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A 19-year-old female patient presented with Staphylococcus aureus infective endocarditis, with suspected subdural brain hemorrhage, disseminated intravascular coagulopathy, and septic renal as well as spleen infarcts. The patient had extensive vegetations on the mitral and tricuspid valves and underwent urgent mitral and tricuspid repair. This paper discusses the clinical case and current evidence regarding the management and treatment of Staphylococcus aureus endocarditis.

Background Cavernous angiomas (CAs) are vascular malformations that may result in stroke. Case Description Herein, we evaluate a CA patient with chronic migraine who experienced 2 documented symptomatic hemorrhages after receiving respective high doses of botulinum toxin (Btx). Conclusions Recently, bacterial lipopolysaccharide has been reported to contribute to CA development through Toll-like receptor signaling, causing hemorrhagic angiogenic proliferation. Lipopolysaccharide and Btx share a common intracellular signaling pathway driving CA development and hemorrhage. Significance of these observations is demonstrated by previous works on plasma molecules showing prognostic associations with symptomatic hemorrhages in human CA, related to the same canonical pathways. Authors suggest careful tracking of the association of Btx and hemorrhage in CA patients.

Intracranial hemorrhage (ICH) a major health problem and the most common imaging method in ICH is computed tomography (CT). Detecting and locating it can help clinicians with diagnosis. Although deep learning models are well suited for detection and segmentation applications, detecting a bounding box may be employed as a major step to increase the segmentation accuracy. Localizing hematoma via bounding box is easier than semantic segmentation that tries to segment pixel-wise. Moreover, it is thought that as the bounding box shows the location, height, and width of the hemorrhage, it may also provide enough information to the doctor for diagnosis or to help the experts to detect anomalies in the brain. To evaluate and validate the proposed approach, Brain Hemorrhage Extended (BHX) dataset was employed. Intraparenchymal, Subarachnoid, Intraventricular, Epidural, Subdural, Chronic Subdural Hematoma were detected and enclosed in bounding box by using recently published YOLOv4 deep learning model. 94%, 92%, and 93% were achieved for overall precision, recall, and F1 score respectively by the proposed approach.

A potential source of confusion in medicolegal death investigations arises when death from natural causes occurs in circumstances that suggest violence. Consequently, the investigating pathologist is confronted with distinguishing between natural disease and violence or a combination of both. The pathologist should ascertain whether the data collected during the medicolegal death investigations corroborates or contradicts the circumstances surrounding the death. This case report aims to show an approach to cases where death from natural causes occurs under circumstances that suggest that violence. History and circumstances surrounding the death were obtained from the investigating police officer, coroner’s order for postmortem examination, and relatives. A postmortem examination was conducted on the decedent following the practice manual for medicolegal death investigations at the State Forensic Pathologist's Office. We report a case of brain hemorrhage due to ruptured arteriovenous malformation that was reported as a homicide. This case shows the importance of correctly interpreting postmortem findings in determining the cause and the manner of death in criminally suspicious deaths. This case is an example where disease mimics trauma. It is imperative for the pathologists in such instances to search for any possible signs of recent and old injuries that may confirm the violence. The burden of acquiring historical, circumstantial, and medical data to reach valid opinions of the cause and manner of death lies with the pathologist. The cause and manner of death must be expressed so that the criminal justice system is well served.

Objective Measurement of plasma levels of protein-conjugated acrolein (PC-Acro) together with IL-6 and CRP can be used to identify silent brain infarction (SBI) with high sensitivity and specificity. The aim of this study was to determine how these biomarkers vary during stroke. Methods Levels of PC-Acro, IL-6 and CRP in plasma were measured on day 0, 2, 7 and 14 after the onset of ischemic or hemorrhagic stroke. Results After the onset of stroke, the level of PC-Acro in plasma was elevated corresponding to the size of stroke. It returned to near control levels by day 2, and remained similar through day 14. The degree of the decrease in PC-Acro on day 2 was greater when the size of brain infarction or hemorrhage was larger. An increase in IL-6 and CRP occurred after the increase in PC-Acro, and it was well correlated with the size of the injury following infarction or hemorrhage. The results suggest that acrolein becomes a trigger for the production of IL-6 and CRP, as previously observed in a mouse model of stroke and in cell culture systems. The increase in IL-6 and CRP was also correlated with poor outcome judging from mRS. Conclusion The results indicate that the degree of the decrease in PC-Acro and the increase in IL-6 and CRP from day 0 to day 2 was correlated with the size of brain infarction, and the increase in IL-6 and CRP with poor outcome at discharge.

