Acute subdural hematoma associated with disruption of tumor vessels due to rapid growth of falx meningioma: A case report and literature review.

Background: Meningiomas associated with acute subdural hematoma (ASDH) are rare. The rapid growth of meningiomas has been shown to be one of the mechanisms underlying bleeding. We report the first case of ASDH during an imaging follow-up for the rapid growth of a falx meningioma. Case Description: A 77-year-old woman was diagnosed with an incidental tumor along the right falx cerebri 3 years before bleeding. The follow-up magnetic resonance imaging (MRI) after 3 years showed that the tumor volume had rapidly increased from 4.31 cm3 to 22.27 cm3. The blood vessels around the tumor were stretched. The patient was scheduled to undergo tumor removal surgery. However, the patient experienced a sudden onset of disturbance of consciousness and was transferred to our hospital. On arrival, her Glasgow Coma Scale (GCS) score was 6 (E1V1M4) and right hemiplegia was observed. The patient had no history of traumatic events. Computed tomography (CT) showed left hemispheric and interhemispheric ASDH. Digital subtraction angiography revealed neither tumor staining nor abnormal vessels. Gross total tumor removal and hematoma evacuation were performed. There were no obvious active intraoperative bleeding points. The pathologic diagnosis was meningioma, the World Health Organization Grade I. Postoperative course revealed a GCS score of 10 (E4V1M5) and she was transferred to a rehabilitation hospital. Conclusion: The disruption of tumor vessels due to the rapid growth of meningiomas may be a cause of bleeding. Incidental falx meningiomas with stretched tumor vessels due to rapid growth could indicate the need for early surgery.

Acute cholecystitis in patients with stroke.

BACKGROUND: Although acute cholecystitis after stroke is rare, an immediate diagnosis and treatment is required. MATERIAL AND METHODS: In the past five years, we observed six patients with acute cholecystitis during the initial hospitalization for stroke. RESULTS: Three patients had cardiac embolism, two had subarachnoid hemorrhage, and one had intra-cerebral hemorrhage. Four had calculous cholecystitis and two had acalculous cholecystitis. One of the patients with acalculous cholecystitis had hemorrhagic cholecystitis. The most commonly presented symptom was fever (50%), whereas only one patient (17%) had abdominal pain. Three patients (50%) were completely asymptomatic. CONCLUSIONS: Acute cholecystitis and stroke are closely associated, and anti-thromboembolic drugs may cause hemorrhagic cholecystitis. Stroke patients tend to have atherosclerotic risk factors resulting in ischemic injury of the gallbladder. Furthermore, severe hemiparesis, a fasting state, dehydration, or bacteremia, which are occasionally exhibited by stroke patients, are known risk factors for acalculous cholecystitis. Stroke patients, especially patients with aphasia and consciousness disturbance, require immediate abdominal examination, if acute cholecystitis is suspected.

[A Case of Segmental Arterial Mediolysis:Subarachnoid Hemorrhage Followed by Abdominal Bleeding].

We describe a case involving subarachnoid and intraperitoneal hemorrhage due to segmental arterial mediolysis(SAM). A 77-year-old female patient with sudden subarachnoid hemorrhage was immediately transferred to our institution. The hemorrhage was classified as grade 2 according to the World Federation of Neurosurgical Societies system. The patient was a non-smoker and did not drink alcohol regularly. A right internal carotid aneurysm was detected using CT angiography and was clipped during frontotemporal craniotomy. Bleeding was observed from the anterior wall of the internal carotid artery, and the tear was clipped. The patient had an uneventful postoperative course until sudden cardiopulmonary arrest eight days after craniotomy. She died of massive intraperitoneal hemorrhage. Autopsy revealed that the hemorrhage was due to dissection of the celiac artery. Tunica media denaturation was observed not only in the celiac artery, but also in the splenic and internal carotid arteries, which exhibited ruptured aneurysms, and the patient was diagnosed with segmental arterial mediolysis(SAM). SAM is an arterial degenerative disease affecting the medial layer of the arterial and dissecting walls. Multiple lesions are sometimes found. Radiographic imaging findings of SAM are similar to those of dissecting aneurysms, which are characterized by a single continuous dissection of the medial layer. As observed in this case, abdominal bleeding caused by SAM can occur after intracranial bleeding. When surgeons encounter unusual intracranial dissecting aneurysms, SAM should be considered as a differential diagnosis.