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PubMed1990

Thalamic hemorrhage with intraventricular hemorrhage in the full-term newborn.

Intraventricular hemorrhage is an uncommon problem in the full-term newborn. In a review of 19 full-term infants with intraventricular hemorrhage diagnosed on computed tomography prior to 1 month of age, thalamic hemorrhage associated with the intraventricular hemorrhage was documented in 12 infants. Thus, thalamic hemorrhage appears to the most common source of intraventricular hemorrhage in this age group, particularly in infants who had uneventful birth histories and in whom clinical abnormalities (signs of increased intracranial pressure, seizures, altered level of consciousness) developed after the first week of life. The majority of these infants had predisposing factors for cerebral venous infarction such as sepsis, cyanotic congenital heart disease, and coagulopathy. The clinical appearance and outcome for infants with thalamic hemorrhage/intraventricular hemorrhage were similar to those in infants with intraventricular hemorrhage originating from other sites, except for an increased incidence of cerebral palsy in infants with thalamic hemorrhage/intraventricular hemorrhage. Definitive diagnosis was made on the basis of characteristic radiologic abnormalities.

Cerebral Hemorrhage↗
PubMed1983

Positron emission tomography in the newborn: extensive impairment of regional cerebral blood flow with intraventricular hemorrhage and hemorrhagic intracerebral involvement.

Of all patients with intraventricular hemorrhage, those with hemorrhagic intracerebral involvement exhibit the highest rates of mortality and neurologic morbidity and, indeed, account for the vast majority of all neurologic impairment in infants with intraventricular hemorrhage. Insight into the basic nature of the critical cerebral involvement requires determination of regional cerebral blood flow, previously not possible. Positron emission tomography (PET) now provides the capability of measuring regional cerebral blood flow with high resolution and little risk. In this study, we utilized PET in six premature infants (920 to 1,200 g) with major intraventricular hemorrhage and hemorrhagic intracerebral involvement to measure regional cerebral blood flow during the acute period (5 to 17 days of age). Cerebral blood flow was determined after intravenous injection of H2O, labeled with the positron-emitting isotope, 15O (oxygen 15). Findings were similar and dramatic in all six infants. In the area of hemorrhagic intracerebral involvement, little or no cerebral blood flow was detected. However, in addition, surprisingly, a marked two- to fourfold reduction in cerebral blood flow was observed throughout the affected hemisphere, well posterior and lateral to the intracerebral hematoma, including cerebral white matter and, to a lesser extent, frontal, temporal, and parietal cortex. In the one infant studied a second time, ie, at 3 months of age, the extent and severity of the decreased cerebral blood flows in the affected hemisphere were similar to those observed on the study during the neonatal period. At the three autopsies, the affected left hemisphere showed extensive infarction, corroborating the PET scans. These observations, the first demonstration of the use of PET in the determination of regional cerebral blood flow in the newborn, show marked impairments in regional cerebral blood flow in the hemisphere containing an apparently restricted intracerebral hematoma, indicating that the hemorrhagic intracerebral involvement is only a component of a much larger lesion, ischemic in basic nature, ie, an infarction. This large ischemic lesion explains the poor neurologic outcome in infants with intraventricular hemorrhage and hemorrhagic intracerebral involvement.

Acute Disease↗
PubMedDate not supplied

Hemorrhage in hemorrhagic fever with renal syndrome in China.

Hemorrhage is a prominent feature of hemorrhagic fever with renal syndrome (HFRS) in China. It occurs in all phases of the disease and is an important cause of death. Petechiae involving skin and oropharyngeal mucosa are the commonest manifestation of hemorrhage, occurring in more than 90% of patients. Gastrointestinal hemorrhage is the next commonest manifestation, occurring in approximately 50% of patients. Suggested mechanisms of hemorrhage include vascular injury, thrombocytopenia and platelet dysfunction, disseminated intravascular coagulation, circulating heparin-like activity, and uremia. Controlled trials of treatment regimens for hemostatic impairment in HFRS have not been performed. Support of blood pressure can lessen hemorrhage by limiting the adverse consequences of hypotension and shock. Dialysis is of benefit in patients with hemorrhage and significant renal failure.

