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5. multiple ich. case report


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Multiple simultaneous ICH

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5. multiple ich. case report

  1. 1. Case ReportMultiple simultaneous intracerebral hemorrhages followingaccidental massive lumbar cerebrospinal fluid drainage:Case report and literature reviewJosé L. Ruiz-Sandoval, Ariel Campos, Samuel Romero-Vargas, María I. Jiménez-Rodríguez, m roErwin Chiquete fDepartment of Neurology and Neurosurgery, Hospital Civil de Guadalajara “Fray Antonio Alcalde” and the Department of d nsNeurosciences; Centro Universitario de Ciencias de la Salud. Guadalajara, Jalisco; México a o overdrainage n lo intimultifocal ICH. To the best of our resulted a knowledge,w is the first report on massive CSF drainage as a Multiple simultaneous intracerebral hemorrhages (ICH) are uncommon. We report the case of an 80-year-old woman o this blic ICHs. d u cause of multiple simultaneous with previous diagnosis of normal pressure hydrocephalus e re w P m).Case Report and who was brought to our hospital with altered mental status and urinary incontinence. Medical history of r f Ano owoman was brought to our hospital with altered hypertension, hematological disorders or severe head fo mental statusc urinary incontinence, as her main complaints. trauma was absent. Platelet count and coagulation profile n 80-year-old k w. and were unremarkable. An initial head computed tomography ble edThe history revealed that inand gait disturbance, which motivated (CT) showed sulcal enlargement and ventricular dilatation, o the previous two months she suffered n ila y M herkcaregivers to seek medical attention intomography (CT) After but no evidence of ICH. A tap test indicated as a guide to from cognitive impairment case selection for shunt surgery accidentally resulted in v a b eclinical evaluation and a head computed another hospital. scan, d cerebrospinal fluid (CSF) overdrainage. The patient a presented sudden neurological deterioration, with s ted w.m was not on anticoagulation or antiplatelet therapy. Medicaltrauma she was given a diagnosis of normal pressure hydrocephalus. She i sluggishly responsive pupils and generalized tonic-clonic history s seizures. A new head CT demonstrated multiple supra and DF ho (ww of hypertension, hematological disorders or severe head infratentorial ICH. The patient became comatose and had was absent. The neurological examination at presentation to our a fatal course. Hence, CSF overdrainage may either cause P te hospital revealed a conscious woman with spatial disorientation or precipitate multiple simultaneous ICHs, affecting both is si the infratentorial and supratentorial regions. h a and bilateral hyperreflexia. Focal neurological signs were absent. Laboratory findings were normal, including platelet count (152 x T Key words: Cerebrospinal fluid, intracranial hemorrhage, 9 10 /liter) and coagulation profile (PT: 90% of control, APTT: intracranial hypotension, lumbar drainage, neurological 27 seconds, fibrinogen: 225 mg/dl). Blood pressure was below examination 130/90 mmHg during her hospital stay. A head CT scan performed in our center showed ventriculomegaly, sulcal enlargement and diffuse white matter disease, with chronic bilateral subcortical infarctions [Figure 1]. No evidence of ICH Introduction was found; nevertheless, a laminar collection of blood in the posterior interhemispheric fissure was observed, suggestive of Lumbar cerebrospinal fluid (CSF) drainage has several being secondary to previous head trauma for which we had nodiagnostic and therapeutic indications, with well documented knowledge on history-taking. In spite of this finding, a tap testhazardous consequences including overdrainage, acute was indicated as a guide to case selection for shunt surgery, sincepneumocephalus, brain collapse and neurological deterioration.[1-3] no mass effect was observed. The procedure was performed by aIntracerebral hemorrhage (ICH) has been reported after lumbar physician in training without supervision. Cerebrospinal fluid waspuncture and lumboperitoneal shunts, sometimes related to other clear, with opening pressure of 150 mmH2O. The catheter wasconditions.[4-6] We report the case of a woman in whom CSF not withdrawn on time and CSF continued to flow for almost 30José L. Ruiz-SandovalServicio de Neurología y Neurocirugía, Hospital Civil de Guadalajara , “Fray Antonio Alcalde” Hospital 278. Guadalajara, Jalisco; Mexico 44280.E-mail: jorusan@mexis.comNeurology India | December 2006 | Vol 54 | Issue 4 421 CMYK421
