Tangled Throughout Life: A Case of Paediatric Ruptured Cerebral Arteriovenous Malformation

@#Arteriovenous malformation (AVM) in children is uncommon occurrence defined as presence of arteriovenous shunting through coiled and tortuous vascular connections. We discussed a case of a 3-year old girl presented with acute left facial asymmetry and right-sided limb weakness. Neurological examination revealed MRC scale of 0 out of 5 for power on her right side. Magnetic Resonance Angiography (MRA) revealed bilateral thalamic AVM. Surgical resection was not advisable in view of deep-seated location. Paediatric AVM most often become apparent following rupture with majority presents with headache. Ruptured paediatric AVM carries high burden of morbidity and mortality. Paediatric intracranial haemorrhage posed tremendous concern regarding its long-term outcome. Treatment would be more appropriate sooner rather than later especially for those presented with ruptured AVM. Surgical resection remains the gold standard treatment for all accessible paediatric AVMs with embolization and radiosurgery as adjunctive therapies. AVM in paediatric population is rare but carries grim prognosis.

Complicaciones neurológicas en un niño con neumonía por influenza: reporte de caso clínico / Neurological complications in a child with influenza pneumonia: clinical case report

RESUMEN La influenza es una enfermedad endémica transmisible, en Ecuador los subtipos de virus que circulan son A(H1N1), A (H3N2) y tipo B. Existen dos picos de circulación del virus que fueron registrados en Ecuador en los años 2016 y 2018, siendo éste último el de mayor incidencia. Las complicaciones neurológicas asociadas a la influenza han sido descritas de manera poco frecuente, representando el 10% de los niños afectados y los reportes que existen la mayoría son de niños y adultos jóvenes. En el presente artículo se reporta un caso ocurrido en el 2018 de un lactante mayor con cuadro de neumonía por Influenza A/H3, Influenza A/pan1, Influenza A/pan2, virus Parainfluenza 1, complicada con derrame pleural izquierdo y atrofia cerebral y microhemorragias cerebrales.Palabras claves: Influenza; neumonía; neurología; derrame pleural; atrofia cerebral; hemorragia cerebral; informes de caso

BSTRACT Influenza is a transmissible endemic disease, in Ecuador the virus subtypes that circulate are A (H1N1), A (H3N2) and type B. There are two peaks of virus circulation that were registered in Ecuador in 2016 and 2018, the latter being the one with the highest incidence. The neurological complications associated with influenza have been described infrequently, representing 10% of the affected children and the reports that there are the majority are of children and young adults. This article presents a case in 2018 of an older infant with Influenza A / H3 pneumonia, Influenza A / pan1, Influenza A / pan2, Parainfluenza virus 1, complicated with left pleural effusion and cerebral atrophy and cerebral microhemorrhages.Keywords: Influenza; pneumonia; neurology; pleural effusion; Brain atrophy; cerebral haemorrhage; case reports.Correspondencia: Paúl MoscosoTeléfonos: (593) 987 038 828e-mail: paulmoscoso@hotmail.comIDs OrcidPaúl Moscoso: https://orcid.org/0000-0001-9018-7611Dayana Navarro: https://orcid.org/0000-0001-8601-9965Nicolás Espinosa:https://orcid.org/0000-0001-9825-0136

Casuística, manejo y resultados de los aneurismas cerebrales en el Hospital de Clínicas - Paraguay, desde el 2011 al 2019 / Casuistry, management and results of brain aneurysms at the Hospital de Clínicas - Paraguay, from 2011 to 2019

