Comparison of long-term clinical outcome after endovascular versus neurosurgical treatment of ruptured intracranial anterior circulation aneurysms: A single-centre experience.

Introduction: In patients with anterior circulation aneurysmal Subarachnoid Haemorrhage (aSAH), endovascular coiling is currently practiced more frequently than neurosurgical clipping. However, despite multiple previous studies, it is still uncertain whether coiling is favourable in terms of long-term clinical outcome. Research question: What is the effect of clipping versus coiling on long-term functional outcome of patients with an aSAH? Material and methods: All anterior circulation aSAH patients (2012-2015) treated with clipping or coiling in two hospitals in the Netherlands were studied up to five years after treatment. Functional outcome, survival, retreatment- and complication rate were measured. Survival analysis was performed in both groups. A multivariable regression model with covariate adjustment was performed to investigate the likelihood of unfavourable outcome (modified Rankin Scale >2). Results: Out of 204 patients, 75 patients were clipped (37%) and 129 received coiling (63%). Coiling had a higher retreatment rate compared to clipping (7.8% vs. 0.0%). Unfavourable outcome at six, 12, 24 and 60 months after treatment was higher for patients after clipping compared to coiling, but was not significant after correcting for clinical severity as represented by the WFNS grade. In 60 months, no difference in survival was found between clipping and coiling. Discussion and conclusion: No differences between clipping and coiling in survival and long-term functional outcome have been found in this study. More research with prospective design and large cohorts is needed to identify possible differences between the two treatments.

Atypical Haemorrhagic Presentation of Neuro-Retinitis and Serous Retinal Detachment Secondary to Cat-Scratch Disease.

Cat-scratch disease (CSD) is a self-limited disease caused by Bartonella henselae, a fastidious gram-negative intracellular bacillus bacterium. Neuroretinitis, a form of optic neuropathy characterised clinically by optic disc swelling and a macular star, is an uncommon manifestation of CSD occurring in approximately 1-2% of cases. We report a case of a 14-year-old female who presented to the emergency department with a chief complaint of acute painless vision loss described as a large black spot in the centre of her right eye vision 2 weeks after being scratched by cats. Fundus examination revealed Frisen grade 5 disc oedema with an atypically diffuse disc and peripapillary haemorrhages with associated subretinal fluid and a macular star in the right eye. Optical coherence tomography (OCT) of the macula and retinal nerve fibre layer showed subretinal fluid involving the fovea, a serous retinal detachment of the nasal macula, and significant optic disc oedema in the right eye. The patient was admitted and treated with doxycycline, rifampin, and prednisone taper. After completing the treatment course, the patient's vision improved, fundus examination showed significantly improved disc oedema and haemorrhages, and OCT demonstrated resolution of the subretinal fluid in the right eye.

The Value of Ultrasonography in Detecting Gastric Haemorrhage.

Gastric intramural haematoma is a very infrequent condition. It can occur due to clotted gastric haemorrhage as a result of peptic ulcer disease, or following trauma, oral anticoagulant therapy and bleeding disorders. It is usually suspected with the symptoms of gastrointestinal haemorrhage such as haematemesis, melena and haematochezia, and detected by endoscopy. In rare cases, the patient is asymptomatic or presents with non-related symptoms and can diagnosed by computerised tomography. In this case, we report the detection of a gastric intramural haematoma during abdominal ultrasonography in a hypotensive patient who was admitted to the emergency department after sliding and falling from a height. LEARNING POINTS: It is crucial to remember that FAST ultrasound is important in examining five areas, and epigastric bleeding appears hypoechoic, making ultrasound evaluation essential.

The Great Mimicker: A Unique Case of Diffuse Subarachnoid Haemorrhage Simulating Acute Myocardial Infarction.