  2. 2. Ruiz-Sandoval JL, et al. : Multiple simultaneous ICHs after CFS overdrainage Discussion Multiple simultaneous ICHs is defined as the presence of two or more intracerebral hemorrhages affecting different arterial territories, without continuity between them and with identical CT density profiles.[7,8] This is a rare presentation of the hemorrhagic cerebrovascular disease, accounting for 0.6 to 2.8% of the cases of nontraumatic, nonaneurysmal ICH.[7,8] The main causative factors are hypertension, cerebral amyloid angiopathy and forms of vasculitis, among other conditions [Table 1]. There is a strong preponderance for the supratentorial space, especially om affecting the basal ganglia (thus denouncing the hypertensive nature seen in most cases).[8] However, most of the knowledge fr regarding multiple simultaneous ICHs is derived from case ad ons reports, which are possibly the type of communications subject toFigure 1: Head CT at presentation, before CSF overdrainage. Severe o the strongest reporting bias. Therefore, the clinical picture, nl ati white matter lesions with chronic bilateral subcortical infarctions(i.e., vascular leukoencephalopathy), as well as sulcal enlargement outcome and even the putative causes may vary more than is (i.e., cortical atrophy) and ventricular dilatation are evident, but ow blicwithout evidence of ICH. Collections of blood over the left parietal reflected in case reports. Since most of the causative factors convexity and posterior interhemispheric fissure are observed previously attributed to multiple simultaneous ICHs were excluded d u in the case presented here and given that neurological deteriorationmin, until the fluid initiated to drain bloody, with a final CSF e re w P m). as well as the hemorrhagic findings in the second head CT begancollection of 250 mL, as measured in a graduated flask. After theprocedure the patient presented sudden neurological deterioration, f immediately after CSF overdrainage, it seems reasonable to thinkwith pupils sluggishly reacting to light and generalized tonic-clonic r fo kno .co that this procedure was the cause or at least, a precipitating factor of multifocal ICH. To our knowledge, this patient had a cause ofoverdrainage, showing multiple infra and supratentorialeseizures. A new head CT was practiced 18h after CSF bl ICHs d now multiple simultaneous ICHs not previously reported [Table 1].with irruption into the ventricular system [Figure 2]. The patient e In the present case, the putative pathophysiological mechanism la M dkbecame comatose, requiring ventilatory assistance.iReplacement that led to multiple simultaneous ICHs points to a continuousof CSF volume could not be practiced. Two days a the patient vlater by e and massive lumbar CSF evacuation resulting in a reduction of CSF volume with the associated lowering in intraspinal and a s ted w.mdeveloped pneumonia, which resulted in sepsis and death in one intracranial pressure, which eventually increased the transmuralweek more. i pressure gradient of the vessels, leading to a secondary wall stress F os w rupture.[1] Advanced age and the presence of diffuse white matter PD te h (w disease could be the other important contributing factors.