Clinical Cases

Figure 2.1

The brain CT scan carried out in urgency found hemorrhaging of the left basal nuclei. The patient was therefore given an emergency CT angiography (see Fig. 2.1A–C).

The CT angiography (Fig. 2.1D, F, G) found no evidence of arteriovenous malformations near the hemorrhage, but it did confirm various diffuse alterations in the size of the intracranial arteries (red arrows), corresponding perfectly to the angiography investigations carried out during the previous hospital admittance (Fig. 2.1E, H–J). The patient was admitted to the stroke unit in order to monitor her vital signs. On arrival at the unit, the neurological examination showed patient’s eyes were open, total language barrier, right-side hemiplegia with spastic hypertonia, and movement of the left limbs retained (NIHSS 17/42).

During the patient’s hospitalization, antihypertensive therapy was increased with erratic checking of diastolic pressure.

Five days after admittance, a state of sopor appeared with a Glasgow Coma Scale score of 6/15. An urgent brain CT scan was carried out (Fig. 2.2).

Figure 2.2

The brain CT scan showed an extensive right-side cerebellar bleeding site with mass effect on the adjacent structures and obliteration of the fourth ventricle.

A neurosurgeon was urgently contacted and prepared for surgical evacuation of the hematoma and posterior fossa decompression.

The postoperative CT (Fig. 2.3) showed that the cerebellar hematoma had been completely removed, with a marked reduction in the mass effect and a possible view of the fourth ventricle. Finally, pneumocephalus was noted. The patient was then transferred to intensive therapy, and a right-side frontal external ventricular shunt was put into place. Finally a tracheostomy was setup. Progressive clinical improvement was then observed. The patient was returned to the stroke unit 7 days after surgery with the neurological examinations reported as follows: patient alert, language barrier, unable to carry out commands, right-side hemiplegia, and valid response to pain stimulus on the left side.

Figure 2.3

After 25 days of hospitalization, the patient was sent to rehabilitation for serious cerebral lesions with mRS 5/6.

Discussion

In this case the occurrence of an infratentorial bleeding together with a severe neurological deterioration is the key indicator for surgical decision. From STICH trial we know that in these cases the surgical approach is linked with a higher likelihood of a better outcome [1].

2.2 Case Study No. 2

Hemorrhage in a patient under anticoagulant therapy (warfarin).

A 70-year-old white Caucasian male was brought to our attention with a medical history of hypertension, type 2 diabetes mellitus with associated retinopathy, previous retinal thrombosis in the right eye, two previous episodes of brain hemorrhages in the basal nuclei which had occurred approximately 5 years before the present hospital admittance with no residual disability, recent replacement of the aortic valve with a bioprosthesis, and mitral annuloplasty. He was undergoing antiplatelet therapy at home (100 mg acetylsalicylic acid), oral anticoagulant (warfarin sodium according to INR), antihypertensives (ace inhibitors and beta-blockers), statins, and oral hypoglycemic agents.

On the day he was admitted, there was a sudden appearance of global aphasia and repeated vomiting.

INR in the emergency department: 1.86.

On arrival in the ER, the patient was given an urgent brain CT scan (Fig. 2.4).

Figure 2.4

The scan showed a large hemorrhage of the left basal nuclei breaking through into the ventricular system and mass effect on the lateral ventricle. In the ER the patient was promptly recoagulated with a prothrombin complex (Prothromplex 2000 UI) with a final INR of 1.2. The neurosurgeon assessed the patient and did not find indications for treatment, considering the patient’s age and the location of the hemorrhagic lesion. The neurological assessment is as follows: patient in a coma, eyes closed, anisocoria left > right photoreactive, torpid bilateral oculocephalic reflexes, reduced right corneal direct and consensual reflexes, decerebrate response to pain stimulus in both arms, slight flexion of both legs, bilateral Babinski, no meningeal signs, regular breathing, and occasional snoring. The patient was admitted to the stroke unit in a serious clinical condition followed by further clinical deterioration.

GCS = 3 after 24 h. Deceased after 48 h.

2.3 Case Study No. 3

We present the case of a 50-year-old male of African race whose medical history reveals no significant pathologies. The patient presented to the ER after approximately 3 days of serious persistent headache. It must be pointed out that the headache appeared suddenly, and the pain was described as severe and pulsating, associated with an episode of projectile vomiting. The clinical examination in the ER revealed no focal deficits. A brain CT scan was then carried out (Fig. 2.5).

Figure 2.5

The scan showed an iso-hyperdense parapontine formation compatible with a clot (Fig. 2.5, yellow arrow). As a subacute subarachnoid hemorrhage was suspected, an urgent CT angiogram was carried out, which showed no aneurysmal lesions; a lumbar puncture was then performed. The results of fluid tests showed that proteins and CSF are within the norm and spinal fluid is yellow. Diagnosis of a non-aneurysmal SAH was confirmed. The patient was then hospitalized in a stroke unit, and an angiogram was carried out, with results within the norm (data not displayed). The clinical course was regular and the patient remained asymptomatic. He was discharged after 5 days under observation with indications for a follow-up angio-MR scan and a brain MR scan approximately 1 month after the episode.

