Good functional outcome following bilateral external capsule hemorrhage mimicking bilateral basal ganglia hemorrhage in a coma patient.

Simultaneous spontaneous bilateral external capsule hemorrhage is a rare clinical entity with extremely poor outcome. However, knowledge on the effective management of this fatal disease is limited. Herein,we described a case of a 42-year-old man with acute coma and quadriplegia as well as respiratory failure related to the disease. The patient underwent minimally invasive surgery plus local thrombolysis. Consequently, he recovered with satisfactory neurological function recovery on the 180th day of follow-up.

Application of neuroendoscopic surgery in treatment of hypertensive basal ganglia hemorrhage. / Aplicación de la neurocirugía endoscópica en el tratamiento de las hemorragias hipertensivas en los ganglios basales.

INTRODUCTION: The influence of Application of neuroendoscopic surgery in treatment of hypertensive basal ganglia hemorrhage remains largely unknown. AIM: To compare the clinical efficacy of minimally invasive neuroendoscopic surgery (NES) and small bone window craniotomy (SBWC) microsurgery on the treatment of patients with hypertensive basal ganglia hemorrhage (HBGH). PATIENTS AND METHODS: The clinical data of 174 HBGH patients treated in our hospital from January 2018 to September 2020 were retrospectively analyzed. They were divided into minimally invasive NES group (n = 90) and SBWC microsurgery group (n = 84). Their operation time, hematoma clearance rate, rebleeding and prognosis were compared. RESULTS: In minimally invasive NES group, the operation time and intraoperative hemostasis time were significantly shorter, and the intraoperative blood loss was significantly less than those in SBWC microsurgery group (p menor de 0.001). The preoperative Glasgow coma scale (GCS) score was 8.64 ± 1.04 points and 8.68 ± 1.02 points respectively in minimally invasive NES group and SBWC microsurgery group (p mayor de 0.05). At 24 h after operation, the GCS score in minimally invasive NES group rose to 12.89 ± 1.56 points, and it had a significant difference from that in SBWC microsurgery group (11.18 ± 1.14 points, p menor de 0.001). The volume of brain edema was 11.82 ± 3.25 mL in minimally invasive NES group and 18.89 ± 3.15 mL in SBWC microsurgery group (p menor de 0.001). In minimally invasive NES group, the clearance of hematoma was superior to that in SBWC microsurgery group, and the prognosis was also better than that in SBWC microsurgery group. CONCLUSIONS: Minimally invasive NES has better efficacy than SBWC microsurgery in the treatment of HBGH.

TITLE: Aplicación de la neurocirugía endoscópica en el tratamiento de las hemorragias hipertensivas en los ganglios basales.Introducción. La relevancia de la neurocirugía endoscópica en el tratamiento de las hemorragias hipertensivas de los ganglios basales no se conoce en buena medida. Objetivo. Comparar la eficacia clínica de la neurocirugía endoscópica mínimamente invasiva con la de la microcirugía con craneotomía de ventana pequeña (SBWC) en el tratamiento de las hemorragias hipertensivas de los ganglios basales. Pacientes y métodos. Análisis retrospectivo de los datos clínicos de 174 pacientes con hemorragia hipertensiva de los ganglios basales tratados en nuestro hospital desde enero de 2018 hasta septiembre de 2020. Los pacientes se dividieron en dos grupos: uno sometido a neurocirugía endoscópica mínimamente invasiva (n = 90) y otro a microcirugía con SBWC (n = 84). Se compararon la duración de la operación, la tasa de eliminación del hematoma, la recidiva hemorrágica y el pronóstico. Resultados. En el grupo sometido a la endoscopia mínimamente invasiva, tanto la duración de la intervención como el tiempo de hemostasia fueron significativamente más breves, y la pérdida de sangre durante la intervención fue significativamente menor que en el grupo de microcirugía con SBWC (p menor de 0,001). La puntuación preoperatoria de la escala de coma de Glasgow (GCS) era de 8,64 ± 1,04 puntos en el grupo de la endoscopia y de 8,68 ± 1,02 puntos en el de la microcirugía (p > 0,05). A las 24 horas de la intervención, la puntuación de la GCS en los sometidos a la neuroendoscopia aumentó hasta 12,89 ± 1,56, con una diferencia significativa respecto al grupo de la microcirugía, que presentaba 11,18 ± 1,14 puntos (p menor de 0,001). El volumen del edema cerebral fue de 11,82 ± 3,25 mL en el grupo de la neuroendoscopia mínimamente invasiva y de 18,89 ± 3,15 mL en el de la microcirugía (p menor de 0,001). En comparación con el grupo sometido a esta última, en el grupo de la endoscopia, la eliminación del hematoma fue más extensa y el pronóstico resultó más favorable. Conclusiones. La neurocirugía endoscópica mínimamente invasiva se mostró más eficaz que la microcirugía con SBWC en el tratamiento de las hemorragias hipertensivas de los ganglios basales.