Subarachnoid haemorrhage (SAH) is a rare yet consequential medical emergency that may mimic an acute myocardial infarction (MI). SAH causes enhanced sympathetic activity, culminating in the development of neurogenic stunned myocardium (NSM), which presents as ST-segment deviations, prolonged QT intervals, T-wave inversions or Q-waves. Reperfusion therapy is contraindicated for SAH because of an increased risk of bleeding and death. Therefore, a prompt diagnosis is crucial. Here, we report a unique case of massive SAH presenting as diffuse ST-segment deviation simulating an acute MI. Our patient was brought to the emergency department after a cardiac arrest and died on day 2 of admission. LEARNING POINTS: Subarachnoid haemorrhage (SAH) can present with EKG changes and significant rise in troponin, mimicking acute coronary syndrome.SAH should be included in the differential diagnosis for patients presenting with neurological symptoms, ST-segment deviations or prolonged QT intervals.Misdiagnosis of SAH as acute coronary syndrome can lead to inappropriate use of anticoagulants or delays in necessary neurological interventions.

Transient Cerebral Circulation Arrest in SAH.

How to cite this article: Salhotra R. Transient Cerebral Circulation Arrest in SAH. Indian J Crit Care Med 2024;28(6):620-621.

Managing Placenta Accreta and Massive Hemorrhage: A Case Report on Anesthetic and Surgical Interventions.

Obstetric haemorrhage is a leading cause of maternal morbidity and mortality and is a common reason for intensive care unit (ICU) admission in the postpartum. Primary postpartum obstetric haemorrhage is associated with four main causes: tone, thrombin, trauma, and tissue. Regarding the last one, placenta accreta is an abnormal invasion of the placenta into the myometrium. Early diagnosis of placenta accreta allows for better perioperative management; however, it is sometimes only identified during caesarean delivery when the placenta cannot be removed. We report a case of a 37-year-old woman with a history of caesarean section due to placenta previa, who was admitted at 36 weeks and 1 day for an urgent caesarean section (c-section) due to cord presentation. A subarachnoid block (SAB) was used for anaesthesia. It was chosen over general anaesthesia because it allows the patient to experience the birth of her children, enhances pain control, and avoids complications associated with general anaesthesia. Besides our centre has expertise in neuraxial anaesthesia. During the procedure, placental accretism and massive haemorrhage occurred, and a life-saving abdominal hysterectomy was needed. The patient experienced hypotension, partially responsive to volume replacement and vasopressors, leading to norepinephrine infusion and conversion to general anaesthesia. The surgery lasted 2.5 hours with a blood loss of 3500 ml. The patient was extubated without complications and transferred to the post anaesthesia care unit (PACU). Risk factors for placenta accreta spectrum (PAS) include previous surgery and placenta previa with a prior c-section. Antenatal diagnosis is crucial, and women with risk factors should undergo imaging at experienced centres. Delivery centres must have protocols for unexpected PAS and major obstetric haemorrhage. Both general and neuraxial anaesthesia can be suitable for managing PAS, and caesarean hysterectomy is often required to control haemorrhage. Postoperatively, adequate monitoring and care is essential. PAS management should involve excellent communication between a multidisciplinary team in specialised centres.

Acute impact of posthemorrhagic ventricular dilatation on cerebral oxygenation in preterm infants with intraventricular haemorrhage.

AIM: To assess the effect of ventricular decompression on cerebral oxygenation in preterm neonates with intraventricular haemorrhage (IVH) and posthemorrhagic ventricular dilatation (PHVD) using near-infrared spectroscopy (NIRS). METHODS: Fifty-three preterm neonates born <34 weeks' gestation between 2013 and 2023 with IVH and subsequent PHVD were prospectively included. Regional cerebral oxygen saturation (rScO2) as well as fractional cerebral tissue oxygen extraction (cFTOE) were analysed 2 weeks before and after ventricular decompression. RESULTS: Ventricular decompression was performed at 18 ± 6 days of life. Patients with repeated lumbar punctures prior to ventricular drainage showed consistently higher rScO2 and lower cFTOE levels 2 weeks before and after intervention compared to those without. Patients who underwent direct ventricular drainage showed an immediate increase in rScO2 levels on the day of the procedure. In patients who underwent prior lumbar punctures, ventricular decompression did not yield additional acute effects on cerebral oxygenation. CONCLUSION: Patients who underwent repeated lumbar punctures preceding ventricular drainage consistently maintained higher rScO2 and lower cFTOE levels during the study period. In these patients, ventricular decompression did not further affect cerebral oxygenation, as they already demonstrated improved cerebral hemodynamics, whereas an immediate improvement was observed in those without prior lumbar punctures.

