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Magid-Bernstein J, Girard R, Polster S, Srinath A, Romanos S, Awad IA, Sansing LH. Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions. Circ Res 2022; 130:1204-1229. [PMID: 35420918 PMCID: PMC10032582 DOI: 10.1161/circresaha.121.319949] [Citation(s) in RCA: 114] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.
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Affiliation(s)
| | - Romuald Girard
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sean Polster
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Abhinav Srinath
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Sharbel Romanos
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Issam A. Awad
- Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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Chen CJ, Brown WM, Moomaw CJ, Langefeld CD, Osborne J, Worrall BB, Woo D, Koch S. Alcohol use and risk of intracerebral hemorrhage. Neurology 2017; 88:2043-2051. [PMID: 28446657 DOI: 10.1212/wnl.0000000000003952] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 03/01/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To analyze the dose-risk relationship for alcohol consumption and intracerebral hemorrhage (ICH) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study. METHODS ERICH is a multicenter, prospective, case-control study, designed to recruit 1,000 non-Hispanic white patients, 1,000 non-Hispanic black patients, and 1,000 Hispanic patients with ICH. Cases were matched 1:1 to ICH-free controls by age, sex, race/ethnicity, and geographic area. Comprehensive interviews included questions regarding alcohol consumption. Patterns of alcohol consumption were categorized as none, rare (<1 drink per month), moderate (≥1 drink per month and ≤2 drinks per day), intermediate (>2 drinks per day and <5 drinks per day), and heavy (≥5 drinks per day). ICH risk was calculated using the no-alcohol use category as the reference group. RESULTS Multivariable analyses demonstrated an ordinal trend for alcohol consumption: rare (odds ratio [OR] 0.57, p < 0.0001), moderate (OR 0.65, p < 0.0001), intermediate (OR 0.82, p = 0.2666), and heavy alcohol consumption (OR 1.77, p = 0.0003). Subgroup analyses demonstrated an association of rare and moderate alcohol consumption with decreased risk of both lobar and nonlobar ICH. Heavy alcohol consumption demonstrated a strong association with increased nonlobar ICH risk (OR 2.04, p = 0.0003). Heavy alcohol consumption was associated with significant increase in nonlobar ICH risk in black (OR 2.34, p = 0.0140) and Hispanic participants (OR 12.32, p < 0.0001). A similar association was not found in white participants. CONCLUSIONS This study demonstrated potential protective effects of rare and moderate alcohol consumption on ICH risk. Heavy alcohol consumption was associated with increased ICH risk. Race/ethnicity was a significant factor in alcohol-associated ICH risk; heavy alcohol consumption in black and Hispanic participants poses significant nonlobar ICH risk.
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Affiliation(s)
- Ching-Jen Chen
- From the Departments of Neurosurgery (C.-J.C.), Neurology (B.B.W.), and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Center for Public Health Genomics and Department of Biostatistical Sciences (W.M.B., C.D.L.), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (C.J.M., J.O., D.W.), University of Cincinnati College of Medicine, OH; and Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL. Coinvestigators are listed at Neurology.org
| | - W Mark Brown
- From the Departments of Neurosurgery (C.-J.C.), Neurology (B.B.W.), and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Center for Public Health Genomics and Department of Biostatistical Sciences (W.M.B., C.D.L.), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (C.J.M., J.O., D.W.), University of Cincinnati College of Medicine, OH; and Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL. Coinvestigators are listed at Neurology.org
| | - Charles J Moomaw
- From the Departments of Neurosurgery (C.-J.C.), Neurology (B.B.W.), and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Center for Public Health Genomics and Department of Biostatistical Sciences (W.M.B., C.D.L.), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (C.J.M., J.O., D.W.), University of Cincinnati College of Medicine, OH; and Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL. Coinvestigators are listed at Neurology.org
| | - Carl D Langefeld
- From the Departments of Neurosurgery (C.-J.C.), Neurology (B.B.W.), and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Center for Public Health Genomics and Department of Biostatistical Sciences (W.M.B., C.D.L.), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (C.J.M., J.O., D.W.), University of Cincinnati College of Medicine, OH; and Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL. Coinvestigators are listed at Neurology.org
| | - Jennifer Osborne
- From the Departments of Neurosurgery (C.-J.C.), Neurology (B.B.W.), and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Center for Public Health Genomics and Department of Biostatistical Sciences (W.M.B., C.D.L.), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (C.J.M., J.O., D.W.), University of Cincinnati College of Medicine, OH; and Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL. Coinvestigators are listed at Neurology.org
| | - Bradford B Worrall
- From the Departments of Neurosurgery (C.-J.C.), Neurology (B.B.W.), and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Center for Public Health Genomics and Department of Biostatistical Sciences (W.M.B., C.D.L.), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (C.J.M., J.O., D.W.), University of Cincinnati College of Medicine, OH; and Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL. Coinvestigators are listed at Neurology.org
| | - Daniel Woo
- From the Departments of Neurosurgery (C.-J.C.), Neurology (B.B.W.), and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Center for Public Health Genomics and Department of Biostatistical Sciences (W.M.B., C.D.L.), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (C.J.M., J.O., D.W.), University of Cincinnati College of Medicine, OH; and Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL. Coinvestigators are listed at Neurology.org
| | - Sebastian Koch
- From the Departments of Neurosurgery (C.-J.C.), Neurology (B.B.W.), and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Center for Public Health Genomics and Department of Biostatistical Sciences (W.M.B., C.D.L.), Wake Forest University School of Medicine, Winston-Salem, NC; Department of Neurology and Rehabilitation Medicine (C.J.M., J.O., D.W.), University of Cincinnati College of Medicine, OH; and Department of Neurology (S.K.), University of Miami Miller School of Medicine, FL. Coinvestigators are listed at Neurology.org.
