Acquired factor XIII deficiency presenting with multiple intracranial hemorrhages and right hip hematoma:A case report

BACKGROUND Factor XIII(FXIII)deficiency is a rare yet profound coagulopathy.FXIII plays a pivotal role in hemostasis,and deficiencies in this factor can precipitate unchecked or spontaneous hemorrhaging.Immunological assays for detecting FXIII inhibitors are indispensable for diagnosing acquired FXIII deficiency;however,the availability of suitable testing facilities is limited,resulting in prolonged turnaround times for these assays.CASE SUMMARY In this case study,a 53-year-old male devoid of significant medical history presented with recurrent intracranial hemorrhages and a hematoma in the right hip.Subsequent genetic analysis revealed a homozygous mutation in the ACE gene,confirming the diagnosis of acquired FXIII deficiency.CONCLUSION This case underscores the significance of considering acquired deficiencies in clotting factors when evaluating patients with unexplained bleeding episodes.

Early antiplatelet therapy used for acute ischemic stroke and intracranial hemorrhage

In this editorial we comment on the article published by Zhang et al in the recent issue of World Journal of Clinical Cases.We evaluate their claims on the benefit of use of Aspirin in the early management of patients with ischemic stroke.We also comment on their contention of using aspirin in the early management of patients with intracranial hemorrhage,a practice not seen in modern medicine.Large clinical trials such as the International Stroke Trial and the Chinese Acute Stroke Trial have shown the benefit of Aspirin use within 48 h of patients with Acute Ischemic Stroke.The findings were corroborated in the open-label trial performed by Zhang et al in a smaller sample group of 25 patients where they showed improvement in functional scores at 90 days without an increase in adverse events.As such,this intervention is also recommended by the American Heart Association stroke guidelines from 2021.With regard to Intracranial hemorrhage,traditional practice has been to discontinue or avoid antiplatelet therapy in these patient groups.However,no studies have been done to evaluate this management strategy that is more borne out of the mechanism behind Aspirin’s effect on the coagulation pathway.Zhang et al evaluate the benefits of Aspirin on patients with low-volume intracranial hemorrhage,i.e.,less than 30 mL on computed tomo-graphy imaging,and show no increase in mortality.The caveat of this finding is that all outcomes were pooled into one group for results,and the number of patients was low.While more studies with larger patient groups are required,the data from Zhang et al suggests that patients with small-volume intracranial hemorrhages may benefit from Aspirin administration in the acute phase of management.

Piezo1 as a potential player in intracranial hemorrhage:From perspectives on biomechanics and hematoma metabolism

Intracranial hemorrhage(ICH)causes numerous neurological deficits and deaths worldwide each year,leaving a significant health burden on the public.The pathophysiology of ICH is complicated and involves both primary and secondary injuries.Hematoma,as the primary pathology of ICH,undergoes metabolism and triggers biochemical and biomechanical alterations in the brain,leading to the secondary injury.Past endeavors mainly aimed at biochemical-initiated mechanisms for causing secondary injury,which have made limited progress in recent years,although ICH itself is also highly biomechanics-related.The discovery of the mechanically-activated cation channel Piezo1 provides a new avenue to further explore the mechanisms underlying the secondary injury.The current article reviews the structure and gating mechanisms of Piezo1,its roles in the physiology/pathophysiology of neurons,astrocytes,microglia,and bone-marrow-derived macrophages,and especially its roles in erythrocytic turnover and iron metabolism,revealing a potential interplay between the biomechanics and biochemistry of hematoma in ICH.Collectively,these advances provide deeper insights into the secondary injury of ICH and lay the foundations for future research.

