Infarto cerebeloso en el puerperio inmediato / Headache after a dural puncture in obstetric patient

La enfermedad cerebrovascular durante la gestación es rara. El presente trabajo tiene como objetivo describir las características clínicas de una paciente con embolismos de la arteria humeral derecha y tallo encefálico en el periodo expulsivo de un parto eutócico sin foco embolígeno causante de dicho accidente cerebrovascular. Se presenta el caso de una parturienta de 29 años con 40,2 semanas de edad gestacional que durante el periodo expulsivo de un parto eutócico comenzó a presentar dolor intenso en el miembro superior derecho con cambios de coloración y temperatura e impotencia funcional, imposibilidad para la apertura palpebral bilateral, vómitos sin náuseas, disartria y dificultad en los movimientos oculares...

The cerebrovascular disease during pregnancy is uncommon. The objective of present paper is to describe the clinical features of a patient with embolisms of the right humeral artery and of the brainstem at expulsion period of a spontaneous labor without emboligen focus causing this cerebrovascular accident...

Infarto cerebeloso en el puerperio inmediato / Cerebella infarction in the immediate puerperium

La enfermedad cerebrovascular durante la gestación es rara. El presente trabajo tiene como objetivo describir las características clínicas de una paciente con embolismos de la arteria humeral derecha y tallo encefálico en el periodo expulsivo de un parto eutócico sin foco embolígeno causante de dicho accidente cerebrovascular. Se presenta el caso de una parturienta de 29 años con 40,2 semanas de edad gestacional que durante el periodo expulsivo de un parto eutócico comenzó a presentar dolor intenso en el miembro superior derecho con cambios de coloración y temperatura e impotencia funcional, imposibilidad para la apertura palpebral bilateral, vómitos sin náuseas, disartria y dificultad en los movimientos oculares...

The cerebrovascular disease during pregnancy is uncommon. The objective of present paper is to describe the clinical features of a patient with embolisms of the right humeral artery and of the brainstem at expulsion period of a spontaneous labor without emboligen focus causing this cerebrovascular accident...

Analysis of thrombi retrieved from cerebral arteries of patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: Information regarding the histological structure of thromboemboli that cause acute stroke provides insight into pathogenesis and clinical management. METHODS: This report describes the histological analysis of thromboemboli retrieved by endovascular mechanical extraction from the middle cerebral artery (MCA) and intracranial carotid artery (ICA) of 25 patients with acute ischemic stroke. RESULTS: The large majority (75%) of thromboemboli shared architectural features of random fibrin:platelet deposits interspersed with linear collections of nucleated cells (monocytes and neutrophils) and confined erythrocyte-rich regions. This histology was prevalent with both cardioembolic and atherosclerotic sources of embolism. "Red" clots composed uniquely of erythrocytes were uncommon and observed only with incomplete extractions, and cholesterol crystals were notably absent. The histology of thromboemboli that could not be retrieved from 29 concurrent patients may be different. No thrombus >3 mm wide caused stroke limited to the MCA, and no thrombus >5 mm wide was removed from the ICA. A mycotic embolus was successfully removed in 1 case, and a small atheroma and attached intima were removed without clinical consequence from another. CONCLUSIONS: Thromboemboli retrieved from the MCA or intracranial ICA of patients with acute ischemic stroke have similar histological components, whether derived from cardiac or arterial sources. Embolus size determines ultimate destination, those >5 mm wide likely bypassing the cerebral vessels entirely. The fibrin:platelet pattern that dominates thromboembolic structure provides a foundation for both antiplatelet and anticoagulant treatment strategies in stroke prevention.

Successful stenting seven days after atherothrombotic occlusion of the intracranial internal carotid artery.

PURPOSE: To report a case of successful stenting after a subacute stroke. CASE REPORT: A 75-year-old man presented with sudden onset of right-sided weakness and difficulty speaking. Imaging revealed an occlusion of the left petrous to lacerum internal carotid artery (ICA) segment and slightly decreased cerebral blood flow in the left hemisphere; there were stenoses of the ostial and cavernous ICA segments on the right. On the seventh day after the stroke, he underwent protected carotid angioplasty of the left intracranial ICA occlusion to reduce the high risk of ischemic stroke owing to bilateral disease. An external arteriovenous shunt was established with an occluding balloon in the proximal ICA and a filter in the femoral vein. After protected balloon dilation of the ICA occlusion, a 3.5 x 18-mm balloon-expandable coronary stent was deployed across the residual stenotic segment. An intraluminal filling defect of the petrous ICA segment suggested an arterial dissection or intraluminal thrombus, so another 2 coronary stents were deployed. Macroscopically visible materials were captured in the filter. The patient had a good clinical course and was discharged without neurological deficits on the twelfth day after the stroke. Angiography at 3 months confirmed no restenosis of the stented vessel. CONCLUSION: This experience suggests that short atherothrombotic intracranial ICA occlusions can be opened in the subacute stroke stage without distal migration of thrombi under proximal protection and flow reversal.

