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Purpose: Post-traumatic cerebral venous sinus thrombosis (ptCVT) is a rare but serious complication of traumatic brain injury (TBI). Managing ptCVT is challenging due to the concurrent risk of traumatic intracranial hematoma (ICH) expansion. Limited data exists on the safety and efficacy of anticoagulation therapy (ACT) in these cases. Methods: This single-center observational cohort study included adult TBI patients with concurrent ICH and ptCVT. Low-molecular-weight heparin (LMWH) or heparin infusion was used to treat all ptCVTs based on institutional protocols. The outcomes of interest were hemorrhagic and thrombotic complications. Results: Out of 1,039 TBI-patients admitted between 2006 and 2020, 32 met the inclusion criteria. The median time from injury to ptCVT diagnosis was 24 h. ACT was initiated at a median of 9 h after ptCVT diagnosis. Patients were administered either heparin infusion (n = 8) or LMWH at dosages ranging from 28 to 72% of the therapeutic level (n = 24). There were no hemorrhagic complications, even in patients receiving LMWH at ≥ 50% of the therapeutic dose. Thrombotic complications occurred in 3 patients (9.4%) – two cases of thrombus progression and one venous infarct. The patients who developed thrombotic complications differed from those who did not by having a 17-h delay in ACT initiation after diagnosis or by receiving an initial LMWH dose at 28% of the therapeutic level. Conclusion: LMWH at approximately 50% of the therapeutic level was effective for managing ptCVT associated with TBI in our retrospective dataset, with no risk of hematoma expansion. Prospective trials are warranted to confirm these results. [ABSTRACT FROM AUTHOR]

Background: Mild traumatic brain injury (TBI) in anticoagulated patients is a common challenge for emergency departments because of lack of appropriate epidemiological data and huge management variability for those under oral anticoagulation therapy. Given the discrepancies between guidelines, the aim of the present study was to quantify the association between oral anticoagulant therapy (either vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC)) and the post-traumatic intracranial hemorrhage worsening compared to admission CT scan. Methods: We included all consecutive records of patients admitted to our emergency department for mild TBI as chief complaint and with a positive admission CT scan. After statistical univariate comparison, cause-specific hazard ratio (HR) and 95% confidence interval (CI) were determined with the use of Cox proportional hazard model. Results: In the study period, 4667 patients had a CT scan for mild TBI; 439 (9.4%) were found to have intracranial hemorrhage. Among these patients, 299 (68.1%) were prescribed observation and control CT: 46 (15.38%) were on anticoagulant therapy, 23 (50%) on VKA, and 23 (50%) on DOAC. In multivariate analysis, only oral anticoagulation therapy was significantly associated to an increased risk of intracranial hemorrhage progression (HR 2.58; 95% CI 1.411–4.703; p =.002 and HR 1.9; 95% CI 1.004–3.735; p =.0048 for VKA and DOAC, respectively). Surgery was due to isolated subdural hematoma in 87.5% of cases, to subdural hematoma associated with intraparenchymal hemorrhage in 9.38% and to intraparenchymal hemorrhage only in 3.12%; 13 cases (4.35%) deceased in intensive care unit. Conclusions: In our series, anticoagulation was associated to a significant increase in intracranial progression, leaving the question open as to what this implies in current clinical practice; subdural hematoma was the major finding associated to evolution and surgery. Against this background, further studies are needed to clarify patients' management and DOAC safety profile compared to VKA in mild TBI. [ABSTRACT FROM AUTHOR]

Krönlein studied the preferred location of the epidural hematomas and recommended a systematic scheme of prophylactic burr holes with the greatest likelihood of exposing the hematoma under the bone [[4]]. It was Petit who recommended timely removal of the hematoma under the fissure, while the fissure itself did not need much attention. One out of four patients with a fissure or fracture will develop a surgically relevant intracranial hematoma. [Extracted from the article]