Repeated multiple intracranial hemorrhages induced by cardiac myxoma mimicking cavernous angiomas: a case report

Background:Repeated intracranial hemorrhages caused by cardiac myxoma is very rare.It is essential for physicians to be aware of such uncommon clinical feature of myxoma.Case presentation:We report a-49-year-old female patient complained of repeated multiple intracranial hemorrhages,with no sign of cardiac dysfunction or cerebral infarction before admission.Cavernous angioma (CA) was misdiagnosded due to the clinical and magnetic resonance (MR) presentation.A sudden ischemic event after admission led to the finding of a left atrial myxoma.Conclusions:Repeated intracranial hemorrhages can be the early and primary clinical presentation of cardiac myxoma,probably caused by its metastasis,without obvious ischemic stroke or cardiac symptoms.

Clinical characteristics and risk factors of intracranial hemorrhage after spinal surgery

BACKGROUND Intracranial hemorrhage after spinal surgery is a rare and devastating complication.AIM To investigate the economic burden,clinical characteristics,risk factors,and mechanisms of intracranial hemorrhage after spinal surgery.METHODS A retrospective cohort study was conducted from January 1,2015,to December 31,2022.Patients aged≥18 years,who had undergone spinal surgery were included.Intracranial hemorrhage patients were selected after spinal surgery during hospitalization.Based on the type of spinal surgery,patients with intracranial hemorrhage were randomly matched in a 1:5 ratio with control patients without intracranial hemorrhage.The patients'pre-,intra-,and post-operative data and clinical manifestations were recorded.RESULTS A total of 24472 patients underwent spinal surgery.Six patients(3 males and 3 females,average age 71.3 years)developed intracranial hemorrhage after posterior spinal fusion procedures,with an incidence of 0.025%(6/24472).The prevailing type of intracranial hemorrhage was cerebellar hemorrhage.Two patients had a poor clinical outcome.Based on the type of surgery,30 control patients were randomly matched in 1:5 ratio.The intracranial hemorrhage group showed significant differences compared with the control group with regard to age(71.33±7.45 years vs 58.39±8.07 years,P=0.001),previous history of cerebrovascular disease(50%vs 6.7%,P=0.024),spinal dura mater injury(50%vs 3.3%,P=0.010),hospital expenses(RMB 242119.1±87610.0 vs RMB 96290.7±32029.9,P=0.009),and discharge activity daily living score(40.00±25.88 vs 75.40±18.29,P=0.019).CONCLUSION The incidence of intracranial hemorrhage after spinal surgery was extremely low,with poor clinical outcomes.Patient age,previous stroke history,and dura mater damage were possible risk factors.It is suggested that spinal dura mater injury should be avoided during surgery in high-risk patients.

Interobserver reliability of computed tomography angiography in the assessment of ruptured intracranial aneurysm and impact on patient management

BACKGROUND Aneurysmal subarachnoid hemorrhage is an emergency that can lead to a high mortality rate and many severe complications.It is critical to make a rapid radiological evaluation of ruptured intracranial aneurysms(RIAs)to determine the appropriate surgical treatment.AIM To assess the reliability of computed tomography angiography(CTA)in assessing different features of ruptured intracranial aneurysm and its impact on patient management.METHODS The final cohort of this study consisted of 146 patients with RIAs(75 male and 71 female)who underwent cerebral CTA.Their age ranged from 25 to 80,and the mean age±SD was 57±8.95 years.Two readers were asked to assess different features related to the aneurysm and perianeurysmal environment.Inter-observer agreement was measured using kappa statistics.Imaging data extracted from non-contrast computed tomography and CTA were considered to categorize the study population into two groups according to the recommended therapeutic approach.RESULTS The inter-observer agreement of both reviewers was excellent for the detection of aneurysms(K=0.95,P=0.001),aneurysm location(K=0.98,P=0.001),and(K=0.98,P=0.001),morphology(K=0.92,P=0.001)and margins(K=0.95,P=0.001).There was an excellent interobserver agreement for the measurement of aneurysm size(K=0.89,P=0.001),neck(K=0.85,P=0.001),and dome-to-neck ratio(K=0.98,P=0.001).There was an excellent inter-observer agreement for the detection of other aneurysm-related features such as thrombosis(K=0.82,P=0.001),calcification(K=1.0,P=0.001),bony landmark(K=0.89,P=0.001)and branch incorporation(K=0.91,P=0.001)as well as perianeurysmal findings including vasospasm(K=0.91,P=0.001),perianeurysmal cyst(K=1.0,P=0.001)and associated vascular lesions(K=0.83,P=0.001).Based on imaging features,87 patients were recommended to have endovascular treatment,while surgery was recommended in 59 patients.71.2%of the study population underwent the recommended therapy.CONCLUSION CTA is a reproducible promising diagnostic imaging modality for detecting and characterizing cerebral aneurysms.