Uncertainty occurs an a relevant amount in the medical problems where the patient cannot communicate his symptoms to the doctor. This often occurs in intense hemorrhage cases. In such situations, there might be over one membership (non-membership) values, and they might have different occurrence probabilities associated with them. Because of these hesitant values and their probabilities, there are huge chances for the loss of information during addressing sensitive situations. To avoid such valuable information in the medical diagnosis of hemorrhage strokes, probabilistic dual hesitant fuzzy sets (PDHFSs) can be used which embeds the features of dual hesitant fuzzy sets (DHFSs) with the probabilistic information to represent the imprecise available information. Meanwhile, a Maclaurin symmetric mean (MSM) has a prominent characteristic and striking ability to capture inter-relationship among the multi-input arguments. So making full utilization of the features possessed by PDHFSs and MSM, in this paper, we propose some weighted averaging and geometric MSM aggregation operators to address the uncertainties in the medical diagnosis problems and handle the gesture quantification. Some desirable properties of the operators are discussed and an optimization model for determining the probabilities in PDHFSs is framed making use of Shanon’s entropy. A decision-making (DM) approach is framed based on the proposed operators followed by comparison analysis and a case study on gesture quantification of a patient suffering from hemorrhage strokes is conducted. The validity of the proposed method is examined with several predominating studies.

Background The outcome of childhood acute lymphoblastic leukemia has improved because of intensive chemotherapy and supportive care. The frequency of adverse events has also increased, but the data related to acute central nervous system complications during acute lymphoblastic leukemia treatment are sparse. The purpose of this study is to evaluate these complications and to determine their long term outcome. Patients and Methods We retrospectively analyzed the hospital reports of 323 children with de novo acute lymphoblastic leukemia from a 13-year period for acute neurological complications. The central nervous system complications of leukemic involvement, peripheral neuropathy, and post-treatment late-onset encephalopathy, and neurocognitive defects were excluded. Results Twenty-three of 323 children (7.1%) suffered from central nervous system complications during acute lymphoblastic leukemia treatment. The majority of these complications (n = 13/23; 56.5%) developed during the induction period. The complications included posterior reversible encephalopathy (n = 6), fungal abscess (n = 5), cerebrovascular lesions (n = 5), syndrome of inappropriate secretion of antidiuretic hormone (n = 4), and methotrexate encephalopathy (n = 3). Three of these 23 children (13%) died of central nervous system complications, one from an intracranial fungal abscess and the others from intracranial thrombosis. Seven of the survivors (n = 7/20; 35%) became epileptic and three of them had also developed mental and motor retardation. Conclusions Acute central neurological complications are varied and require an urgent approach for proper diagnosis and treatment. Collaboration among the hematologist, radiologist, neurologist, microbiologist, and neurosurgeon is essential to prevent fatal outcome and serious morbidity.