[9] The widespread and prolonged degeneration of the intracerebral s hi a si arterioles in older people may also predispose to the development of multiple ICHs. Unfortunately, amyloid angiopathy or other T age-related cerebrovascular conditions were not completely excluded in our patient because no cerebral biopsy was performed. Moreover, we were not able to obtain a necropsy. Since amyloid angiopathy is very common in older people and is also an important cause of multiple simultaneous ICHs [Table 1], our patient might have had an underlying susceptibility (e.g., amyloid angiopathy) of presenting ICH, which in turn was precipitated by CSF overdrainage. Nevertheless, the association of CSF overdrainage with ICH in this patient seems clear, either as an independent causative or precipitating factor.Figure 2: Head CT after CSF overdrainage. (A) A petechial hemorrhage Indeed, the laminar collection of blood over the left parietal in pons (arrow). (B) Bilateral ganglionic hemorrhages (arrows) plus convexity and the posterior interhemispheric space seen in the multiple petechial hemorrhages in the right temporal lobe (arrow head). (C) Ganglionic hemorrhage (arrow) with petechial head CT performed at presentation to our hospital [Figure 1] hemorrhages in right parietal and occipital lobes (arrow heads). need comments. We were not told about the antecedent of head Ventricular irruption is also evident. (D) The extension of the ganglionic hemorrhage with its ventricular irruption (arrows) and trauma that might explain this abnormality; however, considering petechial hemorrhages in occipital lobe (arrow head). the gait instability that the patient was presenting, falls that might422 Neurology India | December 2006 | Vol 54 | Issue 4422 CMYK
  3. 3. Ruiz-Sandoval JL, et al. : Multiple simultaneous ICHs after CFS overdrainage Table 1: Case reports and case series describing nontraumatic, nonaneurysmal multiple simultaneous Intracerebral hemorrhages and the associated causal factorsReference Year of publication Number of cases Putative causal factorsPant SS and Dreyfus PM 1967 1 Amyloid angiopathyMcCormick WF and Rosenfield DB 1973 16 Leukemia, coagulopathy, vasculitis, neoplasmsBrismar J 1980 1 Cerebral vein thrombosisTucker WS, et al. 1980 2 Amyloid angiopathyBeal MF, et al. 1982 1 Cerebral vein thrombosisTyler KL, et al. 1982 1 Amyloid angiopathyHickey WF, et al. 1983 2 IdiopathicTanikake T, et al. 1983 2 HypertensionAssad F and Lins E 1984 1 Mycotic aneurysmGilles C, et al. 1984 11 Amyloid angiopathyPatel DV, et al. 1984 2 Amyloid angiopathyKobayashi Y, et al. 1987 m 1 Amyloid angiopathy roNakamura T, et al. 1988 1 HypertensionWakui K, et al.Mori H, et al. 1988 f 1 Amyloid angiopathy associated to head injuryTanno H, et al. 1989 1989 a d ns 1 5 Evacuation of chronic subdural hygroma Hypertension lo tioGreen RM, et al. 1990 1 Cocaine abuseKase CS, et al. 1990 2 tPA administration wn licaHasegawa Y, et al . 1991 1 VasculitisNagano N, et al . 1991 2 Anticoagulant therapy do ubUno M, et al. 1991 9 HypertensionVerstichel P, et al. 1991 1 HypertensionYanagawa Y, et al . 1994 e 1 Amyloid angiopathy re w P m).Komiyama M, et al. 1995 1 Hypertension rf o oOzawa T, et al. 1995 1 VasculitisSeijo M, et al. 1996 7 Hypertension, coagulopathyDromerick AW, et al.Liou HH, et al. 1997 1997 fo kn .c 1 1 tPA administration Churg-Strauss syndromeNakamura K, et al.Nighoghossian N, et al . 1997 b 1998le ed ow 1 1 Amyloid angiopathyassociated to migraine Antimigrainous drug abuse ila y M dknDaloze A, et al. 1999 1 Hypertension associated to renal cell carcinomaKimura T, et al. 2000 1 VasculitisKohshi K, et al.Mauriño J, et al. ava b e 2000 2001 2 4 Hypertension Hypertension s ted w.mChen CY, et al. 2003 1 Hydrops fetalisOide T, et al. i 2003 6 Amyloid angiopathyShiomi N, et al.Okuno S and Sakaki T F os w 2004 2005 11 1 Hypertension Systemic lupus erythematosus PD te h (wYen CP, et al. 2005 10 HypertensionRuiz-Sandoval, et al. 2006 1 CSF overdrainage s hi a siCSF indicates cerebrospinal fluid; tPA, tissue plasminogen activator.An up-to-date MEDLINE search (in February 2006) was performed using the terms “multiple intracerebral hemorrhage (haemorrhage) (s)”, “multiple simultaneous Tintracerebral hemorrhage (haemorrhage) (s)”, “multiple intracranial hemorrhage (haemorrhage) (s)” and “multiple simultaneous intracranial hemorrhage (haemorrhage)(s)”. Only reports available in English or Spanish describing the number of patients and causative factors were referenced; however, information of abstractswritten in other languages were also included in table. The following reports on cases with multiple ICHs were excluded: non-simultaneous, traumatic, aneurysmal(except mycotic) and arteriovenous malformation ICH.have caused mild head trauma cannot be discarded. Nevertheless, should not exceed 20-25 mL/h.