Trends in prior antithrombotic medication and risk of in-hospital mortality after spontaneous intracerebral hemorrhage: the J-ICH registry.

Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes, but the effects of direct oral anticoagulants (DOACs) remain unclear. This study aimed to clarify trends in prior antithrombotic use and to assess the associations between prior use of antithrombotics and in-hospital mortality using a multicenter prospective registry in Japan. In total, 1085 patients were analyzed. Prior antithrombotic medication included antiplatelets in 14.2%, oral anticoagulants in 8.1%, and both in 1.8%. Prior warfarin use was significantly associated with in-hospital mortality (odds ratio [OR] 5.50, 95% confidence interval [CI] 1.30-23.26, P < 0.05) compared to no prior antithrombotic use. No such association was evident between prior DOAC use and no prior antithrombotic use (OR 1.34, 95% CI 0.44-4.05, P = 0.606). Concomitant use of antiplatelets and warfarin further increased the in-hospital mortality rate (37.5%) compared to warfarin alone (17.2%), but no such association was found for antiplatelets plus DOACs (8.3%) compared to DOACs alone (11.9%). Prior use of warfarin remains an independent risk factor for in-hospital mortality after SICH in the era of DOACs. Further strategies are warranted to reduce SICH among patients receiving oral anticoagulants and to prevent serious outcomes.

Unusually elongated superior thyroid cornu associated with recurrent cerebral embolisms.

The superior thyroid cornu (STC) is a normal anatomic structure that forms part of the thyroid cartilage. Here, we report a patient with unusually elongated and ossified STC that might result in recurrent cerebral embolisms. During a second endovascular therapy for recurrent middle cerebral artery embolism, a segment with an irregular filling defect was noted in the internal carotid artery (ICA), at the C1 level. This defect was unnoticed during the initial endovascular procedure. Three-dimensional computed tomography angiography performed after the second endovascular procedure revealed an ICA segment located between the STC and C1 with a tortuous course and irregular wall of the ICA. Therefore, we assumed that STC compression of the ICA could have resulted in thrombus formation at the site and consequent cerebral embolism. The STC should be considered a structure responsible for cerebral embolism. Careful evaluation of the entire ICA course is imperative prior to performing an endovascular thrombectomy for acute embolic occlusion of the middle cerebral artery.

Cholesterol Crystals in the Retrieved Thrombus by Mechanical Thrombectomy for Cerebral Embolism: A Case Report and Literature Review.

There are only a few case reports in which cholesterol crystals were found in the thrombus retrieved by mechanical thrombectomy for cryptogenic stroke, leading to a definitive diagnosis. We herein report a case of aortogenic embolic stroke diagnosed by the presence of rich cholesterol crystals in the retrieved thrombus and review the previously reported cases. A woman in her 80s was transferred as an emergency due to consciousness disturbance, right conjugate deviation, and severe left hemiparesis. Magnetic resonance imaging showed occlusion of the right middle cerebral artery (MCA) and acute infarction in the territory. The MCA was recanalized by thrombectomy using an aspiration catheter and stent retriever, and the symptoms improved. Although the physiological examination did not detect the embolic source during hospitalization, pathological examination of the thrombus revealed atheroma with numerous cholesterol crystal clefts and intermixing of fibrin. Contrast-enhanced computed tomography performed based on the pathological results showed atheromatous lesions in the aortic arch as the embolic source. As a subsequent treatment, medications of a strong statin and an antiplatelet agent were continued, and the patient had no recurrence. The finding that the retrieved thrombus is a simple atheroma containing cholesterol crystals with poor hemocytes suggests embolism due to plaque rupture. Pathological examination of the thrombus obtained by thrombectomy is one of the useful diagnostic approaches for stroke etiology and the determination of its treatment.

Malignant Subdural Hematoma Associated with High-Grade Meningioma.

A 70-year-old man, who had previously undergone surgical resection of left parasagittal meningioma involving the middle third of the superior sagittal sinus (SSS) two times, presented with recurrence of the tumor. We performed removal of the tumor combined with SSS resection as Simpson grade II. After tumor removal, since a left dominant bilateral chronic subdural hematoma (CSDH) appeared, it was treated by burr hole surgery. However, because the CSDH rapidly and repeatedly recurred and eventually changed to acute subdural hematoma, elimination of the hematoma with craniotomy was accomplished. The patient unfortunately died of worsening of general condition despite aggressive treatment. Histopathology of brain autopsy showed invasion of anaplastic meningioma cells spreading to the whole outer membrane of the subdural hematoma. Subdural hematoma is less commonly associated with meningioma. Our case indicates the possibility that subdural hematoma associated with meningioma is formed by a different mechanism from those reported previously.

[Case of intracerebral hemorrhage due to amphetamine abuse].

