Brain Hemorrhages最新文献

Objective

Central neurocytoma (CN) is a rare benign tumor usually found in the lateral and third ventricles. This report highlights an exceptional case of CN in the fourth ventricle, leading to acute hydrocephalus due to bleeding. The patient later developed cerebellar mutism syndrome (CMS), a rare condition following posterior fossa surgery. We retrospectively analyzed data from a patient who experienced sudden loss of consciousness due to hemorrhagic fourth ventricular CN.

Case presentation

A 43-year-old male presented with sudden loss of consciousness. Initial computed tomography (CT) scan revealed a large left cerebellar hemorrhagic lesion causing hydrocephalus. An external ventricular drainage catheter was inserted to alleviate hydrocephalus, followed by emergent surgery to address the mass. A second surgery was needed due to rebleeding, achieving complete tumor removal. A ventriculoperitoneal shunt was inserted for permanent hydrocephalus management. Post-surgery, the patient presented with significant neurological symptoms, including muteness, ataxia, and hypotonia, which improved with medical treatment involving fluoxetine and bromocriptine. A one-year follow-up magnetic resonance imaging (MRI) confirmed successful tumor removal with no signs of recurrence.

Conclusion

This case emphasizes the unusual occurrence of CN in the fourth ventricle with bleeding and the possibility of CMS in adult patients after posterior fossa surgery.

Objective

Primary immune thrombocytopenia (ITP) paradoxically carries a high risk of developing thrombosis. However, the efficacy of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in ITP patients remains unclear due to its rarity.

Case presentation

A 47-year-old female treated for chronic ITP for 2 years was admitted to the hematology department with severe thrombocytopenia. The patient was started on glucocorticoid therapy, and her platelet count rose soon. On sixth day of hospitalization, she suddenly presented with loss of consciousness, conjugate eye deviation to the left, and left hemiplegia. Magnetic resonance imaging and angiography showed an acute ischemic lesion with the left M1 occlusion. Emergent MT was performed and resulted in successful recanalization. Postoperatively, she recovered consciousness and was able to follow instructions. However, on the third day after MT, the patient suffered hemorrhagic infarction and brain herniation, and decompression craniectomy was performed. Her consciousness slowly recovered, and cranioplasty was performed after brain swelling improved. The patient was transferred to a rehabilitation hospital with modified Rankin Scale (mRS) 4 on 84th day of hospitalization, and eventually improved to mRS 3 with motor aphasia and right hemiparesis.

Conclusion

MT may be effective for AIS in ITP patients with appropriate case selection.

Objective

Pulmonary edema is a common complication in patients receiving clazonsentan. Here, we report our experience in managing fluid balance with loop diuretics in patients with aneurysmal subarachnoid hemorrhage (aSAH) treated with clazosentan.

Methods

Patients with aSAH who received prophylactic agents for vasospasm after aneurysm obliteration between June 2021 and April 2023 were enrolled. Fluid balance parameters and asymptomatic and symptomatic vasospasm and pulmonary edema incidence were compared in three periods: 1st period (fasudil therapy), 2nd period (clazosentan therapy alone), and 3rd period (clazosentan with loop diuretic therapy).

Results

Fluid intake and urine volume during the 2nd and 3rd periods were considerably lesser than those during the 1st period. Asymptomatic vasospasm incidence was considerably lesser in the 3rd period than that in the 1st and 2nd periods. However, the incidences of symptomatic vasospasm and rescue endovascular treatment were comparable among the three groups. Although the clinical outcomes at the last follow-up were comparable among the three groups, pulmonary edema incidence was markedly higher during the 2nd period than that in the 1st and 3rd periods.

Conclusion

Thus, proper management of fluid balance with clazosentan and diuretics would help in effective clazosentan therapy for vasospasm prophylaxis.

Objective

This retrospective study aimed to analyze the prospectively collected data of computed tomography (CT) perfusion imaging and to examine if clazosentan add-on administration prevented post-subarachnoid hemorrhage (SAH) delayed cerebral microcirculatory dysfunctions.

Methods

A total of 36 consecutive patients with non-mild SAH due to ruptured anterior circulation aneurysms and no significant cardiopulmonary dysfunctions (mean age, 67.9 years; and admission World Federation of Neurological Surgeons grades IV–V, 66.7 %) underwent aneurysmal obliteration up to day 3 post-SAH, followed by our conventional treatment (fasudil hydrochloride, cilostazol and perampanel administrations; n = 20; January 2020 to May 2022) or add-on administration of clazosentan (10 mg/hr) to the conventional treatment (n = 16; June 2022 to May 2023).

Results

Clazosentan add-on treatment significantly affected perioperative fluid management, which appeared to have no effects on the finding of CT perfusion imaging performed a median of 6.5 to 7.0 days post-SAH. However, cerebral blood flow and mean transit time were better in patients receiving add-on administration of clazosentan, although angiographic vasospasm frequencies and cerebral blood volume values were similar between the two treatment groups.

Conclusion

The findings suggest that clazosentan add-on treatment has beneficial effects against post-SAH angiographic vasospasm-unrelated delayed cerebral microcirculatory dysfunctions possibly by improving blood flow in smaller resistance arteries or arterioles.