Clinical Study on a Modified Hematoma Puncture Drainage Treatment in Patients with Hypertensive Basal Ganglia Hemorrhage.

OBJECTIVE: We aim to investigate the clinical efficacy and safety of a modified hematoma puncture drainage treatment through the burr hole lateral to Kocher's point from the frontal lobe in patients with hypertensive basal ganglia hemorrhage. METHODS: Twenty-six patients were enrolled in the retrospective study. The volume of hematoma in those patients was between 25 and 35 mL, and the Glasgow Coma Scale scores were between 9 and 11; they were divided into a hematoma puncture drainage treatment group and a traditional conservative treatment group. The volume of remaining hematoma, neurological function defect scores, and life quality after treatment, duration of hospitalization, and cost of hospitalization were analyzed in these 2 groups. RESULTS: The volume of remaining hematoma was significantly less in the drainage group than that in the traditional group on the first day and the third day after treatment (P < 0.05). Posttreatment neurological function defect scores in the drainage group were statistically lower than those in the traditional group (P < 0.05). The duration of hospitalization was significantly shorter and the cost of hospitalization was also significantly less in the drainage group than that in the traditional group (P < 0.05). The Extended Glasgow Outcome Scale and Barthel Index scores were significantly higher in the drainage group than those in the traditional group (P < 0.05). There were no significant differences between the 2 groups in the complication rates (P > 0.05). CONCLUSIONS: The modified hematoma puncture drainage treatment represents an effective and safe way to treat hypertensive basal ganglia hemorrhage.

Combined Decompressive Hemicraniectomy and Port-Based Minimally Invasive Parafascicular Surgery for the Treatment of Subcortical Intracerebral Hemorrhage: Case Series, Technical Note, and Review of Literature.

BACKGROUND: Intracerebral hemorrhage (ICH) is a neurosurgical emergency. Combined decompressive hemicraniectomy (DHC) and minimally invasive parafascicular surgery (MIPS) may provide a practical method of managing subcortical ICH. OBJECTIVE: 1) To present a case series of combined DHC-MIPS for the treatment of subcortical-based ICH; 2) to describe technical nuances of DHC-MIPS; and 3) to provide a literature overview of MIPS for ICH. METHODS: The following inclusion criteria were used: 1) Glasgow Coma Scale (GCS) score <3-4; 2) admission within 6 hours of onset; 3) increased intracranial pressure caused by hemorrhage; 4) patient unresponsive to medical management; 5) hemorrhage >30 cm3; 6) subcortical location; and 7) midline shift (mm). Before DHC, sulcal cannulation used the following coordinates: intersection of tragus-frontal bone and midpoint of midpupillary line and midline; coronal suture: 3-4 cm posterior to this point). RESULTS: Three patients were selected: a 62-year old woman, a 45-year old woman, and a 36-year-old man. GCS and ICH scores on admission were 7 and 3, 3 and 4, and 3 and 4, respectively. ICH was located in left basal ganglia in patients 1 and 3 and right basal ganglia in patient 2, all with intraventricular extension. ICH volume was 81.7, 68.2, and 42.3 cm3, respectively. The postoperative GCS score was 11, 10, and 6, respectively. There were no intraoperative complications or mortalities. Evacuation was within 15 minutes in all patients. The modified Rankin Scale score was 3, 4, and 5, respectively, with semi-independence in case 1. CONCLUSIONS: Combined DHC-MIPS, with the use of craniometric points, can provide a unique and simple surgical option for the management of subcortical ICH.

