Role of b0 image obtained from diffusion weighted sequence in detection of cerebral hemorrhage

Gradient-echo [GRE] -weighted imaging [T2*WI] has higher sensitivity than do other MRI sequences used for detecting cerebral hemorrhage as it is sensitive to magnetic field in homogeneity induced by the presence of the paramagnetic breakdown products of blood. Diffusion weighted [DWI] b0 image obtained with DWI imposes no additional time and could be used for detection of hemorrhage. An Echo-planner Imaging [EPI] is intrinsically sensitive to magnetic field in homogeneity, paramagnetic blood breakdown products, it produces signal loss similar to that in T2*WI. The aim of this study is to evaluate the utility of b0 EPI image obtained from diffusion weighted sequence for detection of intracerebral hemorrhage. The study included 26 patients from Ain-Shams specialized hospital with different stages of intracerebral hemorrhage [ICH]. All patients had MRI examination including DWI including b0 image, T2*WI, TIWI, T2WI, Fluid attenuation inversion recovery sequence [FLAIR], and MRA. Radiologists reviewed the images of the examinations independently in a blinded fashion, followed by a final consensus reading. The sensitivity of hemorrhage detection, conspicuity of lesions, and diagnostic certainty were compared between the b0 EPI and GRE T2*WI sequences. b0 image was 100% sensitive in detecting different stages of intracerebral hemorrhage in the study sample [acute, subacute and chronic]. b0 image was as equal to T2*WI in detection of hemorrhage in 92.30% of cases [24 cases out of 26], in one patient b0 detected hemorrhage more clearly than T2* WI, while in the remaining patient T2*WI detected hemorrhage more clearly than b0 image. b0 EPI is as sensitive as T2*WI in detecting different stages of intracerebral hemorrhage

Effects of dexamethasone in primary intracerebral hemorrhage in the south west of Iran

Previous study revealed the value of dexamethasone in the treatment of vasogenic edema associated with brain tumor and abscess. However there are poor documented studies about its usefulness in primary intracerebral hemorrhage. In this study we evaluated dexamethasone effects in primary intracerebral hemorrhage. In a double blind randomized placebo-controlled clinical trial we evaluated 200 intracerebral hemorrhage cases between 40 to 80 years old whom were admitted at Golestan Hospital [Ahwaz, IR] between March 2002 And March 2003. They were divided in two groups; dexamethasone [N=100] and placebo [N=100]. Then mortality, GI bleeding, fever, electrolytes disturbances, hypertension and hyperglycemic status were analyzed in two groups. Ethical considerations were employed and subjects were followed by appropriate statistical methods for 21 days to assess the major outcomes. Mortality was much higher in the dexamethasone group; Dexamethasone group [49.3%] and placebo [23.4%] and also fever was higher seen in the dexamethasone group; dexamethasone group [40.2%] and placebo group [24.7%] but there was not any significant statistical difference between two groups as regards other complications. Dexamethasone is widely used for cerebral edema associated conditions but in this study we saw that it's complications in intracerebral hemorrhage such as increasing fever and mortality are significantly higher. Hence it use for treatment of primary intracerebral hemorrhage should be reconsidered

Poor diagnostic accuracy and applicability of Siriraj stroke score, Allen score and their combination in differentiating acute haemorrhagic and thrombotic stroke.