Objective

Clazosentan (CLA) reduces cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). However, adverse events including pulmonary edema were reported. We examined whether the strict management of fluid balance reduces the adverse events and improves patient outcomes.

Methods

Patients with aSAH between 2020 and 2023 were included. They were divided into pre-CLA (before CLA approval) and post-CLA (after approval) groups. The patients in the post-CLA group were further divided into the post-CLA1 (before the change in fluid management) and post-CLA2 (after the change) groups. To achieve fluid balance of 0–500 ml/day according to the modified protocol, the infusion volume was restricted.

Results

The daily fluid balance increased from the pre-CLA to the post-CLA1 periods (p = 0.01). The protocol changes decreased the pulmonary edema (post-CLA1 vs. post-CLA2, 44 vs. 22 %, p = 0.09) and discontinuation of CLA (44 vs. 9 %, p < 0.01). The incidence of symptomatic spasm (SS) and delayed cerebral infarction (DCI) in the post-CLA2 were slightly reduced without significant differences (SS: 17 vs. 13 %, p = 0.69; DCI: 11 vs. 9 %, p = 1.00).

Conclusion

Strict management of fluid balance during CLA treatment reduced the adverse events and discontinuation of CLA administration. Fluid restriction may positively affect the management of cerebral vasospasms.

An aneurysmal subarachnoid hemorrhage (aSAH) is a devastating event associated with a high mortality and morbidity rate. Though numerous medications are used to prevent cerebral vasospasm and vasospasm-related cerebral infarction after aSAH, no effective pharmacological treatment has been established. Clazosentan, a highly selective endothelin receptor type A antagonist, was approved for use in Japan in April 2022 based on results of two pivotal randomized, placebo-controlled phase 3 studies (JapicCTI-163369, JapicCTI-163368). These studies indicated that clazosentan significantly reduced the incidence of vasospasm-related morbidity and all-cause mortality after aneurysm coiling and clipping. Clazosentan is thus expected to become a “game changer” for improving the neurological prognosis after aSAH. However, other reports indicate that even when clazosentan or nimodipine are administered for prophylaxis against delayed neurological decline, patients treated with increased colloid administration or hypertonic saline (3% sodium chloride) load exhibit poor functional outcome and higher mortality, suggesting that extra fluid and sodium derived from prophylactic colloid administration contribute to negative outcomes after aSAH. Pharmacological treatments such as clazosentan in addition to perioperative management involving delivery of less water and sodium might be crucial for achieving better outcomes than conventional therapy. Based on a literature review, we present here the future perspectives regarding clazosentan and the necessity for modifying management of the water-electrolyte balance by focusing on endothelin-1 and blood–brain barrier disruption.

Objective

Pulmonary complications, which are occasionally severe, are common adverse events following the administration of clazosentan. This study aimed to identify factors associated with severe pulmonary adverse events due to clazosentan after aneurysmal subarachnoid hemorrhage (aSAH).

Methods

We conducted a retrospective study of 59 patients transported to our hospital and diagnosed with aSAH between April 2022 and May 2023.

Results

The analysis included 33 patients who were treated with clazosentan. Pulmonary complications occurred in 20 patients (61 %) and clazosentan administration was discontinued due to severe pulmonary complications in 7 patients (21 %). The cardiothoracic ratio on admission was significantly higher (57 % vs. 49 %, p = 0.0081) and clazosentan was initiated earlier after aSAH onset (42 vs. 66 h, p = 0.047) in patients who discontinued clazosentan compared with patients who completed administration of clazosentan. The median duration of clazosentan administration was 3.2 days in the discontinuation group. No significant associations were found between the time of clazosentan initiation and the incidence of angiographic vasospasm, delayed cerebral ischemia, or 90-day modified Rankin scale.

Conclusions

The risk of severe pulmonary complications is higher in patients with high cardiothoracic ratios on admission, and delaying clazosentan initiation may prevent pulmonary complications even in high-risk cases.

Objective

This study aimed to assess the changes in patient demographics, aneurysm characteristics, and treatment modalities for subarachnoid hemorrhage (SAH) over the past two decades.

Methods

We analyzed SAH 6,446 patients between 2002 and 2022, which was divided into three periods: 2002–2011 (FP), 2012–2021 (SP), and post-clazosentan 2022 (PC). The final cohort included 2878, 2016, and 152 patients in FP, SP, and PC groups, respectively. We examined patient demographics, surgical procedures, spasm prevention therapy, and delayed ischemic neurological deficits (DIND).

Results

The mean age of the patients increased over the study period (64, 66, and 68 years in FP, SP, and PC groups, respectively). Clipping was the predominant method during FP (79 %); however, coiling surpassed clipping in 2022 (coiling vs. clipping, 47 % vs. 46.3 %). Before clazosentan introduction, fasudil was the primary spasm prevention treatment (>80 %); however, its use decreased (63.9 %) after clazosentan introduction. DIND varied across FP, SP, and PC groups (37.4 %, 24.2 %, and 16.7 % respectively). Age and generation were significantly associated with DIND and irreversibility.

Conclusion

Regarding the management of patients with SAH, shift from clipping to coiling, and the introduction of new spasm prevention treatments such as clazosentan were observed, led to a decrease in DIND.