Computerized Tomography Radiomics Features Analysis for Evaluation of Perihematomal Edema in Basal Ganglia Hemorrhage.

To evaluate the edema area around basal ganglia hemorrhage by the application of computerized tomography (CT)-based radiomics as a prognostic factor and improve the diagnosis efficacy, a total of 120 patients with basal ganglia hemorrhage were analyzed retrospectively. The texture analysis software Mazda 3.3 was used to preprocess the CT images and manually sketch the region of interest to extract the texture features. The extracted texture features were selected by Fisher coefficient, POE+ACC and mutual information. The texture discriminant analysis uses the B11 module in the Mazda 3.3 software. The data were randomly divided into a training dataset (67%) and test dataset (33%). To further study the texture features, the training dataset can be divided into groups according to the median of GCS score, NIHSS score, and maximum diameter of hematoma. Random forest model, support vector machine model, and neural network model were built. AUC of the receiver operating characteristics curve was used to assess the performance of models with test dataset. Among all texture post-processing methods, the lowest error rate was 2.22% for the POE+ACC/nonlinear discriminant. For the maximum diameter of hematoma, GCS score, and NIHSS score group, the lowest error rate were 26.66%, 23.33%, and 30.00%, respectively. The values of AUCs were 0.87, 0.81, and 0.76, for random forest model, support vector machine model, and neural network model in the test dataset, respectively. Radiomic method with proper model may have a potential role in predicting the edema area around basal ganglia hemorrhage. It can be used as a secondary group in the diagnosis of edema area around basal ganglia hemorrhage.

Improvement of Writer's Cramp from an Old Lesion in the Contralateral Hemisphere with Transient Gait Disturbance After Thalamotomy.

BACKGROUND: Stereotactic ventro-oral thalamotomy has been performed in cases of focal task-specific dystonia, including writer's cramp, with excellent outcomes. However, no reports have revealed the outcome of ventro-oral thalamotomy in a patient with a contralateral cerebral lesion. We describe a patient with left-hand writer's cramp with an old lesion in the left hemisphere and transient gait disturbance after right ventro-oral thalamotomy. CASE DESCRIPTION: A 43-year-old man had a hemorrhage in the left basal ganglia due to cerebral arteriovenous malformation at 22 years of age, and right hemiparesis remained as a sequela. He developed left-handed writing ability; however, he became aware of the stiffness of his left hand and difficulty in writing. Writer's cramp was diagnosed. Medical treatments were not effective, and right ventro-oral thalamotomy was performed. Although his writing ability improved, he could not walk. After performing rehabilitation, his walking completely improved, reaching the level before surgery, after 3 months, and his writer's cramp was completely cured. CONCLUSIONS: In patients with basal nucleus lesions, gait disturbance may appear transiently after contralateral thalamotomy. It is crucial to fully explain the potential complications, particularly in relation to temporal gait disturbances, and obtain informed consent.

Treatment of Central Paralysis of Upper Extremity Using Contralateral C7 Nerve Transfer via Posterior Spinal Route.