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Sexual activity as a trigger for intracranial hemorrhage. Acta Neurochir (Wien) 2016; 158:189-95. [PMID: 26589958 DOI: 10.1007/s00701-015-2643-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 11/13/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) has been reported in association with sexual activity. A case-series of patients with ICH following sexual activity is presented to further elucidate the role of the physiologic sexual response as a trigger of ICH. METHOD A retrospective review of the medical record was performed, identifying patients presenting with ICH temporally related to sexual activity. Clinical and radiographic data were collected and reported. RESULTS Sixteen patients presented with non-traumatic ICH temporally related to sexual activity. Eight (50 %) patients presented with aneurysmal subarachnoid hemorrhage, four (25 %) with angiogram-negative subarachnoid hemorrhage, two (12.5 %) with a ruptured arteriovenous malformation, and two (12.5 %) with an intracerebral basal ganglia hemorrhage. Overall average age was 49.9 (range, 28-74) years. Sexual activity involved male-female intercourse in 14 (87.5 %) patients and masturbation in 2 (12.5 %) patients. CONCLUSIONS Sexual-activity-related ICH is rare and includes various etiologies. The human sexual response in associated with dramatic increases in arterial blood pressure, which likely underlies the association.
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Choi-Kwon S, Kim JS. Lifestyle factors and risk of stroke in Seoul, south Korea. J Stroke Cerebrovasc Dis 2013; 7:414-20. [PMID: 17895120 DOI: 10.1016/s1052-3057(98)80125-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/1997] [Accepted: 05/06/1998] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND PURPOSE The importance of stroke risk factors, especially lifestyle associated ones, may differ among different ethnic groups. The purpose of the present study is to elucidate the risk factors for stroke in Seoul, Korea. SUBJECTS AND METHODS Three-hundred four stroke patients and 249 age-matched controls were studied. Patients were divided into those with cerebral infarction (CI) and intracerebral hemorrhage (ICH). Using a structured interview, we assessed risk factors for stroke including lifestyle-associated factors: hypertension (HT); diabetes mellitus (DM); cigarette smoking; alcohol drinking; sodium intake; salt taste preference; physical activity and exercise; consumption of vegetables, fat, fish and fruits; body mass index; total body fat; and skinfold thickness of triceps, subscapular, and abdomen. The results were compared between patients and controls, and between CI and ICH. RESULTS There were 232 CI and 72 ICH. Multivariate logistic regression analyses revealed the following independent risk factors; for CI in men, HT, DM, high sodium intake, low intake of vegetables, and excessive abdominal skinfold thickness; for ICH in men, HT, heavy alcohol drinking, high sodium intake, excessive abdominal skinfold thickness, and low fat consumption; for CI in women, excessive abdominal skinfold thickness, and low fat consumption; for CI in women, HT, high sodium intake, excessive abdominal skinfold thickness, decreased triceps skinfold thickness, and lack of recent physical exercise. On subgroup comparison, DM was found to be a discriminant risk factor favoring CI (v ICH) in women. CONCLUSION Our results showed that in Seoul, Korea, HT is the strongest risk factor for CI and ICH, and high sodium intake, lack of exercise, and central body fat deposition are relatively important factors related to stroke, whereas factors such as cigarette smoking, hypercholesterolemia, and body mass index are not. Low consumption of fat and heavy alcohol drinking appear to be related to the occurrence of ICH. Risk factors for stroke may differ among different ethnic groups and guidelines for stroke prevention should be based on a correct understanding of them.
