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1.  Hemiparesis Caused by Cervical Spontaneous Spinal Epidural Hematoma: A Report of 3 Cases 
Advances in Orthopedics  2011;2011:516382.
We report three cases of spontaneous spinal epidural hematoma (SSEH) with hemiparesis. The first patient was a 73-year-old woman who presented with left hemiparesis, neck pain, and left shoulder pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C3–C6 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The second patient was a 62-year-old man who presented with right hemiparesis and neck pain. A cervical MRI scan revealed a right posterolateral dominant epidural hematoma at the C6-T1 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The third patient was a 60-year-old woman who presented with left hemiparesis and neck pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C2–C4 level. The condition of the patient improved with conservative treatment. The classical clinical presentation of SSEH is acute onset of severe irradiating back pain followed by progression to paralysis, whereas SSEH with hemiparesis is less common. Our cases suggest that acute cervical spinal epidural hematoma should be considered as a differential diagnosis in patients presenting with clinical symptoms of sudden neck pain and radicular pain with progression to hemiparesis.
doi:10.4061/2011/516382
PMCID: PMC3170783  PMID: 21991415
2.  Effects of alteplase in the treatment of acute ischemic stroke 
Background
For the last 15 years, alteplase (recombinant tissue plasminogen activator) has been used widely throughout the world for the treatment of acute ischemic stroke. Although considered to be safe and effective, like all drugs, alteplase has side effects.
Methods
This retrospective cohort study was conducted in the intensive care unit of the department of internal medicine in a mid-size peripheral acute hospital in Germany. Patients with acute ischemic stroke who underwent alteplase-induced thrombolysis were investigated.
Results
Among the 1017 patients admitted for stroke investigation, 23 (2.26%) received thrombolytic therapy consisting of intravenous alteplase. Of these, six patients (26.09%) experienced complications, ie, four (17.39%) had intracerebral hemorrhage, one (4.35%) developed orolingual angioedema, and one (4.35%) had a hematoma on the right arm. After treatment with alteplase, two (33.33%) patients in the study group (n = 6) died because of intracerebral hemorrhage and one (16.67%) died because of aspiration pneumonia. One (5.88%) patient in the control group (n = 17) died of cerebral edema.
Conclusion
The incidence of stroke and number of patients treated with alteplase in the examined hospital subunit has not increased in recent years. Also, in this study, no statistically significant difference was found in the incidence of various complications occurring during treatment for acute ischemic stroke with alteplase, but intracerebral hemorrhage was the most common complication.
doi:10.2147/IJGM.S32142
PMCID: PMC3459662  PMID: 23049267
alteplase; complications; acute ischemic stroke; safety; efficacy
3.  Postoperative spinal epidural hematoma resulting in cauda equina syndrome: a case report and review of the literature 
Cases Journal  2009;2:8584.
Spinal epidural hematoma is a well known complication of spinal surgery. Clinically insignificant small epidural hematomas develop in most spinal surgeries following laminectomy. However, the incidence of clinically significant postoperative spinal epidural hematomas that result in neurological deficits is extremely rare. In this report, we present a 33-year-old female patient whose spinal surgery resulted in postoperative spinal epidural hematoma. She was diagnosed with lumbar disc disease and underwent hemipartial lumbar laminectomy and discectomy. After twelve hours postoperation, her neurologic status deteriorated and cauda equina syndrome with acute spinal epidural hematoma was identified. She was immediately treated with surgical decompression and evacuation of the hematoma. The incidence of epidural hematoma after spinal surgery is rare, but very serious complication. Spinal epidural hematomas can cause significant spinal cord and cauda equina compression, requiring surgical intervention. Once diagnosed, the patient should immediately undergo emergency surgical exploration and evacuation of the hematoma.
doi:10.4076/1757-1626-2-8584
PMCID: PMC2740261  PMID: 19830087
4.  Spontaneous Cervical Epidural Hematoma with Hemiparesis Mimicking Cerebral Stroke 
Aim. Spontaneous cervical epidural hematoma (SCEH) is defined as an epidural hematoma that does not have an etiological explanation. The most common site for SCEH is cervicothoracic area. Early diagnosis and treatment are important for prognosis and good results. In this paper, we aimed to present a case who complains of sudden weakness on right extremities imitating cerebral stroke and that neuroimaging reveals spontaneous cervical epidural hematoma. Case. A 72-year-old woman was admitted to our hospital with acute neck pain and loss of strength on right extremities. On neurological examination, the patient had right hemiparesis. PT, aPTT, and INR results were 50.5, 42.8, and 4.8, respectively. Cranial MRI was in normal limits. Spinal MRI revealed a lesion that extends from C4 to C7 located on the right side and compatible with epidural hematoma. The patient was operated after normalization of INR values. Conclusion. Even though SCEH is a rare condition, it can cause severe morbidity and mortality. Early diagnosis and treatment are quiet important for prognosis. SCEH can easily be mistaken for stroke as with other pathologies and this diagnosis should come to mind especially in patients who have diathesis of bleeding.
doi:10.1155/2014/210146
PMCID: PMC4202256  PMID: 25371831
5.  Spontaneous spinal epidural hematoma with hemiparesis mimicking acute cerebral infarction: Two case reports 
Context
Acute hemiparesis is a common initial presentation of ischemic stroke. Although hemiparesis due to spontaneous spinal epidural hematoma (SSEH) is an uncommon symptom, a few cases have been reported and misdiagnosed as cerebral infarction.
Design
Case reports of SSEH with acute hemiparesis.
