Viper bite envenomation represents a significant occupational hazard among agricultural workers in India. The viper bite envenomation is usually suspected when a patient presents with predominant local symptoms at the bitten site, including pain, swelling, and necrosis. Further, systemic findings such as diffuse intravascular coagulation, hypotension, and shock may alert physicians of viper bite envenomation rather than a neurotoxic snake bite. However, cerebral complications are rare in viper bites but may potentially fatal. Central nervous system involvement in a viper bite is either due to neurotoxins or hemorrhagins present in the venom, which may induce cerebral thrombosis, ischemia, infarction, and hemorrhage. Here we present a case of a previously healthy adult male who succumbed to extensive subarachnoid, intracerebral, and intraventricular hemorrhages involving bilateral cerebral hemispheres following viper snake bite envenomation. This report highlights the importance of anticipating cerebral complications in viper bite envenomation, a rare occurrence. It also emphasizes the need for early antisnake venom administration to prevent and control systemic envenomation and its complications.
Adult ; Humans ; Male ; Snake Bites/complications* ; Hemorrhage/etiology* ; Intracranial Hemorrhages ; Shock ; India

OBJECTIVES: Stroke has become the leading cause of death and disability among adults in China. This study aims to analyze the disease burden based on gender and age and the risk factors for stroke subtypes in China 2019, and to provide reference for targeted stroke prevention and control. METHODS: Based on 2019 data of the Global Burden of Disease (GBD), the gender and age in patients with different stroke subtypes (ischemic stroke, intracranial hemorrhage, subarachnoid hemorrhage) in China 2019 was described by using disability-adjusted life years (DALY), and attributable burden of related risk factors was analyzed. RESULTS: In 2019, the burden of intracranial hemorrhage was the heaviest one in China, resulting in 22.210 6 million person years of DALY, following by ischemic stroke and subarachnoid hemorrhage, resulting in 21.393 9 and 2.344 7 million person years of DALY, respectively. Among them, except the 0-14 age group, the disease burden of different subtypes of stroke in men was higher than that in women. The disease burden of ischemic stroke was increased with age in both men and women, with the heaviest disease burden in ≥70 years group. The disease burden of intracranial hemorrhage and subarachnoid hemorrhage was the heaviest in males aged 50-69 years old, and in females aged ≥70 years and 50-69 years, respectively. Metabolic factors were the main risk factors in all ages of different stroke subtypes, and the most important risk factor was high systolic blood pressure. Other risk factors were different between men and women. Smoking, high body mass index, high low-density lipoprotein, and outdoor particulate matter pollution were the main risk factors for stroke in men, while high body mass index, outdoor particulate matter pollution, and high fasting blood glucose were the main risk factors of stroke in women. The main risk were different among different age groups. CONCLUSIONS The burden and attributable risk factors for different stroke subtypes are discrepancy in different gender and age groups. Targeted interventions should be conducted in the future to reduce the burden of stroke.
Male ; Adult ; Humans ; Female ; Infant, Newborn ; Infant ; Child, Preschool ; Child ; Adolescent ; Middle Aged ; Aged ; Subarachnoid Hemorrhage/epidemiology* ; Quality-Adjusted Life Years ; Cost of Illness ; Stroke/etiology* ; Risk Factors ; China/epidemiology* ; Particulate Matter ; Ischemic Stroke ; Intracranial Hemorrhages/etiology*

Humans ; Data Warehousing ; East Asian People ; Intracranial Hemorrhages/diagnostic imaging* ; Asian People ; Cerebral Hemorrhage/diagnostic imaging*

