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Introduction: Spontaneous intracerebral haemorrhage associated with oral anticoagulants (ICH-OAC) has a high mortality rate. The emergence of new anticoagulant drugs and reversal protocols increases interest in this entity., Objectives: The main objective is to determine the mortality rate in patients with ICH-OAC (early, in-hospital, global) in our health area and to analyse the main variables related to it. The secondary objective is to determine the efficacy of anticoagulation reversal therapies (ART) as reflected by radiological expansion of the haematoma and the functional prognosis., Patients and Methods: A prospective observational study that introduced a protocol aimed at the management of patients with ICH-OAC. It included general measures and neuromonitoring, individualised administration of ART, cranial tomography and a six-month follow-up. Data on the drugs prescribed in the area during this period, mortality and functional prognosis were collected. A bivariate and logistic regression study was designed to investigate mortality-related variables., Results: Forty-nine patients were included over three years; of these, 71.4% received ART. Mortality was 16.3% (first 24 hours), 53.1% (admission) and 61.2% (180 days). Lower survival was observed among patients with higher baseline scores on the National Institutes of Health Stroke Scale (NIHSS) (p < 0.0001), creatinine value (p = 0.02), International Normalised Index (p = 0.048), bleeding volume (p = 0.008), hydrocephalus (p = 0.015) and acenocoumarol intake (p = 0.030). Patients who did not receive ART had a greater rate of early mortality (p = 0.003). The only variable independently related to overall mortality was the baseline NIHSS score (odds ratio = 1.282; 95% confidence interval: 1.023-1.608; p = 0.031)., Conclusions: ICH-OAC has a high mortality rate, related to the use of acenocoumarol and regardless of the initial clinical situation. A lower rate of early mortality was found among patients who received ART.

Introduction: Brain microbleeds (BMB) are haemosiderin deposits contained within macrophages, which are displayed as hypointense images in some T2-weighted magnetic resonance imaging sequences. There are still many questions to be answered about the pathophysiology and clinical relevance of BMB., Development: We conducted a literature review of the main epidemiological, clinical, and anatomical pathology studies of BMB performed in the general population, in patients at risk of or already suffering from a vascular disease, and in patients with cognitive impairment. We analysed the prevalence of BMB, risk factors, and potential pathophysiological mechanisms and clinical implications., Conclusions: The prevalence of BMB is highly variable (3%-27% in the general population, 6%-80% in patients with vascular risk factors or vascular disease, and 16%-45% in patients with cognitive impairment). BMB are associated with ageing, Alzheimer disease (AD), and in particular haemorrhagic or ischaemic cerebrovascular disease. The pathological substrate of BMB is either lipohyalinosis (subcortical BMB) or cerebral amyloid angiopathy (lobar BMB). BMB exacerbate cognitive impairment, possibly through cortical-subcortical and intracortical disconnection, and increase the risk of death, mostly due to vascular causes. BMB also increase the risk of cerebral haemorrhage, particularly in patients with multiple lobar BMB (probable erebral amyloid angiopathy). Therefore, anticoagulant treatment may be contraindicated in these patients. In patients with lower risk of bleeding, the new oral anticoagulants and the combination of clinical and magnetic resonance imaging follow-up could be helpful in the decision-making process., (Copyright © 2016 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.)

