Fatal intracranial hemorrhage due to infantile acute lymphoblastic leukemia mimicking abusive head trauma.

We report the case of a 2-month-old infant who was found moribund in her crib. Postmortem computed tomography (PMCT) was performed before autopsy. As the baby had a severe subdural hematoma, retinal hemorrhage, and encephalopathy on PMCT, abusive head trauma (AHT) was tentatively diagnosed. At autopsy, no scalp hemorrhages or skull fractures were found; however, the classic triad of AHT was present, mainly on the right side. Additionally, there was dark red discoloration around the heart, and the liver, spleen, and pancreas were enlarged. Peripheral blood was macroscopically cloudy with marked leukocytosis. After careful histological examination, B-cell precursor acute lymphoblastic leukemia (ALL) was diagnosed. All the macroscopic lesions could be attributed to ALL. The manner of death was natural. To the best of our knowledge, this is the first report of infantile ALL mimicking AHT on PMCT images. This case demonstrates the importance of a comprehensive systematic approach to considering differential diagnosis when PMCT shows multiple intracranial hemorrhages suggestive of AHT in an infant.

Risk Factors for Progression of Conservatively Managed Acute Traumatic Subdural Hematoma: A Systematic Review and Meta-Analysis.

BACKGROUND: Conservatively managed posttraumatic acute subdural hematoma (SDH) can present with progression of the size of the hematoma with increased mass effect, necessitating delayed surgery. The factors contributing to this progression remain largely unknown. METHODS: A comprehensive search of the PubMed, Embase, and Scopus databases was performed to retrieve case control studies, retrospective cohort studies, and prospective studies with retrospective evaluation of risk factors until August 2, 2020. The different risk factors that were evaluated in the studies were compiled and the results were analyzed to arrive at a conclusion. RESULTS: A total of 7 studies were included in the systematic review and 6 were included in the analysis, with an aggregate of 679 patients. The following factors were found to have a relation with progression of acute SDH: age (odds ratio, 7.12; 95% confidence interval [CI], 2.52-11.72), use of antiplatelet drugs (odds ratio, 1.89; 95% CI, 1.18-2.77), use of anticoagulants (odds ratio, 3.09; 95% CI, 1.21-7.88), thickness of SDH (odds ratio, 4.13; 95% CI, 3.29-4.97), midline shift (odds ratio, 1.86; 95% CI, 0.69-3.03), hypertension (odds ratio, 2.22; 95% CI, 1.25-3.96) and ischemic heart disease (odds ratio, 3.32; 95% CI, 1.63-6.76). CONCLUSIONS: The results of this analysis showed that patients with the risk factors outlined are at higher risk of developing symptomatic chronic SDH after conservatively managed traumatic acute SDH compared with those without them. It is therefore necessary to provide more intensive follow-up for these patients to avoid an adverse outcome.

Hemorrhagic Retinopathy and Optic Nerve Sheath Hemorrhage Associated With Fatal Subarachnoid Hemorrhage from a Ruptured Intracranial Aneurysm Due to Segmental Fibromuscular Dysplasia.

Fibromuscular dysplasia is an idiopathic, nonatheromatous, and noninflammatory arterial disease that most commonly affects the renal and carotid arteries. We report a child with subarachnoid and ocular hemorrhage associated with an aneurysm due to fibromuscular dysplasia. Computed tomography following a witnessed collapse revealed diffuse subarachnoid hemorrhage and severe cerebral edema. An autopsy confirmed the radiographic findings and detected bilateral retinal hemorrhages, optic nerve sheath hemorrhages, and a ruptured saccular aneurysm due to focal fibromuscular dysplasia involving the intracranial right vertebral artery. This case documents a fatal subarachnoid hemorrhage in a child with an intracranial saccular aneurysm caused by fibromuscular dysplasia. The associated retinal hemorrhages are easily detected by postmortem monocular indirect ophthalmoscopy.