© 2014. The 70-kDa heat shock protein (HSP70) is known to protect the brain from injury through multiple mechanisms. We investigated the effect of pharmacological HSP70 induction in experimental traumatic brain injury (TBI). 3-month-old male C57/B6 mice were given 17-N-allylamino-17-demethoxygeldanamycin (17-AAG) intraperitoneally (IP, 2. mg/kg) or intracerebroventricularly (ICV, 1. μg/kg) to determine whether HSP70 could be induced in the brain. Mice were subjected to TBI via cortical controlled impact, and were treated with 17-AAG (or vehicle) IP according to one of two treatment regimens: (1) 2. mg/kg at the time of injury, (2) a total of three doses (4. mg/kg) at 2 and 1. d prior to TBI and again at the time of injury. Brains were assessed for HSP70 induction, hemorrhage volume at 3. d, and lesion size at 14. d post-injury. Immunohistochemistry showed that both IP and ICV administration of 17-AAG increased HSP70 expression primarily in microglia and in a few neurons by 24. h but not in astrocytes. 17-AAG induced HSP70 in injured brain tissue as early as 6. h, peaking at 48. h and largely subsiding by 72. h after IP injection. Both treatment groups showed decreased hemorrhage volume relative to untreated mice as well as improved neurobehavioral outcomes. These observations indicate that pharmacologic HSP70 induction may prove to be a promising treatment for TBI.

Cerebral hemorrhage, which is an important clinical problem, is often monitored and studied using expensive devices, such as magnetic resonance imaging (MRI) and positron emission tomography (PET) that are unavailable in economically underdeveloped regions. Magnetic induction tomography (MIT) is a new type of non-contact, non-invasive, and low-cost detection technology, and exhibits prospects for wide application, especially for the detection of brain diseases. However, the previous studies on MIT have focused on laboratory models and rarely on in vivo applications because the induced signals produced by biological tissues are notably weak. Based on the symmetry between the two brain hemispheres and the fact that a local brain hemorrhage will not affect the contra-lateral hemisphere, a symmetric cancellation-type sensor detection system, which is characterized by one excitation coil and two receiving coils, was designed to improve the detection sensitivity of MIT. This method was subsequently used to detect the occurrence of cerebral hematomas in rabbits. The average phase drift induced by a 3-ml injection of autologous blood was 1.885°, which is a fivefold improvement compared with the traditional single excitation coil and single receiving coil method. The results indicate that this system has high sensitivity and anti-interference ability and high practical value.

Purpose Pump pocket/device infection is one of the most serious complications during long term bridging therapy with implantable left ventricular assist device (iLVAD). Our policy was to treat these patients with adequate irrigation and iLVAD replacement with omentopexy. The aim of this study was to assess our strategy for pump pocket/device infection. Methods We reviewed patients who underwent total iLVAD replacement for pump pocket/device infection in University of Tokyo Hospital between Jan 2011 and Oct 2018. And we assessed patient outcomes including post-operative survival and complications. Results Out of total 154 patients who underwent iLVAD implantation, 13 patients developed pump pocket/device infection which required surgical drainage during study period. Ten patients underwent total iLVAD replacement with omentopexy (expect 1 patient who had previous abdominal surgery). A Jarvik 2000 was implanted in all cases. Mean time from first implantation to diagnosis of pump pocket/device infection was 792 ± 304 days. The most frequent causative microorganism was Pseudomonas aeruginosa (6/10). None of the 10 patients had a recurrence of pump pocket/device infection after replacement. Three patients developed cerebrovascular event post-operatively. Three patients reached heart transplantation during the period. Their mean waiting periods were 2.6 ± 0.2 years. One patient died of brain hemorrhage and another one died of device failure. The other 5 patients are waiting for transplantation. Two year survival after replacement was 65%. Conclusion Our strategy was effective to treat the patients who developed pump pocket/device infection and led to acceptable survival rate. Further study is necessary to prevent post-operative cerebrovascular events in this kind of patients.