OBJECTIVE: To evaluate the relevance of bed side clinical diagnostic scoring systems--Siriraj stroke score (SSS), Allen score and their combined use for differentiating acute haemorrhagic and thrombotic stroke. MATERIAL AND METHODS: The study was conducted on 240 admitted patients of stroke over a period of two years. SSS was calculated immediately and Allen score, 24 hours after admission. CT scan was done immediately and 48 hours after admission if required. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic gain were calculated for both the scores. Comparability between the scores and CT scan finding was determined with the help of kappa statistic programme. Receiver operating characteristic curves (ROC) were plotted to assess the diagnostic accuracy of both scores over a range of cut-off points. RESULTS: One hundred and thirty four patients (55.83%) had infarction and 106 patients (44.17%) had haemorrhage. SSS was applicable in 66.25% patients (159 out of 240) while Allen score was applicable in only 61.25% patients (147 our of 240). The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic gain for SSS were 73%, 85%, 85%, 71% and 30% for infarction and 85%, 73%, 71%, 85% and 27% for haemorrhage respectively, whereas the corresponding figures for Allen score were 91%, 60%, 77%, 82% and 18% for infarction and 60%, 91%, 82%, 77% and 41% for haemorrhage respectively. There was overall moderate comparability between SSS and Allen score for diagnosing supratentorial stroke (k = 0.396). The comparability of these scores in terms of certain results was worse (k = 0.143). However when the results that were within the diagnostic range with both the scores were considered, the agreement in diagnosing infarction and haemorrhage was almost perfect (k = 0.874). While considering CT scan finding as gold standard for differentiation of infarction and haemorrhage, the overall accuracy of SSS and Allen score was seventy eight percent. CONCLUSION: (a) Applicability of SSS only in 66.25% patients and wrong diagnosis in 22.01% patients does not reflect its usefulness because adequate management of stroke requires a gold standard diagnosis which is only possible by immediate CT scan. (b) Allen score is not useful because it can be assessed only after 24 hours of onset of stroke. This deprives the management to all thrombotic patients in speculated time window of modern management.

La hemorragia extradural intracraneal aguda temporalmente contenida. El riesgo de la tomografía axial computada demasiado precoz / Temporarily contained acute intracraneal extradural hemorrhage. The risk of very early computed axial tomography

Una tomografía axial computada (TAC) de cráneo normal o mínimamente anormal obtenida ultratempranamente en el manejo de un paciente traumatizado, no siempre es garantía de una evolución clínica sin problemas. El caso a relatar epitomiza esta aseveración. Un hombre de 35 años de edad fue hospitalizado en la sala de emergencias, en coma, pero hemodinámicamente estable. Unos 30 minutos antes había sufrifo traumatismo mútiple al ser atropellado por automóvil en la vía pública, con inconciencia inmediata. En admisión, la calificación en la Escala de Coma Glasgow (ECG) fue de 7. Después de intubársele por vía orotraqueal e hiperventilado mecánicamente, una fractura expuesta de la tibia y el peroné de la pierna izquierda fue estabilizada en una férula posterior. Una TAC de cráneo, obtenida a unos 60 minutos del accidente, demostró contusión cerebral difusa, discreta hemorragia subaracnoide e intraventricular y una hemorragia insignificante extradural laminar temporal derecha de 3 mL de volumen, subyacente a una fractura lineal de la escama del hueso temporal. Las estructura de línea media y la cisterna ambiens estaban preservadas. Ocho horas más tarde sobrevino cuadro de choque sistémico, el que respondió prontamente a la administración parenteral de soluciones cristaloides. Un lavado peritoneal diagnóstico fue negativo. Dos horas después, la pupila derecha fue descubierta totalmente dilatada y fija y aparecieron en el paciente crisis mesencefálicas de extensión bilateral. La calificación en el ECG cayó a 4. Nueva TAC de urgencia reveló extenso hematoma extradural temporoparietal derecho de 105 mL de volumen, con rechazamiento de estructuras cerebrales y desaparición de la cisterna ambiens. Mediante una apremiante craniectomía, el hematoma fue removido y la arteria meníngea media activamente sangrante, electrofulgorada. Cuando fue dado de alta en el 17º día postoperatorio, el paciente estaba confuso y exhibía una hemiparesis flácida izquierda. A 18 meses de la operación el paciente está parcialmente incapacitado y confinado a una silla de ruedas

Factores de riesgo perinatal y correlación con la incidencia de hemorragia peri-intraventricular temprana en neonatos con peso menor de 1500 g / Perinatal risk factors and incidence of early periventricular intraventricular hemorrhage in very low weight infants

