Cases reported "Cerebral Hemorrhage"

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1/141. Intraventricular hemorrhage as a false localizing sign of a thoracolumbar arteriovenous malformation: case report.

    BACKGROUND: Spinal arteriovenous malformation (SAVM) is a relatively rare disease characterized by a high incidence of intramedullary and subarachnoid haemorrhage. When the hemorrhage is profuse and the SAVM is in the cervical region the symptoms (disturbance of consciousness, papilledema, cranial nerve palsies, and convulsions) may be so severe and rapid in their onset that they may be mistaken for intracranial hemorrhage. We report here on a patient with a SAVM at T10-12, which bled intracranially, mainly intraventricularly, and resulted first in respiratory arrest and unconsciousness. CASE DESCRIPTION: The patient had been well until he was 28 years old when, during intercourse, he suffered a terrible headache and suddenly lost consciousness, with a transient respiratory arrest. He was also noted to have right hemiparesis. A computed tomography scan demonstrated intraventricular hemorrhage. After a 24-hour period of artificial ventilation the patient regained consciousness and the right arm paresis completely recovered, but a gradual worsening of the motor function of the left leg developed. Digital subtraction angiography did not demonstrate any intracranial source of bleeding, whereas spinal angiography revealed a SAVM located at the medullary cone, which was totally removed by surgery. CONCLUSION: The case reported here raises several important issues. First, the advisability of spinal magnetic resonance imaging in the investigation of intraventricular (and subarachnoid) hemorrhage in patients with no demonstrable intracranial source. Secondly, the benefits of early diagnosis and reestablishment of the spinal cord circulation before the onset of thrombosis and the progressive phase of myelopathy. Finally, the necessity of complete obliteration and treatment of SAVMs even in patients with fixed neurologic deficits, because rebleeding of lower thoracic or lumbar SAVMs can lead to impairment at a higher level with severe or lethal consequences.
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2/141. Complications of lumbar puncture with injection of hydrosoluble material.

    We report two cases of severe disorders after spinal puncture with injection of hydrosoluble material. The first case concerned a 36-year-old woman with intrathecal injection of 125 ml of hydrocortisone acetate. An intracranial occipital hematoma developed. The second case concerned a 26-year-old man with intrathecal injection of contrast media and hydrocortisone. A chemical meningitis occurred. In both cases the natural course was favorable. Both complications are well known but rare. A review of the literature is made with description of the mechanisms. Preventive therapeutic measures are reported.
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3/141. Cerebellar hemorrhage after supratentorial surgery for treatment of epilepsy: report of three cases.

    OBJECTIVE AND IMPORTANCE: We report three cases of cerebellar hemorrhage complicating supratentorial craniotomies for the treatment of epilepsy. In a literature review, we identified only four similar cases of cerebellar hemorrhage after temporal lobectomy for the treatment of epilepsy. CLINICAL PRESENTATION AND RESULTS: Three young and otherwise healthy patients underwent frontal, occipital, and temporal resections for the treatment of refractory epilepsy. The hemorrhage manifested as peduncular tremor, ataxia, and decerebrate posturing presenting early in the postoperative period. The diagnosis was established by computed tomography and/or magnetic resonance imaging. Benign outcomes were observed for all patients. CONCLUSION: Based on the available data, it is our opinion that brain dislocation resulting from excessive intraoperative cerebrospinal fluid drainage is a possible mechanism for this rare complication of supratentorial craniotomy. The overdrainage seems to be less hazardous when the procedure is performed for the removal of space-occupying mass lesions. In contrast, the resection of nonexpanding tissues, such as in lobectomies for the treatment of epilepsy, may be an additional risk factor, because the incidence of this complication seems to be higher in these situations.
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4/141. Haemorrhage in the labyrinth caused by anticoagulant therapy: case report.

    We report a patient who experienced a severe vertiginous episode with bilateral tinnitus and progressive right-sided hearing loss. She had Marfan's disease and was on anticoagulant treatment. The fluid in the labyrinth gave higher signal than cerebrospinal fluid on T1-weighted images, suggesting haemorrhage. The radiological follow-up is discussed.
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5/141. Posterior-fossa haemorrhage after supratentorial surgery--report of three cases and review of the literature.

    We present clinical details of three patients with posterior fossa haemorrhage after supratentorial surgery and discuss possible pathomechanisms of this rare complication. All patients were males of advanced age. Two patients presented with a history of hypertension. In all patients the occurrence of haemorrhage was associated with loss/removal of large amounts of cerebrospinal fluid (CSF) either intra-operatively (one patient undergoing aneurysm surgery) or postoperatively (all three patients: drainage of subdural hygromas or chronic subdural haematomas in two, external ventricular drainage in one patient). Treatment consisted in haematoma evacuation and/or external ventricular drainage. Two patients died, one patient recovered completely. Although haematomas distant from a craniotomy site are a well known entity, a review of the literature identified only 25 published cases of posterior fossa haemorrhage after supratentorial procedures in the CT era. Most often disturbances of coagulation, positioning of the patient and episodes of hypertension have been associated with this complication. Only one author described the occurrence of a haemorrhage after drainage of a supratentorial hygroma. We suggest that the loss of large amounts of CSF intra-operatively and post-operatively may lead to parenchymal shifts or a critical increase of transmural venous pressure with subsequent vascular disruption and haemorrhage.
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6/141. Recovery from Duret hemorrhage: a rare complication after craniotomy--case report.