Cerebral Hemorrhage↗
PubMed2000

Postnatal phenobarbitone for the prevention of intraventricular hemorrhage in preterm infants.

BACKGROUND: This section is under preparation and will be included in the next issue. OBJECTIVES: To determine whether postnatal administration of phenobarbitone to preterm infants reduces the risk of intraventricular hemorrhage (IVH), neurodevelopmental impairment or death. SEARCH STRATEGY: See the Search Strategy of the Neonatal Collaborative Review Group. The reviewer has been a active trialist in this area and has personal contact with many groups in this field. Journals handsearched from 1976 (when cranial CT scanning started) to November 1998 include: Pediatrics, J Pediatrics, Archives of Disease in Childhood, Pediatric Research, Developmental Medicine and Child Neurology, Acta Paediatrica, European J of Pediatrics, Neuropediatrics, New England J of Medicine, Lancet and British Medical J. The National Library of Medicine (USA) database (via PubMed) and the Cochrane Controlled Trials Register were searched through to November 1998 using the MeSH terms intraventricular hemorrhage, newborn infants, premature infant, intracranial hemorrhage, phenobarbitone, phenobarbital. The searches were not limited to the English language, as long as the article included an English abstract. Promising articles were read in the original language or translated. SELECTION CRITERIA: Included were randomized or quasi-randomized controlled trials in which phenobarbitone was given to preterm infants identified as being at risk of IVH because of gestational age below 34 weeks, birthweight below 1500 g, or respiratory failure. Adequate determination of IVH by ultrasound or CT was also required. DATA COLLECTION AND ANALYSIS: In addition to details of patient selection and control of bias, the details of the administration of phenobarbitone were extracted. The end-points searched for included: IVH ( with grading), posthemorrhagic ventricular dilatation or hydrocephalus, neurodevelopmental impairment and death. In addition, possible adverse effects of phenobarbitone such as hypotension, mechanical ventilation, pneumothorax, hypercapnia, and acidosis were searched for. MAIN RESULTS: Nine controlled trials were included with 740 infants recruited. There was heterogeneity between trials for the outcome IVH, with one trial finding a significant decrease in IVH and another trial finding an increase in IVH in the group receiving phenobarbitone. Meta-analysis showed no difference between the phenobarbitone treated group and the control group in either IVH (typical relative risk 1.04, CI 0.87, 1.25), severe IVH (typical relative risk 0.91, CI 0.66, 1.27), posthemorrhagic ventricular dilatation (typical relative risk 0.89, CI 0.38, 2.08), severe neurodevelopmental impairment (typical relative risk 1.44, CI 0.41, 5.04) or death before hospital discharge (typical relative risk 0.88, CI 0.64, 1.21) There was a consistent trend in the trials towards increased use of mechanical ventilation in the phenobarbitone treated group, which was supported by the meta-analysis (typical relative risk 1.18, CI 1.06, 1.32; typical risk difference 0.129, CI 0.045, 0.213), but there was no significant difference in pneumothorax, acidosis or hypercapnia. REVIEWER'S CONCLUSIONS: Postnatal administration of phenobarbitone cannot be recommended as prophylaxis to prevent IVH in preterm infants and is associated with an increased need for mechanical ventilation.

Cerebral Hemorrhage↗
PubMed2001

Terlipressin for acute esophageal variceal hemorrhage.