BACKGROUND: Contralateral C7 nerve transfer is widely applied for the treatment of brachial plexus injuries or central paralysis of the upper extremities. The surgical approach has evolved from the precervical subcutaneous route to the prespinal route, which is currently the most commonly used one. We report a patient with central paralysis of the right upper extremity treated with contralateral C7 nerve transfer via the posterior spinal route. CASE DESCRIPTION: A 59-year-old female patient was admitted on 3 July, 2018 with right hemiplegia. The muscle strength of the right lower and upper extremities was grade 4 and 0, respectively. On the basis of magnetic resonance imaging, she was diagnosed with central paralysis of the right upper extremity. Considering the short length of the patient's healthy C7 nerve, contralateral C7 nerve transfer via the posterior spinal route was performed. No intraoperative complication was encountered. The patient reported slight numbness of the volar side of the left thumb, middle finger, and index finger after surgery. The patient showed a right shrug movement 1.5 months after surgery. CONCLUSION: We propose carrying out contralateral C7 nerve transfer via the posterior spinal route because of the shorter distance, no need for nerve transplantation, and low occurrence of the complications encountered with the prespinal route (such as vertebral artery injuries, esophageal fistula, and upper extremity pain when swallowing).

[Severe dysautonomy as a result of intra-cranial bleeding can cause an electrical storm with auricular fibrillation]. / Svær dysautonomi som følge af intrakranial blødning kan udløse elektrisk storm med ventrikelflimren.

A 69-year-old woman with a medical history of stroke and an ICD device due to torsade de pointes was admitted with a right basal ganglia haemorrhage. In the hours after admission the patient's condition severely declined and she developed fever, hypertension and flushing consistent with autonomic dysfunction with sympathetic storming. ICD interrogation revealed electrical storm with 138 appropriate shocks delivered at the night of admission. We wish to draw attention to the close link between brain and heart, which in predisposed patients with a new stroke can cause malignant arrhythmias.

Endoscopic surgery versus conservative treatment for the moderate-volume hematoma in spontaneous basal ganglia hemorrhage (ECMOH): study protocol for a randomized controlled trial.

BACKGROUND: Spontaneous intracerebral hemorrhage is a disease with high morbidity, high disability rate, high mortality, and high economic burden. Whether patients can benefit from surgical evacuation of hematomas is still controversial, especially for those with moderate-volume hematomas in the basal ganglia. This study is designed to compare the efficacy of endoscopic surgery and conservative treatment for the moderate-volume hematoma in spontaneous basal ganglia hemorrhage. METHODS: Patients meet the criteria will be randomized into the endoscopic surgery group (endoscopic surgery for hematoma evacuation and the best medical treatment) or the conservative treatment group (the best medical treatment). Patients will be followed up at 1, 3, and 6 months after initial treatment. The primary outcomes include the Extended Glasgow Outcome Scale and the Modified Rankin Scale. The secondary outcomes consist of the National Institutes of Health Stroke Scale and the mortality. The Barthel Index(BI) will also be evaluated. The sample size is 100 patients. DISCUSSION: The ECMOH trial is a randomized controlled trial designed to evaluate if endoscopic surgery is better than conservative treatment for patients with moderate-volume hematomas in the basal ganglia. TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR-TRC-11001614(http://www.chictr.org/en/proj/show.aspx?proj=1618).

A new cerebral hemorrhage model in cynomolgus macaques created by injection of autologous anticoagulated blood into the brain.

The aim of this study was to establish and validate a clinically relevant model of intracerebral hemorrhage (ICH) via injection of autologous blood into the brains of cynomolgus macaques (Macaca fascicularis). Eight male cynomolgus macaques received 1.5 mL of fresh anticoagulated autologous femoral artery blood into the inner side of the claustrum near the right basal ganglia under stereotactic guidance. Animals were evaluated with MRI and positron emission tomography (PET) scanning before and 24 hours after surgery and once per week thereafter. A neurological deficit scale was used to assess the animals on days 1, 2, 3, 7, 14, 21, and 28 after surgery. Animals showed focal neurological signs corresponding to the MRI-located hematoma. The behavioral impairment progressively ameliorated over time, but never fully resolved. The hematoma was absorbed over time but was still present 4 weeks after surgery, with persistent metabolic deficit detected using PET scanning. Histological examinations confirmed the in vivo findings. This ICH model in a non-human primate mimics human ICH in the basal ganglia and may be useful for assessing the safety and efficacy of neuroprotective agents.

