Cerebral sinus thrombosis as an initial symptom of acute promyelocytic leukemia: Case report and literature review.

Background: Cerebral sinus thrombosis as presentation of acute promyelocytic leukemia (AMPL) is exceptional, with only three cases registered in the literature. Case Description: A 24-year-old female patient was transferred to our center after a car accident. The patient had a witnessed generalized seizure while driving. Computerized tomography (CT) demonstrated a temporal intraparenchymal hemorrhage and CT venogram diagnosed a cerebral sinus thrombosis on the left transverse and sigmoid sinus. The patient underwent surgical evacuation of the hematoma and was treated with anticoagulation 48 h after surgery. Pancytopenia alerted of a possible hematological disorder. The patient was subsequently diagnosed with AMPL and treated with arsenic trioxide. The patient had a complete neurological recovery with no postoperative complications. Conclusion: The management of cerebral sinus thrombosis in patients with AMPL remains controversial. The previous reported cases of cerebral sinus thrombosis preceding the diagnosis of AMPL are reviewed and treatment of cerebral sinus thrombosis with anticoagulation in the setting of intraparenchymal hemorrhage and bleeding disorders is also discussed.

Nicardipine infusion for blood pressure control in patients with subarachnoid hemorrhage.

INTRODUCTION: To evaluate the efficacy, tolerability, and safety of nicardipine infusion in controlling the elevated blood pressure after subarachnoid hemorrhage (SAH). METHODS: Nicardipine infusion was initiated if the individual pre-specified systolic blood pressure (SBP) level goal, mandated by the admitting neurosurgeon, was not met. Systolic and diastolic BPs were measured on admission, hourly during the infusion and 12 h before and after the infusion. RESULTS: Twenty-eight patients with SAH required 50 nicardipine infusions in order to achieve a mean SBP goal of 152 mmHg. The 3,112 extracted BP measurements showed that mean infusion SBP was significantly lower than admission and pre-infusion SBP (mean 146.5 vs. 177.1 and 155.6 mmHg, P < 0.001, respectively) and significantly higher than post-infusion SBP (146.5 vs. 142.6 mmHg, P = 0.002). Five infusions were stopped prematurely, because of hypotension (n = 3), emergent surgery (n = 1), and failure to reach the SBP goal (n = 1). Rebleeding was not observed in any patient. Nicardipine achieved SBP control in 59.9% of hourly infusion measurements, with a trend for higher proportion of success with higher SBP goals. CONCLUSION: In this study, nicardipine infusion was a safe and moderately effective treatment for BP control in patients with SAH. Although SBP during nicardipine infusion was higher than the pre-specified goal in a significant percentage of hourly observations, this may be due to the drug administration protocol and other factors such as analgesia and sedation.

An association of prior statin use with decreased perihematomal edema.

OBJECTIVE: To investigate the impact of statins on perihematomal edema following spontaneous supratentorial intracerebral hemorrhage (ICH). BACKGROUND: Hematoma expansion and evolution of perihematomal edema are most commonly responsible for neurological deterioration following ICH. A possible role of statins in reducing perihematomal edema has been suggested based on studies in animal models. METHODS: Records of consecutive ICH patients admitted to The Johns Hopkins Hospital from 1999 to 2006 were reviewed. Patients with ICH related to trauma or underlying lesions (e.g., brain tumors, aneurysms, and arterio-venous malformations) and of infratentorial location were excluded. Absolute and relative perihematomal edema were assessed on initial head CT. Using regression analysis, the impact of prior statin use on absolute and relative edema at presentation was assessed correcting for other factors possibly impacting perihematomal edema, such as age, coagulopathy, aspirin use, admission mean arterial pressure (MAP), and blood glucose. RESULTS: A total of 125 consecutive ICH patients were studied. Patients with prior statin exposure had a mean edema volume of 13.2 +/- 9.2 cc compared to 22.3 +/- 18.3 cc in patients who were not using statins at the time of ICH. Following multiple linear regression analysis, we have identified a statistically significant association between prior statin use with reduced early absolute perihematomal edema (P = 0.035). Mean relative perihematomal edema was significantly lower in patients on statins at presentation (0.44) as opposed to 0.81 in patients with no prior statin use. This difference remained statistically significant (P = 0.021) after correcting for other variables. CONCLUSIONS: We report the association between statin use prior to ICH and decreased absolute and relative perihematomal edema. A prospective study analyzing the role of statins in perihematomal edema reduction and the resultant effect on mortality and functional outcomes following ICH is warranted.

Prior statin use reduces mortality in intracerebral hemorrhage.

OBJECTIVE: To assess the impact of blood glucose, coagulopathy, seizures and prior statin and aspirin use on clinical outcome following intracerebral hemorrhage (ICH). BACKGROUND: Intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes with mortality rates approaching 50%. Glasgow Coma Scale (GCS), ICH volume, age, pulse pressure, ICH location, intraventricular hemorrhage (IVH) and hydrocephalus are known to impact 30-day survival following ICH and are included in various prediction models. The role of other clinical variables in the long-term outcome of these patients is less clear. METHODS: Records of consecutive ICH patients admitted to The Johns Hopkins Hospital from 1999 to 2006 were reviewed. Patients with ICH related to trauma or underlying lesions (e.g. brain tumors, aneurysms, arterio-venous malformations) and of infratentorial location were excluded. The impact of admission blood glucose, coagulopathy, seizures on presentation and prior statin and aspirin use on 30-day mortality and functional outcomes at discharge was assessed using dichotomized Modified Rankin Scale (dMRS) and Glasgow Outcomes scale (dGOS). Other variables known to impact outcomes that were included in the multiple logistic regression analysis were age, admission GCS, pulse pressure, ICH volume, ICH location, volume of IVH and hydrocephalus. RESULTS: A total of 314 patients with ICH were identified, 125 met inclusion criteria. Patients' age ranged from 34 to 90 years (mean 63.5), 57.6 % were male. Mean ICH volume was 32.09 cc (range 1-214 cc). Following multiple logistic regression analysis, prior statin use (P = 0.05) was found to be associated with decreased mortality with a greater than 12-fold odds of survival while admission blood glucose (P = 0.023) was associated with increased 30-day mortality. Coagulopathy, seizures on presentation, and prior aspirin use had no significant impact on 30-day mortality or outcomes at discharge in our study cohort. CONCLUSIONS: The significant association of prior statin use with decreased mortality warrants prospective evaluation of the use of statins following ICH.