The correlation between the evolution of bilateral basal ganglia hemorrhage using MR imaging and neurological damage recovery in an infant with methylmalonic aciduria.

PURPOSE: We report on one patient with methylmalonic acidemia (MMA) who presented with symmetrical hemorrhage of the caudate nucleus accompanied by severe ventricular dilatation, follow-up magnetic resonance imaging (MRI) findings from one year later, and the clinical manifestations, neuropsychological scores, genetic test results, urine and blood laboratory results and evolution of the disorder. MATERIALS AND METHODS: This study describes the recent and remote neuropathologic findings, reviews the literature, and discusses the possible pathogenetic mechanisms of these central nervous system lesions. RESULTS: Patients with MMA may have signs of basal ganglia hemorrhage during acute onset, and the hemorrhage may disappear after treatment. During the treatment, both laboratory examination indexes and neuropsychological scores improved. There was a correlation between the evolution of bilateral basal ganglia hemorrhage using MRI(magnetic resonance imaging) and neurological damage recovery in this infant with MMA. CONCLUSION: There was a correlation between the evolution of the bilateral basal ganglia hemorrhage using MR imaging and neurological damage recovery in an infant with MMA. We recommend performing conventional MR and diffusion-weighted imaging (DWI) examinations in patients with MMA who present with neurological symptoms.

Fluoxetine for motor recovery after acute intracerebral hemorrhage, the FMRICH trial.

OBJECTIVES: Acute intracerebral hemorrhage (ICH) is a very common cause of disability. Previous evidence suggests that fluoxetine and other selective serotonin reuptake inhibitors improve, the recovery of motor function in patients with cerebral infarct. The purpose of this study was to investigate whether fluoxetine also improves motor recovery in patients with ICH. PATIENTS AND METHODS: This is a double blind, placebo controlled, multicenter randomized trial, patients recruited from three centers were assigned to receive 20 mg/day of fluoxetine or matching placebo for three months from within ten days after onset of symptoms. Primary outcome was change in Fugl-Meyer Motor Scale from baseline to day 90. RESULTS: Thirty patients (50 % women) were recruited to the fluoxetine (n = 14) or placebo (n = 16) groups. Median age was 55 years, the cause of the ICH was hypertension in 93.3 %, median volume of the hematomas was 22mm3. Basal ganglia hematoma was present in 67 % and, lobar location in 20 % of the patients. Improvement in FMMS at day 90 was significatively higher in the treatment group (median score 23) than in the placebo group, (median score 48), p = 0.001. No serious adverse events occurred. CONCLUSION: In addition to standard treatment, early prescription of fluoxetine was safe and helped to increase motor recovery 90 days after ICH. This finding adds to the evidence regarding its beneficial effect upon stroke related disability. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01737541.

A clinical study on the effects of recombinant human colony stimulating factor on the expression of Bcl-2 in serum of patients with basal ganglia hemorrhage and its clinical significance.

OBJECTIVE: We investigated the effects of the colony-stimulating factor (CSF-1) on Bcl-2 expression in serums of patients with basal ganglia hemorrhage and subsequently, its clinical significance. PATIENTS AND METHODS: The expression levels of Bcl-2 in serums of patients with basal ganglia hemorrhage were analyzed, and the effects of the CSF-1 on Bcl-2 expression were observed. Samples of peripheral blood were taken from 120 patients with basal ganglia hemorrhage admitted to the Neurology Department and 120 healthy people undergoing a physical examination at Xiangyang Central Hospital between May 2013 to December 2014. The detection of Bcl-2 levels in serums of patients was performed using the ELISA method, and patients were divided into two groups, the colony-stimulating factor (CSF-1) group and the control group. The CSF-1 group was treated with recombinant human granulocyte colony-stimulating factor after routine treatment, while the control group was treated only with routine treatment. The two groups of patients were followed up for observation of treatment effects. RESULTS: Before treatment, serum Bcl-2 levels in both the CSF-1 and control group showed no significant differences; however, their levels were significantly higher than those of the healthy cohort (p<0.05). After treatment, serum Bcl-2 levels of the CSF-1 group were significantly higher than those of the control group (p<0.05). However, compared to the healthy control group, the levels remained significantly higher and the differences were statistically significant (p<0.05). When compared to the recovering conditions of patients in the CSF-1 group and the control group, we found that the average hospitalization time and occurrences of complications in the CSF-1 group were significantly less than those in the control group (p<0.05). CONCLUSIONS: CSF-1 is clinically effective in improving the serum Bcl-2 levels after a basal ganglia hemorrhage, and it can be used as adjuvant therapy in the treatment of basal ganglia hemorrhage.