Introducción: La Hemorragia Subaracnoidea es el sangrado en el espacio subaracnoideo. La causa espontánea en la mayoría de las veces se debe a ruptura de un aneurisma cerebral. Objetivo: Describir la casuística, manejo y resultados de los aneurismas cerebrales en el Hospital de Clínicas. Pacientes y método: Estudio observacional, descriptivo, transversal, incluyendo pacientes operados de aneurismas cerebrales, mayores de 17 años, en el Hospital de Clínicas del 2011 al 2019. Las variables descriptas fueron: edad, sexo, motivo de consulta, estudios radiológicos, escala de Glasgow y Hunt y Hess, localización, segmento, cantidad, fase, clipado temporario, vasoespasmo e hidrocefalia. Resultados: Se incluyó 249 pacientes; 45% masculino, 65% femenino, con edad promedio de 47,5 años. El motivo de consulta más frecuente fue cefalea. Al ingreso tuvieron predominantemente Hunt y Hess 2, y, Glasgow 15. El 43,2% eran Fisher 4. El Glasgow de egreso fue mayor o igual a 14 en 82,1%. Se diagnosticó el 51,7% con arteriografía; el 50,9% de los aneurismas en la carótida interna y, fueron múltiples en 10,84%. Se operaron en fase aguda 28,3%, 65% en fase tardía y, el 6,7% de los aneurismas fue de hallazgo casual. En 36,44% de los casos se realizó clipado temporario y, en el 70,4% se perforó la lámina terminalis. La mortalidad fue de 4,2%. Presentaron vasoespasmo radiológico en un 46% y, vasoespasmo clínico en 24,5 %. El 11% fue sometido a craniectomía descompresiva y, 5,5% desarrolló hidrocefalia dependiente de VDVP. Conclusión: El clipado de los aneurismas cerebrales es una técnica con buenos resultados y la única accesible en el sector público.

Introduction: Subarachnoid hemorrhage is bleeding in the subarachnoid space. The spontaneous is caused most of the time by rupture of a cerebral aneurysm. Objective: Describe the casuistry, management and results of cerebral aneurysms at the Hospital de Clínicas. Patients and methods: Observational, descriptive, cross-sectional study including patients operated for cerebral aneurysms, older than 17 years, at the Hospital de Clínicas from 2011 to 2019. The variables described were: age, sex, reason for consultation, radiological studies, Glasgow and Hunt and Hess scale, location, segment, quantity, phase, temporary clipping, vasospasm and hydrocephalus. Results: 249 patients were included; 45% male, 65% female, average age 47.5 years. The most frequent reason for consultation was headache. At admission they had predominantly Hunt and Hess 2, and Glasgow 15. 43.2% were Fisher 4. The Glasgow of discharge was greater than or equal to 14 in 82.1%. 51.7% were diagnosed with arteriography; 50.9% internal carotid aneurysms, multiple 10.84%. 28.3% were operated in acute phase, 65% late phase, 6.7% were a casually found. In 36.44% of cases a temporary clipping was performed and in 70.4% the lamina terminalis was perforated. Mortality was 4.2%, radiological vasospasm 46%, clinical vasospasm 24.5%, 11% underwent decompressive craniectomy and 5.5% developed VDVP-dependent hydrocephalus. Conclusion: The clipping of cerebral aneurysms is a technique with good results and the only one in the public sector.

Modified Rood’s approach and ability of independent selfcare in haemorrhagic stroke patients of Assam, India

Background: Stroke is the third leading cause of death and the primary cause of serious, long-term disability which can be regarded as weakness, generalized fatigue, loss of voluntary motor control or limitation in mobility, spasticity, sensory and cognitive dysfunction. In this research, a comparative study on the ability of independent self-care was conducted between two groups of patients during a 3 months follow-up period viz. Group A - patients who were given Home Exercise Programme (HEP) with conventional physiotherapy; and Group B - patients who were given HEP with conventional physiotherapy along with neuro-facilitation via Rood’s approach.Methods: In this study 236 haemorrhagic stroke patients were recruited and randomly divided to two groups.  Both the groups were given a HEP consisting of regular physiotherapy. Additionally, one group out of the two was also taught exercises based on Rood’s approach consisting of facilitation and inhibition with the help of sensory stimulation, purposeful activity based exercises, with additional emphasis on repetition. The output was evaluated in terms of disability using the Barthel Index after 3 months of treatment.Results: After 3 months, it was found that patients who received HEP with both conventional physiotherapy and Rood’s approach had significantly greater improvement in Barthel Index scores compared to patients who received HEP only through conventional physiotherapy.Conclusions: This suggests that HEP consisting of conventional physiotherapy along with Rood’s approach is more effective in improving the ability of independent self-care in case of post intra-cerebral haemorrhagic patients when compared to conventional physiotherapy alone.