Widening of the pericerebral space in infants - consultative problems

The study was an attempt to characterize symptoms and factors suggesting a traumatic cause of pericerebral space widening in infants. This heterogeneous group of disorders, rarely observed in forensic pathological practice, poses consultative problems, as it may be difficult to distinguish between spontaneous disease-related changes and traumatic complications, and differentiate accidental from non-accidental trauma. The study is based on the records of two cases submitted for examination in order to determine the degree of health impairment. In both cases, a female infant was indicated as the injured person. A review of medical records, particularly medical imaging findings, provided evidence to conclude that the subdural hygromas diagnosed in both infants had a post-traumatic origin. On that basis, factors were selected for consideration in medicolegal assessment, including history of head injury, retinal haemorrhage, presence of other external and internal injuries suggesting battered or shaken baby syndromes, onset and rate of symptom aggravation, perinatal anamnesis, presence of arachnoid cysts, and diseases from the group of metabolic defects.

Body mass index and fatal stroke in young adults: A national study.

Rates of stroke and obesity have increased in recent years. This study aimed to determine the body mass index (BMI) of fatal stroke cases amongst young adults, their clinical characteristics and the association with BMI with risk factors. All cases aged 15-44 years where death was attributed to stroke for whom BMI was available were retrieved from the National Coronial Information System (1/1/2009-31/12/2016). 179 cases were identified: haemorrhagic (165), ischaemic (5), thrombotic (6), mycotic (3), embolic (0). Proportions in each BMI category were: underweight (5.6%), normal weight (37.4%), overweight (27.4%), obese (29.6%). There was a significant linear trend in the proportion of subarachnoid haemorrhages as BMI increased (p < 0.05), and between higher BMI and hypertension (p < 0.001). There were no group differences in cardiomegaly or left ventricular hypertrophy where known causes were other than hypertension, cardiomyopathy, severe coronary artery atherosclerosis, endocarditis or cerebral arteries atherosclerosis. A history of alcoholism (p < 0.01) was less likely with higher BMI. There was no association between BMI and previous stroke, diabetes, vasculitis, gravid/post-partum, tobacco use, psychostimulant use or injecting drug use. Overweight and obese cases were prominent among young fatalities of stroke. Reducing rates of obesity, and associated hypertension, would be expected to reduce the escalating stoke rates among young adults.

Histological dating of subdural hematoma in infants.

BACKGROUND: After infant deaths due to non-accidental head injury (NAHI) with subdural hematoma (SDH), the magistrates ask experts to date the traumatic event. To do so, the expert only has tools based on adult series of NAHI. We aimed to develop an SDH dating system applicable to infants aged under 3 years. METHODS AND RESULTS: We studied a retrospective multicenter collection of 235 infants who died between the ages of 0 and 36 months, diagnosed with SDH by forensic pathological examination and with known posttraumatic interval (PTI). Two pathologists assessed blindly and independently 12 histomorphological criteria relating to the clot and 14 relating to the dura mater in 73 victims (31 girls, 42 boys) whose median age was 3.8 months. Histopathological changes were significantly correlated with PTI for the appearance of red blood cells (RBCs) and the presence or absence of siderophages, and regarding the dura mater, the quantity of lymphocytes, macrophages, and siderophages; presence or absence of hematoidin deposits; collagen and fibroblast formation; neomembrane thickness; and presence or absence of neovascularization. Dating systems for SDH in adults are not applicable to infants. Notably, neomembrane of organized connective tissue is formed earlier in infants than in adults. CONCLUSION: Our dating system improves the precision and reliability of forensic pathological expert examination of NAHI, particularly for age estimation of SDH in infants. However, the expert can only define a time interval. Histopathology is indispensable to detect repetitive trauma.

Metastatic prostate cancer mimicking a subdural hematoma: A case report and literature review.

