Author Response: Outcome Predictors of an Intracerebral Hemorrhage also Depend on the Causes of the Bleeding.

How to cite this article: Hazra D. Author Response: Outcome Predictors of an Intracerebral Hemorrhage also Depend on the Causes of the Bleeding. Indian J Crit Care Med 2024;28(9):892-893.

Infective Endocarditis Presenting as Intracranial Hemorrhage: A Case Report.

We describe a 31-year-old woman who presented with acute right-sided weakness and was found to have a subarachnoid hemorrhage in the left Sylvian fissure and an ipsilateral frontal intraparenchymal hemorrhage. CT angiography revealed an occlusion of the left middle cerebral artery's M1 segment and a saccular aneurysm at its bifurcation. A cerebral angiogram confirmed these findings, and the patient subsequently underwent microsurgical aneurysm resection, which revealed a partially thrombosed pseudoaneurysm. Further stroke workup identified mitral valve vegetation, confirming the diagnosis of infective endocarditis.

Recurrent symptomatic intracranial hemorrhage in high-grade astrocytoma with piloid features: illustrative case.

BACKGROUND: High-grade astrocytoma with piloid features (HGAP) is a novel condition introduced in the 2021 World Health Organization classification. Given that it has been recently classified, reports clarifying its clinical features or diagnostic criteria are lacking, especially in cases of atypical presentation. Herein, the authors present a rare case of HGAP with repeated symptomatic hemorrhages. OBSERVATIONS: A woman in her 20s presented with an acute headache and vertigo. Computed tomography and magnetic resonance imaging revealed a 2.5 × 2.8 × 2.3-cm hemorrhagic cerebellar mass with calcifications. After moderate improvement of her symptoms, she developed recurrent hemorrhage, and the tumor size increased (3.0 × 3.6 × 4.0 cm) 18 days later, necessitating resection. Pathological and molecular analyses confirmed the diagnosis of HGAP with an FGFR1-TACC1 fusion, MTAP/CDKN2A/B deletion, and SETD2 rearrangement. Radiologically, the presence of calcification and cystic components and the absence of perilesional edema were atypical features of previously reported HGAP. LESSONS: Although recurrent symptomatic intracranial hemorrhages are rare in HGAP, enhancing lesions on magnetic resonance imaging suggest the need for resection to obtain tissue for molecular diagnosis and guide adjuvant treatment strategies. https://thejns.org/doi/10.3171/CASE24395.

Diagnostic and therapeutic dilemmas of asymptomatic intracranial AVMs: A case report and evidence-based review.

First described by Virchow in the 19th century, intracranial arteriovenous malformations (AVMs) are complex, tangle-shaped vascular lesions with a number of associated neuroparenchymal, hemodynamic, and angio-architectural changes. However, the clinical description of extracranial AVMs dates back to the Ebers Papyrus (c. 1500 BC), with a still unknown definitive underlying etiology thus far. AVMs are rare lesions, with approximately 0.15% incidence and 0.001-0.5% prevalence, but of high importance as they tend to affect young patients who are frequently otherwise healthy. In the majority of cases, AVMs present as sudden intracranial hemorrhages that require immediate intervention, but incidentally-detected unruptured AVMs are only found in ∼15% of cases, leaving a confusing dilemma regarding the appropriate next step, particularly given the several therapeutic interventions available and clinical trials that were vulnerable to follow-up criticism. Herein, we present a case of an incidentally detected asymptomatic AVM in a 15-year-old boy via advanced imaging techniques that was initially misinterpreted as a post-traumatic subarachnoid hemorrhage on routine imaging studies. In providing a comprehensive overview of pathological classification schemes and the currently available diagnostic options for these silent dilemmatic AVMs, we highlight three management techniques: microsurgical resection, endovascular embolization, and stereotactic surgery, with the best option depends mostly on addressing lesion resection properly with minimal associated mortality and morbidity.