Resume Les thrombopenies neonatales (TNN) sont frequentes, elles representent 20 % des hospitalises en unites de neonatologie et de soins intensifs. Les etiologies sont multiples, la consequence principale de cette affection est le risque de saignement notamment d’hemorragie intracrânienne. Objectif Mettre l’accent sur le profil etiologique du syndrome hemorragique d’origine thrombopenique et d’insister sur l’interet d’avoir une demarche diagnostique precise afin d’eviter les sequelles neurosensorielles graves ou de deces. Patients et methodes Notre travail est une etude retrospective portant sur 91 cas de nouveau-nes presentant un syndrome hemorragique d’origine thrombopenique, durant une periode d’etude s’etalant du 1 er janvier 2009 au 30 juin 2010. Resultats Durant la periode d’etude, on a enregistre 91 cas de syndrome hemorragique thrombopenique neonatal ce qui represente 7,02 % des nouveau-nes hospitalises. Les prematures presentaient plus le syndrome hemorragique thrombopenique (68,13 %) que les nouveau-nes a terme. L’hypotrophie etait rencontree chez 27 nouveau-nes (29,67 %) dont 17 d’entre eux etaient des prematures. Sur le plan biologique, 37 cas soit 40,65 % presentaient une thrombopenie severe avec un taux inferieur a 30 000/mm 3 et 13 cas soit 14,28 % avaient un taux entre 30 000/mm 3 et 50 000/mm 3 . Les etiologies du syndrome hemorragique d’origine thrombopenique etaient dominees par l’infection neonatale (74,72 %) et l’asphyxie perinatale (13,18 %). L’evolution etait favorable chez 28 cas ce qui correspond a 30,76 % et 63 cas sont decedes soit 69,23 % dans un tableau de syndrome hemorragique severe. Conclusion Nous insistons sur l’interet d’une prise en charge precoce pour eviter les sequelles neurologiques lourdes et la mortalite non negligeable.

We report the case of a 7-year-old boy with acute status asthmaticus requiring mechanic ventilation in the pediatric intensive care unit. He developed a brain hemorrhage during the course of his illness. We discuss the mechanisms that may have precipitated this neurological complication.

Rationale and Objectives.To determine the sensitivity of susceptibility-weighted imaging (SWI) for depicting hemorrhagic hypointense foci of the brain in comparison with gradient-recalled echo (GRE)- and GRE-type single-shot echoplanar imaging (GREI, GRE-EPI), and to assess the basic characteristics of the susceptibility effect by using a phantom. Materials and Methods.We prospectively examined 16 patients (9 males, 7 females, aged 10‐74 years, mean 43 years) with hypointense foci using SWI, GREI, and GRE-EPI at a 1.5-T magnetic resonance (MR) unit. The contrast-to-noise ratio (CNR), sensitivity to small hypointese foci, and artifacts were evaluated. To assess the basic characteristics of SWI, we performed a phantom study using different concentrations of superparamagnetic iron oxide (SPIO). Results.The CNR of lesions was significantly greater for SWI than the other images (P!.0001). SWI detected the greatest number of small hypointense foci, even in the near-skull-base and infratentorial regions. Quantitative and qualitative analyses in our clinical and phantom studies demonstrated that the degree of artifacts was similar with SWI and GREI. © AUR, 2007

The imaging of head trauma has been one of the fundamental cornerstones of neuroradiology. As the practice of neuroimaging has matured, great strides have been made in the diagnostic as well as prognostic armamentarium available to physicians. Given the vast diversity of trauma mechanisms and clinical pathways, new advanced imaging technologies have had a lasting impact on the detection, description, and depiction of head trauma. Furthermore, these new tools are allowing the imaging specialist to function not only as an interpreter of what is seen but as a 21st century radiographic oracle. We present a comprehensive review of the imaging findings of sequlae of traumatic brain injury and the growing correlation of new neuroimaging techniques and neurotraumatic outcomes.