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Affiliation(s)
- S Choi-Kwon
- Department of Nursing, Dankook University, Cheon-An (S.C.-K.), South Korea; Department of Neurology, University of Ulsan, Asan Medical Center, Seoul (J.S.K.), South Korea
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Narayan SK, Sivaprasad P, Sushma S, Sahoo RK, Dutta TK. Etiology and outcome determinants of intracerebral hemorrhage in a south Indian population, A hospital-based study. Ann Indian Acad Neurol 2013; 15:263-6. [PMID: 23349590 PMCID: PMC3548363 DOI: 10.4103/0972-2327.104333] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 03/20/2012] [Accepted: 06/24/2012] [Indexed: 11/05/2022] Open
Abstract
Background: There is paucity of methodologically sound published studies on intracerebral hemorrhage (ICH) from India, on pub med/embase search. Aims: To explore etiology of ICH and correlate the causes, location, and size of hemorrhage to clinical outcome. Materials and Methods: A hospital-based descriptive study from South Indian eastern coastal town of Puducherry; 60 consecutive subjects aged > 12 years, predominantly of inbred Tamil population, with head CT evidence of intracerebral hemorrhage not associated with trauma and brain tumors, were recruited. Outcome at three months was measured using Glasgow Outcome scale, NIHSS and mortality. SPSS v 19 was used for statistical analysis. Results: Commonest etiological factor was hypertension, followed by bleeding diathesis, thrombolysis for myocardial infarction, and cortical vein thrombosis. Most frequent locations of hematoma were basal ganglia, thalamus, internal capsule, and cerebral and cerebellar parenchyma. Hematoma volume correlated significantly with systolic and mean arterial pressure but not with diastolic blood pressure. Poor outcome was correlated to size (P < 0.05) and intraventricular extension of hematoma (P < 0.05), and to systolic, diastolic and mean arterial pressure, but not to age, gender, smoking, alcoholism, ischemic heart disease, and blood sugar level. Among diabetic patients with ICH, the size of hematoma (P = 0.04) and severity of coma (P = 0.01) at admission were significantly worse compared to the non-diabetic, but not the outcome at three months [Glasgow outcome scale or mortality (P = 0.94 and 0.14)]. Conclusions: The location of hemorrhage and correlation with outcome agreed with the patterns described for the non-white races in prior reports. Independence of outcome to diabetic status despite a more severe initial presentation may indicate importance of good care, even in high risk groups.
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Affiliation(s)
- Sunil K Narayan
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Nervous System. ACTA ACUST UNITED AC 2009. [DOI: 10.1201/9781420036961.ch15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Pontes-Neto OM, Oliveira-Filho J, Valiente R, Friedrich M, Pedreira B, Rodrigues BCB, Liberato B, Freitas GRD. Diretrizes para o manejo de pacientes com hemorragia intraparenquimatosa cerebral espontânea. ARQUIVOS DE NEURO-PSIQUIATRIA 2009; 67:940-50. [DOI: 10.1590/s0004-282x2009000500034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Accepted: 08/15/2009] [Indexed: 01/24/2023]
Abstract
A hemorragia intraparenquimatosa cerebral (HIC) é o subtipo de AVC de pior prognóstico e com tratamento ainda controverso em diversos aspectos. O comitê executivo da Sociedade Brasileira de Doenças Cerebrovasculares, através de uma revisão ampla dos artigos publicados em revistas indexadas, elaborou sugestões e recomendações que são aqui descritas com suas respectivas classificações de níveis de evidência. Estas diretrizes foram elaboradas com o objetivo de prover o leitor de um racional para o manejo apropriado dos pacientes com HIC, baseado em evidências clínicas.