Occurrences of metastatic prostate cancer imitating a subdural hematoma are limited to a small number of case reports, even though prostate cancer spreads to the dura more than other types of cancer. Here, we present the case of a 64 year-old male whose prostate carcinoma's metastasis mimicked a subdural hematoma, and he suffered a middle cerebral artery stroke. Prostate cancer's high rate of progression to the dura is disproportionate to its relatively low rate of brain metastasis. Furthermore, we explore the potential molecular implications of prostate cancer's propensity to spread to the dura.

Spontaneous pneumocephalus and subdural hemorrhage after sneezing.

Spontaneous pneumocephalus is defined as the presence of air in the absence of intracranial factors. The management of spontaneous pneumocephalus can be conservative or surgical, and surgical intervention could be urgently required if clinical deterioration is rapid. Here, we report a case of pneumocephalus and subdural hemorrhage after sneezing. A 24-year-old male reported to our emergency department with a chief complaint of headache and dizziness. The patient gave a history of onset of headache and dizziness after 2 episodes of heavy sneezing. There was neither a history of recent traumatic episode or previous surgery, nor any signs and symptoms of recent fever or upper respiratory tract infections. Physical examination showed no specific findings. Computed tomography was performed, which showed subdural hemorrhage and PNC in the left occipital lobe, left hemomastoid, and maxillary hemosinus. A neurosurgeon was consulted, who suggested admission in the intensive care unit. An otolaryngologist was then consulted for the left ear otorrhea and hearing impairment. Otoscopic examination showed hemotympanum of the left ear, for which pain control and conservative treatment was suggested. The patient was transferred to general ward 4 days later, since the following brain computed tomography showed resolution of the hemorrhage, and discharged 6 days later because of the improved signs and symptoms. Pneumocephalus and intracranial hemorrhage can occur without a history of trauma or surgery. Special attention is required if headache, dizziness, or other neurologic signs and symptoms occur immediately after sneezing. Intracranial hemorrhage and penumocephalus should be considered in the differential diagnosis.

Bilateral Temporal Extradural Hematoma on Top of Bilateral Temporal Arachnoid Cyst: First Case Report and Extensive Literature Review.

BACKGROUND: The traumatic complication of an arachnoid cyst (AC) with intracystic and subdural hematoma has been reported in many cases. However, a unilateral extradural hematoma (EDH) as a complication of AC is extremely rare. Most arachnoid cysts are unilateral and are located in the middle cranial fossa. Bilateral temporal AC alone is an extremely rare condition, and a bilateral EDH on top of a bilateral temporal AC has never been reported in the literature, to our knowledge. CASE DESCRIPTION: We report the case of a 25-year-old man with a known bilateral AC who was involved in a motor vehicle accident and developed a bilateral temporal EDH. The brain computed tomography scan also showed fractures in the skull on both temporal areas. The patient was treated conservatively. He was discharge with Glasgow Coma Scale score of 5. CONCLUSIONS: Bilateral temporal EDH in a bilateral temporal AC has never been reported in the literature. The presence of an AC may predispose a patient to complications because of the anatomic changes in the area. It is important to educate asymptomatic patients and their families about these cysts and the importance of avoiding head injury and not being involved in contact sports or military service.

The Pathogenesis of Subacute Subdural Hematoma: A Report of 3 Cases and Literature Review.

OBJECTIVE: To discuss the pathologic mechanism of subacute subdural hematoma (sASDH). METHODS: Three typical cases of sASDH were reported, and related literature in Chinese published in the past 15 years was reviewed. RESULTS: Intervals from onset of acute subdural hematoma to surgery or symptom deterioration resulting in sASDH were 12.5-15.5 days (mean 14.1 days). Delayed liquefaction of hematoma clots occurred in all 3 reported cases. One patient achieved good curative effect after administration of dexamethasone, and another patient relapsed owing to poor drainage after evacuation of hematoma. CONCLUSIONS: The conversion of acute subdural hematoma to sASDH is an inflammatory reaction process with very regular in time, and it is speculated that the pathologic mechanism may be a delayed hypersensitivity reaction. Antigen released during the liquefaction process of blood clot, with subdural neomembrane cells as antigen-presenting cells, is presented to the T lymphocytes released from the capillaries in the neomembrane and forms sensitized T lymphocytes. When the subsequent antigen is released from the blood clots with a delayed liquefaction and is exposed to sensitized T lymphocytes, the delayed hypersensitivity process occurs.