Resumen Introduccion La hemorragia subaracnoidea (HSA) es una emergencia medica en todos los pacientes. Existen unos factores de riesgo conocidos y una serie de complicaciones asociadas a la HSA por rotura aneurismatica, siendo el resangrado la mayor causa de mortalidad. Material y metodos Presentamos un estudio retrospectivo descriptivo de 234 pacientes con HSA no traumatica atendidos en el Hospital Clinic i Provincial de Barcelona desde Enero del 93 a Diciembre del 99. El diagnostico de HSA se realizo por TC y el diagnostico etiologico por arteriografia cerebral de cuatro troncos. Se recogieron antecedentes patologicos, escalas de Hunt-Hess, WFNS, y Fisher, y se diferenciaron 2 grupos en funcion del tratamiento a que fueron sometidos (cirugia o embolizacion). Se recogieron las complicaciones derivadas de la HSA y el GOS al alta y ano. Resultados La edad media de la poblacion fue de 53,67 anos (16–88 anos), con una relacion hombre: mujer de 1:1’4. Los antecedentes patologicos mas frecuentes fueron la HTA (36,7%) y el tabaquismo (25,9%). Se observo un predominio del sangrado en horas activas (8:00 a 22:00), sobre todo por la manana (8:00 a 14:00). Entre las complicaciones asociadas a la HSA 45 pacientes (19,2% del total) sufrieron vasoespasmo, segun criterios medicos, 24 pacientes (10,25%) resangrado, 61 pacientes (26%) hidrocefalia postHSA, 38 pacientes (16,23%) presentaron crisis convulsivas. En 31 casos el patron de sangrado en el TC de ingreso fue no perimesencefalico (62% de los 50 pacientes con arteriografia negativa) y en 19 casos (38%) fue perimesencefalico. De los pacientes que se realizo arteriografia se observaron 150 aneurismas de circulacion anterior y 12 casos aneurismas de circulacion posterior. 98 pacientes fueron sometidos a cirugia y 38 embolizados. La proporcion de pacientes con peor estado clinico y hemorragias masivas fue notablemente superior en pacientes embolizados, y a su vez, este grupo presento una mayor mortalidad y graves secuelas. Discusion Hemos observado una proporcion entre sexos, antecedentes patologicos y momento del sangrado similares a los publicados, asi como las complicaciones derivadas de esta hemorragia. Se ha analizado con especial enfasis los pacientes con arteriografia negativa y su patron de sangrado, descubriendo, como apuntan los estudios actuales, que el patron de sangrado perimesencefalico puede ser ocasionado por un aneurisma, ante lo cual todos estos pacientes son sometidos a una segunda arteriografia. Destaca, a su vez, entre los grupos de pacientes tratados, que los sometidos a embolizacion estaban en un estado mas precario y por lo tanto su evolucion y tasa de mortalidad fue superior. Respecto a los pacientes intervenidos destaca el porcentaje de complicaciones isquemicas y la no practica global de arteriografia de control, lo cual nos ha conducido a un cambio de criterio. Conclusiones Ha sido un estudio especialmente util para analizar nuestra praxis frente a esta patologia y elaborar un protocolo de tratamiento en base a las tendencias actuales y a nuestra experiencia.

Brain infarcts and brain hemorrhages in patients younger than 20 years are significantly less common than among those older than 65 years; also, their clinical expressions are different from those common to older patients. Congenital defects involving the heart and the arteries supplying the brain are among the most common causes of stroke in the young. In addition to the structural changes affecting the heart and blood vessels, various genetic disorders (hematologic, mitochondrial, and others) are being identified as significant risk factors in an increasing number of young stroke victims.

Hemorrhagic transformation of ischemic cerebral injury occurs commonly in embolic strokes. The incidence, timing, and clinical consequences of hemorrhagic transformation are reviewed. Hemorrhagic complications resulting from heparin therapy and results from recent preliminary thrombolytic treatment trials are discussed.

(20 patients at one month, 13 at 6 months, and 5 at one year), all the stentgrafts were patent without endoleak, with a stable diameter of the aneurysmal sac; one patient died at 40 days of a brain hemorrhage. Conclusion: Although our initial experiment with the endoproth ese Nellix is encouraging for the treatment of AAAs, a prolonged follow-up is necessary to confirm its long-term effectiveness, in particular in the prevention of endoleaks and secondary reinterventions.