Detection of Microhemorrhages in Cerebral Amyloid Angiopathy by Susceptibility Weighted MR Imaging – An Observational Study

Introduction: Cerebral amyloid angiopathy (CAA) is acause for approximately 10-20% of spontaneous intracerebralhaemorrhage in elderly population. Susceptibility weightedimaging (SW1) is a new imaging method is clinically usefulfor evaluating the presence of chronic blood products in thebrain, especially clinically silent microbleeds associatedwith cerebral amyloid angiopathy. Aim of this study was todetermine the advantages of Susceptibility weighted imaging(SW1) over conventional gradient echo (GRE) technique in aprobable diagnosis of Cerebral amyloid angiopathy.Material and Methods: All patients more than 55 yrspresented with neurological signs and symptoms referredfor neuroimaging, were subjected to image with MRI usingT1W, T2W, FLAIR. AXIAL 2D MERGE, Diffusion weightedimaging (DWI) including apparent diffusion coefficient(ADC) and Susceptibility weighted imaging (SWI). Thosecases having multiple macro and micro haemorrhagesinvolving cortical and sub cortical region detected by eithergradient or SWI included in the study.Results: Sudden onset of neurological deficit was the mostcommon symptom which accounted for 37% of cases.Cortical and sub cortical regions are most commonly involvedsites. On comparison between gradient and SWI, 11 caseshaving micro hemorrgages detected only by SWI and absentin gradient.Conclusion: GE - T2* MR imaging is currently the “ standard”for identifying microhemorrhages and diagnosing cerebralamyloid angiopathy based on number and distribution of microhaemorrhages. SW1 identified many more microhemorrhagesthan conventional T2* weighted GE magnitude technique andmay lead to earlier diagnosis of patients with CAA.

Clinical outcome in cases of hypertensive intra-cerebral haemorrhage in relation to size of haemorrhage

Introduction: Stroke is amongst the leading causes of death exceeded only by heart disease and cancer. Those who survive are usually left with permanent disability. Cerebral infarction is responsible for about 80 percent of all strokes, primary intra-cerebral haemorrhage for 10 percent, subarachnoid haemorrhage for 5 percent and 5 percent cases are due to uncertain causes. Predictors of prognosis in primary intraparenchymal haemorrhage have been evaluated in numerous studies. Objective: To observed the effect of different sizes of hematoma and utilizing them, if feasible as a marker of prognostic significance. Material and methods: In this study we observed 60 patients from the time of admission till 30th day in various wards of Department of Medicine RIMS with hypertensive intra-cerebral haemorrhage, during the period of 2008-2009. A simple method of measuring the volume of haematoma (in cc) on the CT scan is by using the following formula: A*B*C A = longest diameter of the haematoma (in cm.), B = Diameter perpendicular to A (in cm.), C = Height (in cm) which is measured by No. of slices showing the haematoma x thickness of each slide. Result: Total 60 patient were taken into study out of which 33(55%) were alive and 27(45%) were dead in 30 days follow up. In our study, 38 were male and 22 were female out of 38 male 22(66.66%) were alive and 16 (59.2%) dead and in 22 female 11(33.33%) were alive and 11 (40.7%) were dead. Outcome with volume of ICH using the χ2 had shown significant correlation (p < 0.005) with GCS at the time stroke onset (P<0.01), IVH/VE (P<0.01), midline shift test (P<0.01), B.P. at the time of admission (P<0.01). Conclusion: In these study patients with hematoma volume exceeds 60 cm3, the mortality was 100%. Mean volume of hematoma in our study was 35.21 cm3.

Platelet transfusion prevents the perioperative bleeding in patients with antiplatelet therapy-associated cerebral hemorrhage / 中国神经精神疾病杂志