Accumulation of contrast medium in the subdural space after diagnostic intraarterial contrast administration is a rare observation. The authors report the case of a subdural contrast effusion (SCE) presenting during endovascular treatment of an intracranial dural arteriovenous fistula (DAVF) mimicking an acute subdural hematoma. Differentiation between the two by computed tomography (CT) or intraprocedural Dyna CT and early neurological examination can be crucial for patient management. We believe that repeated large-volume contrast injections via large-bore intermediate catheters into the territory of an (even partly) occluded DAVF may induce leakage of contrast medium into the extravascular subdural space thereby causing a SCE. [ABSTRACT FROM AUTHOR]

Besides the established spot sign in computed tomography angiography (CTA), recently investigated imaging predictors of hematoma growth in noncontrast computed tomography (NCCT) suggest great potential for outcome prediction in patients with intracerebral hemorrhage (ICH). Secondary hematoma growth is an appealing target for therapeutic interventions because in contrast to other determined factors, it is potentially modifiable. Even more initial therapy studies failed to demonstrate clear therapeutic benefits, there is a need for an effective patient selection using imaging markers to identify patients at risk for poor outcome and thereby tailor individual treatments for every patient. Hence, this review gives an overview about the current literature on NCCT imaging markers for neurological outcome prediction and aims to clarify the association with the established spot sign. Moreover, it demonstrates the clinical impact of these parameters and gives a roadmap for future imaging research in patients with intracerebral hemorrhage. [ABSTRACT FROM AUTHOR]

Cerebral amyloid angiopathy (CAA), a cause of recurrent and multiple lobar hemorrhages, characteristically occurs in persons aged ≥55 years. We report a case of a 32-year-old male who had recurrent hemorrhage in the left multiple lobes, with a history of traumatic brain injury and hematoma evacuation at the age of 1 year. He underwent surgical treatment and was histopathologically diagnosed as having CAA. The literature review yielded six CAA cases, including ours, aged less than 55 years. All were male and four had histories of severe TBI, suggesting that male sex and TBI may be associated with CAA in young persons. [ABSTRACT FROM AUTHOR]

In the fulminant VTE form with cardiac arrest, systemic thrombolysis remains the most effective therapy. However, several contraindications restrict the use such as intracranial neoplasm or a recent history of intracranial surgery. Here, we report the case of a 59-year-old man who underwent glioblastoma resection and suffered from a fulminant pulmonary embolism with cardiac arrest. After CPR, continuous tPA infusion via an endovascularly placed pulmonary catheter was maintained over a period of 8 h. In this case, we report on our decision-making process and the use of local thrombolysis as a successful therapy in a patient with multiple contraindications. [ABSTRACT FROM AUTHOR]

Background: Multiple AVMs are exceptionally rare lesions and only a few larger series have been published, including other vascular pathologies, such as arterio-venous fistulae (AVF) or patients with hereditary syndromes. Our study presents clinical, angiographic, and therapeutic characteristics of patients harboring sporadic multiple AVMs. Methods: Basic demographic data, vascular architecture, clinical presentation, treatment strategies, and treatment outcome were analyzed retrospectively from patients with cerebral AVMs treated in our department between 1990 and 2015. Results: Six out of 539 patients (1.1 %) harbored 15 multiple and distinct cerebral lesions. Nidus size was predominantly small, consequently determining a Spetzler-Martin grade °I-°II (three-tier grading system). In three patients, AVMs shared a proximal feeding artery supply, whereas each AVM displayed its own venous drainage. Five of six patients (83 %) presented with hemorrhage. Four patients received therapy of the AVMs with complete elimination in 3/4 patients (75 %) and 8/9 treated AVMs (89 %). All patients with treatment of the AVM showed good-to-excellent recovery ( n = 4, mRS ≤ 2). Conclusions: Multiple cerebral AVMs are complex vascular lesions. The multiplicity of hemodynamic and malformation-related variables influence treatment strategy and sequence. Thus, awareness of these parameters (of various malformations before and during treatment) is important. The high number of hemorrhagic events in the present series might justify a more aggressive treatment of multiple AVMs than previously thought. [ABSTRACT FROM AUTHOR]