Quality of life with special respect to depression after surgical treatment of hypertensive basal ganglia hemorrhage.

BACKGROUND: Hypertensive intracerebral hemorrhage is associated with high mortality and morbidity. Place of surgery in the primary supratentorial intracerebral hemorrhage is uncertain and the data on the long-term functional outcome of surgery in these patients is limited. AIM: The aim of the study was to determine long-term functional outcome of patients undergoing surgical treatment for hypertensive basal ganglia hemorrhage, especially in respect to depression. STUDY DESIGN AND SETTINGS: Retrospective analysis of database of 44 patients undergoing craniotomy for hypertensive basal ganglia hemorrhage between December 2002 and May 2007. MATERIALS AND METHODS: Long-term was defined as at least 18 months after craniotomy. Neurological status of the patients at admission was assessed by National Institute of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS). Outcome data consisted of the items including functionality, depression and quality of life. Tests applied included Barthel Index (BI), modified Rankin Scale (mRS), Beck Depression Inventory (BDI) and stroke-specific quality of life (SSQOL) scale. RESULTS: The long-term mortality rate was 29.5% (13/44). Of the 31 survivors, 21 (67.7%) patients had a BI >or= 60, 23 (74.2%) patients had a mRS <4 and 21 (67.7%) patients had a SSQOL >or= 60%, each representing a favorable outcome. In retrospect, 19 (61.3%) patients approved the surgery. Eighteen (58.1%) patients developed depression (BDI > 9), which was related to high NIHSS and low GCS score preoperatively, low BI, high mRS and low SSQOL postoperatively. CONCLUSIONS: The study reveals that depression is a common long-term complication after surgical treatment of hypertensive basal ganglion hemorrhage. Both the NIHSS and GCS scores before operation have critical roles in patient's quality of life associated with depression.

Neuroprotective effect of erythropoietin and darbepoetin alfa after experimental intracerebral hemorrhage.

OBJECTIVE: Intracerebral hemorrhage (ICH) is a devastating clinical syndrome for which no truly efficacious therapy has yet been identified. In preclinical studies, erythropoietin (EPO) and its long-lasting analog, darbepoetin alfa, have been demonstrated to be neuroprotective in several models of neuronal insult. The objectives of this study were to analyze whether the systemic administration of recombinant human EPO (rHuEPO) and its long-lasting derivative darbepoetin alfa expedited functional recovery and brain damage in a rat model of ICH. METHODS: Experimental ICH was induced in rats by injecting autologous blood into the right striatum under stereotactic guidance. Subsequently, animals underwent placebo treatment, daily injections of rHuEPO, or weekly injections of darbepoetin alfa. Animals were killed 14 days after injury. RESULTS: Both rHuEPO and darbepoetin alfa were effective in reducing neurological impairment after injury, as assessed by the neurological tasks performed. rHuEPO- and darbepoetin alfa-treated animals exhibited a restricted brain injury with nearly normal parenchymal architecture. In contrast, the saline-treated group exhibited extensive cerebral cytoarchitectural disruption and edema. The number of surviving NeuN-positive neurons was significantly higher in the rats treated with rHuEPO and darbepoetin alfa compared with those that received saline (P < 0.05). CONCLUSION: These results demonstrate that weekly administered darbepoetin alfa confers behavioral and histological neuroprotection after ICH in rats similar to that of daily EPO administration. Administration of EPO and its long-lasting recombinant forms affords significant neuroprotection in an ICH model and may hold promise for future clinical applications.

Gross-total hematoma removal of hypertensive basal ganglia hemorrhages: a long-term follow-up.