Objective To explore the application value of thromboelastography(TEG) in perioperative evaluation of patients with antiplatelet therapy-associated cerebral hemorrhage. We aimed to investigate whether platelet transfu-sion, compared with standard care, reduced bleeding in patients with antiplatelet therapy-associated cerebral hemor-rhage. Methods A retrospective analysis of clinical data was conducted in 30 patients (12 patients receiving platelet transfusion) with antiplatelet therapy-associated basal ganglia hemorrhage who underwent emergency surgery. TEG was used to evaluate the intraoperative bleeding, postoperative bleeding and transfusion treatment. Results The routine co-agulation test was in the normal range in the two groups. However, TEG showed that the platelet function was exces-sively inhibited in patients with antiplatelet therapy before spontaneous cerebral hemorrhage (Platelet inhibition rate>90%). There were significant differences in the intraoperative blood loss (t=-3.998, P=0.008), total transfusion volume (Z=-3.245, P=0.001), postoperative hematoma volume (t=-2.909, P=0.043) and lead volume (t=-8.790, P=0.041) between two groups (P<0.05). One case from platelet transfusion group, and 4 cases from no-platelet transfusion group re-ceived a second surgical operation. However, the difference was not statistical significant ( P=0.317). Conclusion TEG can effectively assess the preoperative coagulation status in the patients with spontaneous cerebral haemorrhage after antiplatelet therapy. Platelet transfusion can reduce intraoperative and postoperative bleeding, decrease blood transfu-sion in the patients with antiplatelet therapy-associated cerebral hemorrhage.

Análisis integral de un caso de moyamoya reportado en la ciudad de Barranquilla (Colombia) / Comprehensive analysis of Moyamoya case reported in Barranquilla (Colombia)

Resumen Este caso clínico muestra los resultados del análisis e intervención interdisciplinar que se realizó en una paciente femenina de 8 años diagnosticada a la edad de 3 años con enfermedad de moyamoya. Remitida para evaluación, se encontró estenosis progresiva de las arterias cerebrales. La evaluación del desarrollo motor mostró poca agilidad motora gruesa y fina, bajo tono, debilidad muscular, dificultad para establecer movimientos alternos y simultáneos, además dificultad al masticar y deglutir, por lo que requirió ajuste de la minuta alimenticia por parte de nutrición. Falta de control esfinteriano. En los aspectos cognitivos se evidenció déficit, falta de comprensión de órdenes, desconocimiento de categorías semánticas, falta de seguimiento de instrucciones, tratado por fonoaudiología y terapia ocupacional. Estado emocional preservado, capacidad de establecer vínculos afectivos y empatía; en lo familiar se presentó disfuncionalidad familiar por miembro enfermo, que es el eje central en la dinámica familiar, negligencia familiar con otros miembros, desajuste de roles. Se estableció intervención psicoterapéutica, con enfoque cognitivo conductual, apoyado en el modelo de Terapia Racional Emotiva, Psicoeducación, Terapia familiar sistémica. Seguimiento médico con fármacos y evaluación de pruebas diagnósticas. En tres años de seguimiento se evidenció: adaptación progresiva en adquisición de habilidades sociales, reacciones afectivas en su núcleo familiar y entorno, lo cual permitió concluir que las estrategias adoptadas generaron un cambio significativo en el contexto familiar, con adopción de factores protectores, identificación de roles, cambios en la adherencia, lo que en conjunto permitió mejoras en la calidad de vida y clínica de la paciente.

Abstract The clinical case presented in this article reflects the results of the analysis and interdisciplinary intervention that was performed on a 8 year old female patient diagnose at 3 years old with the Moyamoya disease, she was referred for evaluation, finding progressive stenosis of the brain arteries, the motor development evaluation exhibit low gross and fine motor agility, low muscle tone, muscular weakness, difficulty to set alternating and simultaneous movements, also trouble to masticate and swallowing, so it required adjustment of the food diet in the behalf of her nutrition. Absence of sphincter control. In the cognitive aspects it was evident the lack of understanding orders, lack of semantic categories, failure to follow instructions, it was treated by speech therapy and occupational therapy. Emotional state preserved, ability to bond and empathy, in the familiar aspect it exhibit family dysfunctionality because of sick family member that is now the focus on the family dynamic, family neglect with other members, mismatch roles. Was established psychotherapeutic intervention with cognitive behavioral approach, supported the model of Rational Emotive Therapy, psychoeducation, systemic family therapy. Medical monitoring with drugs and evaluation of diagnostic tests. It was evident in three years follow-up: Progressive adaptation acquisition of social skills, affective reactions in the household and environment, which it led to the conclusion that the strategies adopted generated a significant change in the family context, with adoption of protective factors, identifying roles, changes in adhesion, which together allowed improvements in quality of life and clinical patient.