[Etiology, clinical variants, diagnosis and treatment tactic of cerebellar infarction]. / Etiologiia, klinicheskie varianty, diagnostika i lechebnaia taktika infarkte mozzhechka.

The article contains a review of revelant medical literature focusing on etiology, diagnosis and treatment of cerebellar infarction (CI). The above health problem occurs relatively seldom covering about 2% of all strokes. Common CI etiological factors include atherothrombotic lesions of the vertebrobasilar arteries, cardiac embolism. CI symptoms depend on localization and size of the infarction site. The infarct topography in accordance with the affected arterial region correlates with neurological disfunction. CI may bring about complications such as acute obstructive hydrocephalus and brain stem compression developing in the wake of the mass-effect. Computerized tomography and magnetoresonance topography permit making an early diagnosis and timely to make detect the development of complications. Cases of complicated CI need the neurosurgical treatment to be carried out.

[Serious cerebral venous thrombosis: can we use fibrinolytic?]. / Thrombophlébite cérébrale grave: peut-on fibrinolyser ?

We report a case of thrombosis of superior sagittal and cavernous sinuses treated by direct instillation of fibrinolytic agents via selective catheterization. Despite risk of bleeding related to the pathology and treatment, no adverse side-effect occurred. This report is unusual regarding the poor initial clinical patient's condition with dilated and unreactive pupil. The good neurologic outcome warrants aggressive treatment in the most severe forms of cerebral venous thrombosis.

Transcranial Doppler evaluation of blood flow velocity changes in basal cerebral arteries in cerebral AVMs following embolisation and surgery.

Blood flow velocities in the basal cerebral arteries were evaluated in 41 patients with supratentorial arteriovenous malformation (AVM), using a transcranial doppler 64-B instrument. The AVM was surgically excised in 20 patients and embolised in 21 patients. Blood flow velocities in feeding basal cerebral arteries were found markedly decreased in both the groups, at 24 hours after intervention. On follow up study at 3 months, blood flow velocity in feeding cerebral artery was found to be increased in 47 percent of patients who were embolised, but remained normal in all the patients who underwent surgery.

Results of early surgical evacuation of packed intraventricular hemorrhage from aneurysm rupture in patients with poor-grade subarachnoid hemorrhage.

OBJECT: The goal of this study was to evaluate the results of early surgical evacuation of "packed" intraventricular hemorrhage (IVH) in patients with poor-grade subarachnoid hemorrhage (SAH). METHODS: The authors performed surgery within 24 hours after onset of SAH, identified on neuroimaging as a cast distending the ventricular system, in 74 patients with poor-grade SAH (World Federation of Neurosurgical Societies Grades IV and V) without intracerebral hemorrhage. Eighteen of these patients had packed IVH; in these patients the intraventricular clots were extensively evacuated via frontal corticotomy performed under microscopic view. CONCLUSIONS: Overall, 42% of the 74 patients undergoing craniotomy in the acute stage had favorable outcomes, whereas 30% died. Using multivariate analysis, variables significantly associated with favorable outcome in patients with poor-grade SAH included absence of a packed intraventricular clot on computerized tomography scanning; absence of a history of cardiac disease; and a Glasgow Coma Scale score of 11 or 12. None of the 18 patients who had packed IVH had favorable outcomes and seven of these died. In six recently treated patients with packed IVH, which was examined using fluid-attenuated inversion recovery imaging, extensive periventricular brain damage was found both immediately after surgery and during the chronic stage. Accordingly, the authors believe that irreversible periventricular brain damage is already complete immediately after packed IVH occurs.

Thromboembolism originated from the pulmonary artery stump after Fontan operation.

