A Novel Brainstem Hemorrhage Model by Autologous Blood Infusion in Rat: White Matter Injury, Magnetic Resonance Imaging, and Neurobehavioral Features.

BACKGROUND: Primary brainstem hemorrhage (BSH) has the highest mortality and morbidity as a subtype of intracerebral hemorrhage. A major limitation of BSH research is the lack of a corresponding animal model. The purpose of this study was to establish a novel rat model of BSH and to characterize the resulting brain injury, especially focusing on white matter injury. METHODS: BSH was produced by stereotactically injecting autologous whole blood into the pons. Time course of hematoma resolution was observed by 7-T magnetic resonance imaging. White matter injury was evaluated in detail by multiple parameters including diffuse tensor imaging (DTI), demyelination, axonal injury, oligodendrocyte degeneration, and oligodendrocyte precursor cell proliferation. Brain water content and neurobehavior were also evaluated. RESULTS: Blood infusion (30 µL) led to a stable, reproducible hematoma in the right basotegmental pons. The hematoma absorption started, became obvious, and was nearly completed at 7, 14, and 30 days, respectively. Hematoma caused obvious brain edema at 3 days. White mater injury was observed pathologically, which was in line with decreased fractional anisotropy (FA) in DTI in the pons. FA reduction was also noticed in the cerebral peduncle and medulla. Behavioral abnormality persisted for at least 14 days and neurofunction was recovered within 1 month. CONCLUSIONS: This novel model can produce a stable hematoma resulting in brain edema, white matter injury, and neurofunctional deficits, which could be useful for future investigation of pathophysiological mechanisms and new treatment evaluation after BSH.

Effects of leonurine on intracerebral haemorrhage by attenuation of perihematomal edema and neuroinflammation via the JNK pathway.

Perihematomal edema plays a critical role in secondary brain injury in intracerebral hemorrhage (ICH), which is associated with inflammation, hematoma toxicity and oxidative stress. In this work, we investigated the protective effects of leonurine, an alkaloid of Herbal Leonuri, and possible mechanisms to provide a basis for a new therapeutic approach for ICH treatment. In in vivo studies, we demonstrated for the first time that leonurine treatment substantially decreased perihematomal edema, ameliorated neurobehavioral function deficits, reduced apoptosis and protected injured cerebral tissue after ICH. These benefits appear to be ascribed to leonurine effectively attenuating bloodbrain barrier (BBB) breakdown in vivo, by inhibiting degradation of hemoglobin and alleviating inflammatory mediator release. In this study, BV-2 cells were exposed in vitro to oxyhemoglobin (OxyHb) at a concentration of 10 µM to mimic neuroinflammation after ICH. Consistent with the results of the in vivo study, leonurine significantly inhibited OxyHbinduced inflammatory proteins expression in BV-2 cells, mainly through inhibiting the c-Jun N-terminal kinase (JNK) signaling pathway. This is the first time that leonurine is proved to be capable to protect the injured cerebral tissue after ICH, based on alleviating neuroinflammation and attenuating BBB breakdown to ameliorate perihematomal edema.

Quality of Life related to Eruption Hematoma in a Twenty Months Old Infant.

AIM: This paper describes a case of an eruption hematoma in a 20-month-old boy and the impact of this hematoma on the quality of life (QoL) related to oral health of this infant and his family. BACKGROUND: Eruption hematoma is a soft benign cyst that contains blood and overlie a tooth that are about to erupt. Oral health conditions can affect the QoL and bring psychological impacts. CASE REPORT: The proposed treatment was based on oral hygiene instruction, normal diet and massage on the lesion area. A weekly follow-up visits up to the spontaneous regression at the 6 weeks of the lesion was conducted. The impact on QoL was assessed though the Brazilian version of the early childhood Oral Health Impact Scale (B-ECOHIS) questionnaire before and after 2 months of the hematoma regression. CONCLUSION: The presence of eruption hematoma impacted, physically and emotionally, the QoL related to oral health of the child and his family, and this impact decreased when the eruption hematoma disappeared. CLINICAL SIGNIFICANCE: It is important the knowledge of the dentists about eruption cyst/hematoma to make the correct decisions to improve the QoL of their patients and families.

The Zeitraffer phenomenon, akinetopsia, and the visual perception of speed of motion: a case report.