Background: Postoperative intracranial hematoma (POIH) is a frequent sequela secondary to cranial surgery. The role of routine early postoperative computed tomography (CT) scanning in the detection of POIH remains controversial. The study was aimed at analyzing the effect of routine early CT scanning after craniotomy for the early detection of POIH. Methods: Routine early postoperative CT scanning was performed at our institute, and a retrospective study was conducted to analyze the data. POIH was defined as an intracranial hematoma requiring surgical management. Results: A total of 1,148 patients undergoing craniotomy were included in this study; 28 of these patients developed POIH. The majority of POIH cases (15/28, 54 %) were detected during the first 6 h following craniotomy. A routine CT scan was performed on all included patients but two; however, CT scans detected only 16 POIH cases. During the first 6 h, the rate at which CT scans detected POIH was 1.9 % (15/786); subsequently, the rate decreased to only 0.3 % (1/360; p < 0.05, compared with the rate during the first 6 h). Among patients without clinical manifestations, the rate at which the routine post-craniotomy CT scan detected POIH was only 0.7 % (5/721) ( p < 0.05, compared with the incidence of POIH). Finally, among high-risk POIH patients, the POIH-positive rate of routine CT scanning was elevated. Conclusions: It appears that routine early CT scan is ineffective for the detection of POIH in patients undergoing craniotomy. However, if the strategy for routine scanning can be improved, its effect may be beneficial. [ABSTRACT FROM AUTHOR]

We report three cases of traumatic microbleeds evaluated by sequential observation. Hypo-intensities on T2* gradient echo imaging (T2*GEI) appeared just 2-3 h after the injury (the hyper-acute period). However, these hypo-intensities on T2*GEI disappeared or became obscure 2-6 days after the injury (the subacute period). A follow-up MRI again revealed clear hypo-intensities on T2*GEI 1-3 months after the injury (the chronic period). Our cases indicate that hypo-intensities on T2*GEI might change dynamically from the hyper-acute to the chronic period. The differences of susceptibility effects by hematoma age might be the cause of this dynamic change. [ABSTRACT FROM AUTHOR]

In this report we detail the case of an infant presenting with a giant intracranial congenital hemangioma and describe the clinical features and surgical management. Congenital hemangiomas are benign vascular tumors that typically present as skin lesions in neonates and infants. On rare occasions they present as intracranial tumors. The possibility that these tumors may undergo spontaneous regression poses a treatment dilemma. [ABSTRACT FROM AUTHOR]

Background: Specific pathophysiological mechanism in intracerebral hemorrhage (ICH) at high altitude is unclear, and at present, there is no relevant and suitable animal model. Methods: A hypobaric chamber was used to simulate an altitude of 4,000 m. Autologous arterial blood (3 ml) was slowly infused into the right basal ganglia of minipigs by a double-injection method for producing ICH. Results: The intracranial pressure and neurological score of the high-altitude group were significantly higher than those of the low-altitude (plain) group. The brain water contents and pathological lesions of perihematoma tissue were more severe in the high-altitude group. Conclusions: The injury resulting from ICH at high altitude was more severe than that in the plain group. This model was able to produce controllable and reproducible hematomas and visible neurological deficits, which may be useful for future studies of the pathophysiology and functional rehabilitation of high-altitude ICH disease. [ABSTRACT FROM AUTHOR]

Background: Coagulation factor XIII and other haemostatic markers are known strengthen fibrin clot formation and, hence, may facilitate safer surgery. Currently however, factor XIII activity levels are not routinely screen. Therefore, the purpose of this study was to determine the association of perioperative factor XIII activity levels and other haemostatic markers with postoperative intracranial haematoma formation in neurosurgical patients. Methods: Between January 2008 to Jun 2009, all neurosurgical patients who underwent intracranial surgery were screened for the study. Patients had blood samples taken preoperatively and within 24 h post-surgery for factor XIII and other haemostatic markers. The intracranial surgeries for the patients involved were performed according to their respective indications using standard neurosurgical techniques. Postoperatively, patients had a computed tomography (CT) brain scan, with the imaging results grouped into three classes: significant haematoma (group I), insignificant haematoma (group II) and no haematoma (group III). Results: Of the total 84 enrolled patients, 5 (6%), 28 (33.3%) and 51 (60.7%) patients were assigned to group I, II and III respectively. Significant postoperative haematoma that required re-surgery was related to low postoperative platelet count ( p < 0.01), and higher odds ratio of developing postoperative intracranial haematoma were shown with two combination factors: low postoperative factor XIII and platelet levels; and low postoperative factor XIII and antithrombin levels. Conclusion: Low platelet count can cause significant volume postoperative intracranial haematoma and in presence of multiple defects in haemostatic markers appears to be clinically useful to predict the formation of postoperative intracranial haematoma in neurosurgical patients. [ABSTRACT FROM AUTHOR]