The hidden risk: Intracranial hemorrhage following durotomies in spine surgery.

Objective: Intracranial hemorrhage (ICH) after durotomy in elective spine surgery, though rare, can pose a significant risk to patient outcomes. Spine surgeries bear a risk of dural tears (DT) with potential of postoperative cerebrospinal fluid leakage (PCSFL). Excessive PCSFL can precipitate a decrease in intracranial pressure, potentially leading to ICH. Literature on ICH as a postoperative complication is scarce. The aim was to assess the incidence and risk factors of ICH in patients undergoing elective spine surgery. Methods: Utilizing the 2020 National Impatient Sample (NIS) adults (>18 years) were selected by primary procedure category codes for spine fusion, discectomy, spinal cord decompression and cervicothoracic/lumbosacral nerve decompression. Exclusion criteria were trauma and malignancy. The primary outcome was occurrence of ICH. Comparative analysis and a multivariable logistic regression were used to identify independent risk. Results: In total, 40,990 patients met our criteria with an incidence of ICH at 0.08%. The ICH-group showed an increased length of stay and higher mortality compared to the control group. Spinal cord decompression, DT and PCSFL were significantly more frequent in patients with ICH. Alcohol, drug abuse and hypertension were significantly more prevalent in patients with ICH. DT, alcohol abuse and hypertension were independent risk factors for ICH. Conclusions: This study underscores the rarity and severity of ICHs following elective spine surgery, emphasizing awareness and looking for possible preventive measures. Our finding suggests that DT, as a complication of surgical techniques, as well as alcohol abuse and hypertension are significant predictors of ICH.

Association of Admission Hyperglycemia with Clinical Outcomes in Patients with Symptomatic Intracranial Hemorrhage After Endovascular Treatment for Large Vessel Occlusive Stroke.

Background: Symptomatic intracranial hemorrhage (sICH) is a fatal complication after endovascular treatment (EVT) for acute large vessel occlusive (LVO) stroke. The aim of this study was to investigate the association between hyperglycemia and outcomes in patients with postprocedural sICH. Methods: Of the 2567 patients with AIS who underwent EVT from two large multicenter randomized trials and two prospective multicenter registry studies, 324 patients occurred sICH with documented admission glucose were included in this study. The primary outcome was functional independence (defined as a modified Rankin Scale score of 0 to 2) at 90 days. Secondary outcomes included mRS score of 0 to 3, 0 to 1, and mRS score at 90 days. Safety outcome was the mortality within 90 days. Admission hyperglycemia was defined as a plasma blood glucose ≥7.8 mmol/L (140 mg/dL) in our analysis. Results: Of 324 eligible participants included in this study, hyperglycemia was observed in 130 (40.1%) patients. The median age was 67 (IQR, 58-75) years, and median blood glucose level was 7.1 (IQR, 6.0-9.3) mmol/L. After adjusting for confounding variables, admission hyperglycemia was associated with decreased odds of functional independence (adjusted odds ratio[OR] 0.34; 95% CI 0.17-0.68; P= 0.003), decreased odds of favorable outcome (adjusted OR 0.31; 95% CI 0.16-0.58; P < 0.001) and increased odds of mortality (adjusted OR 2.56; 95% CI 1.47-4.45; P = 0.001) at 90 days. After 1:1 propensity score matching analysis, the results were consistent with multivariable logistic regression analysis. Conclusion: In patients who suffered sICH after EVT for acute large vessel occlusive stroke, hyperglycemia is a strong predictor of poor clinical outcome and mortality at 90 days.

Impact of a deep learning-based brain CT interpretation algorithm on clinical decision-making for intracranial hemorrhage in the emergency department.

