Primary (granulomatous) angiitis of the central nervous system with multiple aneurysms of spinal arteries. Case report

A 55-year-old woman with primary (granulomatous) angiitis of the central nervous system in association with non-Hodgkin's lymphoma (mucosa-associated lymphoid tissue type) presented with an acute spinal subdural hemorrhage secondary to rupture of one of several fusiform inflammatory aneurysms of the spinal cord radicular arteries. The literature on hemorrhagic complications, aneurysms, and spinal cord involvement in granulomatous angiitis is reviewed. Recognition of granulomatous angiitis is important, as the condition may be responsive to immunosuppressive therapy.     

Comparing the severity of obstructive sleep apnea in patients referred by urban and rural physicians

The occurrence of a subdural hematoma caused by the rupture of an intracranial aneurysm is rare. In our case, the patient is a 43-year-old woman who suffered from sudden onset of severe headache. Computed tomographic (CT) scan disclosed a subdural hematoma associated with subarachnoid hemorrhage. CT angiography and digital subtraction angiography revealed an elongated aneurysm adhering to the dura in the left Sylvian fissure. The subdural hematoma was evacuated and the aneurysm clipped. The patient made a full recovery.     

Emergency magnetic resonance of the brain

We will review the role of magnetic resonance (MR) in assessment of patients with acute neurological abnormalities. The major stumbling block to the use of MR in these patients is the belief that MR is insensitive to hyperacute (<12 h) intracranial hemorrhage and acute subarachnoid hemorrhage (SAH). Hyperacute hemorrhage has characteristic features on MR. Hematomas are iso-to hyperintense on T1-weighted and hyperintense on T2-weighted images. Gradient-echo scans that reveal characteristic peripheral hypointensity are critical to the detection and delineation of hyperacute hematomas. Use of fast fluid-attenuated inversion recovery (FLAIR) sequences has made it possible to detect SAH on MR with a sensitivity that is equal to or greater than computed tomography (CT). SAH produces dramatic hyperintensity in the normally hypointense cerebrospinal fluid on FLAIR. MR has proven useful in the detection of hypertensive encephalopathy and venous thrombosis. These entities can be difficult to diagnose on CT, and in both, early treatment can dramatically improve prognosis. The same is true for acute intracranial infections such as pyogenic abscess, subdural empyema, and herpes simplex encephalitis. MR improves diagnostic accuracy, resulting in more rapid institution of appropriate treatment and improved outcome.     

Arachnoid cyst rupture producing subdural hygroma and intracranial hypertension: case reports

OBJECTIVE: To analyze the association between arachnoid cysts and subdural hygromas. METHODS: We reviewed five cases of arachnoid cysts that ruptured, producing acute subdural hygromas. The surgical management and diagnostic methods used are assessed. RESULTS: Five male patients ranging in age from 6 to 25 years sustained the rupture of arachnoid cysts, which produced acute subdural hygromas. Four of the patients had incurred blunt head trauma. All patients presented with symptoms referable to intracranial hypertension. The pathognomonic features of a middle fossa arachnoid cyst (MFAC) were noted on the computed tomographic scans and/or magnetic resonance images of each patient. The hygroma exerted mass effect on the ipsilateral hemisphere and was noted to be under significant pressure at the time of surgical intervention in each case. Two of the five cases are unique in the literature. In one, a coexisting quadrigeminal cyst ruptured, producing a subdural hygroma ipsilateral to the MFAC and dilating the basal cisterns. In the other, the MFAC ruptured into the basal cisterns as well as into the subdural space. The MFAC in each of the remaining three patients ruptured into the subdural space alone. All patients were treated with drainage of the subdural space. In the two patients in whom the basal cisterns were involved, both the hygromas and the MFACs failed to change significantly in size. The hygromas resolved completely and the MFACs decreased in size considerably in the three patients without cisternal involvement. CONCLUSION: The rupture of an arachnoid cyst can produce a subdural hygroma and intracranial hypertension. The latter mandates emergent drainage of the subdural space. In patients in whom the basal cisterns are not dilated by cyst rupture, both the MFACs and hygromas resolve after subdural drainage.     

Cranial axial computerized tomography in children (author's transl)

This report on computerized tomography in 400 children confirms the high diagnostic value of the new method in neuropediatrics. 31 brain tumours were diagnosed in children. Tumors present themselves as lesions of latered density compared to that of brain matter. Intravenous injection of contrast media increases the density of various lesions as tumors, angiomas, acute infarctions and abscess. Infarctions are low density lesions whereas hemorrhage is a high density lesion and both are thus safely differentiated. Edema may be visualized in the vicinity of tumours in brain injuries and in encephalitis. The normal ventricular system, hydrocephalus, cerebral malformations and subdural hygroma are easily demonstrated. Diseases of the orbits may also be detected.     