The Zeitraffer phenomenon is the altered perception of the speed of moving objects. A single case is reported using the subject's own description of a transient alteration of the visual perception of motion. The literature on the subject is reviewed. The Zeitraffer phenomenon probably arises from dysfunction of brain networks subserving visual perception of speed. It shares characteristics with akinetopsia, the loss of visual ability to perceive motion.

Association between microbleeds observed on T2*-weighted magnetic resonance images and dysphagia in patients with acute supratentorial cerebral hemorrhage.

BACKGROUND: Approximately one-half of all patients with acute intracerebral hemorrhage (ICH) develop dysphagia that can lead to pneumonia or fatal outcomes; however, there are no reports about the relationship between swallowing function and cerebral microbleeds (CMBs) in these patients. Therefore, we investigated whether CMBs were associated with dysphagia in patients with ICH. METHODS: A total of 100 patients (mean age, 65.1 ± 14.1 years; range, 36-95 years) with acute supratentorial ICH were included in this study. CMBs were detected on T2*-weighted magnetic resonance imaging performed during admission using a 1.5-T scanner (mean duration from onset to magnetic resonance imaging, 12.6 ± 8.4 days). We assessed swallowing function by using bedside swallowing assessments on admission and by monitoring the mode of nutritional intake at discharge in relation to the number and location of CMBs. RESULTS: CMBs were detected in 60 of the 100 patients (60%) and were related to dysphagia. The number of CMBs and dysphagia were not related, but a significant relationship was observed in the presence of bilateral hematomas and CMBs. CONCLUSIONS: In addition to assessing just the presence or absence of CMBs, clinicians should identify the presence of bilateral or deep lesions in patients with ICH from the perspective of swallowing dysfunction.

Retrosplenial amnesia without topographic disorientation caused by a lesion in the nondominant hemisphere.

We report the case of a 68-year-old right-handed man who was admitted to our hospital because of sudden onset of headache. On admission, he presented with left homonymous hemianopsia, disorientation, and recent memory disturbance; however, he had normal remote memory and digit span. He was able to recall the room layout of his house and describe the route from the nearest station to his home on a map. However, at the hospital, he sometimes lost his way because of amnesia. Computed tomography (CT) and magnetic resonance imaging revealed a subcortical hematoma in the right occipital forceps and the parietal lobe, involving the cingulate isthmus. Single-photon emission CT imaging showed reduced perfusion not only in the retrosplenial region but also in the right thalamus. These findings suggested that the retrosplenial amnesia might have been caused by the interruption of hippocampal input into the anterior thalamus.

Mast cell blocking reduces brain edema and hematoma volume and improves outcome after experimental intracerebral hemorrhage.

Intracerebral hemorrhage (ICH) is associated with high mortality and disability, and there is no widely approved clinical therapy. Poor outcome after ICH results mostly from a mass effect owing to enlargement of the hematoma and brain swelling, leading to displacement and disruption of brain structures. Cerebral mast cells (MC) are resident inflammatory cells that are located perivascularly and contain potent vasoactive, proteolytic, and fibrinolytic substances. We previously found pharmacological MC stabilization and genetic MC deficiency to be associated with up to 50% reduction of postischemic brain swelling in rats. Here, we studied the role of MC and MC stabilization in ICH using in vivo magnetic resonance imaging and ex vivo digital imaging for calculating brain edema and hematoma volume. In a rat ICH model of autologous blood injection into the basal ganglia, four groups of Wistar rats received either saline or sodium cromoglycate (MC stabilizer, two groups) or compound 48/80 (MC degranulator). Evaluated 24 h later, MC stabilization had resulted in highly significantly better neurologic scores (P<0.001), decrease mortality (P=0.002), less brain swelling (P<0.001), and smaller hematoma volume growth (P<0.001) compared with saline and compound 48/80. Moreover, to support our hypothesis, we induced ICH in MC-deficient rats and their wild-type littermates (WT). MC-deficient rats responded with significantly better neurologic scores (P<0.001), decrease mortality (0% versus 25%), less brain swelling (P<0.05), and smaller hematoma growth (P<0.05) than WT. The role of MC deserves a close evaluation as a potential target in the development of novel forms of ICH therapy.

Effect of posterior temporal-parietal hematoma on orbital frontal chemistry in relation to a cognitive and anxiety state: a combined 1H-MRS and neuropsychological study of an unusual case as compared with 16 healthy subjects.

