Spontaneous cerebellar hemorrhage in children and adolescents

Spontaneous cerebellar hemorrhage is infrequently reported in children, although this disorder account for roughly 10% of nontraumatic intracranial hemorrhages in adults. We studied three cases that demonstrated the clinical features, radiological findings, pathological features, and outcome in this condition. A review of the literature uncovered 21 additional cases. The most commonly encountered cause of hemorrhage found in 62% of the cases was a vascular abnormality. Of the 24 patients, 15 underwent surgery and 14 of these survived. No patient survived without surgery. Computerized tomography has increased the diagnostic yield while decreasing diagnostic morbidity, and early surgical intervention provided dramatic improvement in many patients. The diagnosis of spontaneous cerebellar hemorrhage must always be considered in the examination of a patient with symptoms and signs suggesting an acute onset of a posterior fossa mass lesion.     

Surgically resected brain stem cavernous angioma in an infant

An infantile case of surgically resected brain stem cavernous angioma is presented. This 21-month-old boy was admitted to our department after repeated severe pontine hemorrhage. A deeplying lesion with hematoma was successfully removed via the IV ventricle approach. Few infantile cases of this lesion have been presented previously, and the approaches to brain stem cavernous angiomas in infants are discussed.     

Stereotactic radiosurgery for cavernous malformations: Kjellberg's experience with proton beam therapy in 98 cases at the Harvard Cyclotron

OBJECTIVE: The lack of treatment options for surgically inaccessible cavernous malformations has made radiosurgery a possible alternative to conservative management. The few previous reports of radiosurgical efficacy have been limited by small numbers, short follow-up, or lack of attention to the full spectrum of end points, including neurological disability. In an attempt to elucidate the risk-to-benefit ratio of radiosurgery for cavernous malformations, we undertook a retrospective analysis of of 95 patients with 98 lesions treated by the late Raymond N. Kjellberg. METHODS: Patients were followed for an average of 5.4 years (range, 0.3-12.3 yr), and data regarding hemorrhage, seizure, neurological disability, and incidence of radiation-induced complications were gathered. RESULTS: The analysis revealed a drop in annual hemorrhage rates from 17.3% per lesion per year before treatment to 4.5% per lesion per year after a latency period of 2 years. Improvement in seizure control was evident. However, a 16% incidence of permanent neurological deficit and a 3% mortality rate were attributable to radiographically confirmed radiation-induced complications. Neurological disability scores, measured by the modified Rankin disability scale, indicated a significant decline in neurological functioning during the follow-up interval, a result of the combined effects of radiation-related injury, hemorrhage, and clinical progression of the lesion. CONCLUSION: We conclude that although radiosurgery does seem to reduce hemorrhage, there is potential for complications and continued lesion progression after radiosurgery. These risks and benefits must be carefully balanced against the natural history of untreated lesions if the use of radiosurgery is considered.     

Lipoprotein(a) concentration and molecular weight of apolipoprotein(a) in patients with cerebrovascular disease and diabetes mellitus

Plasma lipoprotein(a) [Lp(a)] concentrations are genetically determined, and hyper-Lp(a)-emia is an independent risk factor for atherosclerosis and thrombosis. To study the implications of Lp(a) in cerebrovascular disease (CVD) and diabetes mellitus (DM), we examined plasma Lp(a) levels and molecular weights of apolipoprotein(a) [apo(a)] in 118 patients with CVD, and 125 cases with DM. Although mean Lp(a) concentrations were higher in those cases with atherothrombotic brain infarction than in those with brain hemorrhage and lacunar infarction, the difference was not statistically significant. Lp(a) levels were significantly higher in the DM cases treated with insulin and in those treated with oral hypoglycemic agents than in those on diet therapy alone, suggesting that insulin and oral agents modulate apo(a) expression. Lp(a) concentrations correlated significantly with the low-molecular-weight isoforms of apo(a) in all CVD and DM groups.     