Discussion

In non-aneurysmal subarachnoid hemorrhage, the opportunity of a repeated conventional angiography examination is debated. From literature we know that repeat angiography seems to be justified only when the initial examination is technically inadequate, when vasospasm is present, or if further bleeding occurs [2].

2.4 Case Study No. 4

(Amyloid angiopathy)

We present the case of an 80-year-old Caucasian female who presented at ER following the sudden onset of right-side hemiplegia. The medical history documented chronic obstructive bronchopneumopathy and osteoporosis. The patient was not taking antiplatelet or anticoagulant therapies. The clinical neurological examination in the ER showed an NIHSS of 8/42 due to asthenic deficit in the right-side limbs.

An urgent brain CT scan was performed (Fig. 2.6).

Figure 2.6

The brain CT scan showed evidence of a hemorrhagic lesion in the left frontal cortico-subcortical parietal region with minimal bleeding into the adjacent, smoothed, cortical sulci and a modest imprint on the posterior portion of the middle ventricular cell, as well as a clearly hypodense area in the right temporal cortico-subcortical region, with a modest ex-vacuo enlargement of the temporal horn. Taking into consideration the characteristics of the hemorrhage, further investigation was carried out by means of an urgent diagnostic Angio-CT scan (Fig. 2.7).

Figure 2.7

The Angio-CT scan did not show any arteriovenous malformations or arteriovenous fistulas. Finally, the patient was assessed by the neurosurgeon who reached the conclusion that treatment to evacuate the hematoma was not indicated due to the patient’s age and clinical condition. The patient was admitted to a stroke unit for continuous monitoring. She was discharged on day 14 to a rehabilitation center with mRS = 4 and BI 10/100. A brain MR scan was recommended approximately 2 months after hospitalization. Five months after discharge, the patient was brought to the ER due to the onset of a motor deficit in the left-side limbs in association with nausea, vomiting, and a slightly raised temperature.The clinical examination in the ER revealed that the patient was soporous and scarcely collaborative, with persistent right-side hemiplegia (as outcome) and slight left-side hemiparesis(NIHSS = 30/42). An urgent brain CT scan was carried out (Fig. 2.8).

Figure 2.8

The brain CT scan revealed the site of an intraparenchymal bleed (max. size approx. 5.6 × 4.2 cm on the axial plane) in the frontobasal and right frontopolar regions, surrounded by a moderate amount of perilesional edema, causing a discrete mass effect on the homolateral frontal horn, with minimum contralateral shift of the median structures. The patient was admitted to a stroke unit; no indications were proposed for neurosurgical intervention. The patient was discharged after 14 days with mRS = 5 and transferred to a ward for serious cerebral lesions. On the basis of the patient’s clinical and instrumental history, the conclusive diagnosis was amyloid angiopathy.

2.5 Case Study No. 5

Sine materia SAH

A 74-year-old Caucasian male was brought to our attention. His medical history showed hypertension. He had been sent from another hospital because a brain CT had revealed a subarachnoid hemorrhage. From a neurological point of view, the patient presented focal deficits with a GCS of 15/15. An urgent angio-CT scan was performed as well as an assessment of the brain CT scan (Figs. 2.9 and 2.10).

Figure 2.9

Figure 2.10

The brain CT scan confirmed the presence of a subarachnoid hemorrhage in the basal cisterns and sylvian fissures as well as some blood component in the III and IV ventricle with slight dilation of the ventricular cavities. The angio-CT scan did not show any imaging to suggest aneurysmal dilations. After hearing the opinion of the neurosurgeon, an angiogram was arranged (Fig. 2.11).

Figure 2.11

The angiogram confirmed the absence of aneurysmal dilations and cerebral arteriovenous malformations. The patient was admitted to the stroke unit for clinical-instrumental monitoring. The neurological clinical examination continued to be negative, with GCS = 15/15; nuchal headache persisted (VAS 7/10) with good response to paracetamol. Considering the nature of the subarachnoid hemorrhage revealed in the first CT scans, the decision was made to repeat an angiographic exam approximately 2 weeks from onset of the clinical episode. The results of the second angiogram were also within the norm, thus excluding the presence of intracranial vascular alterations as the cause of the hemorrhage. The patient was discharged on day 20 without symptoms.

Discussion

As stated before, the repetition of an angiography in cases of non-aneurysmal SAH is usually unnecessary. In this case we decided to do it because of slight hydrocephalus on first CT scans and for the amount of blood that was not typical for a perimesencephalic SAH.

2.6 Case Study No. 6

We present the case of a 29-year-old Caucasian male with a substantially clear medical history. The patient was brought to our attention due to a nocturnal episode of loss of consciousness with morsus, sphincter incontinence, and successive neck pain. Assisted by the paramedics, he was initially found unconscious but regained consciousness after 10 min with no neurological deficits. The patient arrived in the ER department of our hospital, GCS 15, and underwent a brain CT scan (Fig 2.12) and an Angio-CT (Fig. 2.13).