Development and Validation of a Predictive Model for Intracranial Haemorrhage in Patients on Direct Oral Anticoagulants.

BACKGROUND: Intracranial haemorrhage (ICH) poses a significant threat to patients on Direct Oral Anticoagulants (DOACs), with existing risk scores inadequately predicting ICH risk in these patients. We aim to develop and validate a predictive model for ICH risk in DOAC-treated patients. METHODS: 24,794 patients treated with a DOAC were identified in a province-wide electronic medical and health data platform in Tianjin, China. The cohort was randomly split into a 4:1 ratio for model development and validation. We utilized forward stepwise selection, Least Absolute Shrinkage and Selection Operator (LASSO), and eXtreme Gradient Boosting (XGBoost) to select predictors. Model performance was compared using the area under the curve (AUC) and net reclassification index (NRI). The optimal model was stratified and compared with the DOAC model. RESULTS: The median age is 68.0 years, and 50.4% of participants are male. The XGBoost model, incorporating six independent factors (history of hemorrhagic stroke, peripheral artery disease, venous thromboembolism, hypertension, age, low-density lipoprotein cholesterol levels), demonstrated superior performance in the development dateset. It showed moderate discrimination (AUC: 0.68, 95% CI: 0.64-0.73), outperforming existing DOAC scores (ΔAUC = 0.063, P = 0.003; NRI = 0.374, P < 0.001). Risk categories significantly stratified ICH risk (low risk: 0.26%, moderate risk: 0.74%, high risk: 5.51%). Finally, the model demonstrated consistent predictive performance in the internal validation. CONCLUSION: In a real-world Chinese population using DOAC therapy, this study presents a reliable predictive model for ICH risk. The XGBoost model, integrating six key risk factors, offers a valuable tool for individualized risk assessment in the context of oral anticoagulation therapy.

Impaired microglial glycolysis promotes inflammatory responses after intracerebral haemorrhage via HK2-dependent mitochondrial dysfunction.

INTRODUCTION: Intracerebral haemorrhage (ICH) is a devastating disease that leads to severe neurological deficits. Microglia are the first line of defence in the brain and play a crucial role in neurological recovery after ICH, whose activities are primarily driven by glucose metabolism. However, little is known regarding the status of glucose metabolism in microglia and its interactions with inflammatory responses after ICH. OBJECTIVES: This study investigated microglial glycolysis and its mechanistic effects on microglial inflammation after ICH. METHODS: We explored the status of glucose metabolism in the ipsilateral region and in fluorescence-activated-cell-sorting-isolated (FACS-isolated) microglia via 2-deoxy-[18F]fluoro-D-glucose positron emission tomography (FDG-PET) analyses and gamma emission, respectively. Energy-related targeted metabolomics, along with 13C-glucose isotope tracing, was utilised to analyse glycolytic products in microglia. Mitochondrial membrane potential and mitochondrial reactive oxygen species (MitoROS) accumulation was assessed by flow cytometry. Behavioural, western blotting, gene regulation, and enzymatic activity analyses were conducted with a focus on microglia. RESULTS: Neurological dysfunction was strongly correlated with decreased FDG-PET signals in the perihaematomal region, where microglial uptake of FDG was reduced. The decreased quantity of glucose-6-phosphate (G-6-P) in microglia was attributed to the downregulation of glucose transporter 1 (GLUT1) and hexokinase 2 (HK2). Enhanced inflammatory responses were driven by HK2 suppression via decreased mitochondrial membrane potential, which could be rescued by MitoROS scavengers. HK inhibitors aggravated neurological injury by suppressing FDG uptake and enhancing microglial inflammation in ICH mice. CONCLUSION: These findings indicate an unexpected metabolic status in pro-inflammatory microglia after ICH, consisting of glycolysis impairment caused by the downregulation of GLUT1 and HK2. Additionally, HK2 suppression promotes inflammatory responses by disrupting mitochondrial function, providing insight into the mechanisms by which inflammation may be facilitated after ICH and indicating that metabolic enzymes as potential targets for ICH treatment.