Intracranial hemorrhage is a critical emergency that requires prompt and accurate diagnosis in the emergency department (ED). Deep learning technology can assist in interpreting non-enhanced brain CT scans, but its real-world impact on clinical decision-making is uncertain. This study assessed a deep learning-based intracranial hemorrhage detection algorithm (DLHD) in a simulated clinical environment with ten emergency medical professionals from a tertiary hospital's ED. The participants reviewed CT scans with clinical information in two steps: without and with DLHD. Diagnostic performance was measured, including sensitivity, specificity, accuracy, and the area under the receiver operating characteristic curve. Consistency in clinical decision-making was evaluated using the kappa statistic. The results demonstrated that DLHD minimally affected experienced participants' diagnostic performance and decision-making. In contrast, inexperienced participants exhibited significantly increased sensitivity (59.33-72.67%, p < 0.001) and decreased specificity (65.49-53.73%, p < 0.001) with the algorithm. Clinical decision-making consistency was moderate among inexperienced professionals (k = 0.425) and higher among experienced ones (k = 0.738). Inexperienced participants changed their decisions more frequently, mainly due to the algorithm's false positives. The study highlights the need for thorough evaluation and careful integration of deep learning tools into clinical workflows, especially for less experienced professionals.

Risk of Traumatic Intracranial Hemorrhage After Stroke: A Nationwide Population-Based Cohort Study in Taiwan.

BACKGROUND: Stroke and traumatic intracranial hemorrhage (tICH) are major causes of disability worldwide, with stroke exerting significant negative effects on the brain, potentially elevating tICH risk. In this study, we investigated tICH risk in stroke survivors. METHODS AND RESULTS: Using relevant data (2017-2019) from Taiwan's National Health Insurance Research Database, we conducted a population-based retrospective cohort study. Patients were categorized into stroke and nonstroke groups, and tICH risk was compared using a Cox proportional-hazards model. Among 164 628 patients with stroke, 1004 experienced tICH. Patients with stroke had a higher tICH risk than nonstroke counterparts (adjusted hazard ratio [HR], 3.49 [95% CI, 3.17-3.84]). Subgroup analysis by stroke type revealed higher tICH risk in hemorrhagic stroke survivors compared with ischemic stroke survivors (HR, 5.64 [95% CI, 4.97-6.39] versus 2.87 [95% CI, 2.58-3.18], respectively). Older patients (≥45 years) with stroke had a higher tICH risk compared with their younger counterparts (<45 years), in contrast to younger patients without stroke (HR, 7.89 [95% CI, 6.41-9.70] versus 4.44 [95% CI, 2.99-6.59], respectively). Dementia and Parkinson disease emerged as significant tICH risk factors (HR, 1.69 [95% CI, 1.44-2.00] versus 2.17 [95% CI, 1.71-2.75], respectively). In the stroke group, the highest tICH incidence density occurred 3 months after stroke, particularly in patients aged >65 years. CONCLUSIONS: Stroke survivors, particularly those with hemorrhagic stroke and those aged ≥45 years, face elevated tICH risk. Interventions targeting the high-risk period are vital, with fall injuries potentially contributing to tICH incidence.

Stereotactic radiosurgery alone for brain arteriovenous malformations: a single-institute experience.

OBJECTIVE: Brain arteriovenous malformations (BAVMs) represent an ongoing clinical challenge because of their complex nature. The long-term outcomes of BAVMs patients treated with stereotactic radiosurgery (SRS) alone are unclear. METHODS: We conducted a retrospective analysis of 201 patients treated for BAVMs from January 2010 to December 2019. The identified predictors of obliteration or hemorrhage in the multivariate analysis were estimated by odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: A total of 201 patients treated with gamma knife radiosurgery (GKRS) alone as the primary treatment for BAVMs were included. The mean age at GKRS treatment was 31.4 ± 1.1 years, and 61.2% of the patients were male. Multivariate logistic regression revealed that a higher radiosurgery-based AVM score (OR 1.847, 95% CI = 1.292-2.641; p = 0.001) was significantly associated with worse obliteration, and a higher margin dose significantly favored obliteration (OR 0.352, 95% CI = 0.189-0.658; p = 0.001). Multivariate analysis revealed that an increased lesion volume of 1 cm3 (OR 1.279, 95% CI = 1.023-1.600; p = 0.031) and a high margin dose (OR 0.363, 95% CI = 0.134-0.983; p = 0.046) were significant prognostic factors for post-SRS hemorrhage. CONCLUSIONS: In conclusion, our study investigated the available clinical and radiological prognostic factors for BAVMs and revealed that a higher margin dose significantly improved both the obliteration rate and nonhemorrhagic outcomes. Currently, the most appropriate candidates, Spetzler-Martin grade, and optimal radiation dose are still being defined by prospective trials.