The authors report the unusual case of a 58-year-old woman (MJP) suffering from left temporal throbbing headache, associated with confusion. Magnetic resonance imaging showed a 5 x 3 x 2 cm hematoma at the left posterior temporal--parietal junction (PTPJ). Repeated MRI of MJP's brain performed during a 4-month follow-up period showed decrease in hematoma size (2.3 x 1.5 x 1) with evidence for development of encephalomalacia and resorption of blood products involving the area of hemorrhage. MJP had mild transcortical sensory aphasia characterized by difficulty with reading and processing, with semantic paraphasic errors while speaking and some difficulty with repetition. MJP had remained normotensive and seizure free, on Vasotec therapy and Dilantin prophylaxis. An in vivo proton magnetic resonance spectroscopy (1H-MRS) performed during an 8-month follow-up period showed reduced concentration for N-acetyl aspartate (NAA) by 19.3% (F=4.09, P<0.04), and myo-inositol by 32.0% (F=5.16, P<0.02) in the left orbital frontal cortex (OFC) as compared with 16 healthy subjects (age- and sex-matched). Cognitive tests (the Wechsler abbreviated scale of intelligence (WASI) and the Stroop color--word interference) showed a significant impairment suggesting involvement of higher-order cognitive functioning (memory, learning, and general intelligence) and attentional system. The Spielberger state-trait anxiety inventory (STAI) showed increased anxiety at the moment of the current examination and decreased tendency to be anxious over a long period of time. The Beck Anxiety and Depression Inventory revealed minimal anxiety and mild to moderate levels of depression. It is hypothesized that the PTPJ hematoma triggered long-distance pathways linking PTPJ area and frontal lobe, including OFC, which resulted in abnormal chemical changes in the left OFC and in cognitive tests impairment, and in long-term anxiety state changes.

Music alexia in a patient with mild pure alexia: disturbed visual perception of nonverbal meaningful figures.

A 26-year-old female pianist suffered from an intracerebral hematoma caused by an arteriovenous malformation of the left occipital parasplenial region, which was operated on seven months after the onset. Incomplete right hemianopsia, mild pure alexia, and partially disturbed naming of visual objects persisted several months after the removal of the malformation. Evaluation of musical ability one and three months after surgery showed that her auditory recognition of music was intact. She could sing and play melodies already learned and could dictate well the notes after hearing tones. However, she had difficulty in reading music, especially the pitch of notes, even for simple sequences of 4 notes. In contrast, her rhythm reading was fairly good. Her visual recognition of other symbolic figures like road signs was also markedly impaired. These results suggest that her visual recognition of written music as well as of other symbolic figures underwent a preliminary verbal decoding in the left hemisphere and that pitch reading was more dependent on verbal processing than rhythm reading.

Associative agnosia and optic aphasia: qualitative or quantitative difference?

We report a patient who, following the partial removal of a tentorial meningioma, suffered a hematoma in the left occipital lobe, which was resected. He showed severe anomia for visually presented stimuli, while naming was normal when they were presented in the tactile, auditory and verbal modality. His performance on visuo-perceptual tests, not requiring meaning identification, provided evidence that he was able to access the stored representations of stimuli. When recognition was assessed with non-verbal tasks, a mixed pattern of findings emerged and the patient showed features of both associative agnosia and optic aphasia. He was severely impaired in producing pantomimes in response to pictures, but only marginally impaired in sorting figures from the same superordinate category into fine-grained subcategories. He performed within the normal range on an associative task, in which the distractors bore no semantic relation to the target, but made many errors when the distractors and the target were semantically related. We propose that the interpretation advanced by Coslett and Saffran (Brain, 1989) for optic aphasia also holds for associative agnosia and argue that both syndromes reflect the impaired access of structured representations to left hemisphere semantics, but differ in terms of the degree of compensation provided by the semantic resources of the right hemisphere. Since the anatomical basis of the two syndromes may be very similar, we submit that what makes the difference is the semantic potential of the patient's right hemisphere.

Impairment of facial recognition after closed head injuries of varying severity.

Perceptual matching of photographs of unfamiliar faces was studied in 46 patients with closed head injury. The severity of head injury as indexed by duration of coma and neurological deficits was inversely related to accuracy of performance. Impairment of facial recognition was specifically associated with signs of concomitant hemispheric and brain stem injury. The presence of neurologic deficits suggesting less pervasive injury essentially confined to the cerebral hemispheres, skull fracture, and EEG abnormality was not related to this visuoperceptive deficit. The findings are discussed in relation to hypotheses concerning neurological dysfunction in head injury.

