Bleeding risk of small intracranial aneurysms in a population treated in a reference center / Risco de sangramento de aneurismas intracranianos pequenos em uma população tratada em um centro de referência

ABSTRACT Large multicenter studies have shown that small intracranial aneurysms are associated with a minimal risk of bleeding. Nevertheless, other large series have shown that most ruptured aneurysms are, in fact, the smaller ones. In the present study, we questioned whether small aneurysms are indeed not dangerous. Methods: We enrolled 290 patients with newly-diagnosed aneurysms at our institution over a six-year period (43.7% ruptured). We performed multivariate analyses addressing epidemiological issues, cardiovascular diseases, and three angiographic parameters (largest aneurysm diameter, neck diameter and diameter of the nutrition vessel). Risk estimates were calculated using a logistic regression model. Aneurysm size parameters were stratified according to receiver operating characteristic (ROC) curves. Finally, we calculated odds ratios for rupture based on the ROC analysis. Results: The mean largest diameter for the ruptured versus unruptured groups was 13.3 ± 1.7 mm versus 22.2 ± 2.2 mm (p < 0.001). Multivariate analysis revealed a positive correlation between rupture and arterial hypertension (p < 0.001) and an inverse correlation with all three angiographic measurements (all p < 0.01). Aneurysms from the anterior cerebral artery bled more often (p < 0.05). According to the ROC curves, at the largest diameter of 15 mm, the sensitivity and specificity to predict rupture were 83% and 36%, respectively. Based on this stratification, we calculated the chance of rupture for aneurysms smaller than 15 mm as 46%, which dropped to 25% for larger aneurysms. Conclusion: In the population studied at our institution, small aneurysms were more prone to bleeding. Therefore, the need for intervention for small aneurysms should not be overlooked.

RESUMO Grandes estudos multicêntricos demostram que aneurismas intracranianos pequenos são associados a risco de sangramento mínimo. Outras grandes séries têm evidenciado que aneurismas rotos são em sua maioria os pequenos. Neste estudo questionamos até que ponto os aneurismas pequenos não são perigosos. Métodos: Avaliamos 290 novos casos de aneurismas tratados em nossa instituição durante 6 anos (43,7% rotos). Realizamos análises multivariadas com aspectos epidemiológicos dos pacientes, doenças cardiovasculares e três parâmetros angiográficos: maior diâmetro, diâmetro do colo e diâmetro do vaso nutridor do aneurisma. Estimativas de risco foram calculadas utilizando-se modelo de regressão logística. Parâmetros do tamanho aneurismático foram estratificados de acordo com curvas ROC. Também calculamos a razão de chances (odds ratios) de ruptura baseadas nas análises das curvas ROC. Resultados: O maior diâmetro médio para os grupos de aneurismas rotos e não-rotos foi 13.3 ± 1.7mm e 22.2 ± 2.2 (p < 0.001). Análises multivariadas revelaram uma correlação positiva entre ruptura aneurismática e hipertensão arterial (p < 0.001) e uma correlação inversa entre ruptura e as três medidas angiográficas (p < 0.01). Aneurismas da artéria cerebral anterior foram os que mais sangraram (p < 0.05). Análises das curvas ROC demonstram que no maior diâmetro de 15mm, a sensibilidade e especificidade para se predizer ruptura são de 83% e 36%. Baseando-se nessas estratificações, calculamos uma chance de ruptura para aneurismas menores de 15mm de 46% e de 25% para aneurismas maiores. Conclusão: Na população estudada, aneurismas pequenos são mais propensos a romper. Desta forma, a necessidade de intervenção para aneurismas pequenos não deve ser relevada.

The safety and efficacy of tPA intravenous thrombolysis for treating acute ischemic stroke patients with a history of cerebral hemorrhage

Alteplase (tPA) intravenous thrombolysis is an effective treatment for acute ischemic stroke (AIS) when administered within 4.5 h of initial stroke symptoms. Here, its safety and efficacy were evaluated among AIS patients with a previous history of cerebral hemorrhage. Patients who arrived at the hospital within 4.5 h of initial stroke symptoms and who were treated with tPA intravenous thrombolysis or conventional therapies were analyzed. The 90-day modified Rankin scale (90-d mRS) was used alongside mortality and incidence of symptomatic intracerebral hemorrhage (SICH) rates to evaluate the curative effect of these therapies. Among 1,694 AIS patients, 805 patients were treated with intravenous thrombolysis, including patients with (n=793) or without (n=12) a history of cerebral hemorrhage, and the rate of incidence of SICH significantly differed between them (8.3 vs 4.3%, P=0.039). No significant difference was found in 90-d mRS measurements (41.7 vs 43.6%, P=0.530) and 90-d mortality rates (8.3 vs 6.5%, P=0.946). A total of 76 AIS patients with a history of cerebral hemorrhage received tPA thrombolytic therapy (n=12) or conventional therapy (n=64), and a significant difference was noted in the 90-d mRS scores between the two groups (41.7 vs 23.4%, P=0.029), while no significant difference was found in SICH measurements (8.3 vs 4.6%, P=0.610) and 90-d mortality rates (8.3 vs 9.4%, P=0.227). A history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy; tPA intravenous thrombolysis does not increase SICH measurements and mortality rates in patients with a history of cerebral hemorrhage, and they may benefit from thrombolytic therapy.