Exposure to environmental and mainstream tobacco smoke and risk of spontaneous abortion

The present nationwide, multicenter clinical study was carried out in 26 departments of surgery to define the incidence and attendant mortality of intestinal infarction following abdominal aortic surgery, and to identify patients at risk of it. The data consist of 1752 patients who underwent abdominal aortic reconstruction during 1991-1993 as recorded in the Finnish national vascular registry (FINNVASC). Among the 1752 operations, 27 patients treated at 14 different hospitals had intestinal ischemia, and the complete patient records of all 27 cases were reanalyzed. The incidence of bowel infarction was 1.2%. Among patients operated on for a ruptured aneurysm it was 3.1%, whereas 1.0% of patients with nonruptured aneurysm and 0.6% of those operated on for aortoiliac occlusive disease developed intestinal infarction. In 14 patients (67%) the lesion affected the left colon. The overall 30-day mortality rate was 13% but reached 67% among those with intestinal infarction. We conclude that acute intestinal ischemia with bowel infarction is an infrequent but serious complication of abdominal aortic surgery. It is mainly related to surgery due to aneurysmal disease, and patients with occlusive aortoiliac disease present ischemic complications in the intestines less often. Hypotensive patients being treated for ruptured aneurysm are at greatest risk of intestinal ischemia.     

The effect of muscle relaxants on cricothyroid muscle: a report of three cases

PURPOSE: To determine the frequency of the computed tomographic (CT) pattern of nonaneurysmal perimesencephalic subarachnoid hemorrhage in the setting of ruptured posterior fossa aneurysms. MATERIALS AND METHODS: Four neuroradiologists independently and retrospectively reviewed cranial CT scans of 169 patients with ruptured vertebrobasilar aneurysms (44 cases of posteroinferior cerebellar artery aneurysm, 20 cases of superior cerebellar artery aneurysm, and 105 cases of basilar-tip aneurysm). RESULTS: The mean frequency of nonaneurysmal perimesencephalic pattern of subarachnoid hemorrhage in ruptured vertebrobasilar aneurysms was 7.1% (48 of 676 readings) among the four readers. The mean frequency of aneurysms with the pattern of hemorrhage for each location was as follows: basilar tip, 9.8% (41 of 420 readings); superior cerebellar artery, 5.0% (four of 80 readings); and posteroinferior cerebellar artery, 0%. In 75% (six of eight) of the cases in which the CT pattern of hemorrhage was deemed compatible by all readers with nonaneurysmal hemorrhage, the clinical presentation was mild. CONCLUSION: Because ruptured posterior fossa aneurysms manifest with the nonaneurysmal pattern of hemorrhage in approximately 10% of cases, a high degree of suspicion should be maintained even if the pattern of subarachnoid hemorrhage suggests a nonaneurysmal origin and clinical symptoms are mild.     

Predicting mammography and breast self-examination in African American women

In the past ten years four sportsmen with a traumatic perilymphatic fistula were treated. Three of these four patients were surgically treated: two of them underwent a labyrinthectomy and with one of them, the oval window was grafted. After the analysis of these cases, we have made a study of the literature. Careful attention to the patient history and accurate review of the recurrent vestibulocochlear symptomatology isolate a clinical "audiovestibular syndrome of perilymphatic fistule". There is lack of precise preoperatoire diagnostic test. Nevertheless, entire positionnal audiometric test is a reliable and easy to perform test. The medical management is based on bed rest during a reasonable period. Only patients with significant suggestive symptomatology are surgically explored . They sometimes need destruction of vestibular function without preservation of hearing.     

