OBJECTIVES: To determine the prevalence, risk factors, etiology, location, and outcome of non-traumatic intracerebral hemorrhage (ICH) in young Filipino patients. To identify factors associated with poor outcome and mortality
METHODOLOGY: Review of charts of patients age /- 45 years admitted for acute non-traumatic intracerebral hemorrhage with neuroimaging evidence of symptomatic ICH was done. Data regarding risk factors, location, etiology and outcome were analyzed using SPSS 9.01 for Windows and Epi 6 for univariate and multiple regression analysis
RESULTS: Seventy subjects were included. 66 percent were males and 34 percent were females. The mean age of the subjects was 37 years old. Prevalence of non-traumatic ICH among stroke in young adults is 17 percent. The most frequent risk factors were hypertension, smoking, alcohol use, and family history of CVD. The common locations in order were basal ganglia/internal capsule (44 percent), thalamus (22 percent), lobar, and brainstem. The common causes of ICH were hypertension (46 percent), vascular malformations (16 percent) and hematologic/coagulation disorders (13 percent). Arteriography was done in 33 percent of cases. Overall in-hospital mortality rate was 8.5 percent in the acute stage of ICH. Factors independently associated with poor outcome and mortality on multivariate regression analysis were posterior circulation (p=0.005), presence of intraventricular extension (p=0.002), ICH volume 30 cc (p= 0.011), and smoking history (p=0.021)
CONCLUSION: Non-traumatic intracerebral hemorrhage in young Filipino adults has a heterogenous etiology. Non-traumatic ICH occurred in 17 percent of young stroke patients. Posterior circulation involvement, presence of intraventricular extension, ICH volume of 30cc and smoking history were significant factors associated with poor outcome.

Human ; Male ; Female ; Adult ; Adolescent ; Smoking ; Cerebral Hemorrhage ; Stroke ; Cerebral Hemorrhage, Traumatic ; Hypertension ; Brain Stem ; Vascular Malformations

Cranial nerve palsies are relatively common after trauma, but trochlear nerve palsy is relatively uncommon. Although traumatic trochlear nerve palsy is easy to diagnose clinically because of extraocular movement disturbances, radiologic evaluations of this condition are difficult to perform because of the nerve's small size. Here, we report the case of a patient with delayed traumatic trochlear nerve palsy associated with a traumatic subarachnoid hemorrhage (SAH) and the related radiological findings, as obtained with high-resolution three-dimensional (3D) magnetic resonance imaging (MRI). A 63-year-old woman was brought to the emergency room after a minor head trauma. Neurologic examinations did not reveal any focal neurologic deficits. Brain computed tomography showed a traumatic SAH at the left ambient cistern. The patient complained of vertical diplopia at 3 days post-trauma. Ophthalmologic evaluations revealed trochlear nerve palsy on the left side. High-resolution 3D MRI, performed 20 days post-trauma, revealed continuity of the trochlear nerve and its abutted course by the posterior cerebral artery branch at the brain stem. Chemical irritation due to the SAH and the abutting nerve course were considered causative factors. The trochlear nerve palsy completely resolved during follow-up. This case shows the usefulness of high-resolution 3D MRI for evaluating trochlear nerve palsy.
Brain ; Brain Stem ; Cranial Nerve Diseases ; Craniocerebral Trauma ; Diplopia ; Emergency Service, Hospital ; Female ; Follow-Up Studies ; Humans ; Imaging, Three-Dimensional ; Magnetic Resonance Imaging* ; Middle Aged ; Neurologic Examination ; Neurologic Manifestations ; Posterior Cerebral Artery ; Subarachnoid Hemorrhage, Traumatic* ; Trochlear Nerve Diseases* ; Trochlear Nerve*

Holmes tremor is a rare movement phenomenon, with atypical low-frequency tremor at rest and when changing postures, often related to brainstem pathology. We report a 70-year-old female patient who was presented with dystonic head and upper limb tremor after brainstem hemorrhage. The patient had experienced a sudden onset of left hemiparesis and right facial paralysis. Brain magnetic resonance imaging showed an acute hemorrhage from the brachium pontis through the dorsal midbrain on the right side. Several months later, the patient developed resting tremor of the head and left arm, which was exacerbated by a sitting posture and intentional movement. The tremor showed a regular low-frequency (1-2 Hz) for the bilateral sternocleidomastoid and cervical paraspinal muscles at rest. The patient's symptoms did not respond to propranolol or clonazepam, but gradually improved with levodopa administration. Although various remedies were attempted, overall, the results were poor. We suggest that levodopa might be a useful remedy for Holmes tremor. The curative or relieving effect of the dopaminergic agent in Holmes tremor needs more research.
Arm ; Brain ; Brain Stem ; Brain Stem Hemorrhage, Traumatic ; Clonazepam ; Facial Paralysis ; Female ; Head ; Hemorrhage ; Humans ; Levodopa ; Magnetic Resonance Imaging ; Mesencephalon ; Muscles ; Paresis ; Posture ; Propranolol ; Tremor ; Upper Extremity