Findings
In these two cases, acute stroke was suspected initially and administration of intravenous alteplase therapy was considered. In one case, the presentation was neck pain and in the other case, it was Lhermitte's sign; brain magnetic resonance imaging (MRI) and magnetic resonance angiography were negative for signs of ischemic infarction, hemorrhage, or arterial dissection. Cervical MRI was performed and demonstrated SSEH.
Conclusion
Clinicians who perform intravenous thrombolytic treatment with alteplase need to be aware of this possible contraindication.
doi:10.1179/2045772312Y.0000000014
PMCID: PMC3425883  PMID: 22925753
Spontaneous spinal epidural hematoma; Hemiparesis; Tetraparesis; Lhermitte's sign; Cerebral infarction; Intravenous thrombolytic treatment; Magnetic resonance imaging; Computerized tomography; Alteplase
6.  Complete motor recovery after acute paraparesis caused by spontaneous spinal epidural hematoma: case report 
Background
Spontaneous spinal epidural hematoma is a relatively rare but potentially disabling disease. Prompt timely surgical management may promote recovery even in severe cases.
Case presentation
We report a 34-year-old man with a 2-hour history of sudden severe back pain, followed by weakness and numbness over the bilateral lower limbs, progressing to intense paraparesis and anesthesia. A spinal magnetic resonance imaging scan was performed and revealed an anterior epidural hematoma of the thoracic spine. He underwent an emergency decompression laminectomy of the thoracic spine and hematoma evacuation. Just after surgery, his lower extremity movements improved. After 1 week, there was no residual weakness and ambulation without assistance was resumed, with residual paresthesia on the plantar face of both feet. After 5 months, no residual symptoms persisted.
Conclusions
The diagnosis of spontaneous spinal epidural hematoma must be kept in mind in cases of sudden back pain with symptoms of spinal cord compression. Early recognition, accurate diagnosis and prompt surgical treatment may result in significant improvement even in severe cases.
doi:10.1186/1471-227X-11-10
PMCID: PMC3160384  PMID: 21794133
7.  Spinal epidural hematoma – A rare and debilitating complication of thrombolytic therapy 
Thrombolytic therapy directed to the achievement of early reperfusion in cases with acute ST elevation myocardial infarction can have significant complications which can be due to bleeding or in the form of allergic reactions. Sometimes these complications can cause mortality or significant and incapacitating morbidity which may at times surpass the risk possessed by the disease itself.
We are reporting an interesting case of 63-year-old male, who presented to us with acute anterior wall myocardial infarction and developed acute onset paralysis following intravenous administration of streptokinase and heparin. MRI spine revealed spinal epidural hematoma. Patient was advised urgent surgical evacuation of hematoma, but opted for conservative management. Patient had significant residual neurological deficits at follow-up. In conclusion, spinal epidural hematoma is a rare complication following thrombolysis for acute ST elevation myocardial infarction. Though rare, high index of suspicion is required by physicians, as prompt treatment may lead to complete recovery, which otherwise can lead to debilitating neurological sequel.
doi:10.1016/j.jcdr.2014.01.005
PMCID: PMC3953704  PMID: 24653587
LV aneurysm; Spinal epidural haematoma; Thrombolysis; STEMI; Morbidity
8.  Intracerebral Hemorrhage after Intravenous Thrombolysis in Patients with Cerebral Microbleeds and Cardiac Myxoma 
Background and purpose: Cardiac myxoma is a rare etiology of stroke. Both cerebral microbleeds and cardiac myxoma may increase the risk of intracerebral hemorrhage after intravenous (IV) thrombolysis. However, data are still limited. We report a case of multiple cerebral microbleeds treated with IV thrombolysis with later findings of cardiac myxoma.
Summary of case: A 58-year-old-man presented with right-sided hemiplegia and global aphasia. The presumptive diagnosis of acute left middle cerebral artery (MCA) infarction was made. Previous magnetic resonance imaging showed multiple cerebral microbleeds. The patient received IV thrombolysis. Bilateral cerebellar hemorrhage occurred after thrombolysis, and a median suboccipital craniectomy and hematoma removal was performed. Transthoracic echocardiogram found a left atrial myxoma. The tumor was then surgically removed. Six months later, neurological deficit improved.
Conclusion: Cerebral microbleeds may be associated with atrial myxoma. IV thrombolysis could benefit acute ischemic stroke patients with both baseline cerebral microbleeds and atrial myxoma.
doi:10.3389/fneur.2014.00252
PMCID: PMC4248841  PMID: 25520700
microbleeds; cardiac myxoma; thrombolysis; recanalization
9.  Spinal Epidural Hematoma after Pain Control Procedure 
Spinal epidural hematoma is a rare complication associated with pain control procedures such as facet block, acupuncture, epidural injection, etc. Although it is an uncommon cause of acute myelopathy, and it may require surgical evacuation. We report four patients with epidural hematoma developed after pain control procedures. Two procedures were facet joint blocks and the others were epidural blocks. Pain was the predominant initial symptom in these patients while two patients presented with post-procedural neurological deficits. Surgical evacuation of the hematoma was performed in two patients while in remaining two patients, surgery was initially recommended but not performed since symptoms were progressively improved. Three patients showed near complete recovery except for one patient who recovered with residual deficits. Although, spinal epidural hematoma is a rare condition, it can lead to serious complications like spinal cord compression. Therefore, it is important to be cautious while performing spinal pain control procedure to avoid such complications. Surgical treatment is an effective option to resolve the spinal epidural hematoma.
doi:10.3340/jkns.2010.48.3.281
PMCID: PMC2966734  PMID: 21082060
Spinal epidural hematoma; Pain control procedure; Surgical evacuation
10.  Epidural hematoma occurred by massive bleeding intraoperatively in cesarean section after combined spinal epidural anesthesia -A case report- 
Korean Journal of Anesthesiology  2011;61(4):336-340.