Hemorrhagic stroke following viper bites and delayed antivenom administration: three case reports from the Western Brazilian Amazon

Abstract Snakebites were included by the World Health Organization in their list of neglected diseases. In Latin America, most snakebites are caused by species of the Viperidae family, notably by the genus Bothrops. Bothrops atrox accounts for 90% of the cases of envenoming in the Brazilian Amazon. In this report, we present a series of three cases of snakebites that evolved with hemorrhagic stroke due to delays in the access to antivenom in the Brazilian Amazon, being fundamental for diagnosis to validate the clinical suspicion and make decisions that would improve the treatment and prognosis of the patients.

Hemorragia intracraneal asociada a preeclampsia severa / Intracranial haemorrhage associated with severe preeclampsia

La hemorragia intracraneal constituye una patología poco frecuente del embarazo y asociada a pobres resultados materno-fetales. Dentro de sus causas se encuentra, la preeclampsia severa, la cual aumenta la mortalidad en estas pacientes. Se presenta el caso de una gestante que acude al servicio de urgencias con síntomas neurológicos e hipertensión arterial, diagnosticándose preeclampsia severa, con realización de cesárea de urgencia. La tomografía de cráneo mostró hemorragia temporal izquierda, requiriendo manejo en cuidados intensivos con posterior estabilización y alta médica. La hemorragia intracraneal requiere un alto índice de sospecha, monitoreo intensivo y manejo multidisciplinario.

Intracranial hemorrhage is a rare complication during pregnancy, it is associated with poor maternal and fetal outcomes. Cerebral haemorrhage caused by pre-eclampsia increases mortality in these patients. We present the case of a pregnant woman who consulted to the service of urgencies with neurological symptoms and hypertension. Severe preeclampsia was diagnosed. She underwent successful emergent cesarean section. The brain scan showed a left temporal hemorrhage. She required intensive care management with subsequent stabilization and discharged from the hospital. Intracranial hemorrhage requires a high index of suspicion, intensive monitoring, and a multidisciplinary approach.

Hemorragia intracraniana espontânea em pediatria: relato de paciente hemofílico que sobreviveu devido a cisto cerebral / Spontaneous intracranial hemorrhage in children: report of a hemophilia patient who survived due to a brain cyst

RESUMO Relatamos o caso de um uma criança de 2 anos de idade que sobreviveu após um episódio agudo de hemorragia intracraniana espontânea grave com sinais clínicos e radiológicos de hipertensão intracraniana e herniação transtentorial. O paciente foi para cirurgia de urgência para drenagem do hematoma, sendo inserido um cateter para monitorar a pressão intracraniana. Na análise da tomografia de crânio inicial, antes da drenagem do hematoma, constatou-se um cisto cerebral contralateral ao hematoma que, segundo análise do neurocirurgião e do neuroradiologista, possivelmente evitou um desfecho pior, visto que o cisto serviu de acomodação para o cérebro após a hemorragia maciça. Após investigação, constatou-se tratar de um caso de hemofilia tipo A sem diagnóstico prévio. O paciente foi tratado em terapia intensiva com controle da pressão intracraniana, reposição de fator VIII e obteve alta sem sequelas neurológicas evidentes.

ABSTRACT We report the case of a 2-year-old child who survived an acute episode of severe spontaneous intracranial hemorrhage with clinical and radiological signs of intracranial hypertension and transtentorial herniation. The patient underwent emergency surgery to drain the hematoma, and a catheter was inserted to monitor intracranial pressure. In the initial computed tomography analysis performed prior to hematoma drainage, a brain cyst was evident contralateral to the hematoma, which, based on the analysis by the care team, possibly helped to avoid a worse outcome because the cyst accommodated the brain after the massive hemorrhage. After the investigation, the patient was determined to have previously undiagnosed hemophilia A. The patient underwent treatment in intensive care, which included the control of intracranial pressure, factor VIII replacement and discharge without signs of neurological impairment.