The antithrombotic agents are usually interrupted in fear of bleeding complications before neurosurgery. However, the optimal schematic regimen of substitutive medication to prevent thromboembolic events after surgery is unsettled. We report five complex neurosurgical cases with high risk for thromboembolism requiring thromboprophylaxis during craniotomy. In one patient with coronary bare metal stent and antiplatelet therapy, acetylsalicylic acid and clopidogrel was discontinued 5 and 11 days prior to surgery, respectively. Four other patients were on regular warfarin therapy due to previous deep venous thrombosis, pulmonary embolism, or mechanical aortic valve. Adjusted bridging therapy with low-molecular-weight heparin was applied in all cases. The patient with the coronary stent who was managed with reduced-dose dalteparin developed postoperative intracranial hemorrhage despite having platelet and fresh-frozen plasma transfusions, and the patient did not survive. Another patient with a history of lower-extremity deep venous thrombosis developed a postoperative intracranial hematoma but also a recurrence of left lower extremity deep venous thrombosis and had a delayed recovery. The other two patients with history of pulmonary embolism, and one patient having mechanical aortic valve and atrial fibrillation, recovered uneventfully when reduced doses of low molecular weight heparin bridging therapy were administered. Our observations confirm the complexity of balancing the risks of bleeding and thrombosis in neurosurgical patients on antithrombotic medication. In these patients, the individual bleeding risk is likely minimized by the administration of reduced doses of LMWH relatively late after craniotomy and by delaying the start of warfarin after surgery. [ABSTRACT FROM AUTHOR]

Background. Endoscopic evacuation of intracerebral haematoma (ICH) has the advantage of being less invasive than craniotomy, but limited visualisation and difficulties in haemostasis are still a concern. The collapse of the haematoma cavity limits the visualisation of the surgical field. Inflation of the haematoma cavity with saline irrigation improves visualisation and facilitates accurate intra-operative orientation. Method. A unique technique, the cavity inflation–deflation method can help in exploring the residual haematoma and accessing the bleeding points. We also developed a combined irrigation-coagulation suction tube that concentrates the capabilities of suction, irrigation and monopolar coagulation. Findings. The use of this multifunctional dedicated instrument and its application in the cavity inflation–deflation method allows for easy identification of residual haematoma and bleeding vessels. Secure haemostasis can also be accomplished under clear visualisation. No surgical complications and rebleeding occurred in any patient following the procedure. Our results show that the median haematoma evacuation rate was 99% and the surgical outcome was satisfactory. Conclusions. The inflation–deflation method using a combined irrigation-coagulation suction tube can facilitate optimal evacuation of ICH with secure haemostasis. Although further accumulation of patients and careful analyses are needed to be known whether this procedure improves the clinical outcomes in the patients, the preliminary results of its application have been promising. [ABSTRACT FROM AUTHOR]

Background. Most traumatic carotid-cavernous fistula/e (TCCF) are unilateral, and simultaneous bilateral TCCF are uncommon. The purpose of this study was to evaluate the angiographic architecture of bilateral TCCF and report our experience with their endovascular management. Method. Over 15 years, 252 consecutive patients with TCCF were referred to our institute for endovascular treatment. Bilateral TCCF occurred in 5 men and 2 women with a mean age of 31 years. The angiographic architectures of bilateral TCCF were evaluated with cerebral angiography. All patients underwent a single session of transarterial embolisation by using various permanent embolic materials and were followed up clinically or with angiography for a mean of 22 months (range 9–36 months). Findings. All patients presented with neuro-ophthalmic symptoms and signs. No new instances of cerebrovascular ischemia or intracranial haematoma resulted from bilateral TCCF. All fistulae were associated with partial arterial steal and were successfully occluded by using a detachable balloon and/or a detachable coil with or without a liquid adhesive. Of 14 TCCF, 9 were completely obliterated with preserved flow of the internal carotid artery (ICA). In the other 5 fistulae, the ICA had to be sacrificed to achieve occlusion because the anatomy of the fistula was complex. All fistula related symptoms resolved immediately or gradually during clinical follow up. No clinically significant procedure related neurological complications or recurrent fistulae were observed. Conclusions. All bilateral TCCF were associated with a partial arterial steal phenomenon. Single session endovascular treatment using various embolic materials was effective in managing these high-flow fistulae. In all patients, it was possible to preserve one or both ICAs. [ABSTRACT FROM AUTHOR]