We describe a case of acute lumbar epidural hematoma at the L2-3 level complicated by paraplegia, which occurred after coagulation disorder because of massive bleeding intraoperatively in cesarean section. The preoperative coagulation laboratory finding was in normal range and so we tried combined spinal epidural anesthesia. Uterine atony occurred in the operation, and there was persistant bleeding during and after the operation. After the operation, she complained of paresthesia on her both legs and was diagnosed with epidural hematoma (EDH) by radiologic examination. Emergency laminectomy on lumbar spine was carried out for hematoma evacuation and decompression of the epidural space at once. In our experience, massive bleeding during surgery may potentially increase the risk of EDH postoperatively.
doi:10.4097/kjae.2011.61.4.336
PMCID: PMC3219782  PMID: 22110889
Blood coagulation disorder; Cesarean section; Epidural anesthesia; Epidural hematoma; Postpartum hemorrhage; Spinal anesthesia
11.  Primary Angioplasty for the Treatment of Acute ST-Segment Elevated Myocardial Infarction 
Executive Summary
One of the longest running debates in cardiology is about the best reperfusion therapy for patients with evolving acute myocardial infarction (MI). Percutaneous transluminal coronary angioplasty (ANGIOPLASTY) is a surgical treatment to reopen a blocked coronary artery to restore blood flow. It is a type of percutaneous (through-the-skin) coronary intervention (PCI) also known as balloon angioplasty. When performed on patients with acute myocardial infarction, it is called primary angioplasty. Primary angioplasty is an alternative to thrombolysis, clot-dissolving drug therapy, for patients with acute MI associated with ST-segment elevation (STEMI), a change recorded with an electrocardiogram (ECG) during chest pain.
This review of the clinical benefits and policy implications of primary angioplasty was requested by the Ontario Health Technology Advisory Committee and prompted by the recent publication of a randomized controlled trial (RCT) in the New England Journal of Medicine (1) that compared referred primary angioplasty with on-site thrombolysis. The Medical Advisory Secretariat reviewed the literature comparing primary angioplasty with thrombolysis and other therapies (pre-hospital thrombolysis and facilitated angioplasty, the latter approach consisting of thrombolysis followed by primary angioplasty irrespective of response to thrombolysis) for acute STEMI.
There have been many RCTs and meta-analyses of these RCTs comparing primary angioplasty with thrombolysis and these were the subject of this analysis. Results showed a statistically significant reduction in mortality, reinfarction, and stroke for patients receiving primary angioplasty. Although the individual trials did not show significant improvements in mortality alone, they did show it for the outcomes of nonfatal reinfarction and stroke, and for an end point combining mortality, reinfarction, and stroke. However, researchers have raised concerns about these studies.
A main concern with the large RCTs is that they lack consistency in methods. Furthermore, there is some question as to their generalizability to practice in Ontario. Across the RCTs, there were differences in the type of thrombolytic drug, the use of stenting versus balloon-only angioplasty, and the use of the newer antiplatelet glycoprotein IIb/IIIa. The largest trial did not offer routine follow-up angioplasty for patients receiving thrombolysis, which is the practice in Ontario, and the meta-analysis included trials with streptokinase, an agent seldom used in hospitals in Ontario. Thus, the true magnitude of mortality benefit can only be surmised from head-to-head comparisons of current standard therapies for primary angioplasty and for thrombolysis.
By taking a more restrictive sample of the available studies, the Medical Advisory Secretariat conducted a review that was more consistent with patterns of practice in Ontario and selected trials that used accelerated alteplase as the thrombolytic agent.
Results from this meta-analysis suggest that the rates for primary angioplasty are significantly better for mortality, reinfarction, and stroke, in the short term (30 days), and for mortality, reinfarction, and the combined end point at 6 months. When primary angioplasty was compared with in-hospital thrombolysis, results showed a significant reduction in adverse event rates associated with primary angioplasty. However, 1 large RCT of pre-hospital thrombolysis (i.e., thrombolysis given by paramedics before arriving at the hospital) compared with primary angioplasty documented that pre-hospital thrombolysis is an equivalent intervention to primary thrombolysis in terms of survival. Furthermore, a meta-analysis of studies that compared pre-hospital thrombolysis with in-hospital thrombolysis showed a reduction in all hospital mortality rates in favour of pre-hospital thrombolysis, supporting the findings of the pre-hospital thrombolysis study. (2)
Clinical trials to date have reported that hospital stay is often reduced for patients who receive primary angioplasty compared with thrombolysis. Using a cost-analysis performed alongside the only study from Ontario, the Medical Advisory Secretariat concluded that there might be savings associated with primary angioplasty. These savings may partly offset the investment the provincial government would have to make to increase access to this technology. These savings should also be shown outside of a clinical trial protocol if the overall efficiencies of primary angioplasty are to be verified.
Based on this health technology policy analysis, the Medical Advisory Secretariat concludes that primary angioplasty has advantages with respect to mortality and combined end points compared with in-hospital thrombolysis (Level 1 evidence). However, pre-hospital thrombolysis improves survival compared with in-hospital thrombolysis (Level 1 evidence) and is equivalent to primary angioplasty (Level 1 evidence).
Results from the literature review raise concerns about the loss of therapeutic advantage due to treatment delays, time lapse from symptom onset to revascularization, time-of-day variations, the hospital volume of procedures, and the ability of hospitals to achieve in practice what RCTs have shown.
Furthermore, questions relevant to applying primary angioplasty widely, involve the diagnosis by paramedics, ambulance diversion protocols, paramedic training, and inter-hospital transfer protocols. These logistical considerations need to be addressed to realise the potential to improve patient outcomes. In its analysis, the Medical Advisory Secretariat concludes that it is unrealistic to reorganise the emergency medical services across Ontario to fully implement a primary angioplasty program.