Hemorragia talámica bilateral simultánea / About bilateral and simultaneous thalamic hemorrhagic stroke

Las hemorragias intraparenquimatosas corresponden a un 10% de los casos de ACV (1), de las cuales solo el 0.7-3% ocurren de manera bilateral y simultánea (2-8). Este tipo de hemorragias son raras, y en su mayoría secundarias a hipertensión arterial. La gran mayoría de casos se han reportado en pacientes asiáticos, y solo algunos pocos casos se han descrito en América latina. A continuación se reporta el caso de un paciente con hemorragia talámica bilateral simultánea y se revisa la literatura acerca de esta patología en América Latina.

Intracerebral haemorrhages represent about 10% of all stroke causes (1), yet only 0.7-3% happen bilaterally and simultaneously (2-8). This type of haemorrhages are not common, and are mostly secondary to arterial hypertension. The mayority of cases have been reported in asians, with only a few cases described in Latin America. We report the case of a latin patient with a bilateral simultaneous thalamic haemorrhage, and review the literatura concerning this pathology in Latin America.

A Snapshot of Stroke from Miri Hospital

Our objective was to study the profile of cerebrovascular accidents and proportion of cerebral haemorrhage (CH) among stroke patients. This project was designed after we observed higher incidence of CH in Miri hospital as compared to conventionally reported data. Methods: This was a prospective observational study conducted from 1st June 2008 to 31st May 2009. All patients admitted in both male and female wards of the Medical Unit with the first incidence of a stroke were recruited for analysis. CT scan brain was done in all patients. Results: Total admissions in one year in the medical department were 3204 patients, both male and female together, out of which 215 were due to a first incidence of stroke; Stroke accounted for 6.7% of admissions and 16.8% of deaths in medical unit. 139 (64.7%) were ischaemic strokes and 76 (35.3%) were cerebral haemorrhages. The incidence of CH (35.3%) was high compared to regional data. 71.7% % (154) patients had preexisting hypertension. Higher incidence of hypertension, diabetes mellitus and aspirin intake was noted in the ischaemic group. Also compliance to treatment for hypertension was better in the Ischaemic group with more defaults in CH category (P<0.01). Significantly more deaths were noted in patients with higher systolic blood pressure on presentation, poor Glasgow Coma Scale (GCS) and those with dysphagia. Conclusion: Every third stroke was due to cerebral hemorrhage; CH patients were largely unaware of their hypertension or were altogether treatment naïve or defaulters while compliance was far better in ischaemic stroke category.

Capsulo-ganglionic bleed: Murder or pathology.

Intra parenchymal (intra cerebral) haemorrhage is the most common type of spontaneous intracranial haemorrhage. It accounts for 10% of all strokes with a 50% case fatality rate. Hypertension is the one of the most common causes of intra parenchymal haemorrhage followed by other causes like, amyloid angiopathies, cocaine abuse, haematologic disorders and head injury. The present case is a case of death due to intra parenchymal haemorrhage where the relatives of the deceased alleged the death to have been caused as a sequel to an assault by neighbours. Autopsy conducted by experts proved that death was due to pathology and not trauma, thereby assisting in establishment of justice. Usually a single deep seated intracranial haemorrhage in ganglionic region without any injury to scalp, skull and brain is due to natural disease. Hypertension is the most common cause of spontaneous intracranial haemorrhage.

Effect of intensive blood pressure reduction on prognosis and early hematoma growth in acute intracerebral haemorrhage / 中华急诊医学杂志

Objective To study the safety and efficacy of intensive reduction of blood pressure for the treatment of acute cerebral haemorrhage. Method A randomized control trial in 41 consecutive patients with intracerebral haemorrhage admitted from October 2006 to January 2007 were randomly assigned to intensive blood pressure reduction group ( n = 24) or guidelines blood pressure reduction group ( n = 17) (tho guidelines set by American Association of cardiologists). In the intensive reduction group, the systolic pressure was reduced immediately to lower than 140 mmHg, while the blood pressure was reduced to that just below 180 mmHg in guideline reduction group. The size of the haematoma was measured 24 h after treatment by CT scans and the patients were followed up for 90 days. Death and/or disability in 90 days, and the short-term and long-term neurological function and the size of haematoma in 24 hours of two groups were compared. The outcomes were statistically analyzed with SPSS version 10.0 software. Measurement data were analyzed with t -test while numeration data were analyzed with chisquare test. Results There were no significant differences either in death and/or disability or in short-term and long-term neurological function in 90 days after treatment ( P ＞ 0.05). The mean values of proportional enlargement of haematoma were 16.8% in the intensive group and 36. 1% in the guidelines group 24 hours after treatment ( P = 0.012). The mean values of absolute enlargement of haematoma of two groups were 2.7 mL and 5. 1 mL,respectively (P = 0.058). There was significant difference in rate of enlargement of haematoma in the early stage of acute cerebral haemorrhage (4.2% vs. 47. 1%, P = 0.012). Conclusions Although intensive reduction of blood pressure in patients with acute cerebral haemorrhage did not alter the clinical prognosis of patients, it could apparently attenuate the enlargement of haematoma in the early stage of acute cerebral haemorrhage.