BACKGROUND: Terlipressin (triglycyl lysine vasopressin) is a synthetic analogue of vasopressin, which has been used in the treatment of acute variceal hemorrhage. In contrast to vasopressin, terlipressin can be administered as intermittent injections instead of continuous intravenous infusion and it has a safer adverse reactions profile. However, its effectiveness remains uncertain. OBJECTIVES: To determine if treatment with terlipressin improves outcome in acute esophageal variceal hemorrhage and is safe. SEARCH STRATEGY: Randomized clinical trials were identified by searching the following databases: MEDLINE, EMBASE, the Cochrane Controlled Trials Register, the Cochrane Hepato-Biliary Group Controlled Trials Register, Biosis, and Current Contents. The bibliographies of identified publications were checked. Experts in the field and the manufacturers of terlipressin were contacted. SELECTION CRITERIA: All randomized clinical trials which compared terlipressin with: (a) placebo or no treatment, (b) balloon tamponade, (c) endoscopic treatment, (d) octreotide, (e) somatostatin and (f) vasopressin, in the setting of acute variceal hemorrhage. DATA COLLECTION AND ANALYSIS: Eligibility, trial quality assessment and data extraction were done independently by two reviewers. The primary outcome measure was mortality. Secondary outcomes were failure of initial hemostasis, rebleeding, procedures required for uncontrolled bleeding or rebleeding, transfusion requirements and length of hospitalization. MAIN RESULTS: Twenty studies were identified for all the comparison groups, involving 1609 patients. There were seven studies (with 443 patients) comparing terlipressin to placebo, five of which were considered to be high quality studies based on the Jadad scale. The meta-analysis indicates that terlipressin was associated with a statistically significant reduction in all cause mortality compared to placebo (relative risk 0.66, 95% confidence interval 0.49 to 0.88). Three studies (with 302 patients) were identified comparing terlipressin to somatostatin, two of which were high quality studies; only one high quality study (219 patients) comparing terlipressin to endoscopic treatment was identified. Within the limited power provided by these small numbers of patients, no statistically significant difference was demonstrated between terlipressin and either somatostatin or endoscopic treatment in any of the outcomes. For the remaining comparison groups (terlipressin versus balloon tamponade, terlipressin versus octreotide and terlipressin versus vasopressin) only small, low quality studies were identified and no difference was demonstrated in any of the major outcomes. There was no difference between the terlipressin group and any of the comparison groups in the number of adverse events that caused death or withdrawal of medication. REVIEWER'S CONCLUSIONS: On the basis of a 34% relative risk reduction in mortality, terlipressin should be considered to be effective in the treatment of acute variceal hemorrhage. Further, since no other vasoactive agent has been shown to reduce mortality in single studies or meta-analyses, terlipressin might be the vasoactive agent of choice in acute variceal bleeding.

Acute Disease↗
PubMed1975

Vitreous hemorrhage after intracranial hemorrhage.

Eight patients, aged 2 months to 55 years, developed vitreous hemorrhages as a result of subarachnoid or subdural bleeding. Subhyaloid hemorrhages were associated with, or preceded, hemorrhage into the vitreous cavity in four cases. Most vitreous hemorrhages cleared spontaneously, several months later, without major visual sequelae. In one patient, intravitreal blood persisted after 28 months. Vitreous hemorrhage can be a serious complication in patients surviving subarachnoid or subdural hemorrhages and, though uncommon, probably occurs with greater frequency than previously acknowledged. While vitrectomy may be a reasonable therapeutic approach in selected cases, in most instances vitreous hemorrhage following intracranial hemorrhage should be treated conservatively.

Adult↗
PubMed1993

Effect of blood pressure on hemorrhage volume and survival in a near-fatal hemorrhage model incorporating a vascular injury.

STUDY HYPOTHESIS: In a model of near-fatal hemorrhage that incorporates a vascular injury, stepwise increases in blood pressure associated with aggressive crystalloid resuscitation will result in increased hemorrhage volume and mortality. DESIGN: This study used a swine model of potentially lethal hemorrhage in the presence of a vascular lesion to compare the effects of resuscitation with mean arterial pressures of 40, 60, and 80 mm Hg. Twenty-seven fully instrumented immature swine (14.8 to 20 kg), each with a surgical-steel aortotomy wire in place, were bled continuously from a femoral artery catheter to a mean arterial pressure of 30 mm Hg. At that point the aortotomy wire was pulled, producing a 4-mm aortic tear and uncontrolled intraperitoneal hemorrhage. When the animal's pulse pressure reached 5 mm Hg, the femoral artery hemorrhage was discontinued and resuscitation was begun. INTERVENTIONS: Saline infusion was begun at 6 mL/kg/min and continued as needed to maintain the following desired endpoints: group 1 (nine) to a mean arterial pressure of 40 mm Hg, group 2 (nine) to a mean arterial pressure of 60 mm Hg, and group 3 (nine) to a mean arterial pressure of 80 mm Hg. After 30 minutes or a total saline infusion of 90 mL/kg, the resuscitation fluid was changed to shed blood infused at 2 mL/kg/min as needed to maintain the desired mean arterial pressure or to a maximum volume of 24 mL/kg. Animals were observed for 60 minutes or until death. MEASUREMENTS AND MAIN RESULTS: Data were compared using repeated-measures analysis of variance with a post hoc Tukey-Kramer, Fisher's exact test, and Kruskal-Wallis. Mortality was significantly greater in group 3 (78%) compared with either group 1 (11%; P = .008) or group 2 (22%; P = .028). Mean survival times were significantly shorter in group 3 (44 +/- 12 minutes) compared with either group 1 (58 +/- 6 minutes; P = .007) or group 2 (59 +/- 3 minutes; P = .006). The average intraperitoneal hemorrhage volumes were 13 +/- 14 mL/kg, 20 +/- 25 mL/kg, and 46 +/- 11 mL/kg for groups 1, 2, and 3, respectively (group 1 versus 2, P = .425; group 1 versus 3, P < .001; group 2 versus 3, P = .014). Group 2 animals demonstrated significantly greater oxygen deliveries compared with groups 1 and 3. CONCLUSION: In a model of near-fatal hemorrhage with a vascular injury, attempts to restore blood pressure with crystalloid result in increased hemorrhage volume and markedly higher mortality.