Objective. Distal middle cerebral artery (dMCA) aneurysms are very rare with a reported frequency of 2–6%. Typically, patients with ruptured distal MCA aneurysms have poor clinical outcomes because often there is both a subarachnoid haemorrhage (SAH) and an intracerebral haematoma (ICH). The goals of this study were to identify the characteristics of the distal MCA aneurysms and evaluate the optimal treatment for a good outcome. Methods. The clinical, neuroradiological and operative records of 8 patients with a ruptured distal MCA aneurysm who underwent surgical management were reviewed retrospectively. The outcomes were presented according to the Glasgow Outcome Scale (GOS). Results. The clinical characteristics of the patients with ruptured dMCA aneurysms included the following: (1) a fusiform appearance in five out of eight (63%) patients. (2) Mean aneurysm size of 9.4 mm (range 2–35 mm). (3) The location being M2 (insular segment) in three, M2-3 junction in three, and M3 (opercular segment) in two patients. (4) Brain CT images revealed both SAH and an ICH in six of eight (75%) patients with the mean size of the ICH being 10 cc (range 5–25 cc). (5) Re-bleeding occurred in four out of eight (50%) of patients. All patients underwent early surgical treatment and the procedures used for surgical repair were, clipping in five patients, trapping in two, and trapping with end-to-end bypass surgery in one patient. Clinical outcomes were poor in two patients (death) due to severe brain swelling. Conclusions. In this study, dMCA aneurysms had a fusiform shape and a high re-bleeding rate; if ruptured, there was generally ICH and SAH. A good clinical outcome was associated with adequate control of brain swelling and early surgery to prevent re-bleeding. [ABSTRACT FROM AUTHOR]

Background. None of the randomized controlled trials (RCT) on treatment of Intracerebral haematoma (ICH), definitely shows surgery to be beneficial over conservative treatment alone. Systematic reviews that pooled these RCTs were also inconclusive. This systematic review updates previous meta-analyses, using an alternative manner of reviewing with a criteria list constructed specifically for this type of disease and related interventions. Methods. RCTs and quasi-RCTs (q-RCT) published in English were identified with a systematic literature search. They were evaluated with disease/intervention-specific criteria on comparability between intervention and control group concerning prognostic factors, co-interventions and effect measurement. The resulting selection of studies was compared with those of two earlier systematic reviews. In a meta-analysis selected studies were statistically pooled. Findings. The meta-analysis of surgery versus conservative treatment failed to show a statistically significant reduction in the odds of death (OR: 0.84, 95% CI: 0.67–1.07) in surgically treated patients. Conclusions. Like previous reviews, our disease/intervention-specific methodological evaluation showed no reduction in mortality. Sensitivity analysis demonstrates that the manner in which studies are methodologically evaluated in a systematic review has a great impact on its conclusions. [ABSTRACT FROM AUTHOR]