Ruptured venous aneurysm associated with a dural arteriovenous fistula:Two case reports

BACKGROUND In general,venous aneurysm associated with dural arteriovenous fistula(dAVF)is considered to be developed under long standing venous hypertension and manifested as venous ectasia of draining vein itself.However,discrete saccular shaped venous aneurysm without angiographic evidence of venous hypertension arising from the draining vein,like cerebral arterial aneurysm,is quite rare and its pathomechanism remains unclear in patients with dAVF.CASE SUMMARY In this report,we present two cases of ruptured saccular venous aneurysms associated with dAVF without venous hypertension or venous ectasia.In both cases,significant curve or stenosis is observed in draining vein,which is located in just distal portion of the venous aneurysms.These aneurysms were successfully treated with a transarterial embolization.Underlying mechanism of venous aneurysms in these cases is discussed.CONCLUSION Although there is little doubt that hemodynamic stress has a critical role in the development of venous aneurysms in patients with dAVF,preceding venous hypertension or venous ectasia is not necessary for development and enlargement of venous aneurysms.Considering the significant risk of rupture,a careful review of draining vein features including tortuosity or stenosis is needed,especially in venous aneurysms without evidence of venous hypertension.

Subdural empyema complicated with intracranial hemorrhage in a postradiotherapy nasopharyngeal carcinoma patient: A case report and review of literature

The prevalence of nasopharyngeal carcinoma(NPC) is higher in southern China, Hong Kong, and Taiwan than in other areas in the world. Radiotherapy is an important part of treatment for NPC patients, especially those with stage Ⅲ/Ⅳ disease. Subdural empyema is a rare but life-threatening complication in postradiotherapy NPC patients which should be paid more attention. Here, we present the case of a 64-year-old female postradiotherapy NPC patient with subdural empyema complicated with intracranial hemorrhage. She was treated by burr-hole surgery but unfortunately died because of recurrent intracranial hemorrhage. The mechanisms potentially underlying the formation of subdural empyema in postradiotherapy NPC patients and the surgical strategies that can be used in these patients are discussed in this report.

Intracranial hemorrhage in patients treated with bevacizumab:Report of two cases

Treatment with bevacizumab,an antiangiogenic agent,in patients with metastatic or unresectable colorectal cancer was approved less than 4 years ago in Japan.Bevacizumab improves the survival of patients with metastatic colorectal cancer;however,it may lead to complications such as bleeding,which are sometimes fatal.Bevacizumab should be administered only after careful consideration because the potential risks of therapy outweigh its benefits.Therefore,pharma-ceutical companies do not recommend bevacizumab therapy for patients with brain metastases.While some reports support the cautious use of bevacizumab,others report that it is not always necessary to prohibit its use in patients with metastases to the central nervous system(CNS),including the brain.Thus,bevacizumab therapy in colorectal cancer patients with brain metastases is controversial,and it is unclear whether brainmetastases are a risk factor for intracranial hemor-rhage during anti-vascular endothelial growth factor(VEGF)therapy.We report a 64-year-old man and a 65-year-old man with recurrent colorectal cancer with-out brain metastases;these patients developed multifocal and solitary intracranial hemorrhage,respectively,after the administration of bevacizumab.Our findings suggest that intracranial hemorrhage can occur even if the patient does not have brain metastases prior to bevacizumab treatment and also suggest that brain metastases are not a risk factor for intracranial hemor-rhage with bevacizumab treatment.These findings also question the necessity of excluding patients with brain metastases from clinical trials on anti-VEGF therapy.

