T-myelopathy with lower limb paresthesia
姓名:葉OO 病歷號:5298068
48 male, actue onset of LE numbness, buttock tightness up to the umbilicus on 2008/4/2-3
LE weakness, unsteady gait with floating sensation, lower limbs weakness improved by itself
Spine MRI showed a mid-T HIVD with cord compression.
CSF study at other hospital was normal.
SSEP was arranged.
2008年4月18日 星期五
2008年4月15日 星期二
dizziness, unsteady gait for 3 days
a 80y/o man, HTN, CAD s/p CABG,
c/o: dizziness, vertigo, nausea, unsteady gait to either direction, unable to walk for 3 days
NE: mildly drowsy, limbs ataxia bilaterally UE & LE, truncal ataxia
MP 5/5
no abducens palsy
Head CT: heterogenous hyperintensities with perifocal hypodensity in the right cerebellum, mild hydrocephalus
Brain MRI:
姓名：許 先生 生日： 0160729
病歷號：2708662 照會單號：2655160
檢查項目 .....檢查日期：2008-04-16
MRI-HEAD
MRI of head without/with contrast enhancement shows
1. a large irregular shaped acute hematoma in right superior cerebelum, showing hypointensity with minimal patchy hyperintensities on T1WI, mild hypointensity on T2WI with focal fluid-fluid layering suggestive of noncoagulant blood. The hematoma extends along the gyrus . There is no obvious abnormal enhancement after contrast injection. Hemorrhagic infarction in right SCA territory is most favored.
2. DWI shows minimal bright up along the margin of hematoma.
3. the brainstem and 4th ventricle are compressed with dilatation of both lateral and the 3rd ventricles. The degree of hydrocephalus is similar as compared with CT study
4. multiple nonspecific hyperintense patches on T2WI at bil. PVWM, leukoaraiosis is considered.
5. contrast-enhanced MRA of cervicocranial vessels shows moderate stenosis of left proximal ICA
6. the cranial vault and skull base appear normal
Impression
Hemorrhagic infarction in right SCA territory, with mass effect and mild hydrocephalus Mild nonspecific white matter change.
Q: indication of surgical decompression of cerebellar lesion with risk of brainstem compression?
Surgical Care
* Indications for surgery are controversial.
* Ventriculostomy is indicated in patients with hemorrhage and hydrocephalus.
* Suboccipital craniotomy with clot evacuation is indicated in patients with altered level of consciousness and a large clot (>30 mm but no greater than 40 mm).
* Patients with a large central clot and absent brainstem reflexes have a poor prognosis. In these cases, some advocate supportive therapy only.
* Patients may appear to be in stable condition but can worsen suddenly. St Louis et al list clinical and CT findings that may identify patients who are at risk for deterioration.
*
o Admission systolic blood pressure greater than 200 mm Hg
o Pinpoint pupils and abnormal corneal and oculocephalic reflexes
o Hemorrhage extending into the cerebellar vermis
o Hematoma diameter greater than 30 mm
o Brainstem distortion
o Intraventricular hemorrhage
o Upward herniation
o Acute hydrocephalus
* CT-guided stereotactic fibrinolysis of the hematoma has been reported in small numbers of carefully selected patients.
* Endoscopic hematoma evacuation has also been reported to have been effective in a small number of patients.
Consultations
* Consult neurosurgery for all patients, even those who are candidates for conservative management. Sudden deterioration may require neurosurgical intervention.
Further Inpatient Care
* Ideally, admit patients to the care of critical care physicians with expertise in managing intracranial hemorrhages.
* Careful monitoring for level of consciousness, vital signs, and ICP is needed for some patients.
* The risk of sudden deterioration is high and mandates the attention that is available in an intensive care unit.
* If immediate surgical intervention is deferred, a deteriorating clinical course may necessitate surgery at a later time.
*
o Posterior fossa craniotomy and evacuation of the hemorrhage may be necessary for patients with worsening clinical condition.
o If surgical therapy is prompt, some comatose patients still may have a good clinical outcome.
* Physical and occupational therapy may be useful in patients who are in stable condition.