Memory and intellectual ability after head injury in children and adolescents.

In comparison with age-matched groups who sustained mild to moderate head injury, children and adolescents with severe head injury initially exhibited memory deficit. Cognitive impairment persisted primarily in the severely injured children, whereas the follow-up performance of severely injured adolescents more closely approximated that of age-matched patients with mild or moderate head injury. The results suggest that young children are no less and may be even more vulnerable to the deleterious effects of diffuse injury on memory and cognition.

[Hallucinations of supernumerary limbs, left hemineglect and hypersexuality in a case of right capsulo-lenticular hematoma]. / Hallucinations de membres surnuméraires, héminégligence gauche et hypersexualité dans un cas d'hématome capsulo-lenticulaire droit.

Following a right capsulo-lenticular hematoma, a 35-year-old man developed left sensory motor hemiplegia. Three years later, he still describes the existence of a supernumerary phantom limb. Mood disturbances, hypersexuality and attentional left hemineglect were also present.

Risks of acute traumatic intracranial haematoma in children and adults: implications for managing head injuries.

OBJECTIVE: To determine the factors influencing the risk of an acute traumatic intracranial haematoma in children and adults with a recent head injury. DESIGN: Prospective study of incidence of risk factors in samples of patients attending accident and emergency departments and in all patients having an acute traumatic intracranial haematoma evacuated in one regional neurosurgical unit during 11 years. SETTING: Accident and emergency departments in Scotland or Teesside and regional neurosurgical centre in Glasgow. PATIENTS: 8406 Adults and children (less than or equal to 14 years) who attended accident and emergency departments and 1007 consecutive patients who had an operation for an acute traumatic intracranial haematoma. Data were complete in 8366 and 960 patients respectively. RESULTS: Overall, children were less at risk than adults (one in 2100 v one in 348 respectively). In both age groups the presence of a skull fracture and changes in conscious level permitted identification of subgroups of patients with widely differing degrees of risk. In children the absolute risk ranged from one in almost 13,000 without a fracture or altered conscious level to one in 12 for a child in a coma and with a fracture; the pattern was similar in adults, the risks in corresponding groups ranging from one in almost 7900 to one in four. CONCLUSIONS: Although children attending hospital after a head injury have a lower overall risk of a traumatic haematoma, the main indicators of risk, a skull fracture and conscious level, are the same as in adults, and the pattern of their combined effect is similar. Guidelines for managing adults with recent head injury may therefore be applied safely to children; with the increasing provision of facilities for computed tomography they should be revised to ensure early scanning of more patients with head injury.

[Intraventricular hematomas associated with hypertensive intracerebral hemorrhages: with special reference to third ventricular hematoma].

Intraventricular hematoma (IVH) is often associated with many kinds of intracranial hemorrhage; for example, hypertensive intracerebral hemorrhage, subarachnoid hemorrhage, and so on. In this paper we discuss the clinical significance of IVH in the third ventricle, as well as the effects of surgical treatment. Forty-five patients were treated in our hospital because of massive IVH associated with small or mode-rate-size (hematoma volume less than or equal to 15 ml) thalamic or caudate-head hemorrhage between April, 1983 and April, 1988. All cases had an intraventricular cast in at least one ventricle. The patients were divided into two subgroups (depending on the site of the dominant IVH): the third-fourth ventricle dominant type-IVH group, and the lateral ventricle dominant type-IVH group. The former was further divided into two subgroups based on the thickness of the IVH in the third ventricle (its thickness being greater than or equal to 1 cm and less than 1 cm), and the area of IVH in the fourth ventricle (its area being greater than or equal to 1 cm2 and less than 1 cm2) as determined by CT scan monitoring. All cases were also divided according to continuous ventricular drainage (CVD), position of the catheter tip (in either the third ventricle or the lateral ventricle), and the intraventricular administration of urokinase (UK). For each group we checked the consciousness grade using the Glasgow Coma Scale (GCS) on day 0 and on day 7, as well as the interval between day 0 and the day on which the IVH in the third ventricle disappeared on the CT scan.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intracranial pressure in cases of non-traumatic cerebral hematoma-- personal observations and review of the literature]. / Cisnienie wewnatrzczaszkowe w przypadkach nieurazowych krwiaków sródmózgowych--obserwacje wlasne i analiza pismiennictwa.