Animals↗
PubMed1979

[Vitreous hemorrhage as a complication of subarachnoid hemorrhage (Terson's syndrome) (author's transl)].

We represent a case of vitreous hemorrhage due to subarachnoid hemorrhage from a ruptured aneurysm of the right vertebral artery to draw attention to this complication. A 53-year-old man was admitted to our hospital because of generalized headache and reduced visual acuity of both eyes. On admission the patient was alert and there were moderate nuchal stiffness and mild symmetrical hyperreflexia in the extremities. Ophthalmological consultation revealed bilateral retinal, subhyaloid and vitreous hemorrhages. Four-vessel angiography demonstrated an aneurysm of the right vertebral artery. At operation, it became clear that the aneurysm was a dissecting one. The vertebral artery was clipped at the most proximal intracranial portion. Postoperative course was smooth and uneventful except deteriorated visual acuity. His visual acuity deteriorated continuously to hand movements 18 days after subarachnoid hemorrhage. His visual acuity, however, gradually improved without specific treatment. At the time of this writing, his visual acuity is 1.0 on both sides. Vitreous hemorrhage is a rare complication following a reptured aneurysm. Pertinent literature concerning fundal hemorrhage, especially vitreous hemorrhage, associated with subarachnoid hemorrhage suggests that it may occur as a result of sudden increase of intracranial pressure.

Eye Diseases↗
PubMed1997

[Subarachnoid hemorrhage associated to subhyaloid hemorrhage: "Terson syndrome"].

INTRODUCTION: The combination of subarachnoid hemorrhage (SAH) and subhyaloid hemorrhage is known as 'Terson syndrome'. Retinal hemorrhage is commonly observed clinically in the optic fundi of patients with SAH, however, subhyaloid hemorrhage of the globe in the setting of SAH has been rarely on CT of the brain. Several mechanisms of subhyaloid hemorrhage have been proposed: a. A sudden increase in intracranial pressure (ICP) forces blood from the subarachnoid space directly into the preretinal space. b. A sudden rise in ICP is thought to decrease venous return to the cavernous sinus from the veins draining the globe. The increased retinal venous pressure results in stasis followed by vessel rupture. c. A sudden rise in ICP obstructs both the retinochoroidal anastomoses and the central retinal vein due to a rapid effusion of CSF through the communication of the subarachnoid space with the optic nerve sheat. This produces an acute decrease in venous drainage from the retina and results in stasis and hemorrhage. CLINICAL CASE: A 35 year old man, with a history of a non controlled arterial hypertension, dilated cardiopathy and 'agitation episodes'. He had a spontaneous intracranial hemorrhage, consistent in a parenchymal hematoma ruptured into ventricles and subarachnoid space. The CT showed through optic nerve sheath this hemorrhage extended to subhyaloid space. The patient came in coma 'dépassé' and brain death. CONCLUSIONS: We report a case of Terson syndrome demonstrated by CT. This CT allow see the blood from the subarachnoid space erupt directly into the preretinal space through optic nerve sheath, confirming one the proposed mechanism for this syndrome.