Backgrounds. Up to now, extra-dural haematomas (EDH) in elderly patients have been known for their poor prognosis and few studies have focused on the particularity of EDH in the elderly. Most clinical studies relating to EDH have generally focused on its occurrence in children and the middle-aged, grouping people of over 50 and 60 years together as the elderly. The purpose of this paper is to present a series of EDH cases in the elderly. Method. 500 EDH patients (of all ages) were admitted to our Department from January 1990 to December 2003 and this is a retrospective study of 14 of those patients who were aged 70 years and over. Findings. The study consists of 8 women and 6 men with an average age of 74 years. A high incidence of disease predisposes elderly to falls, which are the most frequent cause of head trauma. The elderly are less likely to manifest signs or symptoms of increased intracranial pressure due to cerebral atrophy, and almost all haematomas occurred in the parietal area. Post-operative results were satisfactory and only one death was recorded. Conclusion. This study shows that the elderly, presenting EDH after a fall, have a better prognosis than is often feared. [ABSTRACT FROM AUTHOR]

Summary ¶Objective. Massive intraoperative swelling (IOS) is a potential complication of intracranial surgery for traumatic hematomas. We present a novel design of dural opening to minimize the risks of IOS. Methods. Over the last eight years, we have used and evaluated a “reversed U-shaped” durotomy incision, which leaves the dura intact in the parasagittal region. Accordingly, the dura should be opened initially over the fronto-basal eminence of the frontal lobe anterior to the middle meningeal artery and sylvian region. The incision is then carried across the middle meningeal into the temporal region. Additional slit incisions may be made, as needed, around the circumference of the craniotomy in order to obtain sufficient access to remove a subdural hematoma. Results. We have employed this technique in 220 trauma craniotomies without any case of uncontrolled IOS. In all patients a complete dural closure was obtained. Conclusion. When IOS is suspected, basal durotomy proved to be an excellent technique to prevent it, without compromising the total evacuation of the traumatic intracranial hematoma. [ABSTRACT FROM AUTHOR]

Summary. Background: Extra-axial chronic fluid collections are pathological conditions occurring more frequently in the paediatric age, particularly in children less than two-year-old. Although recognised for many years and repeatedly reported in the literature, some aspects of their treatment are still under debate. This review of the management of chronic subdural collections is based on our experience of 72 cases treated between January 1984 and December 2000. Method: Patients were divided into four groups according to aetiology. Thirty-four cases (47%) occurred following various surgical procedures; 14 cases (20%) occurred as complications of leptomeningeal infections; 13 cases (18%) were post-traumatic, whereas no obvious aetiology could be detected in the last 11 cases (15%). The collections were unilateral in 34 patients (47%) and bilateral in the other 38 (53%). Findings: Thirty-five patients (48%) were treated by means of a temporary subdural external drainage (SED) (for a total of 38 SED procedures), which was maintained for a mean of 5.8 (±3.4) days; it was effective in 26 cases, whereas in the other 9 it was necessary to perform a subdural-peritoneostomy (SPS). Three of these 38 SEDs were complicated by infection. In one more child the external drainage was complicated by a chronic subdural haematoma. A SPS was performed in 44 cases (61%), 9 being failed external drainages. Only in 16 (38%) of these 44 patients the SPS was removed after an average of 27.0 (±16.6) months. Three patients (4%) were treated by craniotomy and resection of the neomembranes lining the subdural fluid collection. Obstruction of the SPS occurred in 6 children, infection in 4. Good results were obtained with either external or internal drainage. In fact post-operative neuroradiological investigation disclosed in all the cases complete or almost complete cerebral re-expansion; also the clinical outcome was generally very good, although largely dependent upon the basic clinical condition. Unilateral subdural-peritoneal and/or external drainage was effective also in case of bilateral collections. Only 2 patients required temporary bilateral external drainage. [ABSTRACT FROM AUTHOR]

Summary. Introduction: Chronic subdural haematomas of the posterior fossa in adults without a history of trauma are very rare. To our knowledge, only 15 cases have so far been reported in the literature, including those with anticoagulation therapy. A case of spontaneous bilateral infratentorial chronic subdural haematoma associated with anticoagulation therapy in an alive adult is presented and the relevant literature is reviewed. Case Report: A 70 year old female presented with progressive dizziness, vertigo and gait ataxia. She was on anticoagulation therapy for heart disease. Neuro-imaging revealed bilateral infratentorial subdural masses. The subdural masses were suspects for chronic subdural haematomas by neuroradiological criteria. Because of the progressive symptomatology, the haematomas were emptied through burrhole trepanations. Chocolate-colored fluid, not containing clotted components, gushed out under great pressure. The source of bleeding could not be identified. The patient recovered well from surgery, but died 4 months later shortly after admission to another hospital from heart failure. Discussion: The chronic subdural haematomas in this patient may have been due to rupture of bridging veins caused by a very mild trauma not noticed by the patient and possibly aggravated by the anticoagulation therapy. Infratentorial chronic subdural haematoma should at least be a part of the differential diagnosis in elderly patients with cerebellar and vestibular symptomatology even without a history of trauma. [ABSTRACT FROM AUTHOR]