Intracerebral haemorrhage accounts for 10%-15% of all strokes; however it has a poor prognosis with higher rates of morbidity and mortality. Neurological deterioration is often observed during the first hours after onset and determines poor prognosis. Intracerebral haemorrhage, therefore, is a neurological emergency which must be diagnosed and treated properly as soon as possible. In this guide we review the diagnostic procedures and factors that influence the prognosis of patients with intracerebral haemorrhage and we establish recommendations for the therapeutic strategy, systematic diagnosis, acute treatment and secondary prevention for this condition., (Copyright © 2011 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Introduction: Lobar intracerebral haemorrhage (LIH), is a rare cause of stroke which accounts for about 20% of primary intracerebral haemorrhages. The most common causes are cerebral amyloid angiopathy (CAA), high blood pressure and others, such as using anti-platelet or anticoagulation agents. We analysed a series of patients with LIH and compared it with subgroups of patients with LIH who were previously receiving anti-platelet or anticoagulation agents. We determined the volume of the bleeding and its predictive value for mortality., Patients and Methods: We consecutively and retrospectively included 162 patients diagnosed with LIH and cared for in the Neurology Department of Hospital Meixoeiro in Vigo between 1991 and 2009. We collected demographic characteristics, risk factors, aetiologies and symptoms, and conducted a comparative analysis between the general series and the subgroups of patients receiving anticoagulation and anti-platelet agents., Results: In the general series, the most common cause was possible or probable CAA followed by hypertension. In the subgroup of patients receiving anti-platelet or anticoagulation agents there were no differences in the variables studied, except for the frequency of heart disease. Nonetheless, there were differences with respect to age, heart disease and bleeding volume between the general series (patients not treated with anti-platelet or anticoagulation agents) when compared with the subgroups of patients receiving anti-platelet and anticoagulation agents., Conclusions: We provide new information regarding the clinical behaviour of LIH and its differences in patients receiving anti-platelet or anticoagulation agents. Mortality is higher in cases of LIH on anticoagulants. LIH. Female sex and the volume of bleeding are predictors of mortality., (Copyright © 2011 Sociedad Española de Neurología. Published by Elsevier España. All rights reserved.)

Background: Oral anticoagulant therapy (ACO) is considered an independent predictor of mortality in patients with intracerebral haemorrhage (ICH), with the role of the international normalised ratio (INR) being unclear. The aim of this work is to evaluate the relationship between ACO and the INR value and the ICH volume, and to determine the relationship between both variables and mortality., Patients and Methods: Patients were retrospectively analysed using the Private Community Cerebrovascular Hospital Register (Registro Cerebrovascular del Hospital Privado de Comunidad), between December 2003 and May 2009. Volumes of the haematomas (dependent variable) were calculated from the first image performed, using the abc/2 method. Independent variables were age, gender, vascular risk factors, site of bleeding, intraventricular dump, clinical severity (Glasgow scale), time to image, antiplatelet drugs, and INR value on admission. An analysis of the relationship between all these variables and mortality was also performed., Results: A total of 327 patients with HIC were identified (35 with ACO). Median volume was higher in the anticoagulated patients (55ml vs 24ml P<.05), with no statistically significant relationship between volume and the other variables. In the multivariate analysis, a statistically significant higher mortality associated to volume was observed, but not with anticoagulation., Conclusions: Oral anticoagulation was associated with a higher initial volume of the haematoma, with no correlation between the INR value and volume. The HIC volume was directly related to mortality, however, like the volume, the INR was not associated with increased mortality., (Copyright © 2010 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.)

Central nervous system haemorrhage is a severe pathology, as a small amount of bleeding inside the brain can result in devastating consequences. Haemostatic agents might decrease the consequences of intra- cranial bleeding, whichever spontaneous, traumatic, or anticoagulation treatment etiology. Proacogulant recombinant activated factor VII (rFVIIa) has been given after central nervous system bleeding, with an off-label indication. In this update, we go over the drug mechanism of action, its role in the treatment of central nervous system haemorrhage and the published evidences regarding this subject. We carried out a literature review concerning the treatment with rFVIIa in central nervous system haemorrhage, neurocritical pathologies and neurosurgical procedures, searching in MEDLINE and in clinical trials registry: http://clinicaltrials.gov (last review September 2010), as well as performing a manual analysis of collected articles, looking for aditional references. The results of randomized clinical trials do not support the systematic administration of rFVIIa for spontaneous intracranial cerebral haemorrhage. In other central nervous system related haemorrhages, the current available data consist on retrospective studies, expert opinion or isolated case reports.