Management of subarachnoid hemorrhage patients who presented with respiratory arrest resuscitated with bystander CPR

BACKGROUND AND PURPOSE: The sudden death rate from aneurysmal subarachnoid hemorrhage (SAH) is 10%. Since 1989, 26 SAH patients who were witnessed to collapse into coma with respiratory arrest and required cardiopulmonary resuscitation (CPR) at the scene survived to reach the hospital and be diagnosed. Although reports on hospital management of grade V SAH suggest improved outcome, no report has previously addressed the issue of respiratory arrest after acute SAH. We analyze our experience with this unique subgroup of aneurysmal SAH patients. METHODS: This is a retrospective analysis of 26 consecutive SAH patients who collapsed at the scene and required CPR for respiratory arrest and survived to reach the hospital and be diagnosed. Statistical analysis was performed using the t test and Mann-Whitney rank-sum test. RESULTS: All patients were grade V on arrival at the emergency department. Twenty-one patients received mouth-to-mouth resuscitation only, and 5 received chest compressions as well. The mean duration of bystander CPR was 12 to 15 minutes. CT scan showed diffuse, thick SAH in all patients, an associated subdural hemorrhage in 2, and an intraparenchymal hemorrhage in 4. After CT scan, an intracranial pressure (ICP) monitor was placed in 24, and 2 were taken to emergency surgery for subdural and intracerebral hemorrhage. ICP was elevated in 24 patients (mean, 54 mm Hg), and a ventriculostomy was placed in all 24. ICP was unresponsive in 12, and all suffered brain death. ICP lessened to < 25 mm Hg in 12, and all underwent angiography. All 12 had an aneurysm and underwent emergency surgical clipping. Time to surgery from SAH was < or = 11 hours in all 12 patients. All were managed with calcium channel blockers and hyperdynamic therapy in addition to aggressive control of ICP. The outcome at 12 months in the 14 surgical cases was normal in 3 patients (21%), good in 2 (14%), vegetative in 1 (7%), and death in 8 (57%). CONCLUSIONS: Aneurysmal SAH patients that present with respiratory arrest present as grade V patients with elevated ICP. Bystander CPR coupled with early retrieval, diagnosis, and therapy can lead to 20% functional survival in what used to be sudden death from aneurysmal SAH.     

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.     

Intracranial hemorrhage associated with idiopathic thrombocytopenic purpura: report of seven patients and a meta-analysis

We present the results of a meta-analysis using clinical data obtained from seven of our patients and 24 previously reported patients with idiopathic thrombocytopenic purpura complicated by intracranial hemorrhage. Twenty-four had an intracerebral hemorrhage (ICH) and seven had a subdural hematoma (SDH). Mean age of the patients with ICH was significantly younger than those with SDH. The mortality rate of ICH associated with ITP was similar to that of spontaneous ICH. All seven patients with SDH improved without sequelae.     

Supratentorial arachnoid cyst and associated subdural hematoma: neuroradiologic studies

CT and MR images of 8 patients with supratentorial arachnoid cyst complicated by subdural hematoma were studied and compared with those of 8 patients who developed nontraumatic subdural hematoma without arachnoid cyst. Of the 8 patients with supratentorial arachnoid cyst, CT and MR disclosed temporal bulging and/or thinning of the temporal squama in all 6 patients with middle fossa arachnoid cysts, and the thinning of the calvaria was evident in another patient with a convexity cyst. Calvarial thinning at the site corresponding to interhemispheric arachnoid cyst was clearly depicted on coronal MR images. In contrast, none of the 8 young patients with nontraumatic subdural hematoma without arachnoid cyst had abnormal calvaria. Temporal bulging and thinning of the overlying calvaria were identified as diagnostic CT and MR features of arachnoid cyst with complicating intracystic and subdural hemorrhage. Radiologists should be aware of this association and should evaluate the bony structure carefully.     