Percutaneous Access via the Recanalized Paraumbilical Vein for Varix Embolization in Seven Patients

OBJECTIVE: To evaluate the feasibility of percutaneous access via the recanalized paraumbilical vein for varix embolization. MATERIALS AND METHODS: Between July 2008 and Jan 2014, percutaneous access via the recanalized paraumbilical vein for varix embolization was attempted in seven patients with variceal bleeding. Paraumbilical vein puncture was performed under ultrasonographic guidance, followed by introduction of a 5-Fr sheath. We retrospectively evaluated the technical feasibility, procedure-related complications, and clinical outcomes of each patient. RESULTS: Recanalized paraumbilical vein catheterization was performed successfully in all patients. Gastroesophageal varix embolization was performed in six patients, and umbilical varix embolization was performed in one patient. Embolic materials used are N-butyl cyanoacrylate (n = 6) and coil with N-butyl cyanoacrylate (n = 1). There were no procedure-related complications. One patient underwent repeated variceal embolization 6 hours after initial procedure via recanalized paraumbilical vein, due to rebleeding from gastric varix. CONCLUSION: Percutaneous access via the paraumbilical vein for varix embolization is a simple alternative in patients with portal hypertension.

Evidências sobre diagnóstico e tratamento do acidente vascular encefálico no serviço de urgência / Evidence on diagnosis and treatment of stroke in the emergency department

O acidente vascular encefálico, independentemente de ser isquêmico ou hemorrágico, é um problema de saúde pública mundial com elevada prevalência, morbimortalidade e custo financeiro. A investigação no setor de emergência busca confirmar seu diagnóstico, iniciando rapidamente as medidas terapêuticas imediatas para reduzir o dano neurológico,possivelmente revertê-lo, e tentar evitar sua recorrência precoce. O seu manejo leva a difíceis decisões terapêuticas para os neurologistas. A utilização de métodos por imagem é imprescindível nos dias atuais e vem evoluindo para dar maior precisão ao seu diagnóstico na fase hiperaguda, como também elucidar sua etiologia posteriormente. A trombólise endovenosa no acidente vascular cerebral isquêmico tem por objetivo recanalizar o vaso ocluído e reperfundir a área cerebral que pode ser salva, sendo esse tratamento aprovado e recomendado pela Academia Brasileira de Neurologia,Academia Americana de Neurologia e Sociedade Europeia de Neurologia. Apesar de não existir terapia específica aprovada para o acidente vascular cerebral hemorrágico, existem muitas medidas clínicas e cirúrgicas que podem ser implementadas no tratamento dessa doença.

Demographic profile of head injury cases in Agra region.

Head injury is a serious health problem throughout the world. Increasing vehicles on roads work as catalyst for high incidence of casualties especially of Cranio-cerebral injuries. This is an autopsy based study of head injury cases, conducted in the Department of Forensic Medicine, S.N. Medical College Agra in year 2009-2010 for their demographic and etiological profile. Majority of the victims of head injury are male (76%) and of 3rd – 4th decade of life (54.4%). 66.4% head injury cases due to accident, Road traffic accident is the single largest cause i.e. 59.2%; out of which two wheelers are responsible for one-third (33%) of the casualties. Most common external injury is laceration of the scalp with or without contusion. Fracture of skull bones (97.2% cases; mostly fissured and comminuted fracture of parietal & temporal) and intracranial hemorrhages (96.4%) are seen in almost all the cases. Contre-coup injuries seen in about 2.8% cases, contre-coup haemorrhage observe mostly fronto-temporal area. Majority of the victim died on the spot or in the way to hospital without any medical assistance where the Cause of death mostly haemorrhage and shock.

Post-transfusion hypertension, convulsion and intracranial haemorrhage in beta-thalassemia major

The haematologic disorder beta-thalassemia major is common in Pakistan. We describe a patient with undiagnosed thalassemia presenting with hypertension and convulsions and found to have cerebral haemorrhage on neuro-imaging. He had been transfused 2 weeks before this illness. Our experience is similar to a few case reports described in literature that were found to have cerebral haemorrhages post-mortem after a similar clinical presentation. All patients had a blood transfusion within 2 weeks prior to the presentation so association with transfusion has been proposed. We have reviewed the several mechanisms presented and discussed the findings

Hemorragia intracraneal como forma de presentación de atresia biliar: presentación de dos casos / Intracranial hemorrhage as initial presentation of biliary atresia: two cases report