Considerations for the Use of Stereotactic Radiosurgery to Treat Large Arteriovenous Malformations.

Stereotactic radiosurgery (SRS) is an effective treatment strategy for cerebral arteriovenous malformations (AVMs). Aggressive treatment achieving complete obliteration is necessary to prevent further intracranial hemorrhage and neurological deficits. However, SRS treatment of large AVMs (>10 cm3) is challenging. To prevent toxicity in the normal brain tissue, it is imperative to reduce the radiation dose as the lesion volume increases; however, this also reduces the rate of obliteration. In this study, we review the various radiosurgical approaches for treating large AVMs and their outcomes, and suggest ways to improve treatment outcomes during SRS for large AVMs.

An Artificial Intelligence Algorithm Integrated into the Clinical Workflow Can Ensure High Quality Acute Intracranial Hemorrhage CT Diagnostic.

PURPOSE: Intracranial hemorrhage (ICH) is a life-threatening condition requiring rapid diagnostic and therapeutic action. This study evaluates whether Artificial intelligence (AI) can provide high-quality ICH diagnostics and turnaround times suitable for routine radiological practice. METHODS: A convolutional neural network (CNN) was trained and validated to detect ICHs on DICOM images of cranial CT (CCT) scans, utilizing about 674,000 individually labeled slices. The CNN was then incorporated into a commercial AI engine and seamlessly integrated into three pilot centers in Germany. A real-world test-dataset was extracted and manually annotated by two experienced experts. The performance of the AI algorithm against the two raters was assessed and compared to the inter-rater agreement. The overall time ranging from data acquisition to the delivery of the AI results was analyzed. RESULTS: Out of 6284 CCT examinations acquired in three different centers, 947 (15%) had ICH. Breakdowns of hemorrhage types included 8% intraparenchymal, 3% intraventricular, 6% subarachnoidal, 7% subdural, < 1% epidural hematomas. Comparing the AI's performance on a subset of 255 patients with two expert raters, it achieved a sensitivity of 0.90, a specificity of 0.96, an accuracy of 0.96. The corresponding inter-rater agreement was 0.84, 0.98, and 0.96. The overall median processing times for the three centers were 9, 11, and 12 min, respectively. CONCLUSION: We showed that an AI algorithm for the automatic detection of ICHs can be seamlessly integrated into clinical workflows with minimal turnaround time. The accuracy was on par with radiology experts, making the system suitable for routine clinical use.

Bilateral Spontaneous Thalamic Hemorrhage: A Case Report.

Bilateral spontaneous thalamic hemorrhage is a rare but serious condition often linked to hypertension. We report a 67-year-old male presenting with a sudden severe headache, decreased consciousness, and right-sided neurological deficits. Both CT and MRI confirmed bilateral thalamic hemorrhage. The patient was managed with supportive care and blood pressure control. This case underscores the importance of early recognition and adds to the limited literature on this condition.

Hybrid clinical-radiomics model based on fully automatic segmentation for predicting the early expansion of spontaneous intracerebral hemorrhage: A multi-center study.