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Rosenow F, Hojer C, Meyer-Lohmann C, Hilgers RD, Miihlhofer H, Kleindienst A, Owega A, Koning W, Heiss WD. Spontaneous intracerebral hemorrhage. Acta Neurol Scand 2009. [DOI: 10.1111/j.1600-0404.1997.tb00263.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Study of the Propensity for Hemorrhage in Hispanic Americans With Stroke. J Stroke Cerebrovasc Dis 2008; 17:58-63. [DOI: 10.1016/j.jstrokecerebrovasdis.2007.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 11/18/2007] [Accepted: 12/07/2007] [Indexed: 11/18/2022] Open
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O'Connor AD, Rusyniak DE, Bruno A. Cerebrovascular and cardiovascular complications of alcohol and sympathomimetic drug abuse. Med Clin North Am 2005; 89:1343-58. [PMID: 16227066 DOI: 10.1016/j.mcna.2005.06.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Alcohol and stimulant abuse represents a major cause of cerebrovascular and cardiovascular disease in young adults. Although mild-to-moderate alcohol consumption has been linked to a decreased risk for stroke and CVD, excessive use is associated with an increased risk for intracranial hemorrhage and cardiomyopathy. Cocaine represents the single largest,cause of medical complications related to illegal drug use. Cocaine has been associated with cerebral infarction, intracranial hemorrhage, myocardial infarction, cardiomyopathy, and cardiac arrhythmias. Abuse of amphetamines is associated with complications similar to those of cocaine. The complications associated with stimulant abuse are thought to be primarily mediated through excess catecholamines, resulting in acute arterial hypertension, vasospasm, thrombosis, and accelerated atherosclerosis. Because many complications of alcohol and stimulant abuse are preventable and reversible, it is important to screen for these in patients with cerebrovascular and cardiovascular disease.
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Affiliation(s)
- Ayrn D O'Connor
- Department of Emergency Medicine, Iniana University School of Medicine, Indianapolis, IN, USA.
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Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) occurs from the rupture of small vessels into the brain parenchyma and accounts for approximately 10% of all strokes in the United States, and carries with it a significantly high morbidity and mortality. SUMMARY This article reviews the course and management of ICH. The most common chronic vascular diseases that lead to ICH are chronic hypertension and cerebral amyloid angiopathy. Additional factors that predispose to ICH include vascular malformations, chronic alcohol use, hypocholesterolemia, and use of anticoagulant medications. The understanding of mechanisms leading to ICH has advanced significantly, but questions regarding site predilection and timing of spontaneous hemorrhage still remain. Management in the acute setting is first focused on reducing hematoma expansion. Although no specific therapy has yet been proven effective, promising agents, particularly recombinant Factor VIIa, are on the horizon. Subsequent care is focused on controlling hemostasis, hemodynamics, and intracranial pressure in efforts to minimize secondary brain injury. CONCLUSION The morbidity and mortality associated with ICH remain high despite recent advances in our understanding of the clinical course of ICH. Novel preventive and acute treatment therapies are needed and may be on the horizon.
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Affiliation(s)
- Neeraj Badjatia
- Neurocritical Care and Acute Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Soares CM, Carvalho ACP, Rodrigues ADJ. Hemorragia intraparenquimatosa encefálica espontânea: achados à tomografia computadorizada. ARQUIVOS DE NEURO-PSIQUIATRIA 2004; 62:682-8. [PMID: 15334231 DOI: 10.1590/s0004-282x2004000400022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Foram analisados os exames de tomografia computadorizada de crânio de 250 pacientes com hematoma intraparenquimatoso encefálico espontâneo em três diferentes hospitais na cidade do Rio de Janeiro, com o objetivo de se levantar os aspectos mais freqüentes desta doença. O hematoma intraparenquimatoso cerebral profundo foi o de maior incidência, seguido do lobar. Mais raramente foi observado sangramento cerebelar e do tronco cerebral. A faixa etária de acometimento mais freqüente foi entre 61 e 70 anos de idade. Não houve diferença expressiva quanto ao sexo predominante ou ao lado mais acometido, porém verificou-se que os homens são mais acometidos em uma faixa etária mais precoce do que as mulheres. A cefaléia foi o sintoma de maior freqüência e a hipertensão arterial esteve presente na maioria dos casos. A drenagem da hemorragia para o sistema ventricular ocorreu mais comumente nos hematomas profundos.
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Abstract
Alcohol abuse has been linked to intracranial hemorrhage, both intracerebral and subarachnoid. Some studies have found a dose-response relationship, so that increasing levels of abuse are associated with greater risk of hemorrhage. However, alcohol abuse has not been clearly linked to cerebral infarction, and some studies find that mild-to-moderate drinking appears to be associated with a decreased risk of cerebral infarction. Intravenous administration of drugs of abuse predisposes to endocarditis, which may lead to embolic stroke. Associations have been reported between various sympathomimetic drugs and cerebral infarction. A possible mechanism for cerebral infarction is focal arterial vasoconstriction and occasionally cerebral vasculitis. Associations have also been reported between various sympathomimetic drugs and intracranial hemorrhage. A likely mechanism for intracranial hemorrhage is acute arterial hypertension. With the exception of endocarditis, management of stroke related to drug abuse is largely supportive, with emphasis on supportive care to prevent stroke complications, physical and occupational therapy, and aggressive addiction rehabilitation.
