Brachial plexopathy secondary to anticoagulant-induced hematoma as a complication of axillary arteriography.

In the patient described, brachial plexopathy was caused by a large anticoagulant-induced hematoma and pseudoaneurysm. The patient was seen at the hospital 2 weeks postarteriography with weakness, numbness, and pain in the left arm, as well as diffuse left-sided ecchymosis. Noncontrast computed tomographic scans of the axilla confirmed the diagnosis by showing an organized hematoma in the axillary compartment. Color-flow Doppler ultrasound studies showed blood flow in a pseudoaneurysm. This is a rare complication of arteriography that requires surgical intervention to remove the hematoma, decompress the brachial plexus, and repair the puncture site responsible for the pseudoaneurysm. Even if there is a delayed diagnosis, surgery should be performed urgently. Prognosis is based on prompt recognition and timely surgical intervention.

Focal atrophy and cerebrospinal fluid rhinorrhea.

Focal atrophy is a diagnosis of exclusion in nontraumatic cerebrospinal fluid rhinorrhea. It is most commonly associated with ethmoid or sphenoid sinus defects and is most prevalent in women between the ages of 30 and 40 years. In the unique case described, a 39-year old woman had focal atrophy and cerebrospinal fluid rhinorrhea secondary to a sphenoid sinus defect. The defect was diagnosed by computed tomography scans and repaired neurosurgically.

Adult Arnold-Chiari malformation: a postpartum case presentation.

Adult Arnold-Chiari malformation, also known as Chiari malformation type I, typically occurs in women during early adulthood and can be a cause of unexplained headaches, as well as associated syringomyelocele. In this unique case report, a 32-year-old, postpartum woman with posturally induced headache from Chiari malformation type I had symptoms occur for the first time during pregnancy. Magnetic resonance imaging of the brain confirmed the diagnosis and is the neuroimaging study of choice in such cases. Neurosurgical decompression, when performed early, is highly successful in symptomatic individuals.

Confirmation of traumatic interhemispheric subdural hematoma by magnetic resonance imaging.

We report a case of interhemispheric subdural hematoma following closed head injury producing contralateral neurological findings and focal seizures. Non-contrast cranial computed tomography scan was initially reported to be normal, but magnetic resonance imaging of the brain demonstrated an interhemispheric subdural hematoma. Head injury, specifically occipital, is the leading cause of interhemispheric subdural hematoma in adults. Most patients develop a "falx syndrome." If adequately interpreted, magnetic resonance imaging of the brain showing the appearance of blood on T1- and T2-weighted images can detect interhemispheric subdural hematoma. However, computed tomography scan should always be done first to detect intercranial bleeding, and it should be performed with and without contrast in patients with prior head trauma and delayed bleeds.

Stroke in young adults. A continuing diagnostic challenge.

Cerebrovascular disease in persons between 15 and 45 years of age is on the rise and represents a diagnostic challenge. With a thorough investigation, the cause of cerebral ischemic infarction or nontraumatic intracerebral hemorrhage can be identified in most cases and appropriate treatment can be administered. Subarachnoid hemorrhage is usually caused by ruptured saccular aneurysm, but misdiagnosis continues to be a problem. Angiography performed early in the course of illness is a safe diagnostic procedure in young adults with any type of cerebrovascular disease. Overall prognosis for young adults with cerebrovascular disease varies with the underlying disorder but is generally good.

Transient global amnesia.

Transient global amnesia is often attributed to a seizure, vascular cause, or migraine, but the outcome is usually benign. The presence of migraine and important risk factors for stroke necessitates close patient monitoring. Anti-platelet therapy should be considered.

Aspirin and stroke prevention: how much?

Media attention concerning aspirin and the prevention of heart attack has been great, but there has been no similar attention to the subject of aspirin and stroke prevention. Clinical information is available in the literature concerning aspirin dosage and stroke prevention following transient ischemic attack (TIA). However, confusion still exists regarding appropriate dosing as well as the effectiveness of other antiplatelet agents. This review focuses on the mechanism of action of aspirin and cites the rationale provided by clinical trials for a recommendation of 1300 mg of aspirin per day as the sole orally administered antiplatelet agent.

High-dose intravenous naloxone for the treatment of acute ischemic stroke.