BACKGROUND: Intracerebral hemorrhage (ICH) is one of the most severe complications during veno-venous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to determine the risk factors for ICH and mortality in such patients. METHODS: We analyzed the clinical data of 77 patients who received VV-ECMO due to severe respiratory failure from July 2013 to May 2019 at China-Japan Friendship Hospital. Demographical data, laboratory indices, imaging characteristics, and other clinical information were collected. Multivariable logistic regression analyses were performed to identify risk factors for ICH and mortality. RESULTS: Of 77 patients, 11 (14.3%) suffered from ICH, and 36 (46.8%) survived. The survival rate was significantly lower (18.2% [2/11] vs. 51.5% [34/66], P = 0.040) in patients with ICH than in those without ICH. Multivariable analysis revealed that factors independently associated with ICH were diabetes mellitus (adjusted odds ratio [aOR]: 12.848, 95% confidence interval [CI]: 1.129-146.188, P = 0.040) and minimum fibrinogen during ECMO (aOR: 2.557, 95% CI: 1.244-5.252, P = 0.011). Multivariable analysis showed that factors independently associated with mortality were acute hepatic failure during ECMO (aOR: 9.205, 95% CI: 1.375-61.604, P = 0.022), CO2 retention before ECMO (aOR: 7.602, 95% CI: 1.514-38.188, P = 0.014), and minimum platelet concentration during ECMO (aOR: 0.130, 95% CI: 0.029-0.577, P = 0.007). CONCLUSIONS Diabetes mellitus and minimum fibrinogen concentration during ECMO are risk factors for ICH in patients with severe respiratory failure managed using VV-ECMO. This indicated that anticoagulants use and nervous system monitoring should be performed more carefully in patients with diabetes when treated with VV-ECMO due to severe respiratory failure.
Adult ; Anticoagulants ; Extracorporeal Membrane Oxygenation ; Humans ; Intracranial Hemorrhages ; Respiratory Insufficiency/therapy* ; Retrospective Studies ; Risk Factors

Boxing/injuries* ; Forensic Medicine ; Humans ; Intracranial Hemorrhages

INTRODUCTION: Telestroke allows for remote determination of suitability for treatment with thrombolysis in patients with acute ischaemic stroke. However, this approach is time-dependent and most centres have yet to achieve the recommended treatment times. We describe a quality improvement initiative aimed at improving the telestroke workflow and treatment times at our centre. METHODS: A multidisciplinary workgroup comprising clinicians, stroke case managers and radiology staff was formed to oversee the initiative. A phase-by-phase review of the existing workflow was done to identify the reasons for delay. Phase-specific measures were then introduced to address these delays, and a data-monitoring system was established to track the impact of these measures. The initiatives were implemented through four Plan-Do-Study-Act cycles. The door-to-needle (DTN) times for thrombolysis and clinical outcomes before and after the interventions were compared. RESULTS: A total of 104 patients were evaluated. The median DTN time improved from 96 minutes to 78 minutes post implementation of initiatives (p = 0.003). Fewer patients had symptomatic intracranial haemorrhages (8.5% vs. 24.2%; p = 0.03), and more patients had improvements in their National Institutes of Health Stroke Scale score (47.9% vs. 25.0%; p = 0.031) after the initiatives were introduced. CONCLUSION The quality improvement initiative resulted in a reduction in median DTN time. Our approach allowed for a systematic method to resolve delays within the telestroke workflow. This initiative is part of an ongoing effort aimed at providing thrombolysis safely to eligible patients in the shortest possible time.
Adult ; Aged ; Aged, 80 and over ; Emergency Service, Hospital ; organization & administration ; Female ; Humans ; Interprofessional Relations ; Intracranial Hemorrhages ; prevention & control ; Male ; Middle Aged ; Quality Improvement ; Severity of Illness Index ; Singapore ; Stroke ; therapy ; Telemedicine ; methods ; organization & administration ; standards ; Thrombolytic Therapy ; methods ; Time ; Tissue Plasminogen Activator ; therapeutic use ; Treatment Outcome

Most cases of spinal subdural hematoma are very rare and result from iatrogenic causes, such as coagulopathy or a spinal puncture. Cases of non-traumatic spinal subdural hematoma accompanied by intracranial hemorrhage are even more rare. There are a few reports of spontaneous spinal subdural hematoma with concomitant intracranial subdural or subarachnoid hemorrhage, but not with intracerebral hemorrhage. Especially in our case, the evaluation and diagnosis were delayed because the spontaneous intracerebral hemorrhage accompanying the unilateral spinal subdural and subarachnoid hemorrhages caused hemiplegia. We report a case of spinal subdural and subarachnoid hemorrhage with concomitant intracerebral hemorrhage, for the first time, with a relevant literature review.
Cerebral Hemorrhage ; Diagnosis ; Hematoma ; Hematoma, Subdural, Spinal ; Hemiplegia ; Intracranial Hemorrhages ; Spinal Puncture ; Subarachnoid Hemorrhage