Rare Instances of Culture-Positive Dengue-Related Panophthalmitis: A Case Series.

Panophthalmitis is an exceptionally rare but severe ocular complication of dengue fever, which is currently a significant health concern in parts of India. It is a purulent inflammation encompassing all structures of the globe (choroid, retina, vitreous fluid, aqueous fluid, cornea, sclera, and conjunctiva) along with surrounding orbital and periorbital structures. This case series highlights the occurrence of panophthalmitis in three patients diagnosed with dengue, who were aged 35, 50, and 75 years. Despite aggressive medical management, including intravenous antibiotics, the patients were ultimately scheduled for evisceration surgery due to the extreme severity of the condition. Healthcare providers must be aware of the potential ocular complications in dengue cases and diagnose them promptly. While ocular involvement in dengue is rare, this case series emphasizes the importance of recognizing ocular manifestations in dengue patients, as early diagnosis and prompt intervention can prevent severe complications.

Evaluation of variants in the ENTPD1 and ENTPD2 genes in athletic horses with exercise-induced pulmonary haemorrhage.

BACKGROUND: Exercise-induced pulmonary haemorrhage (EIPH) in athletic horses is characterized by the presence of blood from the lungs in the tracheobronchial tree after intense exercise. Despite the high prevalence of EIPH in horses, the primary aetiology remains unknown. Variants in the genes encoding CD39 and CD39L1 (ENTPD1 and ENTPD2, respectively) were previously reported as potential genetic causes involved in EIPH pathogenesis. However, the role of these variants in haemostatic functions is unknown. RESULTS: To investigate the association between EIPH and missense variants in the ENTPD1 (rs1152296272, rs68621348, and rs68621347) and ENTPD2 genes (rs782872967), 76 Thoroughbred horses diagnosed with EIPH and 56 without clinical signs of EIPH (control group) by trachea-bronchial endoscopy were genotyped. The rs1152296272 and rs68621347 variants were linked, which explained why the same results were found in all horses. Approximately 96% and 95% of the EIPH and control horses, respectively, carried at least one nonreference allele for these variants. In contrast, 100% of the control horses and 96% of the EIPH horses were homozygous for the reference allele for the rs68621348 variant. In the EIPH group, 1.5% of the horses were homozygotes and 24% were heterozygous for the nonreference allele of the rs782872967 variant. In the control group, the nonreference allele of this variant was observed only in heterozygotes (16%). There were no significant differences between groups for any of the variants. CONCLUSIONS: The variants previously described in the genes encoding the CD39 and CD39L1 enzymes were highly present in the studied population. However, no association was found between the occurrence of EIPH and the presence of these variants in Thoroughbred horses in this study.

Prevalence of ruptured small and very small aneurysms: a retrospective single-centre study.