[12] When used as a guide to caseeven though delayed traumatic ICH exists,[10,11] it is mainly selection for a shunting procedure in normal pressureassociated with severe head trauma and would hardly cause more hydrocephalus[2] or as treatment of CSF fistula,[12] lumbar CSFthan two ICHs affecting both the infratentorial and supratentorial drainage of 40 to 50 mL per session is considered safe andregions. effective.[1,2] When a tap test is indicated, intermittent lumbar or continuous Another concern with respect to the case discussed here is theCSF drainage at controlled rate are safe strategies in avoiding medical error that led to this catastrophe. This complication hasoverdrainage,[1,2] especially because the lower threshold of CSF the possibility to be repeated, especially in teaching hospitals involume compatible with life in humans is rather unknown.[2] In which physicians in training perform without expert supervision.our patient, an advanced age, sulcal enlargement and ventricular Appropriate measures were taken in our center to avoid anotherdilatation allowing a large CSF volume might have permitted accident like this. Excessive work must not be an exception of asuch drainage of the fluid (250 mL in 30 min). Any time lumbar tight supervision to junior doctors.CSF drainage is indicated as diagnostic procedure, it is necessary In conclusion, CSF overdrainage can either cause or precipitateto be warned about an excessive rate of CSF drainage, which multiple simultaneous ICHs, affecting both the infratentorial andNeurology India | December 2006 | Vol 54 | Issue 4 423 CMYK423
  4. 4. Ruiz-Sandoval JL, et al. : Multiple simultaneous ICHs after CFS overdrainagesupratentorial regions. Neurol 2001;58:629-32. 8. Yen CP, Lin CL, Kwan AL, Lieu AS, Hwang SL, Lin CN, et al. Simultaneous multiple hypertensive intracerebral haemorrhages. Acta Neurochir (Wien) References 9. 2005;147:393-9. Smith EE, Gurol ME, Eng JA, Engel CR, Nguyen TN, Rosand J, et al. White matter lesions, cognition and recurrent hemorrhage in lobar intracerebral hemorrhage.1. Bloch J, Regli L. Brain stem and cerebellar dysfunction after lumbar spinal fluid Neurology 2004;63:1606-12. drainage: Case report. J Neurol Neurosurg Psychiatr 2003;74:992-4. 10. Cooper PR. Delayed traumatic intracerebral hemorrhage. Neurosurg Clin N Am2. Fishman RA. Cerebrospinal fluid in diseases of the nervous system. 2nd ed. WB 1992;3:659-65. Saunders: Philadelphia; 1992. 11. Erol FS, Kaplan M, Topsakal C, Ozveren MF, Tiftikci MT. Coexistence of rapidly3. Snow RB, Kuhel W, Martin SB. Prolonged lumbar spinal drainage after the resection resolving acute subdural hematoma and delayed traumatic intracerebral of tumors of the skull base: A cautionary note. Neurosurgery 1991;28:880-3. hemorrhage. Pediatr Neurosurg 2004;40:238-40.4. Adler MD, Comi AE, Walker AR. Acute hemorrhagic complication of diagnostic 12. Shapiro SA, Scully T. Closed continuous drainage of cerebrospinal fluid via a lumbar lumbar puncture. Pediatr Emerg Care 2001;17:184-8. subarachnoid catheter for treatment or prevention of cranial/spinal cerebrospinal5. Stubgen JP. Intraventricular blood after “traumatic” lumbar puncture: A report fluid fistula. Neurosurgery 1992;30:241-5. of two cases. Childs Nerv Syst 1995;11:492-3.6. Suri A, Pandey P, Mehta VS. Subarachnoid hemorrhage and intracereebral om hematoma following lumboperitoneal shunt for pseudotumor cerebri: a rare complication. Neurol India 2002;50:508-10. Accepted on 29-05-20067. fr Maurino J, Saposnik G, Lepera S, Rey RC, Sica RE. Multiple simultaneous intracerebral hemorrhages: Clinical features and outcome. Arch Source of Support: Nil, Conflict of Interest: None declared. oad ons nl ati ow blic d u e re w P m). rf o o fo kn .c e bl ed now ila y M dk ava b e is ted w.m F os w PD te h (w s Thi a si424 Neurology India | December 2006 | Vol 54 | Issue 4424 CMYK