Cerebral thromboembolism is a rare but serious complication after Fontan operation. This is the report of a patient who underwent a successful intracardiac thrombectomy for cerebral thromboembolism after Fontan operation. A 2-year-old girl was referred to us with the diagnosis of tricuspid atresia without pulmonary stenosis, normally related great arteries, and a ventricular septal defect. Although she underwent a successful Fontan operation and division of the main pulmonary artery, she developed a cerebrovascular event at 3 weeks after the operation. Echocardiography demonstrated a large thrombus within the residue of the main pulmonary artery, and suggested that the thrombus had migrated into the systemic circulation by way of the ventricular septal defect. At 2 weeks after the cerebrovascular event, she underwent thrombectomy and excision of the pulmonary valve. Although she has developed slight left-sided hemiparesis, she is leading a normal life at 1 year after the operation.

Endovascular stent placement for cervical internal carotid artery aneurysm causing cerebral embolism: usefulness of neuroradiological evaluation.

We present a case of a cervical internal carotid artery aneurysm that caused cerebral embolism. This lesion was supposed to be a dissecting aneurysm due to blunt neck injury. The large aneurysm with intramural thrombus was treated with endovascular placement of a balloon-expandable stent. Both CT and MRI were useful for evaluating the size and characteristics of the aneurysmal wall. Intravascular ultrasound imaging was also useful for evaluation of the satisfactory stent deployment and identification of the neck of the aneurysm. We discuss effectiveness of endovascular stenting for cervical internal carotid artery aneurysm with intramural thrombus and the usefulness of a combination of the neuroradiological imaging before, during and after the interventional procedure.

[Cerebral ischemia as initial manifestation of neoplastic low-malignancy changes. 2 case reports and review of the literatures]. / Zerebrale Ischämien als Erstmanifestation neoplastischer Veränderungen niedriger Malignität. 2 Fallberichte und Ubersicht über die Literatur.

Thrombembolic events as paraneoplastic complications in malignant disease account for severe morbidity and mortality in these patients. In some cases disturbance in hemostasis is the first manifestation of a neoplastic process. We report the cases of two patients with cerebral and extracerebral vessel occlusions, in whom epithelial tumors of low malignant potential (borderline-tumors) of ovary and peritoneum were diagnosed later on. In one case the removal of the tumor stopped the coagulation problems. The second patient died a few days after the first symptoms with devastating multiple vessel occlusion. In stroke of unknown aetiology a paraneoplastic process should be kept in mind. The diagnosis is more probable with recurrent thrombembolism in different body regions and when warfarin therapy was ineffective. Thoughtful coagulation studies and a tumor search program is recommended in these cases.

[Detection of cerebral embolism using transcranial Doppler sonography: can artifacts be reliably recognized?]. / Zerebrale Emboliedetektion mittels transkranieller Dopplersonographie: Können Artefakte sicher erkannt werden?

A requirement for the use of TCD for the detection of emboli in the field of cardiac and vascular surgery is the reliable differentiation between true emboli and artifacts. In ten healthy volunteers we carried out a study to establish the method with which artefacts can most reliably be identified. Automatic detection of increasing signal intensity misinterpreted 14% of all artifacts as emboli; 1.7% of all artifacts sounded suspicious for embolism, and 0.6% met the classical criteria of an embolus. Using simultaneous recording of the flow signal in two sections of the middle cerebral artery, all artifacts were identified on the basis of their simultaneous manifestation. Reliable intra-operative differentiation of emboli from artifacts requires attentive, continuous acoustic and visual analysis of signals by an experienced investigator familiar with the surgical procedure. The introduction of a multiple-depth algorithm might significantly improve the automatic detection program.

[Recanalization of cerebral cortical venous thrombosis: a case report].

Several clinical cases of sinus thrombosis have been reported, but localized cerebral cortical venous thrombosis is a fairly rare clinical entity. We report a case of a 51-year-old woman who presented with right hemiparesis on admission. CT scan revealed subcortical hemorrhage with perifocal edema in the left front-parietal lobe. A T2W image revealed a large area of hyperintensity indicating edema, and coronal Gd enhanced T1 weighted image showed a reverse-triangle-shaped enhanced lesion. Left carotid angiogram showed cerebral cortical venous thrombosis in the left frontal lobe, but the superior sagittal sinus was not occluded. A month after admission, right hemiparesis had suddenly improved and the patient could walk without any support. Left carotid angiogram showed recanalization of thrombosed cortical veins and CT scan showed disappearance of any low density lesion indicative of edema. It is an important fact that neurological deficit improved quickly a month after onset, and it was suspected that, even without resorting to fibrinolytic therapy, recanalization of thrombosed cerebral veins would still eventually occur. We found the reverse-triangle-shaped enhanced lesion on MRI and we suspected that it was typical finding for cerebral cortical venous thrombosis.