AIM OF STUDY: To retrospectively assess the occurrence and consequences of subarachnoid haemorrhages (SAH) caused by ruptured intracranial aneurysms (RIA), particularly focusing on the treatment outcomes of small aneurysms treated with either endovascular embolisation or surgical intervention. MATERIAL AND METHODS: We retrospectively analysed data from 408 patients (144 males and 264 females) who were hospitalised between 2013 and 2022 at the Department of Neurosurgery and Neurology in University Hospital Nr 2 in Bydgoszcz, Poland. Clinical conditions at admission, assessed using the Glasgow Coma Scale, Hunt-Hess scale (H-H), modified Rankin scale (mRS), as well as age and sex, were recorded. Additionally, aneurysm data including size, localisation, and the method and outcome of endovascular or surgical treatment were examined. RESULTS: Among the 408 patients hospitalised due to SAH, the most common localisation of the 375 RIAs was the anterior communicating artery (AcomA) complex (111 cases, 29.6%), followed by the medial cerebral artery (MCA) (95 cases, 25.3%), internal carotid artery (ICA) (94 cases, 25%), and the vertebrobasilar complex (consisting of the basilar artery (BA) - 25 cases, vertebral artery (VA) - 13 cases, anterior inferior cerebellar artery (AICA) - one case, and posterior inferior cerebellar artery (PICA) - four cases), which accounted for 43 SAH cases (11.46%). In 33 cases, neither RIA nor a haemorrhage source was identified, or arteriography showed no cerebral arteries contrast flow. Among the examined group of 375 RIAs, 45 (12%) were microaneurysms (≤ 3 mm), 35 (9%) were small aneurysms (3 ≤ 5 mm), 89 (24%) were medium-sized (5 ≤ 7 mm), and 151 (40%) were large aneurysms (> 7 mm), serving as the source of SAH. A better outcome was significantly associated with lower initial H-H grade (p < 0.001), higher GCS (p < 0.001), lower mRS at admission (p < 0.001), younger age (p < 0.001), smaller size (≤ 3 mm) (p < 0.001), and endovascular treatment (p < 0.001). CONCLUSIONS: In this series, over 21% of patients suffered from SAH resulting from ruptured small aneurysms (≤ 5 mm), with 12% specifically attributed to ruptured very small aneurysms (≤ 3 mm), despite large aneurysms (> 7 mm) being the most prevalent source of bleeding in 40% of cases. A worse prognosis was primarily associated with the severity of SAH, reflected in poorer clinical status at admission and older age. Endovascular embolisation was found to be effective and associated with better outcomes compared to surgical treatment.

Additional Relevant Intracranial Findings in Persons Screened with MR for Intracranial Aneurysms.

BACKGROUND: Radiological screening for intracranial aneurysms (IAs) may identify other relevant intracranial findings. We investigated their prevalence on MR in persons screened for IAs. METHODS: We included all persons who were screened for the presence of IAs with brain MRI/MRA between 1996 and 2022 because of a family history of aneurysmal subarachnoid haemorrhage (aSAH) or autosomal dominant polycystic kidney disease (ADPKD). We reviewed radiology reports of initial and repeated brain MR to identify additional intracranial findings that needed follow-up or treatment, or carried a risk of becoming symptomatic. RESULTS: We included 766 persons (positive family history of aSAH: n = 681; ADPKD: n = 85) who had 1446 MRI/MRAs. At initial screening, 49 additional relevant intracranial findings were reported in 47 persons (6.1%, 95% CI 4.7-8.1%). Of all included persons, 338 (44%) underwent one (n = 154) or more (n = 184) follow-up screenings (total MRI/MRAs at follow-up: n = 680). In 15/338 persons (4.4%, 95% CI 2.7-7.2%), 16 new additional relevant findings were reported at a median follow-up duration of 10 years (IQR 5-12). CONCLUSIONS: Persons who are counselled for screening for IAs should be informed that there is a six percent chance of identifying an additional finding that requires follow-up or treatment, or may become symptomatic. Additionally, after 10-year follow-up screening there is a four percent chance of identifying a new additional relevant finding. The impact of such findings on quality of life needs further study.