Intracerebral haemorrhage (ICH) results from the spontaneous rupture of an intracranial vessel. It comprises about 15% of all cerebrovascular diseases, and carries the highest risk of mortality and morbidity. ICH volume is the strongest single predictor of a bad outcome. Recent evidence shows that haematoma expansion is associated with early neurological deterioration and it occurs in 38% of patients. Ultra-early haemostatic agents such as recombinant factor VII (rfVII) may have a role in ICH management; although further clinical trials are required for it to be used in routine management. This article reviews its pathophysiology and natural history, and the evidence supporting recent advances in medical and chirurgical management for spontaneous ICH.

We present the case of a patient with an intracerebral hemorrhage as complication of an infectious endocarditis (EI) produced by Neisseria sicca on a prosthetic mitral valve. The patient was anticoagulated previously with Acenocumarol as prophylaxis of thrombosis of the prosthetic valve. He was diagnosed as having IE and later he presented neurological symptoms as consequence of several intracerebral hemorrhagic foci. We decided to continue the anticoagulation with sodium heparin followed of Bemiparina and no new hemorrhagic complications nor thrombosis of the valve were observed after three months of the event. We have not found in the literature any case where low molecular weight heparin has been used as method of anticoagulation in these cases beyond two weeks.

Introduction: Spontaneous cerebral intraventricular hemorrhage (SCIVH) is associated with hydrocephaly which requires ventricular drainage as treatment. Maintenance of adequate debit through the drainage system contributes to reduce morbid mortality. When the drain becomes obstructed, intermittent irrigation is necessary. This causes increased intracranial pressure and risk of infection. We propose the use of recombinant plasminogen tissue activator (r-tPA) in the treatment of SCIVH and associated hydrocephaly., Clinical Cases: We gave two patients with SCIVH 4 cc/day of r-tPA intraventricularly, at a concentration of 1 mg/ml over 4 consecutive days. Daily computerized tomography (CT) series were done. In both cases there was complete resolution of the SCIVH, with no complications related to the treatment. The ventricular drainage systems maintained a constant debit, did not become obstructed and required no revision. The patients did not subsequently require permanent ventricular shunts. One patient died of an unrelated septic condition. The other patient, a year later, could walk unaided, had motor dysphasia and on CT had neither intraventricular blood nor hydrocephaly., Conclusions: The intraventricular administration of r-tPA is a valid therapeutic tool in selected cases. It contributes to lysis of the intraventricular clot, permits permeability of the drainage, and may reduce the incidence of chronic hydrocephaly requiring a permanent ventricular shunt.

Introduction: Spontaneous cerebellar hematomas make up nearly 10% of the intracranial intraparenchymatous hemorrhages. In recent years several algorithms have been published for the management of these patients., Objective: To study the type of treatment, conservative or operative, and the main prognostic factors., Patients and Methods: We present a retrospective analysis of 52 cases of spontaneous cerebellar hematomas diagnosed over the past 10 years in the Hospital General de Galicia. We studied the clinical and radiological factors with the greatest effect on prognosis and the approach to treatment., Results: We found a male/female ration of 2/3. The age of 90.3% of our patients was over 60 years. Arterial hypertension had previously been diagnosed in 55.7% of the cases. The clinical picture was characterized by the profile of a stroke with headache (90.3%), vomiting (63.4%) and impaired consciousness (50%) being the commonest presenting symptoms. The most important factors in prognosis were the level of consciousness and the size of the hematoma. The prognosis was worse in cases with hydrocephalus, intraventricular hemorrhage or extension of the hematoma towards the midline. Neither age, sex nor the previous diagnosis of arterial hypertension were of importance in prognosis. Mortality was 25%., Conclusions: The spontaneous cerebellar hematomas typically affect patients over the age of 60 years and present with headache and vomiting of sudden onset. In our series the major prognostic factors were the size of the hematoma and level of consciousness, and treatment was given in accordance with this.