Objectives This study is important to understand the functional pathology of the disease that leads to death of the mother. This study is designed to understand the end stage of the disease by macroscopic and microscopic examinations of vital organs. We have studied the developing end stage of preeclampsia. Methods We have selected last 100 cases with death due to direct causes of preeclampsia from the teaching tertiary care center since 1932. We have retrospectively inquired the case papers of mothers who died due to preeclampsia during last 17 years. All antenatal, intrapartum, and postnatal records were analyzed. We analyzed all the data and presented them in tabular format. Results We have retrospectively analyzed the case papers of maternal death due to preeclampsia and presented in tabular format. Conclusions The main reasons for maternal deaths are neglected mothers due to poverty and lack of knowledge, high intensity of disease, and coagulation defect. Maternal deaths Registered Not registered Brought dead Indoor Brain hemorrhage 1 20 11 10 Hepatic failure 11 11 14 8 Hepato-renal failure 18 2 20 Coagulation defect 6 30 0 36 Eclampsia 12 4 2 11 Septicemia 20 2 0 22 Live baby 32 25 0 0 Dead baby 24 19 0 0 Disclosure M.C. Jariwala: None.

Objectives: Stroke prevention is the main goal in treating patients with atrial fibrillation (AF). Treatment with anticoagulants, such as vitamin-K antagonists (VKAs; e.g. warfarin and cumarines), was demonstrated to be an effective strategy. However, even though VKAs are the current standard therapy recommended by different guidelines, the significant risk of bleeding and the requirement for a regular monitoring are limiting its use. Apixaban is a novel oral anticoagulant (NOAC) associated with significantly lower hazard rates for stroke/systemic embolism major hemorrhage and discontinuations, compared to VKAs. This study evaluated the cost-effectiveness (CE) of apixaban compared to VKAs in the base-case analysis and alternatively to other NOACs for stroke prevention in non-valvular AF patients in The Netherlands. Methods: A global Markov model developed by United BioSource Corporation was modified to reflect the use of oral anticoagulants in The Netherlands. The model used efficacy data from a published indirect treatment comparison of NOACs and cost data from Dutch costing studies as inputs. Following health states were included in the model: non-valvular AF, primary and recurrent ischemic and hemorrhagic stroke, systemic embolism, myocardial infarction intracranial hemorrhage, other major and non-major bleedings, treatment discontinuations and death. Main outcomes were quality adjusted life years (QALY) and costs. Univariate and probabilistic sensitivity analyses (PSA) were conducted on the incremental cost-effectiveness ratio (ICER). Results: In the base-case analysis apixaban treatment compared to VKAs has an ICER well below an informal minimal willingness-to-pay threshold of € 20,000/QALY for The Netherlands (i.e. around € 7,000/QALY). PSA showed that the results of the base-case analysis were quite robust. Potentials exist for apixaban to be dominant over the other NOACs, rivaroxaban and dabigatran depending on hazard ratios, risks for complications and local price levels. patients in The Netherlands. Conclusions: In patients with AF, we found apixaban to be a cost-effective option in The Netherlands, compared to VKAs.

Certain characteristics of the donor have implications for the early and late survival of transplants. The trends show a progressive worsening in the clinical profile of heart donors. Our objective was to analyze changes in the clinical characteristics of donors. Materials and methods This retrospective study of 396 donors was divided into three periods: 1990 to 1994, 1995 to 1999, and 2000 to 2004. We excluded combination transplantations, retransplantations, and pediatric transplantations. The donor variables included age, cause of death, cardiorespiratory arrest, ICU stay, and ischemia time. Statistical analysis used ANOVA, Kruskall-Wallis, and Chi square test, with significance set at P Results Differences were found in age (1990–1994: 27 ± 1, 1995–1999: 29 ± 1, 2000– 2004: 34 ± 1 years; P = .0001), ischemia time (1990–1994: 119 ± 6, 1995–1999: 145 ± 4, 2000–2004: 156 ± 4 minutes; P = .0001), and death from brain hemorrhage (1990–1994: 28%, 1995–1999: 31%, 2000–2004: 43%; P = .031). Conclusions There were differences in the clinical characteristics of the donors in the study periods. The age of the donor, stroke-related deaths, and ischemia time have increased significantly in recent years.

Non-accidental head injury (NAHI) in infants is an important but difficult topic. To miss or misdiagnose NAHI potentially has important consequences. The evidence base upon which to base decisions is limited but growing. This article aims to summarise current literature and thinking in this difficult area.