Finally, it is important to evaluate the potential of this technology in the context of Ontario’s health system. This includes urban and rural considerations, the ability to expand access to primary angioplasty and to minimize symptom-to-assessment time through a diverse strategy including public awareness. Therefore, a measured, evaluative approach to adopting this technology is warranted.
Furthermore, the alternative approach to pre-hospital or early thrombolysis, especially within 120 minutes from onset of symptoms, should be considered when developing the approach to improving outcomes for acute MI. This could include efforts to decrease the symptom-to-thrombolysis time through strategies such as a concerted public education program to expedite presentation to emergency rooms after onset of symptoms, a pre-hospital ECG and thrombolysis checklist in ambulances to reduce door-to-needle time on arrival at emergency rooms, and, especially in remote areas, access to pre-hospital thrombolysis.
The Medical Advisory Secretariat therefore recommends that this analysis of primary angioplasty be viewed in the overall context of all interventions for the management of acute MI and, in particular, of improving access to primary angioplasty and maximising the use of early thrombolysis.
Outcomes for patients with acute MI can be improved if efforts are made to optimise the interval from symptom onset to thrombolysis or angioplasty. This will require concerted efforts, including public awareness through education to reduce the symptom-to-emergency room time, and maximising efficiencies in door-to-intervention times for primary angioplasty and for early thrombolysis.
Primary angioplasty and early thrombolysis cannot be considered in isolation from one another. For example, patients who have persistent STEMI 90 minutes after receiving thrombolysis should be considered for angioplasty (“rescue angioplasty”). Furthermore, for patients with acute MI who are in cardiac shock, primary angioplasty is considered the preferred intervention. The concomitant use of primary angioplasty and thrombolysis (“facilitated angioplasty”) is considered experimental and has no place in routine management of acute MI at this time. In remote parts of the province, consideration should be given to introducing pre-hospital thrombolysis as the preferred intervention through upgrading a select number of paramedics to advanced care status.
PMCID: PMC3387753  PMID: 23074449
12.  Endocapsular Hematoma: A Rare Form of Ocular Hemorrhage after Thrombolysis with Streptokinase 
Context:
Endocapsular hematoma has previously been described as a cataract surgery complication more commonly observed in eyes receiving a combined cataract and glaucoma surgery. However, it can also be a rare form of ocular bleed following thrombolysis with streptokinase.
Case Report:
A 65-year-old diabetic male presented to us with complain of sudden painless diminution of vision in his left eye, which he developed while he was being thrombolysed with streptokinase administered intravenously for an episode of acute myocardial infarct. On examination, left eye was pseudophakic with collection of blood in the capsular bag (Endocapsular hematoma).
Conclusion:
Endocapsular hematoma can be a rare form of ocular bleeding complicated by thrombolysis. Reporting this case becomes more relevant in the present era with increasing number of patients suffering from ischemic heart disease and likely to undergo thrombolysis.
doi:10.4103/1947-2714.139310
PMCID: PMC4158654  PMID: 25210679
Endocapsular hematoma; Streptokinase; Thrombolysis
13.  Post-operative spinal epidural hematoma causing American Spinal Injury Association B spinal cord injury in patients with suction wound drains 
Background
Subfascial wound suction drains are commonly used after spinal surgery to decrease the incidence of post-operative hematoma. However, there is a paucity of literature regarding their effectiveness.
Objective
To report four cases of post-operative spinal epidural hematoma causing massive neurological deficit in patients who had subfascial suction wound drains.
Methods
During an 8-year period, a retrospective review of 1750 consecutive adult spinal surgery cases was performed to determine the incidence, commonalities, and outcomes of catastrophic neurological deficit caused by post-operative spinal epidural hematoma.
Findings
Epidural hematoma causing major neurological deficit (American Spinal Injury Association B) was identified in 4 out of 1750 patients (0.23%). All four patients in this series had subfascial wound suction drains placed prophylactically at the conclusion of their initial procedure.
Results
Three patients developed massive neurological deficits with the drain in place; one patient had the drain removed at 24 hours and subsequently developed neurological symptoms during the following post-operative day. Significant risk factors for the development of hematoma were identified in two of the four patients. Average time to return to the operating room for hematoma evacuation was 6 hours (range 3–12 hours). Neurological status significantly improved in all four patients after hematoma evacuation.
Conclusions
Post-operative epidural hematoma causing catastrophic neurological deficit is a rare complication after spinal surgery. The presence of suction wound drains does not appear to prevent the occurrence of this devastating complication.
doi:10.1179/2045772312Y.0000000070
PMCID: PMC3654447  PMID: 23809591
Epidural hematoma; Suction drainage; Spinal cord injuries; Laminectomy; Spinal decompression
14.  Misdiagnosis of spontaneous cervical epidural haemorrhage 
European Spine Journal  2008;18(Suppl 2):210-212.