Extensive basal ganglia hematomas treated by local thrombolysis versus conservative management - a comparative retrospective analysis.

OBJECTIVES: Single-target puncture plus catheter insertion into the clot is a routine step in hematoma aspiration and local thrombolysis for spontaneous intracerebral haemorrhage (ICH). However, multiple-target puncture of this procedure may imply faster hematoma reduction for large-area ICH. We retrospectively examined the outcomes after clot aspiration plus local thrombolysis with single-/double-target and conservative therapy for extensive basal ganglic hematomas. METHODS: A case note review was conducted on a consecutive series of ICH patients in a single centre with huge basal ganglia hematomas who underwent clots aspiration and thrombolysis or pure medical therapy. We analysed the clinical presentation, radiological features and treatment outcomes of ICH patients in single-target group, double-target group and conservative group. RESULTS: A total of 92 ICH cases were included in this study. At the post-treatment assessment, the average level by hematoma size in single-target and double-group was respectively smaller than that in the conservative group (20.61 ml vs. 15.75 ml vs 60.53 ml, p < 0.01). The 30-day case fatality rate in conservative group was respectively significantly higher than that in single-target and double-target groups (50% vs. 14.70% vs. 20.59%, p < 0.01). At the time of 6-month follow-up, the proportion of good survival in conservative group was respectively remarkably less than that in single- and double-target group (29.17% vs.64.71% vs. 67.65%, p < 0.01). But no difference was detected with respect to 30-day mortality or long-time outcome between the two micro-invasive groups (p = 0.53 and 0.798, respectively). CONCLUSION: Our data suggested for the massive basal ganglia hematomas, clot aspiration and thrombolysis can improve the short- and long-term prognosis compared with the pure conservative therapy. But, no evidence was found to demonstrate double-target of this procedure to be more effective than single-target to improve the outcome.

[Effect of xingnaojing injection combined with minimally invasive percutaneous drainage in treating brain edema and content of serum AQP4 in patients with moderate hypertensive basal ganglia hemorrhage].

OBJECTIVE: To observe the effect of Xingnaojing Injection combined with minimally invasive percutaneous drainage on brain edema and content of serum aquaporin-4 (AQP4) in patients with moderate hypertensive basal ganglia hemorrhage, and discuss the treatment mechanism of Xingnaojing injection combined with minimally invasive percutaneous drainage for cerebral hemorrhage. METHOD: Forty-two patients with moderate (25-50 mL) hypertensive basal ganglia hemorrhage (< 24 h) were selected and randomly divided into two groups: the observation group (n = 22) and the control group (n = 20). The neurological severity score were evaluated by the NIHSS (national institutes of health stroke scale), the volume of brain edemas were measured by head CT, the serum levels of AQP4 were determined by ELISA method on admission and 1 and 2 weeks after treatment. RESULT: On admission, there was no significant difference in the scores of NIHSS, the volume of brain edemas and the level of serum AQP4 between the observation group and the control group. At the end of the first week after the treatment, the score of NIHSS of the observation group were lower than that of the control group, with significant different (P < 0.05); the observation group showed reduced volume of brain edemas than that on admission (P < 0.05), whereas the control group the control group showed increased volume of brain edemas than that on admission; the control group displayed increased level of serum AQP4 than that on admission, but without significant difference; the observation group displayed decreased level of serum AQP4 than that on admission (P < 0.05). At the end of the second week after the treatment, the control group showed decreased score of NIHSS than that on admission and at the end of the first week after treatment (P < 0.05). Compared with the control group, the observation group showed a much lower score of NIHSS (P < 0.01), the control group displayed reduced volume of brain edemas than that on admission and at the end of the first week after treatment, but the observation group was even lower than the control group. Both of observation and control groups displayed significantly reduced level of AQP4 (P < 0.05), but the observation group showed a lower AQP4 level than that of the control group (P < 0.05). CONCLUSION: The therapy of Xingnaojing injection combined with minimally invasive percutaneous drainage could remarkably reduce brain edema, and promote neural functional recovery, thus could be selected as a therapeutic regimen for patients with moderate hypertensive basal ganglia hemorrhage.