The simple indicator for revascularization of acute middle cerebral artery occlusion using angiogram and ultra-early embolectomy.

BACKGROUND: The purpose of the study was: (1) to find a clinical indicator for revascularization of acute middle cerebral artery (MCA) occlusion using angiograms of 100 patients examined immediately after onset and treated medically and (2) to investigate 10 ultra-early MCA embolectomies. METHODS: Quantity of collateral circulation, based on time required for conduction of contrast media to the insular portion of the MCA from the anterior cerebral artery, MCA conduction time (MCT) was graded as: Grade 1: In the arterial phase, there was conduction not only to the insular portion of the MCA but also to proximal M2; Grade 2: Conduction to the insular portion was present in late arterial phase; Grade 3: Conduction was present in capillary phase; Grade 4: Conduction was present in venous phase; Grade 5: No conduction was seen. The results of embolectomy are discussed. RESULTS: MCT can predict the extent of resultant low-density area on computed tomographic scan. For Grades 3, 4, or 5, embolectomy could be considered superior to medical treatment, if the low-density area was localized in the basal ganglia or centrum semiovale after surgery. Consequently, embolectomy was effective in four cases recanalized within 6 hours of onset. Except for one Grade 5 case, the remaining nine cases showed neither lethal hemorrhagic infarction nor brain edema. Overall outcome was significantly better than cases treated medically (p < 0.05), but some cases did not recover from hemiparesis due to infarcts in the area of the lenticulostriate arteries. CONCLUSIONS: MCT helps to predict the applicability of revascularization of acute MCA occlusion. Efficacy of embolectomy depends on revascularization within 6 hours of onset. Even after complete MCA flow restoration, infarcts in the area of the lenticulostriate arteries cannot always be prevented.

Endovascular stenting of an acutely thrombosed basilar artery: technical case report and review of the literature.

OBJECTIVE AND IMPORTANCE: The goal of this report was to describe the successful percutaneous endovascular use of a Gianturco-Roubin-2 coronary stent in the treatment of an acute atherothrombotic occlusion of the basilar artery. To our knowledge, the percutaneous endovascular deployment of an intra-arterial stent for the treatment of an acute atherothrombotic occlusion of the basilar artery and the percutaneous endovascular placement of a Gianturco-Roubin-2 stent in the basilar artery have not been previously reported. CLINICAL PRESENTATION: An 83-year-old man presented with a recurrent, transient, locked-in syndrome resulting from a lower basilar artery occlusion caused by vertebrobasilar thrombosis superimposed on severe proximal basilar artery atheromatous stenosis. INTERVENTION: After successful superselective intra-arterial thrombolysis of the vertebrobasilar clot, balloon angioplasty of the underlying basilar artery stenosis was performed, without significant angiographic improvement. Percutaneous endovascular deployment of a Gianturco-Roubin-2 coronary stent of 4-mm diameter was subsequently performed, with excellent angiographic results. CONCLUSION: The patient made a very good neurological recovery but unfortunately died as a result of cardiogenic shock and sepsis. Detailed neuropathological follow-up results are presented; stent patency was revealed in the postmortem examination. The anatomic and pathophysiological considerations of basilar artery stent placement for the treatment of acute basilar artery occlusion related to atherosclerotic stenosis are discussed.

Intra-operative colour-duplex-sonography in the surgical management of cerebral AV-malformations.