Risk factors for delayed intracranial hemorrhage secondary to ventriculoperitoneal shunt:A retrospective study

BACKGROUND Delayed intracranial hemorrhage(DICH),a potential complication of ventriculoperitoneal(VP)shunts,has been associated with high mortality,but its risk factors are still unclear.AIM To investigate the risk factors of DICH after VP shunts.METHODS We compared the demographic and clinical characteristics of DICH and non-DICH adult patients with VP shunts between January 2016 and December 2020.RESULTS The 159 adult VP shunt patients were divided into 2 groups according to the development of DICH:the DICH group(n=26)and the non-DICH group(n=133).No statistically significant difference was found in age,sex,laboratory examination characteristics or preoperative modified Rankin Scale(mRS)score between the DICH and non-DICH groups(P>0.05);however,a history of an external ventricular drain(EVD)[P=0.045;odds ratio(OR):2.814;95%CI:1.024-7.730]and postoperative brain edema around the catheter(P<0.01;OR:8.397;95%CI:3.043-23.171)were associated with a high risk of DICH.A comparison of preoperative mRS scores between the DICH group and the non-DICH group showed no significant difference(P=0.553),while a significant difference was found in the postoperative mRS scores at the 3-mo follow-up visit(P=0.024).CONCLUSION A history of EVD and postoperative brain edema around the catheter are independent risk factors for DICH in VP shunt patients.DICH patients with a high mRS score are vulnerable to poor clinical outcomes.

CT examination, clinical situation and experimental characteristics of infants with intracranial hemorrhage induced by delayed vitamin K deficiency