Summary. Object: The management of intracranial aneurysms has truly evolved after the introduction of endovascular treatment by Guglielmi Detachable Coils (GDC). In our department, for every case (ruptured or unruptured aneurysm) we discuss in the first place endovascular treatment. When coiling is feasible, it is done as a first choice. If not (intracranial compressive haematoma, coiling unfeasible or dangerous), the patient is operated upon. Failure of the endovascular technique, like incomplete treatment and regrowth of the residual sac, becomes a subject of discussion. Some cases need complementary treatment for large or unstable residual aneurysm. Methods: Thus, between 1997 and 2000, 59 ruptured aneurysms were treated using an endovascular method by means of GDC. In 15 of this cases complementary treatment was needed, due to the size or instability of the residual aneurysm. In 8 cases a new embolization was possible and in 7 cases a complementary surgical procedure was needed, due to the impossibility of further endovascular treatment. Results: Out of these 7 cases who were operated upon after coiling, clipping of the residual neck was possible in 4 cases; in 3 cases clipping was impossible due to the partial filling of the aneurysm neck by the coils. In these 3 cases, a ligation of the residual neck, associated with coagulation of the sac was performed. Discussion: The difficulty of the treatment of an residual aneurysm after coiling is discussed as well as those surgical techniques alternative to clipping (wrapping or coagulation of the residual sac). [ABSTRACT FROM AUTHOR]

Summary. Background: We prospectively evaluated the role of endoscopic third ventriculocisternostomy in the management of acute obstructive hydrocephalus created by cerebellar hematomas. Method: Following a therapeutic diagram based on clinical and radiological signs, endoscopic third ventriculocisternostomy was used to treat hydrocephalus associated with cerebellar hematomas in 8 patients (male: 5, female: 3, mean age: 67 years-old). Causes of cerebellar hemorrhage were spontaneous in 6 cases, traumatic in 1 case, and acute bleeding of a posterior fossa tumor (lung metastasis) in the remaining case. Deeply comatose patients (Glasgow Coma Score between 3 and 5) and patients with signs of brainstem compression were initially excluded from this study. Findings: Overall clinical improvement after third ventriculocisternostomy was achieved in all patients and was associated with the decrease of the ventricle size on follow-up CT scans. One patient who initially had a clot evacuation associated with an external ventricular drainage and persistant hydrocephalus had a successful third ventriculocisternostomy in the post operative course. No complication related to the procedure was noted. Interpretation: In selected patients, third ventriculocisternostomy can be used to treat hydrocephalus associated with posterior fossa hematomas. [ABSTRACT FROM AUTHOR]

Summary. Objective: A review of the literature shows 33 cases of ipsilateral subdural haematomas (SDH) associated with meningiomas. We suggest that physiopathological mechanisms could be primary haemorrhages from abnormal vessels in the tumours and the opening of the intratumoral haematomas into the subdural space. Our working hypothesis relies on a series of 300 meningiomas operated upon in our department since 1990; of these, 4 were revealed by SDH. Clinical Presentation: The four patients surgically treated in our department had developed a progressive impairment of consciousness. There was no history of trauma, blood dyscrasia or anticoagulant therapy. After diagnosis, the SDH was drained, and the meningeal tumour was totally resected once it had been discovered. In one case, the presence of a tumour was demonstrated by magnetic resonance imaging (MRI) performed only after the evacuation of a recurrent SDH. Intervention: In each case, an acute SDH showing signs of recent bleeding was evacuated. The meningeal tumour discovered proved to be the source of the haemorrhage because of the numerous fresh blood clots both around and inside it. Histology: In the four cases histology showed fresh intratumoral haemorrhages (ITH), large blood vessels with thin endothelial linings and haemosiderin deposits. In this review, SDH is associated with other haemorrhage sites in 24 of 37 cases (33+our 4 cases). ITH was present in 14 cases (40%). Conclusion: The treatment should consist of the extirpation of the meningioma at the same time as the evacuation of the haematoma. If primary ITH from abnormal vessels is the source of SDH, complete meningioma resection should prevent the recurrence of SDH. Subdural membranes and haematomas should therefore be inspected for their intrinsic pathology, especially when there is no history of trauma. [ABSTRACT FROM AUTHOR]