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Affiliation(s)
- Askiel Bruno
- Stroke Service, Department of Neurology, Indiana University School of Medicine, 541 Clinical Drive, R290C, Indianapolis, IN 46202, USA.
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Bernardini GL, DeShaies EM. Critical care of intracerebral and subarachnoid hemorrhage. Curr Neurol Neurosci Rep 2001; 1:568-76. [PMID: 11898571 DOI: 10.1007/s11910-001-0064-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The acute management of primary intracerebral or aneurysmal subarachnoid hemorrhage requires a comprehensive approach involving stabilization of the patient, surgical intervention, and continued intensive care treatment of medical and neurologic complications. The are several causes of intracerebral hemorrhage (ICH), including hypertension, cerebral amyloid angiopathy, sympathomimetic drugs, and coagulopathies. More recently, use of thrombolytic agents in the treatment of acute ischemic stroke has increased the risk of ICH. Treatment of intracerebral hemorrhage is based on blood pressure control, and, in selected cases, surgical evacuation of clot. Patients with aneurysmal subarachnoid hemorrhage may experience rebleeding, symptomatic vasospasm, or hydrocephalus. Medical management in the intensive care unit with careful attention to fluid and electrolyte balance, nutrition, cardiopulmonary monitoring, and close observation for changes in the neurologic exam is vital. This review examines the diagnosis and intensive care management of patients with intracerebral or subarachnoid hemorrhage, and reviews some of the newer therapies for treatment of these disorders.
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Affiliation(s)
- G L Bernardini
- Departments of Neurology and Neurosurgery, Albany Medical Center, 47 New Scotland Avenue, MC-70, Albany, NY 12208-3479, USA.
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Abstract
The present review focuses on evolving concepts in the pathogenesis and management of deep and lobar intracerebral hemorrhage subtypes, with particular focus on the relationship between lobar intracerebral hemorrhage, apolipoprotein E subtypes and cerebral amyloid angiopathy; deep intracerebral hemorrhage and the potential interaction between hypertension and low cholesterol; and new concepts in medical and surgical therapy for acute intracerebral hemorrhage.
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Affiliation(s)
- D L Labovitz
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York, USA.
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Thrift AG, Evans RG, Donnan GA. Hypertension and the risk of intracerebral haemorrhage: special considerations in patients with renal disease. Nephrol Dial Transplant 1999; 14:2291-2. [PMID: 10528646 DOI: 10.1093/ndt/14.10.2291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Thrift AG, McNeil JJ, Forbes A, Donnan GA. Risk of primary intracerebral haemorrhage associated with aspirin and non-steroidal anti-inflammatory drugs: case-control study. BMJ (CLINICAL RESEARCH ED.) 1999; 318:759-64. [PMID: 10082697 PMCID: PMC27788 DOI: 10.1136/bmj.318.7186.759] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To examine the association between use of aspirin or other non-steroidal anti-inflammatory drugs and intracerebral haemorrhage. DESIGN Case-control study. SETTING 13 major city hospitals in the Melbourne and metropolitan area. SUBJECTS 331 consecutive cases of stroke verified by computed tomography or postmortem examination, and 331 age (+/- 5 years) and sex matched controls who were community based neighbours. INTERVENTIONS Questionnaire administered to all subjects either directly or by proxy with the next of kin. Drug use was validated by reviewing prescribing records held by the participants' doctors. MAIN OUTCOME MEASURES Previous use of aspirin or other non-steroidal anti-inflammatory drugs. RESULTS Univariate analysis showed no increased risk of intracerebral haemorrhage with low dose aspirin use in the preceding 2 weeks. Using multiple logistic regression to control for possible confounding factors, the odds ratio associated with the use of aspirin was 1.00 (95% confidence interval 0.60 to 1. 66, P=0.998) and the odds ratio associated with the use of other non-steroidal anti-inflammatory drugs was 0.85 (0.45 to 1.61, P=0. 611) compared with respective non-users in the preceding fortnight. Moderate to high doses of aspirin (>1225 mg/week spread over at least three doses) yielded an odds ratio of 3.05 (1.02 to 9.14, P=0. 047). There was no evidence of an increased risk among subgroups defined by age, sex, blood pressure status, alcohol intake, smoking, and the presence or absence of previous cardiovascular disease. CONCLUSIONS No increase in risk of intracerebral haemorrhage was found among aspirin users overall or among those who took low doses of the drug or other non-steroidal anti-inflammatory drugs. These data provide evidence that doses of aspirin usually used for prophylaxis against vascular disease produce no substantial increase in risk of intracerebral haemorrhage.