OBJECTIVE: To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).METHODS: A single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation.RESULTS: Forty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications.CONCLUSION: Hybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.
Aneurysm ; Aneurysm, Ruptured ; Angiography ; Angiography, Digital Subtraction ; Arteries ; Arteriovenous Malformations ; Blister ; Cerebrovascular Disorders ; Cone-Beam Computed Tomography ; Embolectomy ; Embolization, Therapeutic ; Emergencies ; Hematoma ; Intracranial Hemorrhages ; Operating Rooms ; Retrospective Studies ; Rupture ; Surgical Instruments ; Thrombectomy

OBJECTIVE: Endovascular treatment (EVT) outcomes for acute M2 segment of middle cerebral artery occlusion remains unclear because most results are obtained from patients with large artery occlusion in the anterior circulation. The objective of this study was to assess procedural outcomes for acute M2 occlusion and compare outcomes according to thrombus location (M1 vs. M2).METHODS: A systematic review was performed for online literature published from January 2004 to December 2016. Primary outcome was successful recanalization rate and symptomatic intracranial hemorrhage (S-ICH) after the procedure. A fixed effect model was used if heterogeneity was less than 50%.RESULTS: Eight articles were included. EVT showed successful recanalization rate of 69.1% (95% confidence interval [CI], 54.9–80.4%) and S-ICH rate of 6.1% (95% CI, 4.5–8.3%). The rates of good clinical outcome at 3 months and mortality were 59.4% (95% CI, 49.9–68.2%) and 14.9% (95% CI, 11.4–19.3%), respectively. According to thrombus location (M1 vs. M2), successful recanalization (odds ratio [OR], 1.539; 95% CI, 0.293–8.092; p=0.610) and S-ICH (OR, 1.313; 95% CI, 0.603–2.861; p=0.493) did not differ significantly. Good clinical outcome was more evident in M2 occlusion after EVT than that in M1 occlusion (OR, 1.639; 95% CI, 1.135–2.368; p=0.008). However, mortality did not differ significantly according to thrombus location (OR, 0.788; 95% CI, 0.486–1.276; p=0.332).CONCLUSION: EVT seems to be technically feasible for acute M2 occlusion. Direct comparative studies between EVT and medical treatment are needed further to find specific beneficiary group after EVT in patient with M2 occlusion.
Arteries ; Humans ; Infarction ; Infarction, Middle Cerebral Artery ; Intracranial Hemorrhages ; Middle Cerebral Artery ; Mortality ; Population Characteristics ; Stroke ; Thrombectomy ; Thrombosis

Moyamoya disease (MMD) is a progressive cerebrovascular disease with unknown etiology, characterized by bilateral stenoocclusive changes at the terminal portion of the internal carotid artery and an abnormal vascular network formation at the base of the brain. MMD has an intrinsic nature to convert the vascular supply for the brain from internal carotid (IC) system to the external carotid (EC) system, as indicated by Suzuki’s angiographic staging. Insufficiency of this ‘IC-EC conversion system’ could result not only in cerebral ischemia, but also in intracranial hemorrhage from inadequate collateral anastomosis, both of which represent the clinical manifestation of MMD. Surgical revascularization prevents cerebral ischemic attack by improving cerebral blood flow, and recent evidence further suggests that extracranial-intracranial bypass could powerfully reduce the risk of re-bleeding in MMD patients with posterior hemorrhage, who were known to have extremely high re-bleeding risk. Although the exact mechanism underlying the hemorrhagic presentation in MMD is undetermined, most recent angiographic analysis revealed the characteristic angio-architecture related to high re-bleeding risk, such as the extension and dilatation of choroidal collaterals and posterior cerebral artery involvement. We sought to update the current management strategy for hemorrhagic MMD, including the outcome of surgical revascularization for hemorrhagic MMD in our institute. Further investigations will clarify the optimal surgical strategy to prevent hemorrhagic manifestation in patients with MMD.
Angiography ; Brain ; Brain Ischemia ; Carotid Artery, Internal ; Cerebrovascular Circulation ; Cerebrovascular Disorders ; Choroid ; Dilatation ; Hemorrhage ; Humans ; Intracranial Hemorrhages ; Moyamoya Disease ; Posterior Cerebral Artery