The analysis of intracranial pressure records in 95 cases of non-traumatic intracerebral haematoma is presented. In 74 cases continuous recording was done. No correlation was found between the values of this pressure and consciousness disturbances. Three types of pressure change patterns were demonstrated: type A - low or normal values unchanging in 43 cases, type B - high initial values with normalization during conservative treatment, type C - very high initial values which decreased after operation in only some patients.

[Non-traumatic cerebral hematoma and the mechanisms of intracranial volume compensation]. / Nieurazowy krwiak sródmózgowy a mechanizmy wewnatrzczaszkowej kompensacji objetosciowej.

The results are presented of measurements of the intracranial pressure, pressure instability index and shifting of ventricular structures in 42 patients with non-traumatic intracerebral haematoma. Only the value of the instability index showed a correlation with the state of consciousness. For a more complete assessment of the state of sufficiency of the intracranial pressure compensation mechanism all these parameters should be analysed jointly.

Dermatitis artefacta induced in a patient by one of her multiple personalities.

A young woman suffered for 5 weeks with an inexplicable, severe dermatitis limited to her left arm. During hospitalization it was found that she had multiple personalities, one of whom had been applying the leaves of the poison ivy plant each night to her left arm, using 'his' gloved right hand. The factitial nature of the dermatitis was further documented by the fact that when the 'responsible personality' was cut off from supplies of poison ivy in the hospital, 'he' produced factitious haematomas by trauma to her left hand. Although this appears to be the first report of dermatitis artefacta associated with the multiple personality disorder, it is suggested that psychiatric study of other dermatitis artefacta patients might reveal the presence of unsuspected occult multiple personalities, responsible for skin lesions that patients cannot explain.

[Place disorientation as a clinical feature of a right capsulo-putaminal hematoma. Contribution to the understanding of neuropsychologic symptomatology in subcortical lesions of the right hemisphere]. / Delirio de localización geográfica en el cuadro clínico de un hematoma cápsulo-putaminal derecho. Contribución al conocimiento de la semiología neuropsicológica de las lesiones subcorticales del hemisferio derecho.

A 72-year-old right-handed patient with a hereditary coagulation impairment had a sudden disorder of consciousness with left hemiplegia and immediate collapse. CT showed a right capsulo-putaminal hematoma of about 5 cm and important mass effect. When this lesions developed, the patient had just arrived to Barcelona from Alicante . During three weeks, the outstanding and more dramatic symptom was a delirium of geographical localization, in which the patient appeared convinced that every night he was transferred, along with his attending physicians and his partner in the hospital room, from one to another of the many Hospitals de la Sta. Creu i Sant Pau (or within the same hospital) in many different cities between Alicante and Barcelona. He also gave aberrant information about his room. When he was transferred to his home, he was unable to identify it for two weeks or to locate it in any definite place. He also had a nictemeral chronological disorientation. The accompanying syndrome consisted of proportional left hemiplegia, left hemihypoesthesia, hemianopsia, and, in the neuropsychological area, mysoplegia, anosodiaphoria, impairment of visual memory, mild hemineglect, eyelid motor impersistence and constructive apraxia. Emphasis is made on the deep subcortical and to certain extent anterior topography of the causative lesion of this peculiar neuropsychological syndrome, although the possible mechanisms of remote involvement of other cerebral areas are suggested. The crucial role of the right hemisphere lesions, cortical and primarily noncortical, in the development of many variants of spatial disorders is stressed.

Thalamic hematomas: neuropsychological aspects. Report of 11 cases and review of literature.

We have recently observed 11 cases of thalamic hematomas. 5 of them (3 left and 2 right) were submitted to a detailed neuropsychological examination. All hematomas were mainly limited to the thalamus and the internal capsula without significant invasion or compression of surrounding structures. The level of consciousness was usually good. 4 of the 8 patients with left-sided hematomas showed dysphasia and the 3 patients submitted to a detailed neuropsychological examination suffered also severe and persistent mnesic disturbances (verbal and non-verbal). On the other hand, the two patients with right thalamic hematomas presented on neuropsychological testing non-verbal mnesic disturbances and features indistinguishable from right parietotemporal cortical lesions. Vital outcome was highly favourable since no patient died. Functional recovery was also rather satisfactory but formal neuropsychological testing of memory, language and right cortical functions showed significant persistent deficits at time of follow-up in most cases examined. Relevant literature is reviewed and possible pathogenetic mechanisms are discussed. Among various hypothesis concerning neuropsychological impairments, dysfunction of a specific alerting system appears the most seducing possibility but does not explain all observed deficits.