El propósito en este artículo es conocer la incidencia de hemorragia periventricular temprana (EPIVH), y los factores de riesgo que contribuyen a su desarrollo en recién nacidos de peso bajo al nacer, menos de 1500 g. El rastreo ultrasonográfico de cerebro se realizó en recién nacidos, con factores perinatales de riesgo con peso al nacimiento menor de 1500 g; edad gestacional menor de 34 semanas, y edad extrauterina menor de 24 horas al momento del rastreo cerebral, 91 pacientes presentaron los criterios de inclusión; 48 (52.7 por ciento) tuvieron (EPIVH); 27 (29.7 por ciento) tuvieron ecodensidades periventriculares, y 16 (17.6 por ciento) tuvieron un rastreo cerebral normal. Se encontraron diferencias estadísticamente significativas en el grupo con EPIVH y los pacientes con rastreo cerebral normal, respecto al peso al nacer, edad gestacional, y puntuación de Apgar a los cinco minutos. Los factores de riesgo perinatal que fueron signifcativos a EIVH, más de grado 1 fueron: ruptura prematura de membrana, parto vaginal y puntuación de Apgar de 0-2 al, al minuto. Los factores de riesgo más importantes para EIVH grado III e infarto cerebral fueron embarazo gemelar, parto vaginal, presentación de pelvis; traumatismo obstétrico e infección urinaria. La incidencia de EIVH es similar a la de la literatura; la operación cesárea debe considerarse como una opción o un recurso que disminuye la morbilidad y mortalidad neurológicas

Patrón clínico-tomográfico inicial en la hemorragia intracraneana por acenocumarol / Initial clinical-tomographic pattern in acenocumarol-related intracranial hemorrhage

Se efctuó un análisis retrospectivo de 18 pacientes con hemorragia intracraneana por acenocumarol para determinar su patrón clínico-tomográfico inicial. Hubo 12 hombres y 6 mujeres de 32 a 75 años de edad (media 55,57). En 10 la hemorragia fue intraparenquimatosa y en 8 subdural. Estaban sobreanticoagulados 9 casos (50 por ciento), subanticoagulados 3 casos (16 por ciento) y dentro del nivel terapéutico 6 casos (33 por ciento). Los síntomas iniciales más frecuentes fueron cefaleas en 11 casos y desorientación en 5 casos. Los signos más frecuentes al ingreso fueron: deterioro de la conciencia en 11 casos y hemiparesia en 9 casos. Hubo hemorragias fuera del sistema nervioso sólo en 3 casos. La progresión clínica fue mayor a las 24 horas en 3 hematomas subdurales y en 6 hemorragias intraparenquimatosas. La tomografía axial computada mostró 5 hematomas subdurales hiperdensos, 2 isodensos y 1 iso-hipodenso; hubo disociación clínico-tomográfica en 2 hematomas subdurales. Las hemorragias intraparenquimatosas fueron: 4 cerebelosas, 2 paracapsulares, 2 lobares, 1 múltiple (lobar-cerebelosa) y 1 mixta (lobar-subdural), en 2 se presentaron niveles líquido-sangre y el 87,5 por ciento de las hemorragias intraparenquimatosas fueron consideradas graves tomográficamente. Se puede concluir que: 1) en todo paciente que recibe acenocumarol y comienza con cefaleas y/o desorientación se debe sospechar una hemorragia intracraneana sin importar el nivel de anticoagulación o la ausencia de hemorragias extra-neurológicas, 2) el patrón clínico-evolutivo de la hemorragia por acenocumarol es similar al de la hemorragia por hipertensión arterial. Difieren sobre todo en la distribución de su localización y 3) por el patrón clínico-tomográfico de las hemorragias por acenocumarol se puede inferir que, en su producción, los factores locales juegan un papel fundamental.

Ultrasonography of the brain in preterm infants and its correlation with neurodevelopmental outcome.