BACKGROUND: Early prediction of hematoma expansion (HE) is important for the development of therapeutic strategies for spontaneous intracerebral hemorrhage (sICH). Radiomics can help to predict early hematoma expansion in intracerebral hemorrhage. However, complex image processing procedures, especially hematoma segmentation, are time-consuming and dependent on assessor experience. We provide a fully automated hematoma segmentation method, and construct a hybrid predictive model for risk stratification of hematoma expansion. PURPOSE: To propose an automatic approach for predicting early hemorrhage expansion after spontaneous intracerebral hemorrhage using deep-learning and radiomics methods. METHODS: A total of 258 patients with sICH were retrospectively enrolled for model construction and internal validation, while another two cohorts (n=87, 149) were employed for independent validation. For hemorrhage segmentation, an iterative segmentation procedure was performed to delineate the area using an nnU-Net framework. Radiomics models of intra-hemorrhage and multiscale peri-hemorrhage were established and evaluated, and the best discriminative-scale peri-hemorrhage radiomics model was selected for further analysis. Combining clinical factors and intra- and peri-hemorrhage radiomics signatures, a hybrid nomogram was constructed for the early HE prediction using multivariate logistic regression. For model validation, the receiver operating characteristic (ROC) curve analyses and DeLong test were used to evaluate the performances of the constructed models, and the calibration curve and decision curve analysis were performed for clinical application. RESULTS: Our iterative auto-segmentation model showed satisfactory results for hematoma segmentation in all four cohorts. The Dice similarity coefficient of this hematoma segmentation model reached 0.90, showing an expert-level accuracy in hematoma segmentation. The consumed time of the efficient delineation was significantly decreased, from 18 min to less than 2 min, with the assistance of the auto-segmentation model. The radiomics model of 2-mm peri-hemorrhage had a preferable area under ROC curve (AUC) of 0.840 (95 % confidence interval [CI]: 0.768, 0.912) compared with the original (0-mm dilatation) model with an AUC of 0.796 (95 % CI: 0.717, 0.875). The clinical-radiomics hybrid model showed better performances for HE prediction, with AUC of 0.853, 0.852, 0.772, and 0.818 in the training, internal validation, and independent validation cohorts 1 and 2, respectively. CONCLUSIONS: The fully automatic clinical-radiomics model based on deep learning and radiomics exhibits a good ability for hematoma segmentation and a favorable performance in stratifying HE risks.

Non-HDL-C, Symptomatic Intracranial Arterial Stenosis, and Recurrent Vascular Risk in Minor Stroke.

AIM: We aimed to assess the association between non-high-density lipoprotein cholesterol (non-HDL-C) and symptomatic intracranial artery stenosis (sICAS), as well as the impact of non-HDL-C on recurrent vascular events in patients with mild ischemic stroke ( NIHSS score ≤ 5). METHODS: This prospective study was based on data from patients presenting within 72 hours of stroke occurrence. We included patients admitted to 8 Chinese hospitals between September 2019 and November 2021. The associations of non-HDL-C with sICAS and recurrent vascular risk were assessed using multivariate regression models and a restricted cubic spline analysis. RESULTS: Among the 2,544 patients analyzed at 12 months, 652 (25.6%) were diagnosed with sICAS. Elevated non-HDL-C was linked to a higher incidence of sICAS, and the adjusted odd ratios for quintile variables and continuous variables were 1.36 ([95% CI, 1.01-1.81]) and 1.14 ([95% CI, 1.04-1.24). In comparison to those in the first quintile, the adjusted hazard ratio of the fifth quintile of non-HDL-C was 1.19 ([95% CI 0.78-1.80]) for recurrent ischemic stroke and was 0.39 ([95% CI, 0.17-0.91]) for intracranialhemorrhage. CONCLUSIONS: The non-HDL-C level may be a useful predictor of sICAS. Higher non-HDL-C levels may be associated with a lower risk of intracranial hemorrhage in mild, noncardiogenic stroke, but not a higher risk of recurrent ischemic stroke.