Spontaneous spinal epidural haemorrhage is a rare condition. The initial clinical manifestations are variable. Nonetheless, most spinal cord lesions result in paraparesis or quadriparesis, but not hemi-paresis, if motor function is involved. We report on a 69-year-old man who presented initially with right-side limb weakness. He was initially misdiagnosed at emergency room with a cerebral stroke and treated inappropriately with heparin. One day after admission, correct diagnosis of acute spinal epidural haematoma was based on the repeated neurological examination and cervical magnetic resonance imaging study. The patient underwent emergency surgical decompression and hematoma removal. The pathogenesis of the haematoma could have been due to hypertension, increased abdominal pressure and anticoagulant therapy. We emphasize that patients with hemi-paresis on initial presentation could have an acute spinal epidural haemorrhage. We also draw the misdiagnosis to the attention of the reader because early recognition of spontaneous spinal epidural haematoma is very important for prompt and appropriate treatment to improve the overall prognosis.
doi:10.1007/s00586-008-0819-2
PMCID: PMC2899547  PMID: 19005691
Spontaneous spinal epidural haemorrhage; Hemi-paresis; Cerebrovascular disease
15.  Pharmacological and Non-Pharmacological Recanalization Strategies in Acute Ischemic Stroke 
According to the guidelines of the European Stroke Organization (ESO) and the American Stroke Association (ASA), acute stroke patients should be managed at stroke units that include well organized pre- and in-hospital care. In ischemic stroke the restoration of blood flow has to occur within a limited time window that is accomplished by fibrinolytic therapy. Newer generation thrombolytic agents (alteplase, pro-urokinase, reteplase, tenecteplase, desmoteplase) have shorter half-life and are more fibrin-specific. Only alteplase has Food and Drug Administration (FDA) approval for the treatment of acute stroke (1996). The National Institute of Neurological Disorders and Stroke (NINDS) trial proved that alteplase was effective in all subtypes of ischemic strokes within the first 3 h. In the European cooperative acute stroke study III trial, intravenous (IV) alteplase therapy was found to be safe and effective (with some restrictions) if applied within the first 3–4.5 h. In middle cerebral artery (MCA) occlusion additional transcranial Doppler insonication may improve the breakdown of the blood clot. According to the ESO and ASA guidelines, intra-arterial (IA) thrombolysis is an option for recanalization within 6 h of MCA occlusion. Further trials on the IA therapy are needed, as previous studies have involved relatively small number of patients (compared to IV trials) and the optimal IA dose of alteplase has not been determined (20–30 mg is used most commonly in 2 h). Patients undergoing combined (IV + IA) thrombolysis had significantly better outcome than the placebo group or the IV therapy alone in the NINDS trial (Interventional Management of Stroke trials). If thrombolysis fails or it is contraindicated, mechanical devices [e.g., mechanical embolus removal in cerebral ischemia (MERCI)- approved in 2004] might be used to remove the occluding clot. Stenting can also be an option in case of acute internal carotid artery occlusion in the future. An intra-aortic balloon was used to increase the collateral blood flow in the Safety and Efficacy of NeuroFlo™ Technology in Ischemic Stroke trial (results are under evaluation). Currently, there is no approved effective neuroprotective drug.
doi:10.3389/fneur.2011.00032
PMCID: PMC3105226  PMID: 21660098
intravenous thrombolysis; intra-arterial thrombolysis; acute stroke; mechanism of recanalization; thrombectomy; alteplase; stroke unit; therapeutic time window
16.  Delayed Postoperative Epidural Hematoma Presenting Only with Vesicorectal Disturbance 
Case Reports in Orthopedics  2013;2013:861961.
We present a rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom was vesicorectal disturbance. A 68-year-old man with degenerative spinal stenosis underwent lumbar decompression and instrumented posterolateral spine fusion. The day after his discharge following an unremarkable postoperative course, he presented to the emergency room complaining of difficulty in urination. An MRI revealed an epidural fluid collection causing compression of the thecal sac. The fluid was evacuated, revealing a postoperative hematoma. After removal of the hematoma, his symptoms disappeared immediately, and his urinary function completely recovered. Most reports have characterized postoperative epidural hematoma as occurring early after operation and accompanied with neurological deficits. But it can happen even two weeks after spinal surgery with no pain. Surgeons thus may need to follow up patients for at least a few weeks because some complications, such as epidural hematomas, could take that long to manifest themselves.
doi:10.1155/2013/861961
PMCID: PMC3773434  PMID: 24073350
17.  Abdominal wall hemorrhage after intravenous thrombolysis for acute ischemic stroke 
BMC Neurology  2013;13:6.
Background
Thrombolysis is strongly recommended for patients with significant neurologic deficits secondary to acute ischemic stroke. Extracranial bleeding is a rare but major complication of thrombolysis.
Case presentation
A 78-year-old woman presented with acute ischemic stroke caused by occlusion of the basilar artery. Clinical recovery was observed after successful recanalization by intravenous thrombolysis and intraarterial thrombectomy. However, the patient complained of sudden abdominal pain following the intervention and a newly developed abdominal wall mass was found. CT scan and selective angiography confirmed active bleeding from the left epigastric artery into the abdominal muscle layer and the bleeding was successfully managed by selective embolization of the bleeding artery.
Conclusions
We report a rare case of abdominal wall hemorrhage after thrombolysis for acute ischemic stroke. The findings indicate that abdominal wall hemorrhage should be considered as a differential diagnosis in the presence of abdominal discomfort after thrombolysis for acute ischemic stroke.
doi:10.1186/1471-2377-13-6
PMCID: PMC3571939  PMID: 23317374
Abdominal wall hemorrhage; Extracranial hemorrhage; Thrombolysis
18.  Medullary Hemorrhage after Ischemic Wallenberg's Syndrome in a Patient with Cavernous Angioma 
Background
The main complication of cerebral cavernous angioma is hemorrhage. Ischemic stroke as a complication of cerebral cavernous angioma has rarely been described, and hemorrhage after ischemic Wallenberg's syndrome has not been reported before.
Case Report
A 45-year-old woman presented with perioral numbness, hoarseness, dysphagia, and worsening of her previous sensory symptoms. The patient had been taking aspirin for 3 years after suffering from ischemic Wallenberg's syndrome with left paresthesia as a residual symptom. Brain computed tomography revealed an acute medullary hematoma in the previously infarcted area. Follow-up magnetic resonance imaging revealed a cavernous angioma in the right medulla.