1: Clin Neurol Neurosurg. 1998 Jun;100(2):99-103.
Related Articles, Links
Click here to read
Indication to surgical management of cerebellar hemorrhage.
Pollak L, Rabey JM, Gur R, Schiffer J.
Department of Neurology, Assaf Harofeh Medical Center, Zerifin, Israel.
Few reports have compared patients operated for cerebellar infarcts with those operated for cerebellar hemorrhage. Considering our previous paper about patients with massive cerebellar infarcts, we report on our surgical experience with five patients with cerebellar hemorrhage. The indication for operation was decreased consciousness with signs of brainstem compression. In all patients hydrocephalus was absent or mild, as opposed to patients with cerebellar infarcts. Suboccipital craniotomy with hematoma evacuation was therefore the surgical procedure of choice. The outcome was worse than in patients with cerebellar infarcts. We conclude that depressed mental state in cerebellar hemorrhage is mainly due to pressure of the cerebellum on the activating reticular system of the brainstem. The surgical approach to patients with bleeding in the cerebellum differ somewhat from that of patients with cerebellar infarcts in timing and kind of first choice procedure.
Lancet Neurol. 2005 Oct;4(10):662-72.Click here to read Links
Treatment of intracerebral haemorrhage.
Mayer SA, Rincon F.
Neurological Intensive Care Unit, Division of Stroke and Critical Care, Department of Neurology Columbia University, New York, NY 10032, USA. sam14@columbia.edu
Apart from management in a specialised stroke or neurological intensive care unit, until very recently no specific therapies improved outcome after intracerebral haemorrhage (ICH). In a recent phase II trial, recombinant activated factor VII (eptacog alfa) reduced haematoma expansion, mortality, and disability when given within 4 h of ICH onset; a phase III trial (the FAST trial) is now in progress. Ventilatory support, blood-pressure reduction, intracranial-pressure monitoring, osmotherapy, fever control, seizure prophylaxis, and nutritional supplementation are the cornerstones of supportive care in intensive care units. Ventricular drainage should be considered in all stuporous or comatose patients with intraventricular haemorrhage and acute hydrocephalus. Given the lack of benefit seen in a the recent STICH trial, emergency surgical evacuation within 72 h of onset should be reserved for patients with large (>3 cm) cerebellar haemorrhages, or those with large lobar haemorrhages, substantial mass effect, and rapidly deteriorating condition.
c/o: dizziness, vertigo, nausea, unsteady gait to either direction, unable to walk for 3 days
NE: mildly drowsy, limbs ataxia bilaterally UE & LE, truncal ataxia
MP 5/5
no abducens palsy
Head CT: heterogenous hyperintensities with perifocal hypodensity in the right cerebellum, mild hydrocephalus
Brain MRI:
姓名：許 先生 生日： 0160729
病歷號：2708662 照會單號：2655160
檢查項目 .....檢查日期：2008-04-16
MRI-HEAD
MRI of head without/with contrast enhancement shows
1. a large irregular shaped acute hematoma in right superior cerebelum, showing hypointensity with minimal patchy hyperintensities on T1WI, mild hypointensity on T2WI with focal fluid-fluid layering suggestive of noncoagulant blood. The hematoma extends along the gyrus . There is no obvious abnormal enhancement after contrast injection. Hemorrhagic infarction in right SCA territory is most favored.
2. DWI shows minimal bright up along the margin of hematoma.
3. the brainstem and 4th ventricle are compressed with dilatation of both lateral and the 3rd ventricles. The degree of hydrocephalus is similar as compared with CT study
4. multiple nonspecific hyperintense patches on T2WI at bil. PVWM, leukoaraiosis is considered.
5. contrast-enhanced MRA of cervicocranial vessels shows moderate stenosis of left proximal ICA
6. the cranial vault and skull base appear normal
Impression
Hemorrhagic infarction in right SCA territory, with mass effect and mild hydrocephalus Mild nonspecific white matter change.
Q: indication of surgical decompression of cerebellar lesion with risk of brainstem compression?
Surgical Care
* Indications for surgery are controversial.
* Ventriculostomy is indicated in patients with hemorrhage and hydrocephalus.