Psychopharmacologic intervention after hemorrhagic basal ganglia damage.

Traumatic brain injury (TBI) can result in cognitive and behavioral impairments such as poor attention, learning, memory and planning ability and uncontrolled crying that can be more persistent problems than the physical disabilities. Cognitive enhancers have been shown to improve cognitive and behavioral impairments in patients with hemorrhagic basal ganglia lesions as well as other forms of TBI. There is little research about the use of cognitive enhancers after hemorrhagic basal ganglia damage. We present a case of a 38 year old male who made significant recovery with the use of cognitive enhancers.

Small-vessel disease in the basal ganglia: lacune or microbleed?

Brain microbleeds (BMBs) can be detected on the gradient-echo T2*-weighted magnetic resonance imaging and are considered a risk factor for cognitive impairment and intracerebral hemorrhage. Detailed radiologic findings on the etiology of BMBs and their changes remain scarce. We present a case of subacute change in a BMB in the basal ganglia that mimicked a subacute lacunar infarct. Our findings underscore the need for physicians to be careful to not erroneously diagnose BMBs as lacunar infarctions and prescribe unnecessary antiplatelet medication.

An effective treatment for cerebral hemorrhage: minimally invasive craniopuncture combined with urokinase infusion therapy.

OBJECTIVES: To evaluate and compare the curative effect between the minimally invasive craniopuncture combined with urokinase infusion therapy and the clearance of hematoma by craniotomy with small bone flap in treating patients with 30-80 ml hemorrhage in the basal ganglion part of the brain. METHODS: A multicenter, randomized control clinical trial was undertaken; it comprised of 22 hospitals in China. Three hundred and four patients with hemorrhage in the basal ganglion were randomly assigned to receive the craniopuncture combined with urokinase infusion therapy (n=159) or clearance of hematoma by craniotomy with small bone flap treatment (n=145). The main indexes of evaluation were the neurological impairment degree at day 14 after treatment, activities of daily living at day 90 and the case fatality by 90 days. RESULTS: The main results were as follows: (1) there was a significant difference in favorable outcomes (Barthel index >or=95) between the two groups (chi(2)=3.95, p<0.05), which showed a better prognosis in the craniopuncture group, although there was no significant difference in improving the neurological functions and activities of daily living at day 90; (2) there was a remarkable decrease in case fatality by 90 days in the cranipuncture group, with statistically significant difference between the two groups (chi(2)=5.35, p=0.02); (3) the re-bleeding rate in cranipuncture group was 8.8%, significantly (chi(2)=9.51, p=0.002) lower than 21.4% in the craniotomy group. CONCLUSION: The craniopuncture combined with urokinase infusion therapy could reduce the rate of re-bleeding after surgery and the case fatality by 90 days. It also could improve the activities of daily living (Barthel index >or=95) at day 90. Thus, this therapy was a safe and practical technique in treating cerebral hemorrhage (30-80 ml), especially suitable for hospitals in rural areas or developing countries.

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.

Influence of intraventricular fibrinolytic therapy with rt-PA on the long-term outcome of treated patients with spontaneous basal ganglia hemorrhage: a case-control study.

