findings between Aneurysmal and Traumatic Subarachnoid Hemorrhage

OBJECTIVE: The purpose of this study is to identify any differential point in computerized tomographic(CT) findings between aneurysmal subarachnoid hemorrhage(ASAH) and traumatic subarachnoid hemorrhage(TSAH), which sometimes make us not confident in differentiation. METHODS: CT of 142 ASAH and 82 TSAH patients over the last 2 years were retrospectively reviewed. We evaluated the thickness of SAH, the laterality of sylvian cisternal hemorrhage, the location, the number of involved cisterns, and the associated other lesions between two types of SAH. RESULTS: Suprasellar cisterns and sylvian cisterns were most prominently and frequently involved cisterns in ASAH but cortical sulci and sylvian cisterns were most frequently involved in TSAH. Intraventricular and intracerebral hemorrhage were frequently seen in ASAH. Thickness of SAH over 1 mm, bilateral sylvian SAH, multiple cisternal SAH were in favor of ASAH. The number of involved cisterns were more frequently seen in ASAH than in TSAH. In ASAH, bilateral sylvian hemorrhages were more frequently seen than in TSAH. Skull fracture, subdural hematoma, subgaleal hematoma, and hemorrhagic contusion were frequently associated with TSAH. CONCLUSION: As a result of our study, the authors conclude that when IVH, hydrocephalus, thick SAH>1 mm bilateral sylvian SAH, and multiple cisternal SAH are seen in CT, immediate angiography should be performed to rule out cerebral aneurysms whether associated with other traumatic lesions or not.

Effect of Nimodipine on Prognosis in Traumatic-subarachnoid Hemorrhage Patients / 医学研究杂志

Objective To explore the effect s of nimodipine therapy and prognosis in patients with traumatic subarachnoid hemorrhage.Methods 138 patients were randomly divided into treatment group and control group.The treatment group(70 cases)received early nimodipine therapy and the control group(68 cases)was supported with common method.At the same time,the complications with cerebral infarction and hydrocephalus during treatment were observed and the prognosis were judged.All data were statistily analyse.Results The incidence rate of cerebral infarction and hydrocephalus in nimodipine treatment group was lower obviously than control group.And prognosis in treatment gruoup were better than those of control group.Conclusions It is useful that the cases of cerebral injury with traumatic subarachoid hemorrhage receive the treatment of nimodipine.The early nimodipine therapy can be beneficial to depress the occurrence of cerebral infarction and hydrocephalus and improve the prognosis.

Therapeutic Efficacy of Cinepazide Maleate for Traumatic Subarachnoid Hemorrhage / 中国药房

OBJECTIVE:To evaluate the clinical efficacy of cinepazide maleate in combination with magnesium sulfate for traumatic subarachnoid hemorrhage.METHODS:A total of 160 patients with traumatic subarachnoid hemorrhage were randomly assigned to 4 groups:Control group(n=40)received conventional therapy alone(hemostasis,dehydration,hormone and drugs promoting recovery of nervous function;Group Ⅰ(Control group,n=40)received cinepazide maleate plus conventional therapy;Group Ⅱ(n=40)received magnesium sulfate plus conventional therapy,and Group Ⅲ(n=40)received cinepazide maleate in combination with magnesium sulfate in additional to the conventional therapy.All the drugs were given in every 12 h for 14 consecutive days.Transcranial Doppler(TCD)examination was scheduled at 0,3,7,14 days after admission to observe the incidences of cerebral angiospasm(CVS)and patients' prognosis.RESULTS:There were significant differences between Group Ⅲ and the other 3 groups(Control group,Group Ⅰ and Group Ⅱ)in the incidence of CVS,the change of the blood flow rate of the middle cerebral artery and patients' prognosis at 3 and 6 months respectively(P

Prognostic Factors in Head-injured Patients with Traumatic Subarachnoid Hemorrhage

The presence of traumatic subarachnoid hemorrhage on the initial computerized tomographic scans has been known to be associated with worse results. By means of a simple and reliable computerized tomographic grade system proposed by Greene and his colleagues, prognostic factors of the traumatic subarachnoid hemorrhage was significantly related to clinical outcome at the time of discharge from acute hospitalization. Between February 1992 and August 1995, 3975 patients were admitted to our department of neurosurgery due to head injury. Clinical data were retrospectively reviewed to ascertain the relationship of the thickness of traumatic subarachnoid hemorrhage, its location, evidence of mass lesion(s), midline shift, obliteration of the basal cistern, and cortical sulcal effacement to outcome. Additionally, initial Glasgow coma scale score, arterial gas study, systemic blood pressure and prothrombin time were also analyzed for the same purpose. Among 3975 head-injured patients, 213 patients were identified to h ave traumatic subarachnoid hemorrhage on the initial computerized tomographic scan. Among 213 traumatic subarachnoid hemorrhage patients, the patients treated with calcium channal blocker(32 patients) and 3 patients lost to follow-up were excluded from this study for a total of 178. The computerized tomographic scan findings were divided into a 3 grade system;Grade 1 indicating only traumatic subarachnoid hemorrhage, Grade 2 indicating traumatic subarachnoid hemorrhage with mass lesion(s) , Grade 3 indicating traumatic subarachnoid hemorrhage with mass lesion(s) and midline shift. All these data were compared to Glasgow outcome scale on discharge, and arbitrarily these were divided into the good(good recovery and moderate disability) and the bad(severe disability, vegetative state and death). The authors conclude that the contributing factors to outcome at discharge were as follows:1. midline shift(p=0.002), PT< or =70%(p<0.001), obliteration of the basal cistern(p=0.001) and cortical sulcal effacement(p=0.001) were shown to the statistically significant. 2. initial computerized tomographic grade contributed to outcome at discharge.