BACKGROUND: Delayed vitamin K deficiency is characterized by acute onset, severe illness and high fatality rate. 33%-50% survivors accompany with other various nervous system sequelas. Therefore, diagnosis and treatment of intracranial hemorrhage in time become a key factor for improving healing rate and reducing fatality rate and incidence of sequela. OBJECTIVE: To investigate the clinical situation, experimental characteristics, CT examination and terminative characteristics of infants with intracranial hemorrhage induced by delayed vitamin K deficiency. DESIGN: Case analysis. SETTING: Department of Pediatrics, Zhongshan Hospital Affiliated to Xiamen University. PARTICIPANTS: A total of 17 infants with intracranial hemorrhage induced by delayed vitamin K deficiency aged 1-3 months including 11 boys and 6 girls were selected from Department of Pediatrics, Zhongshan Hospital Affiliated to Xiamen University from January 1994 to December 2005. All infants had drowsiness, rejective milk, spiting milk, gaze of both eyes, tic, coma, full anterior fontanelle, high muscular tension and cerebral hernia, etc. Experimental examination demonstrated that infants had anemia at various degrees; prothrombin time and partial thromboplastin time were prolonged; platelet count was normal. CT examination indicated that screenages of subarachnoid hemorrhage, subdural hematoma, cerebral parenchyma hemorrhage and intraventricular hemorrage were changed. Hemorrhage was stopped by the application of vitamin K. All patients provided informed consent. METHODS: ① Clinical situation and physical sign of infants were observed after hospitalization and scanned with rapid spiral CT scanning system. The thickness and average space of layers were 8-10 mm and the scanning time was 5 s with window width of 30-80 Hu and window position of 28-35 Hu. ② After hospitalization, four items of blood coagulation was measured with Futura meter and biochemical indexes of blood, such as serum calcium, serum alkaline phosphatase, total bilirubin, direct bilirubin and indirect bilirubin, were detected with Roche Modular PPI automatic biochemistry analyzer. ③ After hospitalization, infants were given 5-10 mg vitamin K1 for 3-5 days, and then, they were transfused with 10-15 mL/kg fresh plasma or whole blood for 1-3 times and received other relative therapies. Therapeutic effects were evaluated based on clinical diagnosis and criteria. MAIN OUTCOME MEASURES: ① Clinical situation, physical sign and CT examination; ② results of experimental examination; ③ treatment and termination. RESULTS: A total of 17 infants with intracranial hemorrhage were involved in the final analysis. ① Clinical situation, physical sign and CT examination: All infants had pale facial expression and full or bossing anterior fontanelle. Among them, 13 infants had drowsiness or dysphoria, 12 rejective milk or emesis, 11 tic, 13 injection site hemorrhage, 2 gastrointestinal hemorrhage, 3 cerebral hernia, 11 high muscular tension and 6 cervical rigidity. CT examination demonstrated that most infants (88%, 15/17) had subarachnoid hemorrhage; 10 (59%, 10/17) had subdural hematoma; 8 (47%, 8/17) had cerebral parenchyma hemorrhage; few had intraventricular hemorrhage. In addition, results of CT examination also indicated that 17 infants had intracranial hemorrhage. Hemorrhage sites of 12 infants were equal to or more than 2, which was accounted for 70% (12/17); meanwhile, partial cases accompanied with a large area of focus of cerebral infarction or cerebral hypoxia-ischemia lesion. ② Results of experimental examination: There were 6 infants with elongation of prothrombin time, 5 with partial elongation of prothrombin time, 4 with decrease of serum calcium (1.69-2.25 mmol/L), 3 with increase of serum alkaline phosphatase, 3 with increase of total bilirubin, 3 with increase of direct bilirubin, and 3 with increase of indirect bilirubin. ③ Treatment and termination: After treatment, 12 infants were cured well, 3 improved, 1 given up and 1 died. Later, ten infants received CT re-examination at 3 months after treatment. The results indicated that 3 infants had simple subarachnoid hemorrhage and 4 had subarachnoid hemorrhage accompanying with subdural hematoma. Their focuses were absorbed well and not show as obvious sequela. One infant had subdural hematoma accompanying with subarachnoid hemorrhage, cerebral parenchyma hemorrhage, intraventricular hemorrage and cerebral hypoxia ischemia, and then, after hematom absorption, obvious cerebral malacia focus, hydrocephalus, brain atrophy and inferior accumulating fluid of dura mater were observed; 2 had subdural hematoma accompanying with subarachnoid hemorrhage and cerebral hypoxia ischemia, and then, after bleeding absorption, brain atrophy was changed remarkably; changes of hydrocephalus were observed in one infant. CONCLUSION: ① Symptoms of pale facial expression, full or bossing anterior fontanelle, drowsiness and dysphoria are observed in infants with delayed vitamin K deficiency . ② Experimental indexes demonstrate that prothrombin time and partial prothrombin time are prolonged, and numbers of infants having decrease of serum calcium are in the third place. ③ Poly-intracranial hemorrhage is a notable characteristic of CT examination. Partial infants who have poly-intracranial hemorrhage always accompany with cerebral hypoxia-ischemia lesion or cerebral infarction. Clinical situation and prognosis of infants who have a large area of intracranial hemorrhage and cerebral hypoxia-ischemia changes are poor; however, those of infants who have simple subarachnoid hemorrhage or combination of subarachnoid hemorrhage with subdural hematoma are well. ④ Effect of vitamin K on this kind of disease is well.

Intracranial Hemorrhage in Newborn with TAR Syndrome—A Feared Complication

The thrombocytopenia-absent radius (TAR) syndrome is an autosomal recessive disease characterized by bilateral absence of radius with the presence of both thumbs and thrombocytopenia, many times associated with cardiac anomalies, intolerance or allergy to cow’s milk and phocomelia. Imaging study is important for the correct diagnosis at birth and documentation of one of the diagnosis criteria (absence of radius) in prenatal care. The main hematologic symptoms and the most feared of them, intracranial bleeding, occurs when platelets levels are below 10,000/mm3, which is more common during the first months. Therefore, imaging study is crucial to quickly identify complications and correctly manage the case. In this case report, the patient had upper limps alterations at birth and at first week presented seizures, with transfontanellar ultrasound and head computed tomography without contrast demonstrating intracranial hemorrhage. Laboratory results and imaging review were able to diagnose TAR syndrome. The patient was treated with platelets transfusion and thrombocytopenia was solved. She is currently under specialized medical care, with no neurological deficits and showing satisfactory development.