Over the recent years, fibrinolytic agents have been tested for intraventricular clot fibrinolysis (IVF). Compared with patients who did not receive IVF, administration of rt-PA induces rapid resorption of intraventricular blood and normalization of cerebrospinal fluid (CSF) circulation resulting in a reduced 30-day mortality and beneficial short-term outcome after 3 months. Our objective was to analyze possible influences of IVF on the long-term outcome after 12 months. Based on a prospective data base, patients with ganglionic supratentorial hematoma with additional intraventricular hemorrhage and occlusive hydrocephalus (n = 135) were isolated. Twenty-seven patients received IVF. To design a case-control study, we carefully matched 22 controls without IVF with regard to hematoma volume, Graeb score, Glasgow Coma Scale on admission and age (five patients remained unmatchable). We determined clinical and imaging parameters by reviewing the medical records and CT scans of all included patients. Outcome after 12 months was evaluated using the modified Rankin scale (mRS). One multivariate regression analysis was performed to determine predisposing factors for outcome. IVF significantly reduced Graeb score during treatment (eight on admission, three after IVF, one prior to discharge in the treated group versus 8/6/2 in patients without IVF). In patients with IVF requirement, a second external ventricular drainage (EVD) and a ventriculoperitoneal (VP) shunt were reduced (P = 0.08) and the incidence of a lumbar drainage was significantly higher (P < 0.01), whilst the overall time of extra-corporal CSF drainage was comparable. EVD associated complications were equal in both groups. Overall long-term outcome was poor but no significant differences were found between patients with and without IVF (mRS 4-6: 12/22 (54%) in patients with and 13/22 (59%) in patients without IVF; P = 0.81). The five excluded patients with IVF were similar to the 22 included ones with respect to imaging findings and outcome. The multivariate analysis revealed age and baseline hematoma volume, but not IVF to significantly impact the outcome. In accordance with previous studies, IVF hastened clot lysis and reduced the need for repeated EVD exchanges and permanent shunting. However, despite these advantages, IVF did not influence long-term outcome after 12 months. The results of the prospective randomized trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) need to be awaited.

Basal ganglia haematomas in non-comatose patients: subacute stereotactic aspiration improves long-term outcome in comparison to purely medical treatment.

This study examined whether subacute stereotactic evacuation of basal ganglia haematomas in primarily non-comatose patients is suitable to improve the ultimate outcome of this subgroup of stroke patients. Applying rigorous selection criteria, 56 consecutive non-comatose patients with ganglionic haematomas were treated stereotactically, and 1-year outcomes employing four outcome parameters commonly used to assess outcome were compared with those of 39 similar patients who were treated purely medically. No survival benefit was found in long-term follow-up for either surgical or conservative treatment (total mortality 16.1% vs 28.2%; P=0.121). Among survivors, however, outcome was significantly better in surgical patients. Compared with medical patients, the median Glasgow Outcome Scale score was 1 point higher (P<0.0001) in surgical patients, and the median European Stroke Scale score improvement from baseline to 1-year score was significantly better (P<0.0001). Accordingly, the median Barthel Index score was significantly higher (P=0.002), and the median Modified Rankin Scale score was 1 point lower (P<0.0001). We conclude that primarily non-comatose patients with basal ganglia haematomas can ultimately profit from this form of minimally invasive treatment.

Stereotactic fibrinolysis of spontaneous intracerebral hematoma using infusion of recombinant tissue plasminogen activator.

PURPOSE: The authors present a prospective study on 10 patients with stereotactic infusion of tissue plasminogen activator (rtPA) intraparenchimal hemorrhage. METHODS: Between 1999 and 2000, 10 patients with deep seated hematomas in the basal ganglia were selected for stereotactic infusion of rtPA and spontaneous clot drainage. RESULTS: All cases had about 80% reduction of the hematoma volume in the CT scan at the third day. The intracranial pressure was normalized by the third day too. There were no local or systemic complications with the use of this thrombolytic. The results were shown by the Glasgow Outcome Scale with six patients in V, three in IV and one in III after 3 months. CONCLUSION: Early treatment and drainage with minimally invasive neurosurgery, can make these patients with deep-seated hematomas recover the consciousness and they can be rehabilitated earlier avoiding secondary complications.

Intracerebral infusion of a second-generation ciliary neurotrophic factor reduces neuronal loss in rat striatum following experimental intracerebral hemorrhage.

Neuronal and glial cell death in the striatum of a rat model of collagenase-induced intracerebral hemorrhage begins at 1 day and continues for at least 3 weeks. We hypothesized that administration of a neurotrophic agent would reduce neuronal loss in this experimental model. Because it has been shown to protect striatal neurons against excitotoxic injury, a second-generation ciliary neurotrophic factor (CNTF) (AXOKINE) was administered by continuous intracerebral infusion (2 microg/day) beginning 28 h after hemorrhage and continuing for 2 weeks. Magnetic resonance imaging showed that the hematoma size was comparable in control and treated rats prior to treatment. Counts of medium-sized striatal neurons within 320 microm of the hematoma 8 weeks after the hemorrhage revealed a slight but statistically significant benefit with a 42.5% loss in treated rats compared to 51.7% loss in controls. The results suggest that AXOKINE might be protective of striatal neurons in the vicinity of a hemorrhagic lesion.