In this prospective study the role of intra-operative Colour-Duplex-Sonography (= CDS) during surgery of arteriovenous malformations (= AVM) is evaluated. During the last three years 20 consecutive patients with supratentorial AVMs were examined by intra-operative CDS in order to evaluate the potential of CDS to 1) localize the AVM, 2) differentiate between embolized and perfused parts, 3) identify feeding and draining vessels and 4) control the complete excision of the AVM. All AVMs were localized supratentorially, 9 were grade I and II (according to Spetzler and Martin [31]), 8 grade III and 3 grade IV. 11 were partly embolized and 8 associated with an intracerebral bleeding. In all cases the nidus was correctly localized sonographically by its typical bidirectional flow pattern in Colour-mode. CDS guided the surgeon directly to all (11 cases) deep-seated AVMs (2 to 4 cm subcortically). The smallest nidus measured 10 mm. 28 of 34 angiographically defined main feeding and 18 of 23 draining vessels were identified. 14 patients were controlled sonographically at the end of the resection regarding the completeness of excision. In 11 patients CDS was negative and was confirmed by either postoperative angiography or MRI in 10 patients. In one case residual AVM tissue was missed by CDS. Positive CDS findings in 3 cases were all confirmed by microscopic re-inspection, angiography and CCT. Our results suggest that CDS is able to localize AVMs intra-operatively with minimal instrumentation. It allows safe navigation to deep-seated malformations with high accuracy. Feeding and draining vessels can be identified and completeness of resection can be controlled.

Vascular reconstruction using interposed small vessels.

OBJECTIVE: This study presents the relationship between the patency of short-vessel graft bypasses and their diameter/length. METHODS: The authors performed interposed graft bypass operations using small vessels for four patients with moyamoya disease, six patients with cerebral thrombosis, and one patient with aortitis syndrome. The donor artery was the superficial temporal artery (10 patients) or the occipital artery (1 patient), and the recipient artery was the cortical branch of the middle cerebral artery (8 patients) or the cortical branch of the anterior cerebral artery (3 patients). The interposed graft used between these donor and recipient vessels was the superficial temporal vein (seven patients), the superficial temporal artery (three patients), or the epigastric artery (one patient). RESULTS: Good patency of the graft was confirmed for 7 of these 11 patients. Regarding the relationship between the diameter/length and the patency, we found that long-term patency could not be expected when the discriminant function of y = (15.39 x diameter) - (0.35 x length) - 14.37 was below zero. CONCLUSION: Short-vessel graft bypass is a practical option for cerebral revascularization surgery when short large vessels are used.

[Emergency heart valve replacement after acute cerebral embolism during florid endocarditis]. / Dringlicher Herzklappenersatz nach akuter Hirnembolie während florider Endokarditis.

BACKGROUND: The indication for urgent cardiac surgical interventions in patients with active infective endocarditis has to be considered carefully following thromboembolic events, because of the high recurrence rate of such complications. In the case of brain embolisms the prognostic benefit of urgent surgery has been discussed controversially as effective anticoagulation during open heart surgery may result in secondary cerebral hemorrhages. PATIENTS AND METHODS: Between 1978 and 1993 infective endocarditis (IE) was proven in 288 consecutive and prospectively followed patients (131 females, 157 males; mean age 53.6 +/- 8.7 [9 to 81] years). To analyze potential benefits and risks of an urgent surgical intervention early after embolic cerebral infarction, cumulated survival rates were calculated for patients with and without surgical intervention with special reference to incremental risk factors and the timing of surgery. RESULTS: In 50 patients (17.4%) the clinical course was complicated by one, and in 58 patients (20.2%) by recurrent embolic events. In 80% the first embolism occurred within 33 days following the first manifestation of typical signs and symptoms of IE. 80% of recurrent events were observed within 32 days following the initial embolism. 71% of all embolic events were cerebral. In patients with cerebral embolism corroborated by computed tomography (CCT), the clinical course was complicated by intracranial hemorrhage in 12.5% while it was only 1.5% for patients without cerebral embolism. Because of a lack of therapeutic alternatives, 22 of 49 patients with recurrent embolic events, of which at least one was cerebral, underwent urgent cardiac surgery within 4 to 366 hours after the first cerebral manifestation. The cumulated survival rate of patients operated within 72 hours after the initial cerebral embolism was significantly more favorable (p < or = 0.000) than for unoperated patients or those who were operated after more than 8 days. CONCLUSION: An embolic event during IE carries a more than 50% risk of recurrence. In patients with short duration of signs and symptoms of IE and postembolic echocardiographic demonstration of persistent vegetations the probability is > 80%. At least for those patients urgent surgical intervention to remove the source of infection and embolic hazard seems to be beneficial. Surgical intervention using the heart-lung-machine should be performed within 72 hours. Such early timing results in a significant lower rate of secondary cerebral hemorrhages (p < or = 0.00) than a postponed operation. To exclude early reperfusion hemorrhage due to spontaneous thrombus fragmentation, CCT should be repeated directly preoperatively.