Conclusions
We presume that cerebral cavernous angioma was responsible for both the ischemia and the hemorrhage, and we also cautiously speculate that the aspirin contributed to the development of hemorrhage in the previously infarcted area.
doi:10.3988/jcn.2010.6.4.221
PMCID: PMC3024528  PMID: 21264204
cavernous angioma; hemorrhage; ischemia; medulla oblongata
19.  Cognitive Performance in Late Adolescence and the Subsequent Risk of Subdural Hematoma: An Observational Study of a Prospective Nationwide Cohort 
PLoS Medicine  2011;8(12):e1001151.
Anna and Peter Nordström analyzed a prospective nationwide cohort of 440,742 Swedish men and found that reduced cognitive function in young adulthood was associated with increased risk of subdural hematoma later in life, whereas a higher level of education and physical fitness were associated with a decreased risk.
Background
There are few identified risk factors for traumatic brain injuries such as subdural hematoma (SDH). The aim of the present study was to investigate whether low cognitive performance in young adulthood is associated with SDH later in life. A second aim was to investigate whether this risk factor was associated with education and physical fitness.
Methods and Findings
Word recollection, logical, visuospatial, and technical performances were tested at a mean age of 18.5 years in a prospective nation-wide cohort of 440,742 men. An estimate of global intelligence was calculated from these four tests. Associations between cognitive performance, education, physical fitness, and SDH during follow-up were explored using Cox regression analyses. During a median follow-up of 35 years, 863 SDHs were diagnosed in the cohort. Low global intelligence was associated with an increased risk of SDH during follow-up (hazard ratio [HR]: 1.33, per standard deviation decrease, 95% CI = 1.25–1.43). Similar results were obtained for the other measures of cognitive performance (HR: 1.24–1.33, p<0.001 for all). In contrast, a high education (HR: 0.27, comparing more than 2 years of high school and 8 years of elementary school, 95% CI = 0.19–0.39), and a high level of physical fitness (HR: 0.76, per standard deviation increase, 95% CI = 0.70–0.83), was associated with a decreased risk of suffering from a SDH.
Conclusions
The present findings suggest that reduced cognitive function in young adulthood is strongly associated with an increased risk of SDH later in life. In contrast, a higher level of education and a higher physical fitness were associated with a decreased risk of SDH.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 10 million people worldwide sustain a traumatic brain injury that needs medical attention or that proves fatal. Such injuries occur when the head is suddenly hit or jolted or when an object such as a bullet pierces the skull and enters the brain. Motor vehicle accidents are responsible for many traumatic brain injuries, but falls, assaults, and military action can also cause these serious injuries. The symptoms of a traumatic brain injury, which may not appear until many days after the injury, include loss of consciousness, headaches, dizziness, and nausea. Affected individuals can experience changes in their memory, concentration, or ability to think clearly (“cognitive” changes) and can have behavioral or emotional problems. Although the initial brain damage caused by trauma cannot be reversed, immediate medical treatment is essential to prevent further injury occurring. In particular, patients need to be monitored for “subdural hematoma,” a common outcome of traumatic brain injury in which blood from ruptured vessels collects between the brain and the skull. Subdural hematoma puts pressure on the brain and has to be removed surgically to prevent further brain damage.
Why Was This Study Done?
Not everyone who has a traumatic brain injury develops subdural hematoma. If the factors that increase a person's risk of developing subdural hematoma could be identified, it might be possible to devise public-health interventions that would reduce the incidence of subdural hematomas. In this prospective population-based analysis, the researchers investigate whether low cognitive performance in early adulthood is associated with subdural hematoma later in life. Impaired cognitive functioning is sometimes recorded as a symptom of subdural hematoma but the researchers hypothesize that these cognitive deficits might have been present before the traumatic head injury that led to subdural hematoma. Low cognitive performance is associated with a reduced ability to compare objects and patterns (perceptual speed) and with impaired judgment, planning, and risk behavior (executive functions), so low cognitive performance might increase a person's risk of having an accident that results in a head injury and subdural hematoma.
What Did the Researchers Do and Find?
The researchers calculated a global intelligence score for 440,742 male Swedish military conscripts (average age 18.5 years) from cognitive tests completed by the men between 1969 and 1978. They obtained information about diagnoses of subdural hematoma up to 40 years later among these men from medical records, and then used several statistical approaches to look for associations between cognitive performance, education (recorded during conscription assignment), physical fitness (measured during conscription assignment), and subsequent subdural hematoma. During the follow-up period, 863 subdural hematomas were diagnosed among the men. Conscripts with a low global intelligence score in early adulthood were more likely to develop subdural hematoma during later life than those with a high score. Specifically, when the men were divided into five groups (quintiles) on the basis of their global intelligence score, men with a score in the lowest quintile were more than twice as likely to develop subdural hematoma as those with a score in the highest quintile. By contrast, men who had had more than 2 years high school education were much less likely to develop subdural hematoma than those who had only had 8 years of elementary school education. A high level of physical fitness in early adulthood also reduced the risk of subdural hematoma.
What Do These Findings Mean?
These findings suggest that low cognitive function in early adulthood is associated with subdural hematoma later in life, whereas high levels of education and physical fitness is associated with a decreased risk of subdural hematoma. Because this study was observational, these findings do not prove that low cognitive performance, low education level, or low physical fitness is causally linked to subdural hematoma. Other unidentified factors (confounders) shared by people with these characteristics might actually be responsible for the observed association between these factors and subdural hematoma. For example, poorly educated people might work in more hazardous environments than those who attended high school. However, if these findings can to be confirmed in other large studies, an exploration of the mechanistic basis of the associations reported here might eventually inform the development of public-health interventions designed to reduce the occurrence of subdural hematoma.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001151.