    A 44-year-old female presented with Duret hemorrhage due to transtentorial herniation by extradural hematoma as a complication after craniotomy for treatment of spontaneous middle cranial fossa cerebrospinal fluid leakage through the oval window. Brain computed tomography revealed linear hemorrhage in the midbrain and the rostral pons. She awoke after 2 weeks in a coma, despite showing ocular bobbing and bilateral intranuclear ophthalmoplegia. She was discharged from the hospital with minimal neurological defects. Duret hemorrhage is usually fatal, but this case shows that early surgical decompression is the most important factor to avoid the worst sequelae.
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7/141. Fatal cerebral hemorrhage associated with cyclosporin-A/FK506-related encephalopathy after allogeneic bone marrow transplantation.

    We report a case of cerebral hemorrhage associated with cyclosporin A (CsA)/FK506-related encephalopathy that developed in a 16-year-old woman after allogeneic bone marrow transplantation. Hematopoietic engraftment occurred on day 15, and the patient developed systemic convulsions after CsA was replaced by FK506 for the treatment of acute graft-versus-host disease (GVHD). Based on magnetic resonance imaging, laboratory findings and cerebrospinal fluid studies, she was diagnosed as having CsA/FK506-related encephalopathy with cerebral hemorrhagic infarction. Although she recovered completely after discontinuation of FK506, she developed convulsions again 15 days after re-administration of FK506. A computed tomography scan showed cerebral hemorrhage. She died of respiratory failure. Vascular damage induced by immunosuppressive drugs and enhanced by acute GVHD seemed to be the cause of the cerebral hemorrhage. Since hypertension, which was present during both of the central nervous system events, seemed to have contributed to the development of the cerebral hemorrhage, it is proposed that CsA and FK506 should be reduced or discontinued when patients who have risk factors of hypertension become hypertensive even if they have no symptoms of neurotoxicity.
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8/141. Spontaneous brain hemorrhage associated with lyme neuroborreliosis.

    We present the case of a patient with late neuroborreliosis and a spontaneous temporal lobe hemorrhage. Although ischemic stroke and subarachnoid hemorrhage have been reported in association with lyme disease, intraparenchymal brain hemorrhage has not been previously described in the course of this disease. The patient is a 48-year old male with a progressive spastic paraparesis of months' duration who presented acute headache, confusion, severe left hemiparesis with sensory deficit and homonymous hemianopsia. A cranial computed tomography scan showed an extensive right temporal lobe hemorrhage with subarachnoid invasion. Brain angiographic and angio-magnetic resonance imaging studies excluded hemorrhage-predisposing vascular abnormalities. cerebrospinal fluid (CSF) studies disclosed mononuclear pleocytosis with elevated protein levels. Both serum and CSF anti-borrelia titers were significantly increased, and serum Western Blot showed bands to protein 34 (ops B), 57, 59 and 62. The patient was treated with ceftriaxone for 4 weeks, with a favorable outcome. It is suspected that cause of the hemorrhage was parenchymatous Lyme-associated vascular damage and/or microaneurysmatic rupture.
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9/141. Transtentorial herniation after unilateral infarction of the anterior cerebral artery.

    BACKGROUND: Fatal cerebral herniation is a common complication of large ("malignant") middle cerebral artery infarcts but has not been reported in unilateral anterior cerebral artery (ACA) infarction. CASE DESCRIPTION: We report a 47-year-old woman who developed an acute left hemiparesis during an attack of migraine. Cranial CT (CCT) was normal but demonstrated narrow external cerebrospinal fluid compartments. Transcranial Doppler sonography was compatible with occlusion of the right ACA. Systemic thrombolytic therapy with tissue plasminogen activator was initiated 105 minutes after symptom onset. Follow-up CCT 24 hours after treatment revealed subtotal ACA infarction with hemorrhagic conversion. Two days later, the patient suddenly deteriorated with clinical signs of cerebral herniation, as confirmed by CCT. An extended right hemicraniectomy was immediately performed. Within 6 months, the patient regained her ability to walk but remained moderately disabled. CONCLUSIONS: This is the first reported case of unilateral ACA infarct leading to almost fatal cerebral herniation. Narrow external cerebrospinal fluid compartments in combination with early reperfusion, hemorrhagic transformation, and additional dysfunction of the blood-brain barrier promoted by tissue plasminogen activator and migraine may have contributed to this unusual course.
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10/141. Bilateral frontal haemorrhages associated with continuous spinal analgesia.

    We report a case of intracerebral haemorrhages associated with continuous spinal analgesia. Continuous spinal analgesia is frequently employed for postoperative analgesia in high-risk patients in our institution. The analgesia is administered via a 20 gauge catheter passed through an 18 gauge Tuohy needle (Portex). A 71-year-old man with severe respiratory impairment had an intrathecal catheter placed for postoperative analgesia. He had a difficult postoperative course, including wound dehiscence, and died from respiratory failure some five weeks postoperatively. On day nine postoperatively he had two tonic-clonic seizures and was subsequently found to have developed bilateral frontal intracerebral haemorrhages. There was no previous history of seizures. Although several confounding variables exist, the most likely explanation for the intracerebral event appears to be an association with the dural puncture and intrathecal catheter Possible mechanisms and risk factors are discussed.
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