Two patients with traumatic aneurysm were children below 10 years and the aneurysmal sac located at the peripheral branch o f the anterior cerebral artey. One of the traumatic aneurysm had been found by rupture of aneurysmal sac during medical treatment under the impression of traumatic cerebral hemorrhage. The other had been found during disabiliy evaluation with unruptured status. In the latter case, traumatic aneurysm was suspected by the small sized enhancing lesion below the falx cerebri in Brain CT scan and confirmed by transfemoral carotid angiography. We clipped neck of these traumatic aneurysm successfully. So. we report these two cases of traumatic aneurysms with review of the literatures.
Aneurysm* ; Angiography ; Arteries* ; Brain ; Cerebral Hemorrhage, Traumatic ; Child ; Humans ; Neck ; Rupture ; Tomography, X-Ray Computed

PURPOSE: An increase in optic nerve sheath diameter (ONSD) has been associated with elevated intracranial pressure due to brain lesions, such as hemorrhage, infarction, and tumor. The aim of this study was to evaluate whether the difference of both ONSDs can predict surgical treatment in patients with traumatic brain hemorrhage. METHODS: A prospective analysis of the data acquired between September 2016 and November 2016 was performed. We included 155 patients with traumatic brain hemorrhage undergoing computed tomography in the emergency room. We performed an ultrasonography to measure ONSDs for all included patients. The primary outcome of this study was operation indication in patients with traumatic brain hemorrhage. RESULTS: The average age was 63.4±17.0 years (male 60.3±17.3, female 69.8±14.4). There were 61 (39.35%) patients with an indication for operation and 94 (60.65%) patients with an indication for no operation. Indications for operation showed a strong association with the difference of both ONSDs in patients with subdural hemorrhage (p<0.001), no association between them in patients with epidural and intracerebral hemorrhage. In patients with subdural hemorrhage, the area under the curve was 0.988 (0.653-0.998), and the cut-off value for the difference of ONSDs with respect to determining the indications for operation was 0.295 mm f maximizing the sum of the sensitivity (96.9%) and specificity (90.7%) using the receiver operating curve. CONCLUSION: A difference of both ONSDs above 0.295 mm was useful in predicting the indications for operation in patients with traumatic subdural hemorrhage, but not in patients with epidural and intracerebral hemorrhage.
Brain ; Brain Hemorrhage, Traumatic* ; Cerebral Hemorrhage ; Emergency Service, Hospital ; Female ; Hematoma, Subdural ; Hemorrhage ; Humans ; Infarction ; Intracranial Hypertension ; Optic Nerve* ; Prospective Studies ; Sensitivity and Specificity ; Ultrasonography*

Traumatic brainstem hemorrhage after blunt head injury is an uncommon event. The most frequent site of hemorrhage is the midline rostral brainstem. The prognosis of these patients is poor because of its critical location. We experienced a case of traumatic brainstem hemorrhage. A 41-year-old male was presented with drowsy mentality and right hemiparesis after blunt head injury. Plain skull radiographs and brain computerized tomography scans revealed a depressed skull fracture, epidural hematoma, and hemorrhagic contusion in the right parieto-occipital region. But, these findings did not explain the right hemiparesis. T2-weighted magnetic resonance (MR) image of the cervical spine demonstrated a focal hyperintense lesion in the left pontomedullary junction. Brain diffusion-weighted and FLAIR MR images showed a focal hyperintensity in the ventral pontomedullary lesion and it was more prominent in the left side. His mentality and weakness were progressively improved with conservative treatment. We should keep in mind the possibility of brainstem hemorrhage if supratentorial lesions or spinal cord lesions that caused neurological deficits in the head injured patients are unexplainable.
Adult ; Brain ; Brain Stem ; Brain Stem Hemorrhage, Traumatic ; Contusions ; Craniocerebral Trauma ; Head ; Head Injuries, Closed ; Hematoma ; Hemorrhage ; Humans ; Magnetic Resonance Spectroscopy ; Male ; Paresis ; Prognosis ; Skull ; Skull Fracture, Depressed ; Spinal Cord ; Spine