The US National Institute of Neurological Disorders and Stroke provides detailed information about traumatic brain injury (in English and Spanish)
The US Centers for Disease Control and Prevention also provides detailed information about traumatic brain injury
The UK National Health Service Choices website has an article about severe head injury that includes a personal story about a head injury sustained in a motor vehicle accident, and an article about subdural hematoma
MedlinePlus provide links to further resources on traumatic brain injury and information on subdural hematoma; it also provides an interactive tutorial on traumatic brain injury (available in English and Spanish)
The UK charity Headway, which works to improve life after brain injury, has a collection of personal stories about brain injury
doi:10.1371/journal.pmed.1001151
PMCID: PMC3246434  PMID: 22215989
20.  Intracranial hemorrhage following lumbar spine surgery 
European Spine Journal  2012;21(10):2091-2096.
Background
Intracranial hemorrhage is a serious but rare complication of spinal surgery, which can occur in the intracerebral, cerebellar, epidural, or subdural compartment.
Purpose
To describe patients with intracranial hemorrhage after lumbar spinal surgery and present clinical and diagnostic imaging findings.
Methods
In this retrospective study, medical records of 1,077 patients who underwent lumbar spinal surgery in our tertiary referral neurosurgery center between January 2003 and September 2010 were studied. The original presentations of the patients before the surgical intervention were herniated lumbar disc, spinal canal stenosis, spondylolisthesis, lumbar spinal trauma, and lumbar spine and epidural tumor. The operations performed consisted of discectomy, multiple level laminectomy, stabilization and fusion, lumbar instrumentation, and lumbar spinal and epidural tumor resection.
Results
Four cases developed intracranial hemorrhage including acute subdural hematoma (one case), epidural hematoma (one case), and remote cerebellar hemorrhage (two cases). The clinical and diagnostic imaging characteristics along with treatments performed and outcomes of these four patients are described and the pertinent literature regarding post-lumbar spinal surgery intracranial hemorrhages is reviewed.
Conclusion
Though rare, intracranial hemorrhage can occur following lumbar spinal surgery. This complication may be asymptomatic or manifest with intense headache at early stages any time during the first week after surgery. Dural tear, bloody CSF leakage, focal neurologic symptoms, and headache are indicators of potential intracranial hemorrhage, which should be considered during or following surgery and necessitate diagnostic imaging.
doi:10.1007/s00586-012-2187-1
PMCID: PMC3463703  PMID: 22349967
Intracranial hemorrhage; Lumbar spine surgery; Remote cerebellar hemorrhage; Subdural hematoma; Epidural hematoma
21.  Multimodal endovascular management of acute ischemic stroke in patients over 75 years old is safe and effective 
Journal of Neurointerventional Surgery  2012;5(Suppl 1):i33-i37.
Introduction
Greater attention has been directed to endovascular recanalization of acute ischemic stroke in septuagenarians and above.
Technique
A retrospective chart review was conducted to include patients treated for acute ischemic stroke from 2006 to 2012. All patients underwent initial neurological assessment and non-contrast head CT. Patients treated from 2009 to 2012 additionally received emergent CT angiogram and CT perfusion. 51 patients met the clinical and radiographic criteria and underwent multimodal endovascular revascularization for acute ischemic events.
Results
All patients underwent cerebral angiography and met angiographic criteria for endovascular thrombolysis. 34 patients (67%) were older than 80 years of age. 23 patients (45%) received intravenous tissue plasminogen activator prior to admission. Eight (16%) patients underwent stent placement after intra-arterial thrombolysis, 10 (20%) underwent balloon angioplasty and seven (14%) underwent both angioplasty and stent placement. 21 (41%) required only intra-arterial thrombolytics. An improvement in Thrombolysis in Myocardial Infarction score was noted in 34 patients (67%). The average modified Rankin Scale score on discharge was 3.9. Symptomatic intracranial hemorrhage occurred in three patients (6%); none required surgery. One patient (1.9%) had a postoperative retroperitoneal hematoma, which was managed conservatively. Two fatalities resulted from intraoperative vessel rupture (3.9%), with a combined morbidity and mortality of 27.5%.
Conclusions
Multimodal endovascular recanalization of acute ischemic stroke is a relatively safe treatment option in patients older than 75 years of age. Careful patient selection by clinical and radiographic inclusion criteria is necessary for the successful management of stroke in this age group.
doi:10.1136/neurintsurg-2012-010422
PMCID: PMC3623029  PMID: 22791182
22.  Cervical spine intradural-extramedullary hematoma presenting as ipsilateral hemiparesis 
Neurology International  2011;3(2):e8.
A 75-year-old Taiwanese man suffered from acute onset of right-sided extremity weakness while talking to his neighbors. He was transferred to the hospital within three-hour time after symptom onset. Initial acute ischemic cerebral infarct was diagnosed based on his symptom and cerebral computed tomography. Thrombolytic therapy was held after his symptom improved promptly and could not excluded other etiology. Thorough history taking unraveled previous Chinese medicine clinic visit because of neck sore. However, he received limited improvement after several times of massage treatment. Magnetic resnance imaging (MRI) of the cervical spine demonstrated hematoma compressing right side intradural-extramedullary space at the C2/C3 level. Through his clinical course, muscle weakness was the sole neurological finding with sparing of sensory defects. Given the close anatomy relationship between sensory and motor lamina distribution in the cervical spinal cord, our patient presented a rare manifestation. Cases of cervical spine intradural-extramedullary hematoma are not often seen and only sporadic in the documented literature. We wish, through the report of this article, to inform the first- line physicians with the following information. Among the elderly, neck sore is a common symptom. Over- stretching or overt local massage is not suggested due to relatively fragile musculature. In the clinical diagnosis and localization of lesion, cerebral or cervical spine lesion could mimic with each other and manifest hemiparesis as their first symptom. Meticulous history taking, neurological/ physical examination and pertinent laboratory work-up should be done before initiation of intravenous thrombolytic therapy as it could cause catastrophic consequences if not used properly.
doi:10.4081/ni.2011.e8
PMCID: PMC3207234  PMID: 22053262
stroke; cervical spine hematoma; magnetic resonance imaging.