BACKGROUND AND PURPOSE: Hypertensive basal ganglia hemorrhage (HBGH) accounts for 35%-44% of cases of hypertensive intracranial hemorrhage (ICH), which is one of the most devastating forms of cerebrovascular disease. In this study, intracerebral hematoma was evacuated with a burr hole craniectomy. The relationships of residue hematoma volume to brain edema, inflammation factors and the long-term prognosis of HBGH patients were studied. METHODS: One hundred and seventy-six patients with HBGH were randomly divided into gross-total removal of hematoma (GTRH) and sub-total removal of hematoma (STRH) groups. The pre-operative and post-operative data of the patients in the two groups were compared. The pre-operative data included age, sex, hematoma volume, time from the ictus to the operation, Glasgow Coma Scale (GCS) scores, and the European Stroke Scale (ESS) scores. The post-operative information included edema grade, level of thromboxane B2 (TXB2), 6-keto-prostaglandin F1a (6-K-PGF1a), tumor necrosis factor-a (TNF-a) and endothelin (ET) in hematoma drainage or cerebral spinal fluid (CSF), ESS and Barthel Index (BI). RESULTS: There was no statistical difference between the two groups (P>0.05) in the pre-operative data. The levels of TXB2, 6-K-PGF1a, TNF-a and ET in the GTRH group were significantly lower than those in the STRH group at different post-operative times. The ESS in the GTRH group increased rapidly after the operation and was higher than that in the STRH group. There was a significant difference between the two groups (P<0.05). The post-operative CT scan at different times showed that the brain edema grades were better in the GTRH group than in the STRH group. The BI was higher in the GTRH group than in the STRH group (P<0.05). CONCLUSIONS: GTRH is an effective method to decrease ICH-induced injury to brain tissue. Such effect is related to decreased perihematomal edema formation and secondary injury by coagulation end products activated inflammatory cascade.

Subacute stereotactic aspiration of haematomas within the basal ganglia reduces occurrence of complications in the course of haemorrhagic stroke in non-comatose patients.

BACKGROUND AND PURPOSE: Medical complications occurring after stroke of both ischaemic and haemorrhagic origin are frequent and constitute an important problem. The strongest factor predicting the occurrence of complications is known to be the initial neurological impairment level. The aim of this study was to examine whether subacute stereotactic aspiration of haematomas within the basal ganglia is suitable to reduce the occurrence of complications in the course of haemorrhagic stroke in non-comatose patients. METHODS: Following rigorous selection criteria, 56 consecutive non-comatose patients were treated by subacute stereotactic evacuation of the haematomas. Glasgow Coma Scale (GCS) scores after initiation of treatment, medical complications, mortality and length of in-patient stay before discharge for further rehabilitative treatment were recorded for each patient and were compared with the results obtained in a comparable group of 39 patients treated purely medically in another hospital. RESULTS: The level of consciousness improved markedly after stereotactic surgery, and GCS scores were significantly higher than those after pure medical treatment (p < 0.0001). In comparison with medical patients, complications were considerably fewer in the surgical group, and thus peri-ictal morbidity and mortality were significantly lower. Length of necessary treatment in the intensive care unit as well as total in-patient stay in the acute care facility were significantly reduced. CONCLUSIONS: Improving alertness, subacute stereotactic aspiration of deep-seated haematomas decreases occurrence of medical complications in the course of haemorrhagic stroke. Recovery can be accelerated, and patients are earlier suitable for further rehabilitative treatment.

Basal ganglia hemorrhagic ablation associated with temporary suppression of obsessive-compulsive symptoms

Currently, basal ganglia (BG) are considered regulators of motor and emotional activity. It's operationality encompass Obsessive Compulsive Disorder (OCD). The case of a patient suffering with severe OCD is described of note, his symptoms disappeared following a hemorrhage of the left BG. However, once the hemorrhage was reabsorbed his symptoms returned. It is possible that lesions affecting cerebral OCD association circuits may influence the evolution of obsessive-compulsive symptoms