Objectives: Management with vitamin K antagonists (VKAs) has been an effective and cost-effective strategy for stroke prevention in atrial fibrillation (AF) but is associated with shortcomings. Novel oral anticoagulants (NOACs) were developed with the aims of no monitoring requirement and improved effectiveness and safety profiles. Economic evaluations require the comparison of all relevant options. However, there are no randomized controlled trials (RCTs) directly comparing these agents. In such cases, indirect treatment comparison (ITC) can be used to synthesize indirect comparative evidence. Through ITC-based evidence synthesis the cost-effectiveness of all available NOACs for stroke prevention in AF patients may be evaluated. Methods: ITC models were based on RCTs data comparing dabigratran, rivaroxaban, or apixaban with VKA treatment. Relative effectiveness was estimated for stroke/systemic embolism, intracranial hemorrhage, myocardial infarction, extracranial hemorrhage, and minor bleeding. A Markov model was developed using ITC-synthesized evidence with VKA as the baseline. Health utilities were collected from international sources whereas costs and mortality data were extracted from Dutch sources. Univariate and probabilistic sensitivity analyses (PSA) were conducted on the base-case incremental cost-effectiveness ratio (ICER). Results: The ICERs for dabigatran, apixaban, and rivaroxaban compared to VKA were € 12,146/QALY, € 12,488/QALY, and € 24,124/QALY, respectively. Sensitivity analysis using the upper and lower limits of the 95% confidence interval for absolute stroke risk with VKA treatment resulted in ICERs that varied drastically from dominance for VKA to being dominated by all NOACs. This is likely due to the large uncertainty observed between the baseline risk profiles of the VKA arms in the three RCTs. The options with the highest probabilities of cost-effectiveness in PSA were VKA at thresholds under € 13,000/QALY and dabigatran or apixaban at thresholds above this mark. Conclusions: Dabigatran and apixaban were shown to be cost-effective options for AF patients in The Netherlands. However, these results were strongly influenced by uncertainty around stroke risk with VKA treatment.

Background: The temporal course of rebleed after intracerebral hemorrhage (ICH) is unknown. To test the hypothesis that mortality may be predicted by rebleed in 24 hours, we surveyed ICH admissions to the University of Michigan (UM) and University of Kentucky (UK) Medical Centers over 2 years. Methods: All cases of ICH (ICD-9 431) admitted to UM or UK between July 2000 and June 2002 underwent retrospective audit. Cases of posterior fossa ICH, subarachnoid hemorrhage, coagulopathy, tumor, or pregnancy were excluded. CT scans obtained on remaining cases of spontaneous ICH were analyzed for rebleed. Results: At UM, 85 of 193 ICH cases qualified. Second CT in 85 cases showed rebleed in 15 (18%; 95% CI 10–27%). In-hospital mortality with rebleed was 33%. Mean time of ictus-first CT was 4 hours (median 45 min; range 0–48 hrs). Mean time of ictus-second CT confirming rebleed was 12 hours (median 4 hrs; range 45 min–120 hrs). At UK, 104 of 183 ICH cases qualified. Second CT in 40 cases showed rebleed in 5 (13%, 95% CI 4–27%). In-hospital mortality with rebleed was 60%. Mean time of ictus-first CT in the 40 patients was 4.8 hours. Second CTs in 5 patients with rebleed were completed in under 15 hours. Conclusion: Our results show rebleeding under 15 hours may increase mortality up to 60% in spontaneous ICH. Prospective study of rebleed after ICH is warranted to select best time for potential treatment.

A hamartomatous type of juxtaglomerular cell tumor was found in a young person with long standing refractory hypertension and a clinical picture of secondary aldosteronism terminating in massive brain hemorrhage. This cause of potentially lethal hypertension is generally not thought of because of its varity and may defy discovery because of its occult, nature. A review of the hitherto described world experience indicates the character of the tumor and points to the dramatic cure that rewards its timely discovery and excision.