Perioperative management of patients with traumatic intracranial hemorrhage and pretraumatic oral warfarin

Objective To study perioperative management in treatment of traumatic intracranial hemorrhage in patients with pretraumatic anticoagulation therapy of oral warfarin.Methods 10 patients of traumatic intracranial hemorrhage with pretraumatic anticoagulation therapy of oral warfarin received vitamin K,FFP and PCC

Manifestation of the malignant progression of glioma following initial intracerebral hemorrhage:A case report

BACKGROUND Intracranial hemorrhage is extremely rare during the initial stages of glioma.Here,we report a case of glioma with unclassified pathology and intracranial bleeding.CASE SUMMARY After the second surgery for intracerebral hemorrhage,the patient experienced weakness in the left arm and leg,but could walk unassisted.One month after discharge,the weakness in the left limbs had exacerbated and the patient also suffered from headaches and dizziness.A third surgery was ineffective against the rapidly growing tumor.Intracerebral hemorrhage may be the initial symptom of glioma in some rare cases,and atypical perihematomal edema can be used for diagnosis during an emergency.Certain histological and molecular features seen in our case were similar to that of glioblastoma with a primitive neuronal component,which is termed diffuse glioneuronal tumor with features similar to oligodendroglioma and nuclear clusters(DGONC).The patient underwent three surgeries to remove the tumor.The first tumor resection had been performed when the patient was 14-years-old.Resection of the hemorrhage and bone disc decompression were performed when the patient was 39-years-old.One month after the last discharge,the patient underwent neuronavigation-assisted resection of the right frontotemporal parietal lesion plus extended flap decompression.On the 50^(th)d after the third operation,computed tomography imaging showed rapid tumor growth accompanied by brain hernia.The patient was discharged and died 3 d later.CONCLUSION Glioma can present as bleeding in the initial stage and should be considered in such a setting.We have reported a case of DGONC,which is a rare molecular subtype of glioma with a unique methylation profile.

A Double-Branch Xception Architecture for Acute Hemorrhage Detection and Subtype Classification

This study presents a deep learning model for efficient intracranial hemorrhage(ICH)detection and subtype classification on non-contrast head computed tomography(CT)images.ICH refers to bleeding in the skull,leading to the most critical life-threatening health condition requiring rapid and accurate diagnosis.It is classified as intra-axial hemorrhage(intraventricular,intraparenchymal)and extra-axial hemorrhage(subdural,epidural,subarachnoid)based on the bleeding location inside the skull.Many computer-aided diagnoses(CAD)-based schemes have been proposed for ICH detection and classification at both slice and scan levels.However,these approaches performonly binary classification and suffer from a large number of parameters,which increase storage costs.Further,the accuracy of brain hemorrhage detection in existing models is significantly low for medically critical applications.To overcome these problems,a fast and efficient system for the automatic detection of ICH is needed.We designed a double-branch model based on xception architecture that extracts spatial and instant features,concatenates them,and creates the 3D spatial context(common feature vectors)fed to a decision tree classifier for final predictions.The data employed for the experimentation was gathered during the 2019 Radiologist Society of North America(RSNA)brain hemorrhage detection challenge.Our model outperformed benchmark models and achieved better accuracy in intraventricular(99.49%),subarachnoid(99.49%),intraparenchymal(99.10%),and subdural(98.09%)categories,thereby justifying the performance of the proposed double-branch xception architecture for ICH detection and classification.