Giant intracranial arteriovenous malformation as the focus of epileptic seizures.

A man in his late thirties was found in a supine position in the hallway of his house. He had been diagnosed with epilepsy at approximately 20 years old. Since stopping treatment, epileptic events occurred more frequently and his condition deteriorated in the past 2 years. Autopsy revealed that head injuries were found on the left side of his head. A fracture from the left parietal bone to the anterior cranial fossa was also detected. A subdural hemorrhage (hematoma) spanned a wide range. A subarachnoid hemorrhage was also identified in the left parietal region. His brain weighed 1603 g, was edematous, and showed right uncal herniation. In the right cerebral hemisphere, a thick, enlarged blood vessel ran from the sagittal sinus. An egg-sized tumorous lesion of blood vessels was found on the bottom of the frontal lobe. This vascular lesion had formed between the sagittal sinus and right anterior cerebral artery. Pathologically, veins and arteries were found together, and, thus, this case was diagnosed as an arteriovenous malformation (AVM). No other pathological and toxicological findings were observed. Subdural hematoma, the cause of death, occurred from the fall to the floor. An epileptic seizure may have been the cause of the fall. AVM on his brain was considered to be the focal lesion of epileptic seizures.

Post-traumatic acute-on-chronic subdural haematoma: an unusual presentation of skull metastasis from prostate carcinoma.

The authors report on a case of an 80-year-old man operated on urgently for evacuation of an acute-on-chronic subdural haematoma after a minor blunt head trauma that had occurred the day before. The haematoma was revealed by a plain CT scan on arrival at the accident and emergency department. During operation, the calvarial bone and dura mater were found to be of pathological aspect and histology subsequently confirmed metastatic involvement from a known primary prostate cancer (PC). After an initial successful technical and clinical result, the patient worsened again due to a rebleed and succumbed soon after. The awareness of the possibility of osteodural metastatic involvement could have led to the adjunct of a contrast-enhanced CT study and altered the treatment strategy.

Intracranial multiple myeloma may imitate subdural hemorrhage: How to overcome diagnostic limitations and avoid errors in treatment.

BACKGROUND: Although the diagnosis of subdural hematoma is usually straightforward, occasionally it may be erroneous, leading to mistakes in the treatment. For example, leptomeningeal malignancies, even in the absence of bleeding, may clinically and radiologically mimic subdural hemorrhage. OBJECTIVE: To stress the importance of not only intuitive thinking but also in analytic thinking in appropriate and accurate treatment strategies. METHODS AND ILLUSTRATIVE CASE: In this report, the clinical and radiological pitfalls in differentiating malignant leptomeningeal infiltration and subdural hematomas are discussed. A sample case of an intracranial extra-osseous manifestation of a multiple myeloma that is atypical with regard to its location and clinical presentation is presented for illustration. CONCLUSIONS: The variability of intracranial presentation and the wide spectrum of leptomeningeal malignancies necessitate careful preoperative evaluation of the patient's individual history as well as radiological images to avoid misdiagnosis. A clinician who has become familiar with the pitfalls in the differential diagnosis between leptomeningeal infiltrations and subdural hematoma will act more analytically to solve the patient's problems properly and avoid potential complications for the patient.

Imaging of Subdural Hematomas.

The imaging of subdural hematoma has evolved significantly. Computed tomography and MRI have supplanted other procedures and rendered most obsolete for the evaluation of intracranial pathology because of ease of use, tremendous soft tissue resolution, safety, and availability. Noncontrast computed tomography has become the accepted standard of care for the initial evaluation of patients with suspected subdural hematoma because of widespread availability, rapid acquisition time, and noninvasive nature. MRI offers important features in determining potential secondary causes of subdural hematoma, such as dural-based neoplasms.