A complex case of recurrent intracranial bleeds due to malaria-induced coagulopathy: A case report and literature review.

Background: Malaria, a prevalent disease in the developing world, is a significant cause of morbidity and mortality. Infection with Plasmodium falciparum, although uncommon, can lead to severe brain injury, including intracranial hemorrhages, resulting in serious neurological deficits. Malaria-induced coagulopathy, while rarely reported, poses a challenge in understanding the exact mechanisms behind the development of intracranial bleeds. Proposed mechanisms include sequestration of parasitized erythrocytes in the brain's microvasculature, leading to capillary occlusion, endothelial damage, cytokine activation, and dysregulation of the coagulation cascade. Case Description: We present the case of a 53-year-old male rapidly deteriorating following a history of traumatic brain injury (TBI). Upon admission, a computed tomography scan revealed bilateral acute on chronic hematomas, necessitating a lifesaving craniotomy. Subsequently, the patient experienced three consecutive recurrent intracranial bleeds post-surgery, attributed to Falciparum-induced coagulopathy. Prompt recognition and intervention stabilized the patient's condition, leading to discharge on the 4th post-operative day. Conclusion: This case underscores the challenges posed by consecutive recurrent intracranial bleeds following TBI exacerbated by P. falciparum infection. It highlights the obstinate nature of malaria-induced coagulopathy and underscores the importance of timely and aggressive interventions in managing such cases.

Revolutionizing Intracranial Hemorrhage Diagnosis: A Retrospective Analytical Study of Viz.ai ICH for Enhanced Diagnostic Accuracy.

Introduction Artificial intelligence (AI) alerts the radiologist to the presence of intracranial hemorrhage (ICH) as fast as 1-2 minutes from scan completion, leading to faster diagnosis and treatment. We wanted to validate a new AI application called Viz.ai ICH to improve the diagnosis of suspected ICH. Methods We performed a retrospective analysis of 4,203 consecutive non-contrast brain computed tomography (CT) reports in a single institution between September 1, 2021, and January 31, 2022. The reports were made by neuroradiologists who reviewed each case for the presence of ICH. Reports and identified cases with positive findings for ICH were reviewed. Positive cases were categorized based on subtype, timing, and size/volume. Viz.ai ICH output was reviewed for positive cases. This AI model was validated by assessing its performance with Viz.ai ICH as the index test compared to the neuroradiologists' interpretation as the gold standard. Results According to neuroradiologists, 9.2% of non-contrast brain CT reports were positive for ICH. The sensitivity of Viz.ai ICH was 85%, specificity was 98%, positive predictive value was 81%, and negative predictive value was 99%. Subgroup analysis was performed based on intraparenchymal, subarachnoid, subdural, and intraventricular subtypes. Sensitivities were 94%, 79%, 83%, and 44%, respectively. Further stratification revealed sensitivity improves with higher acuity and volume/size across subtypes. Conclusion Our analysis indicates that AI can accurately detect ICH's presence, particularly for large-volume/large-size ICH. The paper introduces a novel AI model for detecting ICH. This advancement contributes to the field by revolutionizing ICH detection and improving patient outcomes.

Twig-like MCA: A rare cause of intracranial bleeding.

Twig-like or unfused middle cerebral artery (MCA) is a rare congenital vascular anomaly defined by the absence of the M1 segment. It can be found incidentally or can be revealed by cerebral ischemia or hemorrhage. Although rare, neuroradiologists should be familiar with such findings in order to differentiate them from differential diagnoses such as Moyamoya disease and steno-occlusive disorders of the MCA. We report a case of a twig-like MCA revealed by intracranial bleeding in an 84-year-old woman.

Assessing mortality and safety of IV thrombolysis in ischemic stroke patients on direct oral anticoagulants (DOACs): A systematic review and meta-analysis.