Introduction: Congenital afibrinogenemia is a very rare hereditary anomaly of coagulation. Only 150 cases have been published. Clinical manifestation in the form of some type of bleeding is similar to that of other congenital coagulopathies, although the pattern of presentation is different. Spontaneous bleeding is rare, but slight injury, which may be unnoticed, may trigger it off. In spite of being a congenital condition, it may be of late onset, as in our patient, with bleeding episodes occurring in the second decade of life., Clinical Case: We describe a woman who had several episodes of bleeding, two of which were intracerebral. The principal feature of this was dissociation between the clinical findings and their detection by neuro-imaging. Substitutive therapy led to the disappearance of symptoms., Conclusion: Cerebral haemorrhage in the presence of afibrinogenemia may fail to be detected early on CT. On clinical suspicion of bleeding, early substitutive treatment should be started.

Introduction and Objective: The value of acetylsalicylic acid (ASS) in the secondary prevention of ischemic stroke is well established. However, the optimum dose of AAS for stroke-threatened patients remains unsettled. This paper reviews the pattern of adverse reactions to AAS and their relationship to the dosage of ASS evaluated., Method: All the clinical trials in which AAS was used as the sole antiaggregant in the secondary prevention of ischemic stroke were reviewed. The crude odds ratio for the different adverse reactions was calculated using three sub tests: AAS versus placebo; AAS < 330 mg/d versus AAS > 330 mg/d; and each dosage level versus a placebo., Results: There is an increased risk associated with the use of AAS as compared to a placebo with respect to gastrointestinal bleeding (OR 2.3, IC 95% (1.6-4.1)), peptic ulcer (10.1 (2.5-85.2)), intracerebral hemorrhage (2.2 (1.3-4)) and other hemorrhagic phenomena (2.6 (2-3.3))., Conclusions: There seems to be a direct relationship between the dosage of AAS and the frequency with which adverse reactions occur, except in the case of intracerebral hemorrhage. In the latter case there was no relationship with the dose given (0.8 (0.5-1.4)).

During an eight-months period, we studied every newborns under 34 gestation weeks who needed mechanical ventilation (MV) from the moment they were born and whom had an ultrasonogram without intraventricular hemorrhage in the first six hours after birth. Patient were separated in two groups: the first, a group of 30 patients received phenobarbital 20 mg/kg IV in the first 6 hours of life and then 2.5 mg/kg, I.V., every 12 hours for the next five days. Blood levels were measured 24 and 96 hours after the initial dose was given. The second group of 30 patients was not treated with phenobarbital. In both groups a brain ultrasonogram was made every 48 hours until 15 days of life. There were no difference in weight, gestational age, Apgar score, way of birth, initial diagnosis, incidence of pneumothorax, mortality and days with MV between the two groups. During the first three days were measured blood glucose, blood pressure, mean airway pressure, PCO2, PO2 and found no significant difference between both groups. The blood pH showed statistically significant difference, with better values at 48-72 hours in the group treated with phenobarbital. The global incidence of intraventricular hemorrhage was 16 (53%) in the group treated and 14 (46%) in the not treated, this difference was not statistically significant. The degree of hemorrhage, found was: I and II degree, eleven (69%) in the treated group and four (28%), in the control group; III and IV degree five (31%), in the treated group and ten (71%), in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Conventional treatment of two patients with chronic idiopathic thrombocytopenic purpura (CITP) and petechial intracranial hemorrhage was ineffectual. However, after a treatment with vincristine, the neurological manifestations disappeared and platelet counts improved; clinical recovery was complete. This success contrast with results informed in similar patients treated with corticosteroids or splenectomy, among whom the mortality is as high as 100%. The favorable reaction may be related to the various mechanisms of the action of vincristine, which usually lead to control of CITP. The use of this drug is proposed in association of conventional therapy of this severe complication, especially in patients in whom splenectomy is contraindicated.