Effects of tranexamic acid preconditioning on the incidence of postpartum haemorrhage in vaginal deliveries with identified risk factors in China: a prospective, randomized, open-label, blinded endpoint trial.

OBJECTIVE: This study aimed to evaluate the effects of tranexamic acid (TXA) in preventing postpartum haemorrhage (PPH) among women with identified risk factors for PPH undergoing vaginal delivery in China. METHODS: This prospective, randomized, open-label, blinded endpoint (PROBE) trial enrolled 2258 women with one or more risk factors for PPH who underwent vaginal delivery. Participants were randomly assigned in a 1:1 ratio to receive an intravascular infusion of 1 g TXA or a placebo immediately after the delivery of the infant. The primary outcome assessed was the incidence of PPH, defined as blood loss ≥500 mL within 24 h after delivery, while severe PPH was considered as a secondary outcome and defined by total blood loss ≥1000 mL within 24 h. RESULTS: 2245 individuals (99.4%) could be followed up to their primary outcome. PPH occurred in 186 of 1128 women in the TXA group and in 215 of 1117 women in the placebo group (16.5% vs. 19.2%; RR, 0.86; 95% CI, 0.72 to 1.02; p = 0.088). Regarding secondary outcomes related to efficacy, women in the TXA group had a significant lower rate of severe PPH than those in the placebo group (2.7% vs. 5.6%; RR, 0.49; 95% CI, 0.32 to 0.74; p = 0.001; adjusted p = 0.002). Similarly, there was a significant reduction in the use of additional uterotonic agents (7.8% vs. 15.6%; RR, 0.50; 95% CI, 0.39 to 0.63; p < 0.001; adjusted p = 0.001). No occurrence of thromboembolic events and maternal deaths were reported in both groups within 30 days after delivery. CONCLUSIONS: In total population with risk factors for PPH, the administration of TXA following vaginal delivery did not result in a statistically significant reduction in the incidence of PPH compared to placebo; however, it was associated with a significantly lower incidence of severe PPH.

Prophylactic administration of TXA did not yield a statistically significant reduction in the incidence of PPH among women with risk factors in vaginal deliveries.Prophylactic use of TXA may help to reduce the incidence of severe PPH.

Incidence and outcomes of delayed intracranial hemorrhage: a population-based cohort study.

Head trauma is a common reason for emergency department (ED) visits. Delayed intracranial hemorrhage (ICH) in patients with minor head trauma is a major concern, but controversies exist regarding the incidence of delayed ICH and discharge planning at the ED. This study aimed to determine the incidence of delayed ICH in adults who developed ICH after a negative initial brain computed tomography (CT) at the ED and investigate the clinical outcomes for delayed ICH. This nationwide population cohort study used data from the National Health Insurance Service of Korea from 2013 to 2019. Adult patients who presented to an ED due to trauma and were discharged after a negative brain CT examination were selected. The main outcomes were the incidence of ICH within 14 days after a negative brain CT at initial ED visit and the clinical outcomes of patients with and without delayed ICH. The study patients were followed up to 1 year after the initial ED discharge. Cox proportional hazard regression analysis was used to estimate the hazard ratio for all-cause 1-year mortality of delayed ICH. During the 7-year study period, we identified 626,695 adult patients aged 20 years or older who underwent brain CT at the ED due to minor head trauma, and 2666 (0.4%) were diagnosed with delayed ICH within 14 days after the first visit. Approximately two-thirds of patients (64.3%) were diagnosed with delayed ICH within 3 days, and 84.5% were diagnosed within 7 days. Among the patients with delayed ICH, 71 (2.7%) underwent neurosurgical intervention. After adjustment for age, sex, Charlson Comorbidity Index, and insurance type, delayed ICH (adjusted hazard ratio, 2.15; 95% confidence interval, 1.86-2.48; p < 0.001) was significantly associated with 1-year mortality. The incidence of delayed ICH was 0.4% in the general population, with the majority diagnosed within 7 days. These findings suggest that patient discharge education for close observation for a week may be a feasible strategy for the general population.