Preoperative hair removal: a case report with implications for nursing

Experimental acute subdural hematoma in the rat has been shown to produce a zone of apparent infarction under the clot, and excitatory amino acid toxicity appears to play a role in the damage observed. We report the effect of dextromethorphan, a commonly used antitussive and a noncompetitive NMDA-type glutamate receptor antagonist, on the volume of histologic damage seen at 72 h after acute subdural hematoma in the rat. Sixty-five Long-Evans rats underwent placement of acute subdural hematoma using the "cranial window" model. Fourteen animals received oral dextromethorphan, 10 mg/kg/dose, twice daily for 3 days, and an additional 20 animals also received a single 20 mg/kg intraperitoneal dose 15 min after clot placement in addition to the oral regimen. Control animals received equal volumes of sterile water. Brain lesions in all animals were characterized by well-circumscribed infarctions underlying the subdural hematoma. Lesion volume in control animals was 88.3 +/- 9.3 mm3 (mean +/- standard error of the mean), while animals receiving dextromethorphan had significantly smaller lesions, which was independent of dosing schedule (59.9 +/- 9.2 mm3)(p = 0.0403). Animal weight was also found to be a significant covariate (p = 0.038). Because of its safety in humans and efficacy as a neuroprotectant in a variety of models, dextromethorphan may be a promising agent for clinical use, particularly in children.     

A difficult case involving a bradycardic patient

A seven-week-old, male chow chow-keeshond cross puppy was presented with acute paraplegia and episcleral hemorrhage. An X-linked, hereditary coagulopathy was suspected and confirmed by clotting factor analysis and necropsy findings of intraspinal hemorrhage. In young, male puppies with acute spinal pain and long-tract signs, intraspinal hematoma secondary to inherited X-linked coagulation factor deficiencies should be considered in the differential diagnosis.     

Unexpected death during a brain scintigraphy

Brain scintigraphy was performed for differential diagnosis of suspected subdural hemorrhage in a 79-year-old woman. Planar pertechnetate (99mTcO4-) brain scan with AP, PA, lateral and vertex projections was planned. The procedure was started with AP-projection, continuing with lateral projections. After these images the patient was determined dead and the planned scannings were aborted. There was a clear difference in the intracranial uptake (choroid plexuses) in the lateral views as well as in the uptake in the venous sinuses. The findings in the AP view were normal and no signs of subdural hemorrhage were observed. The patient died during a routine nuclear medicine procedure, and cessation of intracranial circulation was observable on 99mTcO4- scans; the lack of uptake in cerebral sinuses confirmed the lack of intracerebral flow. In this rare case, brain death could be timed accurately using a static nuclear medicine procedure. Autopsy confirmed sudden brain circulatory disorders and general arteriosclerosis.     

Studies on supratentorial subdural bleeding using a porcine model

A porcine model for an acute lethal arterial subdural bleeding in man is presented. Blood from the abdominal aorta was led via an electronic drop recorder into a collapsed intracranial subdural rubber balloon. Systemic arterial pressure (SAP), two intracranial pressures and 6 other vital parameters were monitored continuously in spontaneously breathing (n = 4) and mechanically ventilated (n = 4) pigs. In both animal groups bleeding caused an immediate rise in intracranial pressures (ICP) with transtentorial pressure gradients developing. As a result the cerebral perfusion pressures (CPP) decreased progressively, leading to an isoelectric EEG. In spontaneously breathing animals, the pressure changes resulted in apnoea within 2-4 minutes, irregularities in heart rhythm and in a marked rise in SAP (the Cushing reaction). A final collapse of all pressures occurred after 222 +/- 68 sec at a mean bleeding volume of 10.3 +/- 1.9 ml. In contrast, in mechanically ventilated animals, the course of bleeding was less dramatic. No change in cardiac rhythm or rise in SAP appeared despite a larger mean bleeding volume (12.0 +/- 1.6 ml). Instead, SAP slowly fell, reaching a level of approximately 40 mm Hg within 1 hour, while CPP concomitantly decreased from 120 mm Hg to 15 mm Hg. The findings in this and in a parallel study are explained in terms of the intracranial volume tolerance concept (Zwetnow et al. 1986). The beneficial effect of assisted ventilation on the course of subdural bleeding is multifactorial, involving both metabolic and mechanical mechanisms.     