Percutaneous coronary angioscopy: 200 observations in 100 candidates for angioplasty

Due to the recent technological advances, it is possible to perform percutaneous coronary angioscopy in a straightforward fashion in most patients. To know the safety and usefulness of this technique we present 200 observations in 100 patients candidates for coronary intervention. We used a coronary angioscope (Baxter, Edwards LIS Division), that can be placed using the conventional technique for percutaneous coronary angioplasty. The system incorporates a proximal occluding balloon, and distally a movable optical fiber. Case selection considered non-ostial coronary segments relatively straight. It was possible to obtain adequate images in 86 percent of cases. The technique is safe in experienced hands: there were two cases of ventricular fibrillation, and two cases of local dissection occurred, none of these associated with clinical consequences. No myocardial infarction, surgery or death, related to this procedure occurred. Valuable diagnostic information is derived from angioscopy as the method provides some histopathological correlation. Stable plaques are usually uniformly white or yellow. Unstable plaques are yellow and ulcerated. Thrombus can be easily recognized in acute coronary syndromes. Also in percutaneously treated segments, the final result and the presence of dissection or hemorrhage can be visualized. Coronary percutaneous angioscopy is safe and brings useful clinical information. Its applications in the clinical practice are still to be determined.     

More children are unable to get dental care than any other single health service

True congenital peripheral aneurysms of the cerebral arteries are rare and may constitute a special entity. We report a rare case of nonmycotic peripheral aneurysm of the posterior cerebral artery (PCA) found in association with aneurysms of distal middle cerebral artery (MCA), junction between basilar artery (BA) and superior cerebellar artery (SCA) and MCA trunk. Our present case was a 37-year-old man with a history of abrupt loss of consciousness. Cerebral angiography revealed a right PCA aneurysm originating at the junction between the trunk of the PCA and the posterior temporal branch, and also aneurysms of the right distal MCA, at the right BA-SCA junction and at the trunk of right MCA just distal to the anterior temporal artery. Distal PCA aneurysm causing subarachnoid hemorrhage was successfully clipped and all the other aneurysms were treated in a one-stage procedure. Pathological examination of the surgically excised distal PCA aneurysmal sac demonstrated no infectious etiology. There have not been any similar cases showing an association of vascular anomalies with distal PCA aneurysm. This is the only reported case with the association of nonmycotic peripheral aneurysms involving the MCA and PCA.     

Prenatal sonographic appearance of hemorrhagic cerebellar infarction

To date, the prenatal diagnosis of cerebellar hemorrhage has been limited to isolated case reports, which have demonstrated either a hyperechoic cerebellar hemisphere or a hyperechoic mass within the cerebellum in near-term fetuses. We demonstrate the ultrasonographic findings of intracerebellar hemorrhagic infarction in a fetus at approximately 21 weeks' gestation. In contrast to previous case reports, the hemorrhagic infarcts seen in our case were hypoechoic.     

Carotid restenosis: clinical significance and indications for reintervention

Carotid restenosis is defined as a new > 50% diameter-reducing lesion present in sites of previous surgery. The clinical aspects of this complication are strongly connected with their anatomopathologic evolution: fibromuscular hyperplasia in early recurrent disease, atherosclerotic degeneration in the later lesions. Routine postendarterectomy duplex surveillance is able to detect this pathologic evolution. On 570 surgically treated carotid artery a postoperative duplex surveillance was made at 3, 6, 12 months and then yearly. Totally 42 cases of recurrent stenosis (7.3%) were present: in seven cases (16.6%) with a complicated restenosis the patients were symptomatic. In 27 cases (64.2%) restenosis was < 75%, in 8 cases (19.2%) > 75%. Indication to surgery was given for all the complicated restenosis and for high grade stenosis (> 75%). In the 27 cases of restenosis < 75% a conservative therapy together with duplex surveillance was applied: in none of these cases the restenosis increased in an average follow-up of 13.7 months. In the reoperated cases we didn't observe any mortality nor postoperative stroke. With regard to their mainly hyperplastic origin, carotid restenosis are low symptomatic and with a quite benign evolution. Surgical reintervention is to be limited to the symptomatic cases and to the asymptomatic high grade stenosis cases. A particular attention should be reserved to the morphologic characteristics of the lesion in order to detect the atherosclerotic degeneration that might cause cerebral symptoms.     

