From Spot Sign to Bleeding on the Spot: Classic and Original Signs of Expanding Primary Spontaneous Intracerebral Hematoma

Expansion of a primary spontaneous intracranial hemorrhage (PSICH) has become lately of increasing interest, especially after the emergence of its early predictors. However, these signs lacked sensitivity and specificity. The flood phenomenon, defined as a drastic increase in the size of a PSICH during the same magnetic resonance study, was first described in this paper based on the data of a university medical center in Lebanon. Moreover, further review of this data resulted in 205 studies with presumed diagnosis of primary spontaneous intracranial hemorrhage within the last 10 years, of which 29 exams showed typical predictors of hematoma expansion on computed tomography. The intended benefit of this observation is to draw the radiologists’ attention towards minimal variations in the volume of the hematoma between the two extreme sequences of the same MRI study, in order to detect inconspicuous flood phenomena—a direct sign of hematoma expansion.

Occult Brain Arteriovenous Malformation Superimposed on a Pial Arteriovenous Fistula: Case Report

<b><i>Introduction:</i></b> Pial arteriovenous fistulas are characterized by an abnormal connection between an intracranial artery and vein without an intervening nidus. Their predominant symptoms largely arise from mass effect, shunting, or hemorrhage. Most conservatively managed cases progress to death, but endovascular and/or surgical intervention is often successful. <b><i>Case Presentation:</i></b> We present the unique case of a 15-year-old girl with spontaneous intracranial hemorrhage from a single-vessel arteriovenous fistula. Although preoperative imaging failed to show a distinct nidus, intraoperative indocyanine green angiography performed after successful clipping of the primary fistulous site revealed residual shunting from a peri-lesional arteriovenous malformation. <b><i>Discussion/Conclusion:</i></b> This case demonstrates the importance of intraoperative imaging and meticulous circumferential inspection of these lesions to detect residual vascular shunting.

Role of early surgical intervention in outcome and prognosis of spontaneous cerebellar hemorrhage with intraventricular extension

Spontaneous cerebellar hematomas represent 5 to 13% of all cases of spontaneous intracranial hemorrhage. The main controversy involves deciding which cases require surgical evacuation of the hematoma versus other options, such as ventricular drainage only or conservative treatment. Furthermore, because the clinical course is variable in some cases, timing of such treatment should be carefully considered. The duration from the onset of hemorrhage also plays an important role in prognosis and recovery of the patient. Both the clinical presentation and subsequent course vary among cases. Unpredictable rapid deterioration in consciousness levels has been recognized. The majority of patients with such decline in consciousness experience the deterioration primarily within 72 hrs after onset⁠. Acute presentation was observed to be correlated with poor outcomes. In our report, the first case presented with sudden onset of headache in the right frontal region of head with vertigo. He came to hospital within 6 hours of onset. However, the second case had an onset of symptoms around 72 hours before the presentation.

Hemorrhagic Shock after Neonatal Circumcision: Severe Congenital Factor XIII Deficiency

A Caucasian male infant born full term via normal spontaneous vaginal delivery was given vitamin K after birth, circumcised on day of life (DOL) 1, and discharged from the nursery on DOL 2. At the time of circumcision, oozing from the surgical site was noted and initially resolved with silver nitrate. Over the next two days, he presented to local emergency rooms multiple times for recurrent bleeding, eventually developing hemorrhagic shock resulting in admission to the neonatal intensive care unit. After extensive work up, he was ultimately diagnosed with severe congenital factor XIII deficiency. Congenital factor XIII deficiency is a rare bleeding disorder characterized by normal prothrombin time (PT) and activated partial thromboplastin time (aPTT) coagulation labs on routine screening, and has a high risk of complications, such as spontaneous intracranial hemorrhage. Although uncommon, when caring for a child with bleeding, physicians must have a high index of suspicion to make this diagnosis in order to initiate proper treatment and start prophylaxis given the risk of morbidity and mortality in untreated patients.