Origin of chronic subdural haematoma and relation to traumatic subdural lesions

The origin of chronic subdural haematoma (CSDH) and the pathogenesis of subdural hygroma (SDG) are still controversial issues. These issues and relationships between these traumatic subdural lesions are discussed. The origin of CSDH is usually a SDG, although a few cases are caused by acute subdural haematomas (ASDH). Subdural hygroma is produced by separation of the dura-arachnoid interface, when there is sufficient subdural space. When the brain remains shrunken, the SDG remains unresolved. Any pathologic condition inducing cleavage of tissue within the dural border layer at the dura-arachnoid interface can induce proliferation of dural border cells with production of neomembrane. In-growth of new vessels will follow, especially along the outer membrane, then bleeding from these vessels occurs. These unresolved SDGs become CSDHs by repeated microhaemorrhage from the neomembrane. Although most victims with ASDH underwent surgery or died, some patients could be managed conservatively. Since the ASDH is usually absorbed within a few weeks, only a very few ASDHs become CSDHs, when there is a sufficient potential subdural space. Chronic subdural haematoma can arise from ASDH, but more commonly from SDG. Such transformation, or development of a new subdural lesion, is a function of the premorbid status and the dynamics of absorption and expansion.     

Vitrectomy in Terson's syndrome

Five patients with nonclearing vitreous hemorrhage associated with subarachnoid or subdural hemorrhages (Terson's syndrome) underwent pars plana vitrectomy. All six eyes of the five patients had postoperatively improved visual acuity and visual function. We recommend treating this rare syndrome with vitrectomy after careful preoperative ophthalmologic examination and a minimum observation period of six months to one year.     

Migrainelike headache in a patient with a hemorrhagic pituitary macroadenoma

A 23-year-old woman presented with a 4-day history of a severe migrainelike headache with a normal neurological examination. The headache resolved after a ketorolac injection, but recurred a few hours later. An MRI scan of the brain showed a hemorrhagic pituitary macroadenoma for which she underwent transsphenoidal removal of the tumor 1 month later. Although uncommon, pituitary hemorrhage with and without apoplexy should be considered in the differential diagnosis of acute headache. Pituitary hemorrhage can be routinely identified on an MRI scan even without pituitary views. However, the pathology can be overlooked and underimaged on a CT scan for acute headache using 10-mm and even 5-mm slices.     

Massive adrenal hemorrhage secondary to metastasis of lung cancer

Hemorrhagic adrenal metastasis from lung cancer is extremely rare, although adrenal involvement is common in widely disseminated cancer. We report a case of massive adrenal hemorrhage secondary to metastasis of lung cancer. A 47-year-old female was treated by left upper lobectomy and mediastinal lymph node resection for an adenocarcinoma with intrapulmonary metastasis in the left upper lobe. Eight months later, she presented with right flank and back pain, and abdominal ultrasonography and computed tomography showed a right solitary adrenal tumor with massive hemorrhage. The tumor was not resectable and partially responded to chemotherapy. A massive adrenal hemorrhage, secondary to metastasis of lung cancer, presents with nonspecific clinical signs and symptoms. In lung cancer patients with an acute flank or back pain, hemorrhagic adrenal metastasis should be considered in the differential diagnosis.     

HIV infection among women of reproductive age

PURPOSE: To report on an exceptional case of spontaneous, idiopathic, unilateral adrenal gland rupture that caused massive retroperitoneal hemorrhage. METHODS AND RESULTS: US and CT were performed in a patient who presented with acute abdominal pain. Urgent adrenalectomy was required to prevent the blood loss from continuing. The CT findings were correlated with the histological findings. CONCLUSION: CT proved to be an accurate imaging modality by which to diagnose adrenal hemorrhage. The absence of irregular tissue enhancement showed that neoplasia was not the underlying cause of the hematoma.     

Fetal intracranial hemorrhage. Imaging by ultrasound and magnetic resonance imaging

OBJECTIVE: To describe the magnetic resonance imaging (MRI) findings associated with fetal intracranial hemorrhage and to compare them with ultrasound findings. STUDY DESIGN: In four pregnancies complicated by fetal intracranial hemorrhage, fetal imaging was carried out using T2-weighted fast spin echo sequences and T1-weighted fast low angle shot imaging sequences and by transabdominal ultrasonography. RESULTS: An antepartum diagnosis of hemorrhage was made by ultrasound in one case and by MRI in two. Retrospectively, the hemorrhagic area could be identified from the MRI images in an additional two cases and from the ultrasound images in one case. In the cases of intraventricular hemorrhage, the MRI signal intensity in the T1-weighted images was increased in the hemorrhagic area as compared to the contralateral ventricle and brain parenchyma. In a case with subdural hemorrhage, T2-weighted MRI signals from the hemorrhagic area changed from low-to high-intensity signals during four weeks of follow-up. Better imaging of the intracranial anatomy was possible by MRI than by transabdominal ultrasonography. CONCLUSION: MRI can be used for imaging and dating fetal intracranial hemorrhages. Variable ultrasound and MRI findings are associated with this complication, depending on the age and location of the hemorrhage.     

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.