We report a case of intracranial hemorrhage due to amphetamine abuse in a young adult. A 34-year-old, confused woman was transferred to our emergency room with right hemiparesis and aphasia. CT at admission demonstrated intracerebral hemorrhage in the left frontal and parietal lobes, associated with subarachnoid hemorrhage. MRA shortly after admission revealed no intracerebral vascular anomaly. Cerebral angiography following admission showed irregularity of the vessel wall in the left anterior and middle cerebral arteries. Later, a toxicology screen test for urine was found to be positive for amphetamines and metamphetamines. These findings suggested that cerebral vasculitis and hypertensive surge induced by amphetamines caused intracranial and subarachnoid hemorrhage. Amphetamine abuse should always be considered as a cause of intracranial hemorrhage in young adults.

Clinical experience with a dual switch valve (Miethke) for the management of adult hydrocephalus.

The dual switch valve (DSV), which switches between two parallel valve chambers depending on the patient posture, was evaluated in 101 consecutive adult patients with hydrocephalus who required shunt surgery. The opening pressure was 5 or 10 cmH(2)O for the supine position and 30 or 40 cmH(2)O for the upright position depending on the sitting height. The results clearly showed that the DSV can regulate the intraventricular pressure (IVP) to 5 to 10 cmH(2)O in the supine and almost zero in the upright position, independently of posture. Ninety-four of the 101 patients received the DSV and 86 patients showed some clinical improvement. However, three patients required irrigation of subdural hematoma and six were thought to suffer underdrainage (4 probable and 2 possible). Such underdrainage probably resulted from the relatively high opening pressure in the supine position of 10 cmH(2)O and the bedridden state of these patients. This problem may be solved by the DSV with the 5 cmH(2)O setting in the supine position. The DSV can maintain physiological IVP in hydrocephalic patients independently of posture and provides generally satisfactory clinical outcome, but cannot prevent all inadequate drainage-related problems.

[Papillary glioneuronal tumor with highly degenerative pseudopapillary structure accompanied by specific abortive glial cells: a case report].

Recently, unusual examples of tumors of the mixed glioneuronal type have been reported, including the papillary glioneuronal tumor (PGNT). A 23-year-old woman with a 2-3 months history of headache and insomnia presented with a tumor. Neuroimaging showed a right temporal lobe cystic tumor with a mural nodule enhanced by contrast medium. She underwent gross total resection of the tumor. The tumor was histologically marked by a mixture of glial and neural components. A pseudopapillary component was comprised of highly hyalinized vessels surrounded by a single layer of thin spindle cells stained for glial fibrillary acidic protein. Specific abortive glial cells stained for vimentin/S-100 protein accompanied pseudopapillary structure. Intervening neural areas were occupied by neural cells of varying size, including neurocyte-like cell and ganglionic cells. Ganglionic cells demonstrated abnormal cluster, lack of normal polarity and epiperikaryal immunoreactivity for synaptophysin staining suggesting neural neoplastic nature. No mitotic activity or necrosis was noted. A MIB-1 labeling index was 1.8%. Our patient remains free of disease 33 months after surgical treatment.

A case of giant expanding cephalhematoma: does the administration of blood coagulation factor XIII reverse symptoms?

BACKGROUND: The mechanism of continuous massive hemorrhage into the subperiosteal space in children without coagulation defects is unknown. We report a case of giant expanding cephalhematoma reversed by the administration of blood coagulation factor XIII concentrate. METHOD: The patient was an 8-year-old boy with a history of minor head trauma who developed a giant expanding cephalhematoma with intraorbital extension. The laboratory data showed severe anemia, but a routine blood coagulation test showed no abnormalities except for a low factor XIII level. RESULT: The administration of factor XIII concentrate completely reversed the symptoms in 2 weeks. CONCLUSION: We speculate that one of the possible mechanisms of cephalhematoma expansion without blood coagulation defects might be acquired factor XIII deficiency from severe hemorrhage in a hematoma.

Distinctive pleomorphic xanthoastrocytoma-like tumor with exclusive abortive or aberrant neuronal differentiation and repeated recurrence--case report.

A 9-year-old girl with a 1-month history of generalized seizure presented with a distinctive tumor resembling pleomorphic xanthoastrocytoma. Neuroimagings showed a right frontotemporal lobe tumor. Histological examination of the resected tumor indicated similarity to pleomorphic xanthoastrocytoma without staining for glial fibrillary acidic protein. The neuronal immunoreactivity and ultrastructural features showed two discrepancies: Numerous cytoplasmic processes containing rich structures suspected to be microtubules and neurofilaments were present, but neurofilament protein 70 kd/200 kd staining was negative; and many tumor cells showed synaptophysin staining, but no synaptic structures or vesicles were observed. She suffered recurrence 14 months after the first surgery. The specimen from the second operation revealed no malignant transformation with a MIB-1 labeling index of 1.9%. Only 2 months after the second operation, there was a second recurrence. Irradiation was administered (60.2 Gy). Twenty-eight months later, no tumor progression was seen. This tumor was an unconventional type with "abortive" or "aberrant" neuronal differentiation or an extreme variant of pleomorphic xanthoastrocytoma.