Naloxone potentiates the anxiolytic but not the amnestic action of chlordiazepoxide in C57BL/6 mice

There are some cases in which conservatively treated acute subdural hematoma (ASDH) does not disappear naturally and progresses to chronic subdural hematoma-like hematoma (CSDH) (hematoma with capsule formation). The objective of the present study was to identify factors which can be used to predict this unfavorable course during the early phase after the onset of the lesion. During the past 13 years, 10 of 96 cases of mild, conservatively treated ASDH (excluding suckling infants) progressed to CSDH, and those 10 patients showed the following background characteristics. There were 7 males and 3 females, and the mean age was 63.1 years. Five of the patients had a history of alcohol consumption, and one case each had a history of cerebral infarction, cerebral hemorrhage and a VP shunt. Acute-phase computerized tomography (CT) at the time of ASDH showed, in all 10 cases, an expansive-type lesion with a low density area in the hematoma, with expansion of the hematoma into the interhemispheric fissure. The hematoma was observed to undergo transient natural shrinkage in the acute phase. The period for progression to CSDH was indicated to be a mean of 20.5 days after the onset of the lesion, and its cure was possible with trepanation. In consideration of these results, it was surmised that ASDH patients with the following characteristics have a high risk of progression to CSDH during the subacute and chronic phases when conservative therapy is administered during the acute phase of the lesion: (1) old age, (2) a history indicative of brain atrophy, (3) an expansive-type image of ASDH on acute-phase CT, and (4) acute-phase CT indicative of cerebrospinal fluid mixing in the hematoma.     

Nigrostiatally induced motor reactions in the rat. II. Cholinergic effect on rotational behavior and posture asymetry

In a period of 3 years 12 patients with meningiomas of the posterior cranial fossa were treated surgically. The group included 2 cases of meningioma situated on the cerebellar convexity, 5 on the tentorium, 2 on the posterior aspect of the pyramid bone, 1 of Blumenbach clivus, 2 of foramen magnum. The neurological findings and pneumoencephylographic changes in cases of meningiomas of cerebellar convexity, tentorium and posterior aspect of the pyramid bone made possible the diagnosis of posterior fossa tumour and the diagnosis of meningioma was made possible by carotid and vertebral angiography. In the case of Blumenbach clivus meningioma and in foramen magnum meningiomas the neurological changes were characteristic of tumours at the craniovertebral junction. One meningioma growing through the tentorium was approached from the middle cranial fossa, the remaining ones from the posterior cranial fossa. The tumour could have been removed radically in 7 cases. In 5 cases only partial removal was possible. Three patients died, two after operations for tentorial meningioma and one after operation for Blumenbach clivus tumour. The results in the remaining cases were good.     

Acute ischaemic lesions in death due to ischaemic heart disease. An autopsy study of 333 cases of out-of-hospital death

The frequency of acute coronary artery thrombus and myocardial infarction in subjects dying suddenly or unexpectedly from ischaemic heart disease (IHD) is still unclear, with previous autopsy studies reporting an incidence between 4% and 100%. In this study of 333 randomly selected out-of-hospital deaths, detailed autopsy showed IHD as the sole cause of death in 206 (62%). One hundred and seventeen acute coronary thrombi were present in 96 cases whilst four had an established acute infarct without an identifiable coronary thrombus. Thus 100 (48.5%) IHD deaths had evidence of an acute ischaemic lesion. Acute lesions were equally prevalent among males and females, but the incidence declined with increasing age and they were less frequent among those with a prior clinical history of heart disease. One hundred and forty-seven IHD deaths were witnessed. The proportion of cases with an acute ischaemic lesion increased with the duration of pre-morbid symptoms. Of those with an acute lesion, only 17% died without symptoms compared to 63% of those without an acute lesion. All cases with symptoms lasting more than 3.5 h had an acute lesion. Overall, almost half out-of-hospital IHD deaths in this study were related to an acute ischaemic lesion. Differences in the detail of the pathological examination and examination of differing sub-groups of the out-of-hospital death population probably account for the differing results of previous studies.     