Adult↗
PubMed1996

Immune function is more compromised after closed bone fracture and hemorrhagic shock than hemorrhage alone.

OBJECTIVE: To determine whether closed bone fracture in conjunction with hemorrhagic shock compromises immune functions more severely than hemorrhagic shock alone. DESIGN: In a randomized, controlled trial, closed bone fracture of the right lower leg and/or hemorrhagic shock (mean +/- SEM arterial blood pressure, 35 +/- 5 mm Hg for 90 minutes) were induced in male C3H/HeN mice (weight, 25 g). Animals subjected to hemorrhage were resuscitated with the shed blood and lactated Ringer solution. At 72 hours after the experiment, all animals were killed to obtain whole blood, splenocytes, and splenic and peritoneal macrophages. Macrophage interleukin-1 and splenocyte interleukin-2 and interleukin-3 release were determined by bioassay, and splenocyte proliferation was measured by tritiated thymidine incorporation. RESULTS: Closed bone fracture alone did not affect immune functions 72 hours after the trauma. Hemorrhagic shock, however, induced a significant depression of splenocyte and macrophage functions. Bone fracture followed by hemorrhagic shock further depressed splenocyte proliferation and splenocyte interleukin-2 and interleukin-3 release as well as interleukin-1 release. CONCLUSION: Since bone injury coupled with hemorrhagic shock produces more severe depression of immune functions than hemorrhage alone, bone injury appears to play a contributory role in further depressing immune functions in trauma patients who experience major blood loss.

Animals↗
PubMed2001

Brainstem hemorrhage in descending transtentorial herniation (Duret hemorrhage).

OBJECTIVES: To review clinical and radiological findings in patients with Duret hemorrhages and to discuss the pathophysiology and differential diagnosis of these lesions. PATIENTS AND METHODS: We reviewed the case records of four patients with Duret hemorrhages who had been admitted to the neurological intensive care unit with supratentorial mass lesions. RESULTS: Descending transtentorial and subfalcine herniations were present in all cases. Three patients were admitted with acute subdural hematoma and one with intraparenchymal hemorrhage. Computed tomography revealed the presence of blood in the mesencephalon and upper pons. Three patients died; one survived with severe disabilities. DISCUSSION: Duret hemorrhages are typically located in the ventral and paramedian aspects of the upper brainstem (mesencephalon and pons). The pathophysiology of Duret hemorrhage remains under debate: arterial origin (stretching and laceration of pontine perforating branches of the basilar artery), versus venous origin (thrombosis and venous infarction). Multifactorial causation seems likely. CONCLUSION: Duret hemorrhages are delayed, secondary brainstem hemorrhages. They occur in craniocerebral trauma victims with rapidly evolving descending transtentorial herniation. Diagnosis is made on computed tomography of the brain. In most cases the outcome is fatal. On the basis of our observations we believe that arterial hypertension and advanced age are risk factors for the development of Duret hemorrhage.

Aged↗
PubMed2006

Asymptomatic hemorrhage after thrombolysis may not be benign: prognosis by hemorrhage type in the Canadian alteplase for stroke effectiveness study registry.