OBJECTIVE: Patients with traumatic acute subdural hematoma (ASDH) often require surgical treatment. Among patients who primarily underwent craniotomy for the removal of hematoma, some consequently developed aggressive intracranial hypertension and brain edema, and required secondary decompressive craniectomy (DC). To avoid reoperation, we investigated factors which predict the requirement of DC by comparing groups of ASDH patients who did and did not require DC after craniotomy. METHODS: The 129 patients with ASDH who underwent craniotomy from September 2007 to September 2017 were reviewed. Among these patients, 19 patients who needed additional DC (group A) and 105 patients who underwent primary craniotomy only without reoperation (group B) were evaluated. A total of 17 preoperative and intraoperative factors were analyzed and compared statistically. Univariate and multivariate analyses were used to compare these factors. RESULTS: Five factors showed significant differences between the two groups. They were the length of midline shifting to maximal subdural hematoma thickness ratio (magnetization transfer [MT] ratio) greater than 1 (p < 0.001), coexistence of intraventricular hemorrhage (IVH) (p < 0.001), traumatic intracerebral hemorrhage (TICH) (p=0.001), intraoperative findings showing intracranial hypertension combined with brain edema (p < 0.001), and bleeding tendency (p=0.02). An average value of 2.74±1.52 was obtained for these factors for group A, which was significantly different from that for group B (p < 0.001). CONCLUSION: An MT ratio >1, IVH, and TICH on preoperative brain computed tomography images, intraoperative signs of intracranial hypertension, brain edema, and bleeding tendency were identified as factors indicating that DC would be required. The necessity for preemptive DC must be carefully considered in patients with such risk factors.
Brain ; Brain Edema ; Cerebral Hemorrhage, Traumatic ; Craniotomy* ; Decompressive Craniectomy* ; Hematoma ; Hematoma, Subdural ; Hematoma, Subdural, Acute* ; Hemorrhage ; Humans ; Intracranial Hypertension ; Multivariate Analysis ; Reoperation ; Risk Factors

We present a case of angiographically confirmed transection of the cisternal segment of the anterior choroidal artery (AChA) associated with a severe head trauma in a 15-year old boy. The initial brain computed tomography scan revealed a diffuse subarachnoid hemorrhage (SAH) and pneumocephalus with multiple skull fractures. Subsequent cerebral angiography clearly demonstrated a complete transection of the AChA at its origin with a massive extravasation of contrast medium as a jet trajectory creating a plume. We speculate that severe blunt traumatic force stretched and tore the left AChA between the internal carotid artery and the optic tract. In a simulation of the patient's brain using a fresh-frozen male cadaver, the AChA is shown to be vulnerable to stretching injury as the ipsilateral optic tract is retracted. We conclude that the arterial injury like an AChA rupture should be considered in the differential diagnosis of severe traumatic SAH.
Angiography ; Arteries* ; Brain ; Cadaver ; Carotid Artery, Internal ; Cerebral Angiography ; Choroid* ; Craniocerebral Trauma ; Diagnosis, Differential ; Humans ; Male ; Pneumocephalus ; Rupture ; Skull Fractures ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic* ; Visual Pathways

PURPOSETraumatic brain injury (TBI) is a leading cause of death and disability. Intracranial hemorrhage (ICH) secondary to TBI is associated with a high risk of coagulopathy which leads to increasing risk of hemorrhage growth and higher mortality rate. Therefore, antifibrinolytic agents such as tranexamic acid (TA) might reduce traumatic ICH. The aim of the present study was to investigate the extent of ICH growth after TA administration in TBI patients.

METHODSThis single-blind randomized controlled trial was conducted on patients with traumatic ICH (with less than 30 ml) referring to the emergency department of Vali-Asr Hospital, Arak, Iran in 2014. Patients, based on the inclusion and exclusion criteria, were divided into intervention and control groups (40 patients each). All patients received a conservative treatment for ICH, as well as either intravenous TA or placebo. The extent of ICH growth as the primary outcome was measured by brain CT scan after 48 h.

RESULTSAlthough brain CT scan showed a significant increase in hemorrhage volume in both groups after 48 h, it was significantly less in the TA group than in the control group (p = 0.04). The mean total hemorrhage expansion was (1.7 ± 9.7) ml and (4.3 ± 12.9) ml in TA and placebo groups, respectively (p < 0.001).

CONCLUSIONIt has been established that TA, as an effective hospital-based treatment for acute TBI, could reduce ICH growth. Larger studies are needed to compare the effectiveness of different doses.

Adult ; Antifibrinolytic Agents ; therapeutic use ; Brain Injuries, Traumatic ; diagnostic imaging ; drug therapy ; Cerebral Hemorrhage, Traumatic ; drug therapy ; Female ; Humans ; Male ; Middle Aged ; Single-Blind Method ; Tomography, X-Ray Computed ; Tranexamic Acid ; therapeutic use

Progressive hemorrhagic injury (PHI) can be divided into coagulopathy-related PHI and normal coagu- lation PHI. Coagulation disorders after traumatic brain injuries can be included in trauma-induced coagulopathy (TIC). Some studies showed that TIC is associated with PHI and increases the rates of disability and mortality. In this review, we discussed some mechanisms in TIC, which is of great importance in the development of PHI, including tissue factor (TF) hypothesis, protein C pathway and thrombocytopenia. The main mechanism in the relation of TIC to PHI is hypocoagulability. We also reviewed some coagulopathy parameters and proposed some possible risk factors, predictors and therapies.
Blood Coagulation Disorders ; epidemiology ; etiology ; Brain Injuries, Traumatic ; complications ; Cerebral Hemorrhage ; epidemiology ; etiology ; therapy ; Fibrin Fibrinogen Degradation Products ; analysis ; Humans ; Incidence ; Protein C ; physiology ; Risk Factors ; Thromboplastin ; physiology