Neuron-specific enolase concentrations in blood as a prognostic parameter in cerebrovascular diseases

BACKGROUND AND PURPOSE: To investigate the clinical relevance of plasma concentrations of neuron-specific enolase (NSE) in patients with severe cerebrovascular diseases, serial analyses were performed during the first 10 days after the acute event. METHODS: Plasma samples taken from 61 patients (30 with brain infarction, 13 with intracerebral hemorrhage, 11 with cardiogenic hypoxia-ischemia, and 7 with myocardial infarction [as control group]) were analyzed for NSE concentration using an enzyme immunoassay. The time course of plasma NSE was correlated with clinical findings, clinical outcome, cranial computed tomography, intracranial pressure, and other laboratory data. RESULTS: In cases of hypoxia-ischemia there was close correlation between plasma NSE values during the first 72 hours and the clinical outcome. In brain infarction and intracerebral hemorrhage, high plasma NSE mostly indicated an unfavorable outcome, but low values did not permit a reliable prognostic estimation. In cases of cerebral infarction and intracerebral hemorrhage with secondary neuronal destruction (for example, due to malignant edema), increasing NSE concentrations in plasma preceded the change of clinical or other diagnostic parameters. CONCLUSIONS: The course of plasma NSE levels is seen as a relevant parameter for assessing the prognosis of cerebral hypoxia-ischemia. Additionally, it may prove to be a useful tool for monitoring space-occupying brain infarctions and intracerebral hemorrhages and therefore may contribute to improved therapeutic management of severe cerebrovascular diseases.     

The in vitro effect of hydrocortisone on endocytosis in cultured mouse peritoneal macrophages

Three juvenile patients with cerebellar astrocytomas which have seeded the spinal subarachnoid space are presented. Histologic verification of the similarity between the posterior fossa tumor and its spinal implant was obtained in two of the three patients. The cerebellar tumors in all cases have been benign (grade I),and the behavior, other than their seeding has also been indolent. Review of pertinent literature discloses no similar experience with cerebellar astrocytomas. Aggressive therapy is advocated for the rare patient with subarachnoid seeding from this benign lesion.     

Treatment of anorexia nervosa

Although the histogenesis of meningeal hemangiopericytomas (HMP) remains controversial, both biological and clinical evidence seems to identify these neoplasms as a separate entity with respect to meningiomas. In order to assess the current prognosis of HMP we reviewed our personal experience limited to the last decade (1986-1995): during this period 7 patients (4M, 3F) were treated by surgery alone or surgery combined with postoperative radiotherapy. In spite of meticulous attempts at radical resection, the tumors recurred in all but two cases with a mean interval of 85 months, and a total of 18 operations were performed (2.57/patient; range 1-4). Massive intratumoral hemorrhage determined acute deterioration and required emergency surgery in two cases while in one patient diffuse visceral metastases were discovered at autopsy. Five patients are still alive at follow-up but only 2 of them are in good neurological conditions and without evidence of disease. These results are similar to those reported in other series. In view of our results we conclude that intracranial hemangiopericytomas still have a dismal prognosis. Advances in neuroimaging, neuroanesthesia, microneurosurgery and adjuvant therapy do not seem to have significantly affected the recurrence rate, quality of life and mortality.     

Unexpected results in long-term medically treated ruptured intracranial aneurysm including data on 14 patients followed more than 30 years each