Using neonatal rats as a model system, we investigated the response of the brain vascular system to ionizing radiation and found that distinct petechial hemorrhages developed in the cerebral cortex within a few hours after irradiation, reached a maximum about 13 to 24 hours, and decreased exponentially with time. No brain hemorrhage was found in neonatal rats 12 days after irradiation. Our experimental results indicate that a dose of a few hundred rad of X rays can induce a significant number of hemorrhages in the brain, and the number of lesions increases exponentially with dose. Heavy ions induce more hemorrhages than X rays for a given dose, and the RBE for 670 MeV/u neon particles ranges from about 2.0 for low doses to about 1.4 for high doses. A histological study of the hemorrhages indicates that a large number of red blood cells leak from the blood vessels. The radiation-induced hemorrhages may be a result of some capillary membrane damages or reproductive death of some blood vessel epithelial cells. The fast onset of hemorrhage after irradiation suggest that some membrane damage may be involved. The effect of heavy-ion radiation on the embryonic development was studied with energetic iron particles. Pregnant mice were whole-body irradiated with 600 MeV/u iron particles on day 6 of gestation and were sacrificed 12 days after irradiation. Various physical abnormalities were observed, and embryos irradiated with 1 rad iron particles showed retardation of body development.

Congophilic angiopathy has been separated into two forms. A primary vasculopathy is described in which amyloid deposition is the initial morphological brain change and is of pathogenetic importance in the development of dementia or brain hemorrhage. Another form occurs in Alzheimer's disease and is incidental to the brain damage resulting from senile plaques.

A critical review of the ultrasound features of neonatal intracranial anatomy is undertaken. Particular attention is paid to the ventricular and paraventricular region because of their importance in the diagnosis of cerebroventricular hemorrhage. A technique to visualize the important areas is described

Seven cases of puerperal hemiplegia were seen at the Peking Union Medical College Hospital within a period of four years. Six of the patients were Chinese women. Two cases were apparently due to cerebral hemorrhage, two to cerebral thrombophlebitis, and three to cerebral embolism. Puerperal hemiplegia from brain hemorrhage usually comes on during or shortly after labor, probably always as the result of a coexisting toxemia of pregnancy. The mechanism of the hemorrhage is best explained on the ground that the toxemias of pregnancy produce structural damage to the vessel walls which become so weakened that the elevated blood pressure and the bearing-down efforts incident to labor cause rupture. Puerperal hemiplegia from cerebral thrombosis, possibly the most common type of the condition, occurs most often in the second or third week of the puerperium. It is probably always secondary to a pelvic infection, although the latter may be so slight as to escape detection. In many instances the cerebral thrombosis is preceded by a toxemia of pregnancy and it is suggested that here, as in cerebral hemorrhage, vessel damage may play an important etiologic role. Certain changes in the colloidal state of the blood further augment the tendency to thrombosis in the puerperium. Puerperal hemiplegia from cerebral embolism may be due either to detached cardiac vegetations or to emboli of pelvic origin. The former probably represents a coincidence not directly related to the puerperal state. The mechanism by which detached pelvic thrombi may reach the brain through the pulmonary capillaries is obscure, but numerous necropsy studies attest its occurrence and its actuality must be conceded. Although the seven cases of this report all survived, the prognosis of puerperal hemiplegia is usually grave. Cerebral hemorrhage occurring during labor is particularly likely to prove fatal. Patients who survive the apoplectic seizure seldom escape a certain degree of permanent paralysis.

One hundred fifty-five patients who died from apoplexy were studied in relation to associated cardiovascular disease. Hypertension was present in nearly 90 per cent. Functional cerebrovascular disease (probably spasm) appeared to be the important factor in most cases, while systemic circulatory failure accounted directly for very few cerebral accidents. A cause and effect relationship was entertained in patients with cerebral aneurysm with hypertension.

Traumatic intracranial hemorrhage may be extradural (epidural), subdural, subarachnoid, or intracerebral in location. A condition closely linked with subdural hematoma is subdural accumulation of cerebrospinal fluid. Intracerebral hemorrhage may be massive or petechial. In this chapter, we are concerned primarily with massive epidural, subdural, intracerebral, and intracerebellar hematomas. Detailed discussion of these various types of hemorrhage follows.