La atresia biliar en lactantes se presenta habitualmente con la tríada ictericia, acolia y coluria, y ocasionalmente con sangrado intracraneal, nasal o gastrointestinal. Presentamos dos niñas, de cuatro y dos meses, que fueron asistidas por presentar convulsiones, cefalohematoma y sopor. En la tomografía computada cerebral se halló hemorragia subdural en una paciente e intraventricular y parenquimatosa en la otra. Al ingreso, presentaban antecedentes, signos clínicos y de laboratorio de colestasis, sin diagnóstico etiológico. La niña con hematoma subdural requirió drenaje quirúrgico. La paciente con sangrado intraventricular y parenquimatoso no requirió cirugía y se le administró vitamina K. Se diagnosticó atresia de vías biliares mediante centellograma con HIDA y colangiografía intraoperatoria previa al procedimiento de Kasai (portoenteroanastomosis). Ambas niñas presentaron buena evolución neurológica a los seis meses. Requirieron trasplante de hígado alrededor del año de vida. La atresia biliar se debe considerar en el diagnóstico de lactantes pequeños que presentan sangrado agudo y colestasis.

Biliary atresia in infants occasionally presents as intracranial, nasal or gastrointestinal bleeding, instead of the classical triad of jaundice, acholia and choluria. We present two female infants aged four and two months, who were hospitalized with convulsive episode, cephalohematoma and drowsiness. Computed tomography fndings were subdural hemorrhage in one patient and intraventricular and parenchymal bleeding in the other one. At admission they have history, clinical and laboratory signs of cholestasis of unknown etiology. The patient with subdural hemorrhage required surgical drainage. The other girl with intraventricular and parenchymal bleeding received vitamin K and no surgery. Biliary atresia was diagnosed and treated in both girls. At six months both had an adequate neurological outcome and required liver transplantation at one year old. Biliary atresia should be considered in all infants with sudden acute bleeding and cholestasis.

Original research paper patterns of head injuries in fatal road traffic accidents in a rural district of Maharashtra- autopsy based study.

Road traffic accidents are the major causes of death worldwide. Head injury is the single most common cause of mortality in road traffic accidents; head being the most vulnerable part of the body. The present study was undertaken on 138 victims of road traffic accidents, died due to head injury to find out the patterns of head injuries, their age and sex distribution and site distribution of different types of fractures. The highest incidence was seen in age group of 21-30 years and males clearly outnumbered females. In the present study, most of the incidents occurred between 1200 to 1800 hours. The maximum number of victims (39.57%) died while on the way to hospital. The motor-cyclists were the commonest group of victims and trucks being the commonest offending vehicles. Intracranial haemorrhages were seen in 113 cases, skull fractures were found in 95 cases and injury to brain in 51 cases. Linear fracture of skull with basal fracture was the commonest type and temporo-parietal region was involved predominantly. Subdural haemorrhage was the commonest haemorrhage observed.

Pattern of fatal blunt head injury: A two year retrospective / prospective medico legal autopsy study.

The current study was conducted from 1 November 2002 to 31 October 2004 at Topiwala National Medical College & BYL Nair Charitable Hospital, Mumbai. A total of 189 victims of fatal blunt head injury were recorded and a complete medicolegal autopsy was conducted on each of these victims during this period. The postmortem study revealed that males were the most common victims with the highest number being in the age group of the third and fourth decades. Accidents were responsible for most of them, followed by homicidal deaths, with suicides recorded as the least. Of the accidents, railway accidents were responsible for the maximum number. The study revealed that the highest number of fatalities occurred during the peak hours of the day. The fissured fracture was the most common type of fracture observed. Among the specialized fractures of the base of the skull, type-1 hinge fracture was the most common. A combination of subdural and subarachnoid haemorrhages was the most common observation. Blunt cranio-cerebral injury was the primary cause of death in more than half of the victims

Subarachnoid and Intraventricular Hemorrhage due to Ruptured Aneurysm after Combined Spinal-Epidural Anesthesia

A patient received combined spinal-epidural anesthesia for a scheduled total knee arthroplasty. After an injection of spinal anesthetic and ephedrine due to a decrease in blood pressure, the patient developed a severe headache. The patient did not respond to verbal command at the completion of the operation. A brain CT scan revealed massive subarachnoid and intraventricular hemorrhages, and a CT angiogram showed a ruptured aneurysm. Severe headaches should not be overlooked in an uncontrolled hypertensive patient during spinal anesthesia because it may imply an intracranial and intraventricular hemorrhage due to the rupture of a hidden aneurysm.