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Affiliation(s)
- A G Thrift
- Department of Epidemiology and Preventive Medicine, Monash Medical School, Alfred Hospital, Prahran 3181, Australia.
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Hsiang JN, Zhu XL, Wong LK, Kay R, Poon WS. Putaminal and thalamic hemorrhage in ethnic chinese living in Hong Kong. SURGICAL NEUROLOGY 1996; 46:441-5. [PMID: 8874542 DOI: 10.1016/s0090-3019(96)00157-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hemorrhagic stroke is very common in the Chinese population, and it is one of the leading causes of mortality in Chinese communities. The risk factors to explain this high incidence are unknown. It is the purpose of this study to look into the features of hemorrhagic stroke in the Hong Kong Chinese. METHODS We conducted a prospective hospital-based study in which 60 consecutive Chinese patients with computed tomography diagnosis of putaminal or thalamic hemorrhage were included. Their demographic and clinical data were collected and analyzed. RESULTS Two major findings evolved from the present study. (1) Unlike the Western studies, the majority of our patients were about a decade younger; (2) 50% of the patients had previously diagnosed hypertension, but only 20% of these patients were compliant with their antihypertensive medication. Our results also suggested that low admission Glasgow Coma Scale scores, large hematoma size, and the presence of intraventricular blood were associated with poor outcomes. CONCLUSIONS This study concludes that hemorrhagic stroke is indeed a serious health problem in Hong Kong. Simple measures, such as improvement of health education and the primary care system in the management of hypertension, would help to reduce the incidence of hemorrhagic stroke.
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Affiliation(s)
- J N Hsiang
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong
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19
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Abstract
Hypertensive intracerebral hemorrhage has been considered as a one-time event with rare recurrence. This observation is quite different from our experience in Taiwan. We, therefore, conducted a systematic review of our series of consecutive patients with recurrent bleeding. During a 2-year period, we encountered 47 patients with recurrent hypertensive intracerebral hemorrhage from a total of 892 consecutive patients with hypertensive hemorrhage (5.3%). There were 25 men and 22 women with a mean age of 59 +/- 10 (range: 36-78) years at the onset of the first hemorrhage and 62 +/- 9 (range: 39-80) years at the second hemorrhage. The median interval between 2 hemorrhages was 2 years and 4 months (range: 1 month to 8.5 years). All except one recurrent hemorrhages occurred at a site different from the previous one. Of the 38 patients admitted to our hospital for both hemorrhages only 5 were regularly treated with antihypertensive therapy. The outcome for the recurrent bleeding was grave: 26% died and 51% became totally dependent or vegetative. Recurrent hypertensive hemorrhage is not as rare as previously thought; it comprises 5.3% of our patients with hypertensive intracerebral hemorrhage. The recurrent hemorrhage, however, rarely occurs at the same location as the previous one. Uncontrolled hypertension appears to be an important risk factor for the recurrence. Control of blood pressure after the first bleeding should be attempted to prevent recurrent hemorrhage.
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Affiliation(s)
- S T Chen
- Department of Neurology, Chang Gung Memorial Hospital and Medical College, Taipei, Taiwan
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20
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Dourado ME, Freitas ML, Marti-Vilalta JL. [Lobar cerebral hemorrhage. Clinical aspects, etiology and course. Review of 58 cases]. ARQUIVOS DE NEURO-PSIQUIATRIA 1993; 51:183-9. [PMID: 8274078 DOI: 10.1590/s0004-282x1993000200006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Fifty eight patients with spontaneous lobar hemorrhage of a 264 patients series with intracerebral hemorrhage seen during a six years period are reviewed. Twenty nine had arterial hypertension, 9 had other etiologies, and in the remaining 20 cases no apparent etiology was detected. Headache was a prominent symptom and occurred in 56%. Seizures occurred in 12%. Coma was infrequent. Clinical findings on admission depended on the location of the hematoma. Lobar hemorrhage occurred most commonly in the parietal region. Mortality rate was 8.6%. Size of hematoma (larger than 4 cm) on CT and altered consciousness on admission correlated with poor outcome.