This is the longest reported follow-up of patients with ruptured intracranial aneurysms treated entirely medically with hypotension. Patients with ruptured brain aneurysms, untreated except for plain bedrest, are at a well-recognized risk of recurrent hemorrhage. Some surgically treated patients also remain at risk of recurrent hemorrhage in follow-up. This is a review of results in patients whose active but entirely medical (hypotensive) treatment was started in the first 10 years of a 40-year study. It suggests a way of reducing risks in both of the above 2 groups. 53 consecutive patients with proven ruptured brain aneurysm(s) were treated as early as possible with medical-hypotensive therapy alone by the author and followed, personally, until death or, if they survived, for at least 30 years each (or until lost to follow-up). The patients included many considered to have been poor operative risks with some having been designated inoperable by the referring neurosurgeons. As part of the long-term follow-up, magnetic resonance angiography (MRA) has been begun. Long-term follow-up was defined as the time beginning after 9 weeks from (admission) hemorrhage. 9 patients had died during the earlier stages of hemorrhage (and treatment) i.e., before the 9 weeks period had elapsed; their data was presented previously. This yielded 44 patients for long-term follow-up. Only 2 patients (both had multiple aneurysms) on this regimen have died of either proven hemorrhage (1 patient) or presumed hemorrhage (1 patient). Most patients survived and maintained an excellent condition. Medical-hypotensive therapy of ruptured intracranial aneurysms has produced much better long-term results than expected. This is significant for (1) patients requiring medical treatment alone and (2) surgically treated patients who may benefit from additional long-term protection.     

Spontaneous intracranial hypotension syndrome]

Spontaneous intracranial hypotension is a rare but well known entity first described by the German neurosurgeon Schaltenbrand. We report the clinical and radiological findings of four patients (2 males, 2 females, mean age 55 years) presenting with this clinical entity and peculiar constant MRI findings. Intense postural headache was present in all patients together with a very low CSF pressure at lumbar tap although none of the patients had any history of recent lumbar puncture, spinal or cerebral surgery or cranio-cervical trauma. MRI revealed in all patients an intense meningeal enhancement and thickening which was most prominent on the dural side of the subdural space. The ventricular system was thin, presenting almost like slit ventricules. A downward shift of the cerebellar tonsils and hemorrhagic subdural collections were also observed in two patients. Biopsy of meninges performed in two patients showed fibrosis of the leptomeninges together with signs of old hemorrhage in one case. We postulate that histologic and radiologic changes are due to chronic subdural bleeding in relation with abnormal displacement of the nervous structures due to intracranial hypotension. The underlying cause of spontaneous intracranial hypotension is rarely established and the course of the disease is benign. Some authors have advocated to perform isotopic cysternography in search for a CSF leak, particularly in the spine, that could be surgically corrected. No such investigation has been conducted yet in our patients because the spontaneous evolution has been mostly favorable.     

Motor evoked potentials in unilateral lingual paralysis after monohemispheric ischaemia

OBJECT: A retrospective analysis was conducted of 10 patients (three women and seven men) who were treated for spinal dural arteriovenous shunts (AVSs) located at the craniocervical junction. This analysis was performed to evaluate the characteristics of this unusual location in contrast with those of the more common thoracic and lumbar AVSs. METHODS: Seven patients presented with subarachnoid hemorrhage (SAH) and one with slowly progressive quadriparesis and dyspnea due to myelopathy. The other two cases were detected incidentally and included a transverse-sigmoid dural AVS and a cerebellar arteriovenous malformation. Angiographic studies revealed that the spinal dural AVSs at the C-1 and/or C-2 levels were fed by the dural branches of the radicular arteries that coursed from the vertebral artery and drained into the medullary veins. Venous drainage was caudally directed in the patient with myelopathy. In contrast, the shunt flow drained mainly into the intracranial venous system in patients with SAH. Furthermore, in four of these patients a varix was found on the draining vein. In all patients, the draining vein was interrupted surgically at the point at which this vessel entered the intradural space, using intraoperative digital subtraction angiography to monitor flow. The postoperative course was uneventful in all patients and no recurrence was confirmed on follow-up angiographic studies obtained in seven patients at 6 months after discharge. CONCLUSIONS: If computerized tomography scanning shows SAH predominantly in the posterior fossa and no abnormalities are found on intracranial four-vessel angiographic study, proximal vertebral angiography should be performed to detect dural AVS at the craniocervical junction. The results of surgical intervention for this disease are quite satisfactory.