The HSACAT Project: A Prospective Multicentre Observational Study of Spontaneous Subarachnoid Haemorrhage in Catalonia (Spain).

BACKGROUND: Incidence, clinical course, and fatality of spontaneous subarachnoid haemorrhage (SAH) are evolving, with prevalence of risk factors diminishing, implementation of early detection programs and strategies for priority aneurysm exclusion, technical refinement towards less invasive procedures, and improvements in neurocritical care. Modern epidemiological and prognostic data are lacking, especially in southern European and Mediterranean populations. METHODS: A prospective multicentre observational study on SAH was held in Catalonia, Northeast Spain, 2020-2022 (HSACat project). All public tertiary hospitals participated in a common registry. Primary endpoints were functional outcomes (modified Rankin Scale, mRS) and mortality at 12-months. Secondary aims included epidemiological data, flux of patients between referral and tertiary hospitals, diagnostic and treatment delays, and in-hospital complications. RESULTS: Of 550 SAH cases reported in Catalonia (2020-2022), 474 had a complete registry for analysis. Death rate was 20.6% during hospital admission and 26.9% at one year. Good functional outcome (mRS 0-2) was observed in 63.4%, 70.1% and 76.0% at 3, 6 and 12 months. Age at presentation was lower in men, smokers, and hypertensives (p<0.05). The female:male ratio was 3:2, except in non-aneurysmal group. Time from onset to tertiary-hospital admission was longer in rural than metropolitan zones (7.0h vs 4.7h, p<0.01). Aneurysm occlusion in the first 72h was achieved in 83.3%; mainly endovascularly (77.5%) than microsurgically (19.3%). CONCLUSION: Even when most patients received timely aneurysmal treatment, rates of case fatality are considerably high. Data provided by the HSAcat project may have public health repercussions and be used to guide prevention programs and screening strategies.

Acute calcitriol treatment mitigates vitamin D deficiency-associated mortality after intracerebral haemorrhage.

OBJECTIVE: Vitamin D deficiency (VDD) is emerging as a predictor of poor prognosis in various neurological conditions, where clinical outcomes are often worse in stroke patients with VDD. This study aimed to provide experimental evidence on whether and how pre-existing VDD would affect survival and neurofunctional outcomes in intracerebral haemorrhage (ICH), and to evaluate whether acute vitamin D (VD) supplementation would improve post-stroke outcomes. METHODS: Experimental ICH models were induced in mice with and without VDD. Haematoma size was measured using T2*-weighted MRI and haemoglobin concentration. Post-ICH mortality, neurofunctional outcomes and the extent of blood-brain barrier (BBB) leakage were assessed to identify their correlations with VD status. Therapeutic benefits of acute VD administration were also evaluated. RESULTS: Mice with VDD exhibited significantly higher acute mortality rates and more severe motor deficits than mice without VDD post-ICH. Marked haematoma expansion and increased Evans blue extravasation were observed in VDD mice, suggesting that VDD was associated outcomes with increased BBB disruption. Acute treatment with a loading dose of VD (calcitriol) significantly improved outcomes in VDD mice. CONCLUSION: This study provides novel insights into the pathophysiological mechanisms at play in ICH concomitant with VDD and a scientific rationale for acute treatment with VD.

Acute headache with a twist.

This case report follows the events of a 36-year-old woman who presented to a hospital five days post-partum with an acute severe headache and vomiting. Despite a normal initial computed tomography (CT) head scan, a CT venogram was done due to neurological deterioration and revealed hydrocephalus secondary to subarachnoid haemorrhage (SAH). We discuss the role of CT imaging in the diagnosis of SAH, the risks of current guidelines for lumbar puncture (LP) and describe other important differential diagnoses for headache in the postpartum patient.