Two hundred and eighteen preterm neonates had ultrasonography (USG) brain done on third, and/or seventh and fourteenth day of life. Fifty eight (26.3%) had intraventricular/ periventricular hemorrhage, 3 had parenchymal lesions. 46 had Grade I hemorrhage, 9 had Grade II, 2 had Grade III and 1 had Grade IV hemorrhage. Grade III and IV hemorrhages occurred in neonates below 34 weeks gestation. There was an inverse relationship between gestation age and hemorrhage (p = 0.0001). A comparison of incidence of hemorrhage between preterms who were appropriate for gestational age was not significant. Out of the 63 neonates who had serial USGs on the third and seventh day of life, 15 of the 16 bleeds (94%) were detected on the third day itself, indicating it to be a opportune time for doing an USG. USG at term (40 weeks postconceptual age) was done in 99 infants to see if it could correctly predict the neurodevelopmental outcome using the Bayley Scales of Infant Development. Out of these 99 infants, 72 came for the developmental assessment at one year. One neonate who had periventricular leucomalacia with cystic changes on USG at term, was grossly abnormal with cerebral palsy and mental retardation. Six infants showed delayed development with a mean mental development quotient of 79.1 +/- 1.72 at 2 years. The specificity of USG at term for predicting outcome was 89.2% and negative predictive outcome was 90%, indicating that a normal USG at term predicted a good neurodevelopmental outcome.

Comparison of Siriraj and Guy's Hospital score to differentiate supratentorial ischaemic and haemorrhagic strokes in the Indian population.

In India, 70% of the population does not have access to computerised brain scanning. Siriraj score is a safe and reliable clinical method to asses acute stroke syndrome. 160 patients with acute stroke were analysed by Siriraj and Guy's hospital stroke score simultaneously. CT Scan was performed in all and subarachnoid haemorrhage was excluded. Ninety two patients (57.5%) had infarction and 68 (42.5%) had haemorrhage. Siriraj score formula revealed haemorrhage in 53 (80%) and infarction in 78 (83%), while in the rest the results were equivocal or incorrect. Guy's hospital score revealed haemorrhage in 45 (66%) and infarction in 59 (69%). Clinical features are also helpful in differentiating infarction from haemorrhage, but the accuracy is not as high as with Siriraj score and secondly Siriraj score is a very simple formula in comparison to Guy's score.

Informe de un caso de hemorragia intraventricular espontánea en un recién nacido a término

Se informa de un caso de un recién nacido con hemorragia intraventricular, a quien se le confirmó con estudios neuroradiológicos, hemorragia de los plexos coroides, sin que se pudiera demostrar factores de riesgo asociados a este evento.

Clinical course of spontaneous gangliothalamic hemorrhage in the acute period: who requires surgical removal?

We analyzed the clinical courses of 93 consecutive patients with gangliothalmic hemorrhage for the first three weeks after the ictus and investigated the factors affecting the clinical course and the final outcome. The clinical status was assessed daily using the Glasgow Coma Score (GCS) and patients were divided into two groups according to the clinical course; Group I included those who improved and Group II consisted of patients who deteriorated. There were 44 patients (47.3%) in Group I and 49 patients (52.7%) in group II. Each group was subdivided into the conservative group and the surgical group. In Group I only eight patients (18.2%) received surgery while twenty-five patients (51.0%) received surgery in Group II. Clinical features and computed tomography characteristics of these four groups were compared. Our results suggested that the surgery is rarely required for patients 1) whose GCS values are 12 or more without deterioration; 2) with hematomas smaller than 3 cm in diameter or 20 ml in volume; 3) with midline shifts of less than 3 mm, and 4) whose subtypes of the hematomas are P1, P2a, T1, T2a, and T2b. For proper comparison of the results of medical and surgical treatment, the patient population should include the patients 1) who became deteriorated progressively regardless of initial GCS values; 2) whose GCS values are below 12; 3) with hematomas larger than at least 3cm in diameter or 20ml in volume; 4) with midline shift of more than 3mm, and 5) whose subtypes of the hematoma are P2b or GT.