23.  Details of a prospective protocol for a collaborative meta-analysis of individual participant data from all randomized trials of intravenous rt-PA vs. control: statistical analysis plan for the Stroke Thrombolysis Trialists' Collaborative meta-analysis 
International Journal of Stroke  2013;8(4):278-283.
Rationale
Thrombolysis with intravenous alteplase is both effective and safe when administered to particular types of patient within 4·5 hours of having an ischemic stroke. However, the extent to which effects might vary in different types of patient is uncertain.
Aims and Design
We describe the protocol for an updated individual patient data meta-analysis of trials of intravenous alteplase, including results from the recently reported third International Stroke Trial, in which a wide range of patients enrolled up to six-hours after stroke onset were randomized to alteplase vs. control.
Study Outcomes
This protocol will specify the primary outcome for efficacy, specified prior to knowledge of the results from the third International Stroke Trial, as the proportion of patients having a ‘favorable’ stroke outcome, defined by modified Rankin Score 0–1 at final follow-up at three- to six-months. The primary analysis will be to estimate the extent to which the known benefit of alteplase on modified Rankin Score 0–1 diminishes with treatment delay, and the extent to which it is independently modified by age and stroke severity. Key secondary outcomes include effect of alteplase on death within 90 days; analyses of modified Rankin Score using ordinal, rather than dichotomous, methods; and effects of alteplase on symptomatic intracranial hemorrhage, fatal intracranial hemorrhage, symptomatic ischemic brain edema and early edema, effacement and/or midline shift.
Discussion
This collaborative meta-analysis of individual participant data from all randomized trials of intravenous alteplase vs. control will demonstrate how the known benefits of alteplase on ischemic stroke outcome vary across different types of patient.
doi:10.1111/ijs.12040
PMCID: PMC3816333  PMID: 23639145
acute stroke therapy; clinical trial; rt-PA; stroke; thrombolysis; treatment
24.  Vitreo-Retinal Hemorrhage after Thrombolysis in a Patient with Acute Ischemic Stroke: A Case Report 
Purpose: Bleeding is the major side effect of thrombolysis with alteplase (tissue plasminogen activator, t-PA) used for the treatment of acute ischemic stroke. Life-threatening intracranial, retroperitoneal, gastrointestinal, respiratory, and genitourinary bleeding can occur with the use of t-PA. Vitreo-retinal bleeding in the context of acute ischemic stroke treatment has not been reported in the literature before and therefore is not posed as a potential risk during decision making. Here we describe the first reported case of vitreo-retinal hemorrhage due to alteplase administration in a patient with acute ischemic stroke. Summary: An 84-year-old white male presented to the emergency room with complaints of right arm and leg weakness. The onset of symptoms was approximately 30 min prior to presentation to the emergency room. After ruling out contraindications including the presence of hemorrhage on head CT scan, patient was administered alteplase within 2 hours of symptom onset. Four hours after the administration of alteplase, the patient developed right-sided vision changes. A repeat CT scan demonstrated a newly developed right intraocular hemorrhage. Throughout the hospital course, patient’s neurological status improved, but he continued to have right-sided visual loss. Conclusion: Clinicians should be aware of the potential for ocular hemorrhage especially in high-risk patients. The likelihood of a subsequent vision-loss needs to be therefore discussed with the patient and family in such situations.
doi:10.3389/fneur.2012.00071
PMCID: PMC3347041  PMID: 22586418
stroke; alteplase; ocular; retinal; hemorrhage; thrombolysis; t-PA
25.  Drug Treatment of Acute Ischemic Stroke 
Acute ischemic stroke (AIS) is the fourth leading cause of death and the leading cause of adult disability in the USA. AIS most commonly occurs when a blood vessel is obstructed leading to irreversible brain injury and subsequent focal neurologic deficits. Drug treatment of AIS involves intravenous thrombolysis with alteplase (recombinant tissue plasminogen activator [rtPA]). Intravenous alteplase promotes thrombolysis by hydrolyzing plasminogen to form the proteolytic enzyme plasmin. Plasmin targets the blood clot with limited systemic thrombolytic effects. Alteplase must be administered within a short time window to appropriate patients to optimize its therapeutic efficacy. Recent trials have shown this time window may be extended from 3 to 4.5 hours in select patients. Other acute supportive interventions for AIS include maintaining normoglycemia, euthermia and treating severe hypertension. Urgent anticoagulation for AIS has generally not shown benefits that exceed the hemorrhage risks in the acute setting. Urgent antiplatelet use for AIS has limited benefits and should only promptly be initiated if alteplase was not administered, or after 24 hours if alteplase was administered. The majority of AIS patients do not receive thrombolytic therapy due to late arrival to emergency departments and currently there is a paucity of acute interventions for them. Ongoing clinical trials may lead to further medical breakthroughs to limit the damage inflicted by this devastating disease.
doi:10.1007/s40256-013-0007-6
PMCID: PMC3840541  PMID: 23381911

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