To evaluate the safety and possible efficacy of high-dose naloxone for the treatment of acute cerebral ischemia, 38 patients received a loading dose of 160 mg/m2 over 15 minutes followed by a 24-hour infusion at the rate of 80 mg/m2/hr. Nausea and/or vomiting were common side effects. Naloxone was discontinued in seven patients (because of hypotension in one, bradycardia and hypotension in two, myoclonus in one, focal seizures in two, and hypertension in one); all seven patients responded to treatment and no permanent sequelae to naloxone were noted. Twelve of the 38 patients showed early neurologic improvement (by completion of the naloxone loading dose). However, there was no correlation between such a loading dose response and clinical outcome at 3 months. Our experience suggests that naloxone is safe at the dose used, but data for efficacy are inconclusive.

Spontaneous subarachnoid hemorrhage in young adults.

We evaluated 95 hospitalized patients (50 women and 45 men) aged 15 to 45 who had nontraumatic subarachnoid hemorrhage (SAH). Aneurysmal SAH was identified in 75 patients. Other causes for SAH were ruptured arteriovenous malformations (2 cases), amphetamine arteritis (1 case), and leptomeningeal melanoma (1 case). The cause of SAH was undetermined in 16 (17%) patients. Thirteen patients had histories of hypertension, 5 used oral contraceptives, and 4 had consumed large quantities of alcohol during the day before SAH. Only 1 patient had Type I diabetes mellitus. Diagnosis was delayed in 21 patients. Operation was performed in 71 patients, with only 3 (4.2%) deaths. The overall mortality was 8.4% (8 of 95), with all deaths due to neurological causes. Our data suggest that the overall management and surgical results of treatment of ruptured aneurysms in young adults are excellent, diabetes is rare among young adults with SAH, recent alcohol consumption does not seem to be a major factor predisposing to SAH in young adults, and misinterpretation of the early symptoms of SAH continues to be a serious problem.

Angiography of nonhemorrhagic cerebral infarction in young adults.

The radiographic examinations and hospital records of 93 young adult patients (15-45 years of age) with nonhemorrhagic cerebral infarction evaluated at our institution during the past 9 years were reviewed. The angiographic examinations were abnormal in 76% of patients. The most common abnormalities were embolic disease and atherothrombotic disease. Forty-seven patients underwent angiography within 7 days of their event. There were no major neurologic or systemic complications related to early angiography. We believe that angiography performed early in the course of the illness is a high-yield, safe procedure that may significantly alter the management of acute stroke in young adults.

Nontraumatic intracerebral hemorrhage in young adults.

We reviewed our experience with 72 patients, aged 15 to 45 years, who were hospitalized for nontraumatic intracerebral hemorrhages (ICHs) between 1978 and 1985. Evaluation included arteriography in 61 patients. Computed tomography demonstrated 41 lobar, 11 putaminal, four thalamic, four pontine, four intraventricular, two caudate, two midbrain, two cerebellar, one globus pallidum, and one corpus callosum hemorrhage. Forty-three patients, with either progressive neurologic deterioration, arteriovenous malformations (AVMs), or saccular aneurysms underwent surgery. The overall in-hospital survival, including those patients treated medically, was 87.5%. A presumed cause for the ICH was found in 55 (76.4%) patients. The main causes were ruptured arteriovenous malformations (21), hypertension (11), ruptured saccular aneurysms (seven), and sympathomimetic drug abuse (five). Surgical explorations demonstrated a necrotizing angiitis in one patient and arteriovenous malformations in two patients who had negative arteriograms. Young patients with nontraumatic ICHs represent a heterogeneous group. A cause can be established in most patients. Arteriovenous malformations account for less than one third of the hemorrhages in young adults, and other causes should be sought.

Pitfalls in diagnosing brain death in infancy.

A 3-year-old child with phenotypic trisomy 18 syndrome survived 26 days after a cardiopulmonary arrest, secondary to an acute viral illness. The child was deeply comatose. No barbiturates, other sedatives, or aminoglycoside antibiotics had been recently administered. The child was normothermic with adequate cardiovascular function. Brain stem function was absent, as assessed by testing of brain stem reflexes. Serial cerebral radionuclide angiograms (CRAG) documented intact cerebral blood flow while electrocerebral silence (ECS) was present on two consecutive EEG recordings within 24 hours. Preservation of intracranial circulation was confirmed by rapid rotational computed tomographic (CT) scans. Cranial CT scans also revealed communicating hydrocephalus, and bilateral basal ganglia hemorrhages. This unusual case illustrates discordance between apparent irreversible loss of cortical function as indicated by electrocerebral silence with preserved cerebral blood flow. The implications of these apparent paradoxical events will be discussed in the context of defining brain death in children.