Summary. Background: Spontaneous intracranial haemorrhage is not common in infants, with differences from adults in both aetiology and severity. The infantile CNS is more vulnerable because of incomplete hydrovenous maturation. We analyzed infantile intracranial haemorrhage mainly caused by structural brain lesions and discuss specific aetiologies with regard to haemodynamic characteristics. Subjects and Methods: We reviewed 20 infants less than 2 years of age from a total of 328 neonates and infants with intracranial vascular lesions seen in our institution since 1985. Associated or causative lesions were arteriovenous malformation (AVM) in 6, dural sinus malformation (DSM) in 4, arteriovenous fistula (AVF) in 3, aneurysm in 2, developmental venous anomaly (DVA) in 1, vein of Galen malformation (VGAM) in 1, and others in 3. The locations of haematomas were intracerebral (ICH) in 8, combined ICH and intraventricular haemorrhage (IVH) in 5, IVH alone in 5, subarachnoid haemorrhage (SAH) in 1, and combined SDH and ICH in 1. Findings: Three patterns of haemorrhage were noted in high-flow vascular lesions such as AVM or AVF (n=9); haemorrhage at the site of nidus or fistula corresponding to nidal pseudoaneurysm in 4, regional venous hypertension with pial venous reflux in 3, global venous infarction causing multifocal haemorrhage in distant brain areas in 2. Aneurysmal bleeds were caused by dissecting aneurysms at the level of dural penetration of cranial vessels. One infant had haemorrhage near a DVA without evidence of cavernous malformation suggesting the possibility of venous ischaemia. IVH was associated with shunt operations in 4 infants with DSM, and SDH followed by ICH in a infant with VGAM. Interpretation: Spontaneous intracranial haemorrhage in infants and neonates is rare; it is associated with specific lesions which show some differences from their adult counterparts. The vein-related causes of hemorrhage are largely the pathophysiologic characteristics in this age group. Absence of hemorrhage in VGAM is remarkable in addition to occurrence of most hemorrhages after shunting. [ABSTRACT FROM AUTHOR]

Summary¶ We report about 50 patients with spontaneous intracerebral haematomas (ICH) caused by intracranial neoplasms to assess the underlying histological condition, their presentation on admission, diagnostic work-up, treatment, histological diagnosis, and clinical outcome. These patients were identified in a prospective series of 2041 patients with intracranial neoplasms and 692 patients with spontaneous ICH, which were both consecutively collected over a nine-year-period. The frequency of ICH in patients with intracranial neoplasms was 2.4%. The frequency of tumour related ICH in the ICH group was 7.2%. The leading cause of tumour related ICH were metastases of extracranial origin (n=18; 36%), followed by glioblastoma multiforme (n=15; 30%). Nine patients (18%) had benign primary intracranial neoplasms. On admission 18 patients were somnolent (36%) and 14 patients (28%) were comatose. In 29 cases (58%) ICH was the first clinical sign of neoplastic disease, while in 21 patients (42%) a malignant tumour was already known. We operated on 45 patients (90%), four patients (8%) were not operated on because of poor clinical condition and died, one patient refused surgical treatment. Six patients (12%) died despite surgery. This series confirms the importance of a proper neuroradiological and clinical work-up of patients with suspected tumour related ICH followed by operative treatment and histological confirmation of the diagnosis. This is supported by the fact that 18% of patients had prognostically favourable intracranial tumours which would not otherwise have been adequately treated. [ABSTRACT FROM AUTHOR]