Outcomes of intracranial hemorrhage in critically ill patients with acute leukemia: Results of a retrospective cohort study

Background:Admission to the intensive care unit(ICU)is frequently required for patients with acute leukemia(AL)because of life-threatening complications such as intracranial hemorrhage(IH).In this study,we evaluated the impact of IH on survival and neurological outcomes in this population.Methods:This was a single-center retrospective cohort study including adult patients with AL requiring ICU ad-mission and experiencing IH between 2002 and 2019 at Saint Louis Hospital.Leukemia type was determined according to the French-American-British classification.Brain imaging(either computed tomography or mag-netic resonance imaging)was available for all the patients.The primary endpoint of the study was to describe the clinical and biological characteristics and evaluate the mortality and neurological outcome of patients hospi-talized in the ICU with newly diagnosed AL and IH.The secondary endpoint was to identify predictive factors of IH in these patients.Results:Thirty-five patients with AL were included,median age of the patients was 59.00(interquartile range[IQR]:36.00-66.00)years.Twenty-nine patients(82.9%)had acute myeloid leukemia,including 12 patients with acute promyelocytic leukemia.Thrombocytopenia was constant,and 48.5% of patients had disseminated intravascular coagulation(DIC).At ICU admission,the median Sequential Organ Failure Assessment score was 5(IQR:3-9).The median time between AL onset and IH was 2.0(IQR:0.0-9.5)days.The ICU and hospital mortality rates were 60.0%(n=21)and 65.7%(n=23),respectively.In univariate analysis,mechanical ventilation and stupor were associated with mortality,but DIC and acute promyelocytic leukemia were not.Upon multivariate analysis,stupor or coma was the only factor significantly associated with a poor outcome(odds ratio=8.56,95% confidence interval:2.40 to 30.46).Conclusion:IH is associated with a high mortality rate in AL patients,with stupor or coma at the onset of intracranial bleeding being independently associated with poor outcomes.

Aggressive blood pressure treatment of hypertensive intracerebral hemorrhage may lead to global cerebral hypoperfusion:Case report and imaging perspective

Hypoperfusion injury related to blood pressure decrease in acute hypertensive intracerebral hemorrhage continues to be a controversial topic. Aggressive treatment is provided with the intent to stop the ongoing bleeding. However, there may be additional factors, including autoregulation and increased intracranial pressure, that may limit this approach. We present here a case of acute hypertensive intracerebral hemorrhage, in which aggressive blood pressure management to levels within the normal range led to global cerebral ischemia within multiple border zones. Global cerebral ischemia may be of concern in the management of hypertensive hemorrhage in the presence of premorbid poorly controlled blood pressure and increased intracranial pressure.

Serum calcium,albumin,globulin and matrix metalloproteinase-9 levels in acute cerebral infarction patients

BACKGROUND Hemorrhagic transformation(HT)is a common complication in patients with cerebral infarction.However,its pathogenesis is poorly understood.The knowledge of factors that may increase risk for HT may help in improving the safety of thrombolytic therapy.AIM To investigate the predictive value of serum calcium,albumin,globulin and matrix metalloproteinase-9(MMP-9)levels for HT after intravenous thrombolysis(IVT)in patients with acute cerebral infarction.METHODS Five hundred patients with acute cerebral infarction who received IVT with alteplase within 4.5 h after the onset of disease between January 2018 and January 2021 at our hospital were selected as the study subjects.They were divided into groups based on computed tomography scan results of the brain made within 36 h after thrombolysis.Forty patients with HT were enrolled in an observation group and 460 patients without HT were enrolled in a control group.Serum calcium,albumin,globulin and MMP-9 levels were compared between the two groups.Regression analysis was used to discuss the relationship between these indices and HT.RESULTS The previous history of hypertension,diabetes,atrial fibrillation,cerebrovascular diseases,smoking and alcohol intake were not associated with HT after IVT in patients with acute cerebral infarction(all P>0.05).The National Institutes of Health stroke scale(NHISS)score was associated with HT after IVT in patients with acute cerebral infarction(P<0.05).The serum calcium and albumin levels were lower in the observation group than in the control group(all P<0.05).The levels of globulin and MMP-9 were significantly higher in the observation group than in the control group(all P<0.05).Logistic regression analysis showed that NHISS score,serum calcium,albumin,globulins and MMP-9 were independent factors influencing the occurrence of HT following IVT in patients with cerebral infarction(P<0.05).CONCLUSION Serum calcium,albumin,globulin and MMP-9 levels are risk factors for HT after IVT in patients with acute cerebral infarction.Moreover,NHISS score can be used as a predictor of post-thrombolytic HT.