BACKGROUND: Intravenous thrombolysis (IVT) is considered a standard reperfusion therapy for acute ischemic stroke (AIS) patients presenting within 4.5 hours of the last known well (LKW). Current guidelines contraindicate the use of IVT in patients within the window who are on Direct Oral Anticoagulants (DOACs) and took their last dose within 48 hours of presentation, due to a risk of symptomatic intracranial hemorrhage (sICH). OBJECTIVE: To assess the safety of IVT as management of AIS in patients who take DOACs. METHODS: A thorough literature search of four databases (PubMed, Scopus, Medline, Google Scholar, Web of science and ScienceDirect) was done from inception until May 2023. Double-arm studies that reported outcomes of mortality, sICH, and mRS scores were selected. Results from these studies were presented as odds ratios (ORs) with 95 % confidence intervals (CIs) and were pooled using a random-effects model. RESULTS: Four eligible studies were included with a total of 238,425 stroke patients who underwent IVT (3330 in the DOAC arm and 235,217 in the placebo arm). The group with prior DOAC intake showed a significant decrease in sICH development and an increase in functional independence at 90 days compared to the control group. No significant association was seen between prior DOAC use and any serious alteplase-related complication within 36 hours, serious systemic or life-threatening hemorrhage within 36 hours, mortality within 3 months, or mRS score at 3 months. CONCLUSION: The pooled analysis suggests that IVT is a safe management option for acute ischemic stroke in patients with DOAC intake before symptom onset without an increased risk of serious adverse events.

Case Report: resolution of refractory seizures after neurosurgical intervention in newborns with cerebral extra-axial hemorrhages.

Introduction: Intracranial hemorrhage is a significant cause of neurological damage in newborns. Extra-axial hemorrhages with intraparenchymal extension can precipitate acute clinical deterioration. Seizures are one of the presenting symptoms, which can be refractory to treatment. These hemorrhages can result in considerable long-term morbidity and mortality. Aim: The objective of this report was to present three cases of extra-axial hemorrhages in neonates, all exhibiting refractory seizures that resolved after neurosurgical intervention. In addition, a review of literature is provided. Methods: Data collected included clinical history, laboratory findings, neuroimaging studies, type of neurosurgical intervention, and patient outcome. All infants presented with extra-axial hemorrhages along with clinical and radiological signs of increased intracranial pressure within the first 6 days of life. These manifestations included a decreased level of consciousness, hypertension, bradycardia, and cerebral midline shift on imaging. Refractory seizures were present in all cases. Urgent magnetic resonance imaging was performed followed by neurosurgical intervention (two needle aspirations, one cranial trepanation), leading to amelioration of clinical symptoms and complete resolution of seizures. Follow-up outcomes included normal psychomotor development in one infant, mild cerebral paresis in another, and delayed motor development in the third. None of the infants developed epilepsy. Conclusion: This study underscores the critical importance of monitoring seizure activity, conducting urgent and appropriate imaging, and implementing targeted neurosurgical intervention, preferably through minimally invasive methods such as percutaneous needle aspiration. Clinicians should be aware of this clinical picture and respond promptly to mitigate neurological damage.

Successful management of intracranial hemorrhage with brain herniation in a postpartum patient on extracorporeal membranous oxygenation: A case report.

Managing intracranial hemorrhage in patients supported by extracorporeal oxygenation (ECMO) presents significant clinical challenges. We report a case of a postpartum patient with severe acute respiratory distress syndrome (ARDS) necessitating venovenous ECMO support, complicated by multicompartmental intracranial hemorrhage resulting in brain herniation and necessitating emergent medical and surgical management of refractory intracranial hypertension. Care was guided by multimodal neuromonitoring, including intracranial pressure monitoring and electroencephalography. Despite these challenges, the patient achieved excellent neurological recovery. This case underscores the intricacies of managing neurological complications during ECMO and highlights the potential benefits of comprehensive neuromonitoring strategies.