BACKGROUND AND PURPOSE: There is ongoing controversy about the impact of hemorrhagic transformation after thrombolysis on long-term functional outcome. We sought to study the relation between the type of hemorrhagic transformation on CT scans and functional outcome. METHODS: Data were obtained from the Canadian Alteplase for Stroke Effectiveness Study. This study was established as a registry to prospectively collect data for acute stroke patients receiving intravenous alteplase within 3 hours from stroke onset between February 1999 and June 2001. Follow-up was completed at 90 days, and good functional outcome was defined as a modified Rankin Scale score of 0 or 1. Copies of head CT scans obtained at 24 to 48 hours after starting treatment were read in consensus by a central reading panel consisting of 1 neuroradiologist and 1 stroke neurologist. According to European Cooperative Acute Stroke Study criteria, hemorrhagic transformation was classified as none, hemorrhagic infarction (HI-1 and HI-2), or parenchymal hematoma (PH-1 and PH-2). We compared outcome across groups and performed a multivariable analysis including previously determined important predictors of good outcome in acute ischemic stroke. RESULTS: From 1135 patients enrolled at 60 centers across Canada, 954 follow-up CT scans were assessable. We observed some hemorrhagic transformation in 259 of 954 (27.1%) patients (110 HI-1, 57 HI-2, 48 PH-1, and 44 PH-2). Proportions of patients with good outcome were 41% with no hemorrhagic transformation, 30% with HI-1, 17% with HI-2, 15% with PH-1, and 7% with PH-2 (P<0.0001, chi(2) test). After adjustment for age, baseline serum glucose, baseline Alberta Stroke Program Early CT score, and baseline National Institutes of Health Stroke Scale score, HI-1 was not a predictor of outcome. However, HI-2 (odds ratio=0.38, 95% CI=0.17 to 0.83), PH-1 (odds ratio=0.32, 95% CI=0.12 to 0.80), and PH-2 (odds ratio=0.14, 95% CI=0.04 to 0.48) were all negative predictors of outcome. CONCLUSIONS: The likelihood of a poor outcome after thrombolysis was proportional to the extent of hemorrhage on CT scans. HI grades of hemorrhagic transformation may not be benign.

Adult↗
PubMed2004

Study of clinical features of amyloid angiopathy hemorrhage and hypertensive intracerebral hemorrhage.

OBJECTIVE: The purpose of this study was to differentiate between cerebral amyloid angiopathy (CAA) and hypertension (HTN) based on hemorrhage pattern interpretation. METHODS: From June 1994 to Oct., 2000, 83 patients admitted to our service with acute intracerebral hemorrhage (ICH) were investigated retrospectively; 41 patients with histologically proven diagnosis of cerebral amyloid angiography and 42 patients with clear history of hypertension were investigated. RESULTS: Patients with a CAA-related ICH were significantly older than patients with a HTN-related ICH (74.0 years vs 66.5 years, P < 0.05). There was a significantly higher number of hematomas > or = 30 ml in CAA (85.3%) when compared with HTN (59.5%). No basal ganglional hemorrhage was seen in CAA, but in 40.5% in HTN. In CAA-related ICH, subarachnoid hemorrhage (SAH) was seen in 26 patients (63.4%) compared to only 11 patients (26.2%) in HTN-related ICH. Intraventricular hemorrhage was seen in 24.4% in CAA, and in 26.2% in HTN. Typical features of CAA-related ICH included lobar distribution affecting mainly the lobar superficial areas, lobulated appearance, rupture into the subarachnoid space, and secondary IVH from the lobar hemorrhage. More specifically, multiplicity of hemorrhage, bilaterality, and repeated episodes also strongly suggest the diagnosis of CAA. Multiple hemorrhages, defined as 2 or more separate hematomas in multiple lobes, accounted for 17.1% in CAA-related ICH. CONCLUSION: There are certain features in CAA on CT and MRI and in clinical settings. To some extent, these features may contribute to distinguishing CAA from HTN related ICH.

Adult↗
PubMed2005

Frequency of ocular hemorrhages in patients with subarachnoidal hemorrhage.

BACKGROUND: Vitreous hemorrhage (Terson's syndrome) and other intraocular hemorrhages have been reported in up to 40% of patients with subarachnoidal hemorrhage (SAH). Our objective was to determine prospectively the frequency of intraocular involvement and its relationship to the grade of SAH. METHODS: Seventy-four consecutive patients with SAH were prospectively examined. The patients were classified according to Hunt and Hess and ophthalmological examination was performed by an ophthalmologist. RESULTS: In all patients SAH was caused by a ruptured cerebral aneurysm. Intraocular hemorrhages were present in 28% of the patients, all of whom had retinal hemorrhages, which were detectable unilaterally in 45%, while 15% of these patients exhibited typical retrohyaloidal or vitreal hemorrhages. Ocular involvement was statistically more frequent in patients with a higher grade of SAH according to Hunt and Hess. CONCLUSIONS: Due to ocular involvement in more than a quarter of the patients with SAH and due to the fact that ocular involvement is related to the severity of SAH, screening of patients with SAH is recommended, especially when no reliable data about visual function are available. Early vitrectomy of vitreous hemorrhages provides a more effective rehabilitation.

Aneurysm, Ruptured↗