Nerve growth factor precursor and sortilin effects on perihematomal brain tissue and the relationship to secondary cell apoptosis

BACKGROUND： Neuronal apoptosis in perihematomal brain tissues following intracerebral hemorrhage is strongly related to the formation of a compound signal pathway between nerve growth factor precursor （proNGF）, p75NTR, and sortilin receptor. Sortilin acts as a co-receptor and molecular switch governing the p75NTR-mediated pro-apoptotic signal induced by proNGF. OBJECTIVE： To investigate proNGF and sortilin expressions in perihematomal brain tissues following intracerebral hemorrhage, and to study the effects of proNGF and sortilin on secondary cell apoptosis. DESIGN, TIME AND SETTING： A paired, comparison study was performed at the Laboratory of Histology and Embryology, Xi＇an Jiaotong University from October 2007 to September 2008. MATERIALS： Brain tissue samples were obtained from 15 patients with intracerebral hemorrhage, who were treated at the Department of Neurosurgery, First Affiliated Hospital, Medical College of Xi＇an Jiaotong University from October 2007 to March 2008. Rabbit anti-proNGF polyclonal antibody was provided by Chemicon, USA; rabbit anti-sortilin polyclonal antibody by Abcam, UK; and TUNEL kit by Promega, USA. METHODS： Perihematomal brain tissues selected 0.5 cm from the hemorrhage area were considered to be the hemorrhage group, while brain tissues from the middle temporal gyrus served as the control group. MAIN OUTCOME MEASURES： Histopathological changes were detected using hematoxylin-eosin staining, cell apoptosis was determined using the TUNEL method, and proNGF and sortilin expressions were determined using immunohistochemistry. RESULTS： Edema was clearly observed in perihematomal brain tissues, and infiltration of inflammatory cells was visible, with the presence of irregular and necrotic bodies. The apoptotic rate in the hemorrhage group was significantly greater than in the control group （P 〈 0.01）. Moreover, sortilin expression significantly increased （P 〈 0.01）, but proNGF expression remained unchanged （P 〉 0.05）. Correlation analysis suggested that sortilin expression positively correlated with apoptosis （rs = 0.648, P 〈 0.01）. CONCLUSION： proNGF expression was stable, but sortilin expression increased in perihematomal brain tissues following intracerebral hemorrhage, suggesting that sortilin acted as a co-receptor and molecular switch to govern p75NTR-mediated cell apoptosis.

Disseminated intravascular coagulation scores as predictors for progressive hemorrhage and neurological prognosis following traumatic brain injury

Coagulation abnormalities, such as disseminated intravascular coagulation （DIC）, are associated with progressive hemcrrhagic injury （PHI） following head trauma. However, the exact relationship between coagulopathy and PHI remains unclear. The present study utilized a scoring system defined by the International Society of Thrombosis and Haemostasis to investigate whether a high DIC score is predictive for PHI. This study was a multicenter prospective design involving four hospitals, a 6-month observation, and follow-up. Of 352 traumatic brain injury （TBI） patients, serial CT scan indicated approximately one third of patients developed progressive hemorrhage, which was most frequently observed in the frontal, temporal, and orbitofrontal lobes of patients with brain contusion. PHI-positive patients exhibited poor prognosis, as indicated by prolonged length of hospital/intensive care unit stay and high mortality. More importantly, a DIC score after TBI, as well as patient age and sex, could serve as predictors for PHI. In addition, DIC scores were closely associated with injury severity. Therefore, the DIC scoring system facilitated early PHI diagnosis in TBI patients, and DIC scores might serve as a valuable predictor for TBI patients with PHI.