Relation and prevention between aspirin and relapsing haemorrhage after operation in cerebral haemorrhage patients / 中华急诊医学杂志

Objective To explore the relation and measures prevention between aspirin and relapsing haemorrhage after operation in cerebral haemorrhage patients. Method It' s a prospective control study. A total of 725 patients with hypertensive basal ganglia cerebral haemorrhage admitted to department of neurosurgery from January 2001 to May 2007 were enrolled. They were diagnosed according to the diagnostic criteria set by the fourth national cerebrovascular disease conference in 1995. Haematoma volume was ＞ 50 mL. All patients were treated with craniotomy. And those with respiration and circulation failure, neurologic function deficit before the onset of the disease,major organ dysfunction, haemorrhagic disease and bleeding tendency or applied medicines affecting coagulation function excepted aspirin were excluded. The patients without use of aspirin before the onset of the disease were operated as the control group(group A), and there were 389 patients in group A.The patients with use of aspirin before the onset of the disease were randomly assigned to group B and C group,and there were 168 patients in group B or group C.The patients in group C received the frozen apheresis platelets. We counted different haematoma volume of relapsing haemorrhage after operation,death rate,ADL scores grades by 6 months follow-up survey in three groups. Quantitative data were expressed as mean ± standard deviation (-x ± s). The data were analyzed by using Chi-square test and Student's t test and rank sum test with SPSS 13.0 statistical package. A P value less than 0.05 indicated statisticals significance. Results Haematoma volume of relapsing haemorrhage was (40.59 + 20. 061 )mL, (53.21 ± 21.260) mL, (40.68 ± 19.517) mL in groups A, B, C,respectively. There was significant difference between group A and group B ( P ＜ 0.01 ), between group B and group C ( P ＜ 0.05), but there was no significant difference between group A and group C(P ＞ 0.05). ADL scores grades at 6-month follow-up was (67.04 ± 26. 176), (54.47 ± 29.403 ), (68.21 ± 25.254) in groups A, B, C, respectively. There was more significant difference between group A and group B, in ADL scores grades and the death rate between group B and group C (P ＜ 0.01), but there was no significant difference between group A and group C (P ＞ 0.05). Conclusions Aspirin can increase the occurrence rate of haemorrhage after operation, disablement and death in cerebral haemorrhage patients, but frozen apheresis platelets can reduce the occurrence rate.

Relationship between the homocysteine level and stroke / 中国康复理论与实践

@#ObjectiveTo study the relationship between the homocysteine (Hcy) level and stroke. Methods57 cases, including cerebral haemorrhage (CH, 21 cases) and cerebral infarction (CI, 36 cases) , and 28 healthy cases as control group were selected to measure their level of Hcy, VitB12 , folic acid and creatinine(Cr). At the same time, the clinical neurological disfunction scale(CNDS) of all patients was evaluated and the hematom volume (HV) of the CH group was assayed. ResultsThe Hcy level of both CI and CH group was significantly higher than that of the control group(P<0.05 or P<0.01). No significant difference was found between CI and CH group on Hcy level. The Hcy level showed a very strong or strong reverse association with folic acid level in the CI and CH group (r=-0.442,P=0.007 or r=-0.531,P=0.013), but no significant correlation with VitB12 level. No correlation was found between Hcy level and CNDS in both the CI and CH group, either no correlation between Hcy level and HV in the CH group. ConclusionThere is a close relationship between hyperhomocysteine and stroke. Hcy level is reversely associated with folic acid level but not correlated with VitB12 level.