Cerebral biopsy: comparison between frame-based stereotaxy and neuronavigation in an oncology center / Biópsia cerebral: comparação entre estereotaxia com arco e neuronavegação em um centro de oncologia

Treatment of intracranial tumoral lesions is related to its correct histological diagnostic. We present a retrospective analysis of 32 patients submitted to 36 cerebral biopsies using neuronavigation and 44 patients using frame-based stereotaxy. Mean age was 46.6 and 49.3 years old respectively. Sex distribution in both groups was 50 percent for each. Most of lesions were lobar in both groups. Diagnostic yielding was 91.7 percent and 83.4 percent, respectively (p=0.26). We found in the postoperative CT scans intracranial hemorrhages in 13.8 percent cases of the first group and 9.8 percent cases in the second. Most of them were mild post-operative hemorrages in the biopsy site. There was one death related to the procedure in each group. Astrocytomas and metastatic adenocarcinomas were the most frequent diagnosis. Diagnostic yielding and the number of postoperative hemorrhage and death were similar on both groups and the same found in the literature.

O manejo das lesões intracranianas tumorais está relacionado ao seu diagnóstico histológico adequado. Foi realizado estudo retrospectivo com 32 pacientes submetidos a 36 biópsias cerebrais por neuronavegação e 44 pacientes por estereotaxia com arco. A idade média foi 46,6 e 49,3 anos respectivamente. Nos dois grupos a distribuição por sexo foi 50 por cento para cada. A maioria das lesões biopsiadas eram lobares nos dois grupos. A positividade diagnóstica foi 91,7 por cento para neuronavegação e 83,4 por cento para a estereotaxia com arco, respectivamente (p=0,26). Identificou-se hemorragia intracraniana na TC pós-operatória em 13,8 por cento dos casos no primeiro grupo e em 9,8 por cento no segundo, a maioria de pequena monta sem provocar piora neurológica. Ocorreu uma morte relacionada ao procedimento em cada grupo. Os diagnósticos mais freqüentes foram astrocitomas e adenocarcinomas metastáticos. A positividade diagnóstica, taxas de hemorragia pós-operatória e de mortalidade foram equiparáveis estatisticamente entre os dois métodos e se assemelham com as descritas na literatura.

Analysis of 112 cases with diffuse axonal injury / 法医学杂志

OBJECTIVE@#To investigate the relationship between the diffuse axonal injury (DAI) and cerebral contusion, primary brain stem injury and brain concussion.@*METHODS@#One hundred and twelve cases with DAI were analyzed according to the characteristics of clinical signs and imaging features.@*RESULTS@#Of 112 cases of DAI, 70.5% injured in traffic accident, 60.7% injured with blunt trauma more than one time and 71.4% injured with cerebral contusion. And 90 cases with brain with hemorrhage were found in CT or MRI imaging.@*CONCLUSION@#DAI may be associated with cortical contusion and primary brain stem injury. The CT or MRI is useful to investigate the cause of death and to evaluate the personal disability.

Immune thrombocytopenia in children with reference to low income countries

Immune thrombocytopenia is a benign and self-limiting disorder. Data about the condition and its incidence from low-income countries is limited. This paper reviews the research about immune thrombocytopenia, comparing low- and high-income countries. Diagnosis is usually based on complete blood count and peripheral smear and, in selected cases, bone marrow aspiration. The disease has a high remission rate both in high- and low-income countries and intracranial haemorrhage is rare. The recommended treatment is simply observation of cases, especially when the platelet count is > 10 000 /mm[3]. If drug therapy is required, oral steroids are the most economical choice

Intracranial haemorrhage in typhoid fever

Intracranial haemorrhage in typhoid fever is very rare. We report another case of non-traumatic intracranial hemorrhage in a 6-year-old boy suffering from typhoid fever, unconsciousness, seizure and non-coherent speech. Investigations revealed severe thrombocytopenia and prolonged prothrombin time. CT scan of brain showed intraparenchymal haemorrhage in frontal regions bilaterally with perilesional oedema, subarachnoid bleed and extension into the lateral ventricles. No aneurysm or arterio-venous malformation was seen on MR angiography. The patient recovered without any neurological deficit

Head trauma and hemophilia B: case report about a challenging hematologic emergency

Bleeding emergencies are common chief complaints in visits to the Emergency Department (ED) but hemophilia, a rare congenital bleeding disorder requires immediate treatment. Hemophilia B is characterized by a deficiency of coagulation Factor IX. As emergency medicine physicians we must be prepared to deal with such emergencies. One of the most feared complications in this population is the spontaneous or post-traumatic development of intracranial hemorrhage (ICH). We present a case of a 69 year-old man with a past medical history of hemophilia B who presented to the emergency department after suffering a head trauma with development of acute and delayed ICH.