* Suboccipital craniotomy with clot evacuation is indicated in patients with altered level of consciousness and a large clot (>30 mm but no greater than 40 mm).
* Patients with a large central clot and absent brainstem reflexes have a poor prognosis. In these cases, some advocate supportive therapy only.
* Patients may appear to be in stable condition but can worsen suddenly. St Louis et al list clinical and CT findings that may identify patients who are at risk for deterioration.
*
o Admission systolic blood pressure greater than 200 mm Hg
o Pinpoint pupils and abnormal corneal and oculocephalic reflexes
o Hemorrhage extending into the cerebellar vermis
o Hematoma diameter greater than 30 mm
o Brainstem distortion
o Intraventricular hemorrhage
o Upward herniation
o Acute hydrocephalus
* CT-guided stereotactic fibrinolysis of the hematoma has been reported in small numbers of carefully selected patients.
* Endoscopic hematoma evacuation has also been reported to have been effective in a small number of patients.
Consultations
* Consult neurosurgery for all patients, even those who are candidates for conservative management. Sudden deterioration may require neurosurgical intervention.
Further Inpatient Care
* Ideally, admit patients to the care of critical care physicians with expertise in managing intracranial hemorrhages.
* Careful monitoring for level of consciousness, vital signs, and ICP is needed for some patients.
* The risk of sudden deterioration is high and mandates the attention that is available in an intensive care unit.
* If immediate surgical intervention is deferred, a deteriorating clinical course may necessitate surgery at a later time.
*
o Posterior fossa craniotomy and evacuation of the hemorrhage may be necessary for patients with worsening clinical condition.
o If surgical therapy is prompt, some comatose patients still may have a good clinical outcome.
* Physical and occupational therapy may be useful in patients who are in stable condition.
1: Clin Neurol Neurosurg. 1998 Jun;100(2):99-103.
Related Articles, Links
Click here to read
Indication to surgical management of cerebellar hemorrhage.
Pollak L, Rabey JM, Gur R, Schiffer J.
Department of Neurology, Assaf Harofeh Medical Center, Zerifin, Israel.
Few reports have compared patients operated for cerebellar infarcts with those operated for cerebellar hemorrhage. Considering our previous paper about patients with massive cerebellar infarcts, we report on our surgical experience with five patients with cerebellar hemorrhage. The indication for operation was decreased consciousness with signs of brainstem compression. In all patients hydrocephalus was absent or mild, as opposed to patients with cerebellar infarcts. Suboccipital craniotomy with hematoma evacuation was therefore the surgical procedure of choice. The outcome was worse than in patients with cerebellar infarcts. We conclude that depressed mental state in cerebellar hemorrhage is mainly due to pressure of the cerebellum on the activating reticular system of the brainstem. The surgical approach to patients with bleeding in the cerebellum differ somewhat from that of patients with cerebellar infarcts in timing and kind of first choice procedure.
Lancet Neurol. 2005 Oct;4(10):662-72.Click here to read Links
Treatment of intracerebral haemorrhage.
Mayer SA, Rincon F.
Neurological Intensive Care Unit, Division of Stroke and Critical Care, Department of Neurology Columbia University, New York, NY 10032, USA. sam14@columbia.edu
Apart from management in a specialised stroke or neurological intensive care unit, until very recently no specific therapies improved outcome after intracerebral haemorrhage (ICH). In a recent phase II trial, recombinant activated factor VII (eptacog alfa) reduced haematoma expansion, mortality, and disability when given within 4 h of ICH onset; a phase III trial (the FAST trial) is now in progress. Ventilatory support, blood-pressure reduction, intracranial-pressure monitoring, osmotherapy, fever control, seizure prophylaxis, and nutritional supplementation are the cornerstones of supportive care in intensive care units. Ventricular drainage should be considered in all stuporous or comatose patients with intraventricular haemorrhage and acute hydrocephalus. Given the lack of benefit seen in a the recent STICH trial, emergency surgical evacuation within 72 h of onset should be reserved for patients with large (>3 cm) cerebellar haemorrhages, or those with large lobar haemorrhages, substantial mass effect, and rapidly deteriorating condition.
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