Cervicocephalic arterial dissections. A ten-year experience.

Between April 1976 and April 1986, cervicocephalic arterial dissections were diagnosed in 19 of 4531 patients undergoing cerebral arteriography for acute cerebrovascular symptoms. Most dissections were extracranial. Spontaneous cases were as frequent as those following known trauma. Cerebral infarction was the most common presentation. Thirteen patients received only medical therapy, and six had surgery. Most patients survived the initial insult. Many questions remain to be answered regarding the optimal management of this condition, but treatment should be individualized based on clinical status, computed tomography, and angiographic findings.

Basilar artery occlusion in an adolescent girl: a risk of oral contraceptives?

An 18-year-old adolescent girl died of an extensive pontine infarction. At postmortem examination she was found to have a thrombosis of the basilar and intracranial vertebral arteries with associated focal hyperplasia of the intima. Her ovaries were grossly small and inactive, with absent corpora lutea. Based on these findings, we suspect she was taking oral contraceptives. In cases of unexplained fatal strokes in young females, careful pathologic examination of the ovaries may provide etiological clues.

Paradoxical cerebral embolism: eight cases.

We evaluated eight patients with possible or probable paradoxical cerebral embolism. One patient had a hemispheric transient ischemic attack; the others had infarcts. Ischemic symptoms followed a Valsalva's maneuver in three cases. Others were linked to placement of a Swan-Ganz catheter, deep venous thrombosis and pulmonary embolism, right atrial myxoma, and use of oral contraceptives. Four had no known predisposing conditions. In six patients, contrast echocardiography showed right-to-left shunting. Cardiac catheterization showed a patent foramen ovale in three patients; one had an atrial septal defect. In the clinical setting of otherwise unexplained cerebral embolism in a young patient, paradoxical cerebral embolism should be considered. Contrast echocardiography is a useful screening test for this purpose.

The predicted value of arteriography in nontraumatic intracerebral hemorrhage.

We retrospectively assessed the diagnostic value of cerebral arteriography for the search of an etiology in 102 patients with nontraumatic intracerebral hemorrhages evaluated between 1980 and 1985. Arteriography was diagnostic in 22 of 50 non-hypertensive patients and in only 6 of 47 hypertensive patients. Five patients with a bleeding diathesis had normal arteriography. From the total group, we found 12 saccular aneurysms, 9 arteriovenous malformations, 3 cases of moya-moya and 3 instances of superior sagittal sinus thrombosis. One patient had metastatic choriocarcinoma. Sites of hemorrhage among all patients with diagnostic arteriograms were: lobar 19, intraventricular 5, thalamic 2, caudate 1, and corpus callosum 1. Lobar hemorrhages in the non-hypertensive group and intraventricular hemorrhages in hypertensive individuals had the highest yield of arteriographic abnormalities. We believe cerebral arteriography is indicated in non-hypertensive patients with lobar hemorrhages. Most hypertensive patients, in particular those with putaminal hemorrhages, do not require arteriography.

Normal cerebral radionuclide angiogram in a child with electrocerebral silence.

Pediatric neurologists agree that the determination of brain death in children, and especially retarded children, is difficult and that the criteria used in adult brain death may not be sufficient in pediatric cases. An unusual case of sustained electrocerebral silence on electroencephalogram (EEG) in a three-year-old retarded comatosed child with preserved intracerebral perfusion documented by a series of cerebral radionuclide angiograms (CRAG) is presented. The EEG showing electrocerebral silence represents loss of cerebrum (cortex) function (Barlow 1976). This absence of cortical function is demonstrated even though intracranial circulation is shown to be intact. We believe that the correlative studies presented accurately document a discordance between apparent loss of cortical function in a child as indicated by electrocerebral silence in the face of preserved cerebral blood flow. It is suggested that when evaluating brain death in retarded children with known cerebral atrophy, special emphasis should be placed on the CRAG and that the EEG should be read with caution.