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Affiliation(s)
- M E Dourado
- Serviço de Neurologia do Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona (UAB), Espanha
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21
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Shinton R, Sagar G, Beevers G. The relation of alcohol consumption to cardiovascular risk factors and stroke. The west Birmingham stroke project. J Neurol Neurosurg Psychiatry 1993; 56:458-62. [PMID: 8505634 PMCID: PMC1015000 DOI: 10.1136/jnnp.56.5.458] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The disputed relation between recent alcohol consumption and stroke was examined in a community case control study. One hundred and twenty five incident first time stroke patients and 198 controls, aged 35 to 74 years, were recruited over two years from a general practice population. The age and sex adjusted relative risks for stroke by recent weekly "drinks" of alcohol were; 0-1.0 (reference), 1 to 14-0.57, 15 to 29-0.63, and > 29-0.99. Among the controls it was noted that non-drinkers were more likely than light/moderate drinkers (1 to 29 drinks per week) to have the following characteristics; history of obesity (p < 0.001), not a recent walker (p < 0.05), and no vigorous exercise in early adulthood (p < 0.01). The apparent association of light and moderate alcohol consumption with decreased stroke risk disappeared when these variables were included in the multiple risk factor adjusted analysis; 0-1.0, 1 to 14-0.88, 15 to 29-1.11, and > 29-1.23. The pattern for proved cerebral infarction (n = 81) was similar. The results of this study do not support the idea that recent heavy alcohol consumption is an important cause of either overall stroke or cerebral infarction. The association of non-drinking with a history of overweight and inactivity may explain the apparent protective effect of lighter alcohol consumption on the risks of both stroke and coronary heart disease.
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Affiliation(s)
- R Shinton
- Department of Medicine, University of Birmingham
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22
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Fogelholm R, Murros K. Cigarette smoking and risk of primary intracerebral haemorrhage. A population-based case-control study. Acta Neurol Scand 1993; 87:367-70. [PMID: 8333240 DOI: 10.1111/j.1600-0404.1993.tb04119.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
From September 1985 to December 1989 a total of 158 patients had primary intracerebral haemorrhage in the population of 116,000 in the Jyväskylä Region, Central Finland. All had the diagnosis confirmed by either computerised tomography or necropsy, and information on cigarette smoking habits was available in 155 patients, 20% of whom were current cigarette smokers. One control was selected for each of the 155 patients matched on sex, age, and residence from the census of Central Finland. The odds ratio of primary intracerebral haemorrhage of current cigarette smokers compared with current non-smokers was estimated on basis of the number of discordant pairs as 1.4 (95% confidence interval 0.7 to 2.8). Adjustment for hypertension or diabetes did not change this estimate. Our data did not show evidence of an positive association of cigarette smoking and risk of primary intracerebral haemorrhage. This assumption was strengthened when the results of previous studies and the present study were pooled giving an odds ratio of 1.0 (95% confidence interval 0.8 to 1.3).
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Affiliation(s)
- R Fogelholm
- Department of Neurology, Central Hospital of Central Finland, Jyväskylä
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23
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24
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Bae HG, Lee KS, Yun IG, Bae WK, Choi SK, Byun BJ, Lee IS. Rapid expansion of hypertensive intracerebral hemorrhage. Neurosurgery 1992; 31:35-41. [PMID: 1641108 DOI: 10.1227/00006123-199207000-00006] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
We report a series of 10 patients who had a rapid expansion of a hypertensive intracerebral hemorrhage (HICH). It occurred in approximately 3% of 320 patients who sought treatment for HICH during the past 2 years. The site of hemorrhage was the putamen in 6 patients and the thalamus in 4 patients. Neurological deterioration occurred in a mean time of 40 hours after the onset of symptoms (range, 5.5-109 h). Fifty percent of all patients deteriorated within 24 hours. Persistent hypertension was recorded in all patients. Repeat computed tomography showed an increase of hematoma volume that was twice as large in thalamic hemorrhage and about three times as large in putaminal hemorrhage. Six patients died, whereas 3 survived with severe disability and 1 survived with moderate disability. This study indicates that continued or subsequent bleeding can occur in HICH. If those lesions are not detected early and microsurgically evacuated, they are almost always fatal. Early stereotactic evacuation with urokinase irrigation is considered more dangerous than open craniotomy by microsurgical techniques. We stress the need for attention to this problem during the acute phase of HICH.