Subdural hematoma - a cause of death in the development of a prostatic adenocarcinoma with dural metastases: case report.

Non-traumatic subdural hematoma secondary to dural metastases is a rare complication. Dural metastases from a prostate adenocarcinoma occur in the advanced stages of this pathology and may sometimes be the first manifestation of a prostate carcinoma. Less than 40 cases of subdural hematoma are reported in the literature as a consequence of dural metastases from a prostate adenocarcinoma. The authors present the case of a male patient diagnosed with stage IV prostate adenocarcinoma with bone metastasis, who is admitted for left hemisphere subdural hematoma with right hemiparesis. The evolution of the patient is unfavorable, and the autopsy shows dural metastases and a collection of subdural coagulated blood. The chronic subdural hematoma with re-bleeding is a rare cause of death in the development of a prostate adenocarcinoma.

[Cerebellar hemangioblastoma and thrombocytopenia: Report of one case]. / Hemangioblastoma cerebeloso y trombocitopenia: Reporte de caso.

The association between vascular tumors and thrombocytopenia is rare. Kasabach-Merritt Syndrome is seen in childhood and is characterized by hemangiomas and thrombocytopenia. A 42 years-old man with a cerebellar hemangioblastoma and thrombocytopenia, admitted with a subarachnoid hemorrhage is reported. The patient was operated and required a splenectomy to manage the thrombocytopenia. After the splenectomy the patient developed a subdural hematoma that was operated. Despite the surgical treatment, the patient died.

Hemangioblastoma cerebeloso y trombocitopenia: reporte de caso / Cerebellar hemangioblastoma and thrombocytopenia: report of one case

The association between vascular tumors and thrombocytopenia is rare. Kasabach-Merritt Syndrome is seen in childhood and is characterized by hemangiomas and thrombocytopenia. A 42 years-old man with a cerebellar hemangioblastoma and thrombocytopenia, admitted with a subarachnoid hemorrhage is reported. The patient was operated and required a splenectomy to manage the thrombocytopenia. After the splenectomy the patient developed a subdural hematoma that was operated. Despite the surgical treatment, the patient died.

Longitudinal extension of myelomalacia by intramedullary and subdural hemorrhage in a canine model of spinal cord injury.

BACKGROUND CONTEXT: In canine intervertebral disc (IVD) extrusion, a spontaneous animal model of spinal cord injury, hemorrhage is a consistent finding. In rodent models, hemorrhage might be involved in secondary tissue destruction by biochemical mechanisms. PURPOSE: This study aimed to investigate a causal association between the extents of intramedullary, subdural and epidural hemorrhage and the severity of spinal cord damage following IVD extrusion in dogs. STUDY DESIGN/SETTING: A retrospective study using histologic spinal cord sections from 83 dogs euthanized following IVD extrusion was carried out. METHODS: The degree of hemorrhage (intramedullary, subdural, epidural), the degree of spinal cord damage in the epicenter (white and gray matter), and the longitudinal extent of myelomalacia were graded. Associations between the extent of hemorrhage and the degree of spinal cord damage were evaluated statistically. RESULTS: Intramedullary and subdural hemorrhages were significantly associated with the degree of white (p<.001/ p=.004) and gray (both p<.001) matter damage, and with the longitudinal extension of myelomalacia (p<.001/p=.005). Intriguingly, accumulation of hemorrhagic cord debris inside or dorsal to a distended and ruptured central canal in segments distant to the epicenter of the lesion was observed exhibiting a wave-like pattern on longitudinal assessment. The occurrence of this debris accumulation was associated with high degrees of tissue destruction (all p<.001). CONCLUSIONS: Tissue liquefaction and increased intramedullary pressure associated with hemorrhage are involved in the progression of spinal cord destruction in a canine model of spinal cord injury and ascending or descending myelomalacia. Functional and dynamic studies are needed to investigate this concept further.