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Affiliation(s)
- H G Bae
- Department of Neurosurgery, Soonchunhyang University Chonan Hospital, Korea
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25
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Rapid Expansion of Hypertensive Intracerebral Hemorrhage. Neurosurgery 1992. [DOI: 10.1097/00006123-199207000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Werneck LC, Scola RH, Ferraz LE. [Spontaneous intracerebral hematomas: study of 121 cases]. ARQUIVOS DE NEURO-PSIQUIATRIA 1991; 49:18-26. [PMID: 1863237 DOI: 10.1590/s0004-282x1991000100003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Results are reported on the study of 121 patients committed by spontaneous intracerebral haematomas (HIE): mean age 53.4 years, 62.8% males, mean admission time of 36 hours (3 hours to 12 days) from onset; 63.5% were graded over 7 in the Glasgow scale and 81.9% were graded 3 or over in the Boterell scale. The HIE location was 45.5% in the basal ganglia, multilobar in 14.7%, lobar in 22.8%, brain stem in 4%, and cerebellum in 2%. The mean diameter was 46.6 mm (16-93) and mean area was 1422.9 mm2 (60-4818). CSF in 67 cases showed mean opening pressure of 234 mmH20 and mean protein content of 416.9 mg/dl. Treatment was conservative in 107 cases and surgical in 14; 55.8% cases survived. The majority of patients who died were graded 3 in the Boterell scale and below 9 in the Glasgow scale. It was found a statistical correlation between death and: low Glasgow and high Boterell scales grading, motor ocular nerve palsy, motor deficit, decerebration signs, bronchopneumonia, large diameter and area of hematomas. No statistical correlation was found regarding survival and treatment with dexamethasone, antifibrinolytics, anticonvulsants, antihypertensive drugs and diuretics. Use of mannitol, fall in the systolic blood pressure and surgical therapy increased the mortality rate. From 14 patients who underwent surgical drainage, 11 died. The main complication who lead to death was bronchopneumonia. A discussion is made on HIE pathogenesis, localization, present day incidence, clinical findings, death causes, size of hematomas and type of treatment used.
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Affiliation(s)
- L C Werneck
- Departamento de Clínica Médica, Hospital de Clínicas, Universidade Federal do Paraná, Brasil
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27
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Auer LM, Deinsberger W, Niederkorn K, Gell G, Kleinert R, Schneider G, Holzer P, Bone G, Mokry M, Körner E. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg 1989; 70:530-5. [PMID: 2926492 DOI: 10.3171/jns.1989.70.4.0530] [Citation(s) in RCA: 456] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A controlled randomized study of endoscopic evacuation versus medical treatment was performed in 100 patients with spontaneous supratentorial intracerebral (subcortical, putaminal, and thalamic) hematomas. Patients with aneurysms, arteriovenous malformations, brain tumors, or head injuries were excluded. Criteria for inclusion were as follows: patients' age between 30 and 80 years; a hematoma volume of more than 10 cu cm; the presence of neurological or consciousness impairment; the appropriateness of surgery from a medical and anesthesiological point of view; and the initiation of treatment within 48 hours after hemorrhage. The criteria of randomization were the location, size, and side of the hematoma as well as the patient's age, state of consciousness, and history of hypertension. Evaluation of outcome was performed 6 months after hemorrhage. Surgical patients with subcortical hematomas showed a significantly lower mortality rate (30%) than their medically treated counterparts (70%, p less than 0.05). Moreover, 40% of these patients had a good outcome with no or only a minimal deficit versus 25% in the medically treated group; the difference was statistically significant for operated patients with no postoperative deficit (p less than 0.01). Surgical patients with hematomas smaller than 50 cu cm made a significantly better functional recovery than did patients of the medically treated group, but had a comparable mortality rate. By contrast, patients with larger hematomas showed significantly lower mortality rates after operation but had no better functional recovery than the medically treated group. This effect from surgery was limited to patients in a preoperatively alert or somnolent state; stuporous or comatose patients had no better outcome after surgery. The outcome of surgical patients with putaminal or thalamic hemorrhage was no better than for those with medical treatment; however, there was a trend toward better quality of survival and chance of survival in the operated group.
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Affiliation(s)
- L M Auer
- Department of Neurosurgery, University of Graz, Austria
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Bianchi E, Savasta S, Torcetta F, Solmi M, Beluffi G, Gajno TM. Thalamic hemorrhage in a 4-year-old child induced by nephro-vascular hypertension. Pediatr Radiol 1989; 19:513-5. [PMID: 2797933 DOI: 10.1007/bf02389560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A child affected by cardiomyopathy from the age of 12 months suddenly manifested right hemiparesis and dysarthria at the age of 48/12 years. Emergency brain CT showed a hemorrhage in progress in the left thalamic area. A severe form of hypertension was concomitant and resisted all pharmacological treatment. Retrograde transfemoral aortography pointed out an atrophy of the right renal artery. This finding, together with the high renin and aldosterone values, indicated a nephrogenic hypertension causing both the cardiomyopathy found at 12 months of age and the endocranial hemorrhage. Right nephrectomy led to normalization of blood pressure.
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Affiliation(s)
- E Bianchi
- Pediatrics Clinic, University of Pavia, Italy
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