- Email: [email protected]
Delayed Brainstem Hemorrhage Secondary to Mild Traumatic Head Injury: Report of Case with Good Recovery
Accepted Manuscript Delayed brainstem hemorrhage secondary to mild traumatic head injury: report of a case with good recovery Kun Hou, MS, Jinchuan Zhao, MS, Xianfeng Gao, MS, Xiaobo Zhu, M.D., Guichen Li, MS PII:
S1878-8750(17)30923-3
DOI:
10.1016/j.wneu.2017.06.031
Reference:
WNEU 5902
To appear in:
World Neurosurgery
Received Date: 8 April 2017 Revised Date:
2 June 2017
Accepted Date: 5 June 2017
Please cite this article as: Hou K, Zhao J, Gao X, Zhu X, Li G, Delayed brainstem hemorrhage secondary to mild traumatic head injury: report of a case with good recovery, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.06.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Delayed brainstem hemorrhage secondary to mild traumatic head injury: report
of a case with good recovery AUTHORS: Kun Hou MS1, Jinchuan Zhao MS1, Xianfeng Gao MS1, Xiaobo Zhu
RI PT
M.D.1, Guichen Li MS2 DEPARTMENTAL and INSTITUTIONAL AFFLIATIONS:
1
Department of
Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin,
SC
2
M AN U
China
Kun Hou and Jinchuan Zhao contribute equally to this manuscript and they are co-first authors. #
Corresponding Author:
TE D
Guichen Li, Department of Neurology, The First Hospital of Jilin University, 3302 Jilin Road, Changchun 130031, China
EP
Email: [email protected]; Tel: +8618704479380; Fax: +86043184808174
AC C
Conflict of interest: The authors declare that they have no conflict of interest. Presentation at a conference: None
ACCEPTED MANUSCRIPT Delayed brainstem hemorrhage secondary to mild traumatic head injury: report
of a case with good recovery Introduction
RI PT
Traumatic brainstem hemorrhage, which occurs in 1-10% of closed head injuries, is commonly classified as the primary type and secondary type.
1
While primary
traumatic brainstem hemorrhage results from injury at the moment of impact,
SC
secondary traumatic brainstem hemorrhage occurs at a later stage after the primary
M AN U
head injury. In clinical practice, secondary traumatic brainstem hemorrhage often develops during descending transtentorial herniation due to raised intracranial pressure, which is known as Duret hemorrhage.
1-4
Duret hemorrhage is always
considered a fatal and irreversible event. However in rare circumstances, victims of 1, 3, 5
To our knowledge, secondary
TE D
Duret hemorrhage could gain favorable outcomes.
brainstem hemorrhage due to mild traumatic head injury without descending transtentorial herniation has never been reported. In this report, we present a case of
EP
delayed brainstem hemorrhage secondary to a relatively mild traumatic head injury
AC C
that experienced a rapid and favorable recovery. Case report
A 48-year-old man was admitted for a motor cycle accident. He was a smoker and
had alcoholic abuse for more than 20 years. Head computed tomography (CT) 2 hours after the accident revealed mild subarachnoid hemorrhage (SAH) at the interpeduncular cistern (Figure 1a). Physical examination on admission showed a Glasgow Coma Scale (GCS) score of 14 (E4, V4, M6). Nine hours after the accident
ACCEPTED MANUSCRIPT his mental state began to decline. His GCS score declined to 10 (E2, V3, M5). Head CT revealed brainstem hemorrhage adjacent to the previous SAH and increase of the primary SAH (Figure 1b). A digital substraction angiography was performed with no
RI PT
positive finding of vascular anomaly and evident cerebral vasospasm. CT performed one day after the accident showed no extension of the brainstem hemorrhage. Two days later his mental state gradually recovered. He could obey command and correctly
SC
answer some easy questions until on the fourth day after the accident that his mental
M AN U
state declined once again. Physical examination showed a GCS score of 10 (E2, V3, M5). An emergent CT revealed further increase of the brainstem hemorrhage (Figure 1c). His mental state never deteriorated anymore and further CT showed no increase of the brainstem hemorrhage and SAH. He experienced a rapid and favorable
Discussion
TE D
recovery. His Glasgow Outcome Scale score was 5 at 3 months’ follow-up.
As nearly all of the reported cases of secondary brainstem hemorrhage were
EP
secondary to descending transtentorial herniation, Duret hemorrhage was always 1, 2
The pathogenesis of
AC C
considered the synonym of secondary brainstem hemorrhage.
secondary brainstem hemorrhage is still obscure to us, although it has been noticed for decades.
6
Generally speaking, there was no consensus on the origin (arterial or
venous) of Duret hemorrhage. Some authors believed that stretching and disruption of the paramedian pontine perforating arteries during brainstem downward movement lead to hemorrhaging.
1
While some other authors insisted that veins may be
compressed more easily than arteries, and hemorrhagic transformation of an area of
ACCEPTED MANUSCRIPT venous ischemia may also contribute to Duret hemorrhage.
1, 7
Besides, surgical
decompression may promote Duret hemorrhage by the way of reperfusion injury. 1 However, our patient represents a unique case, because the hypotheses mentioned
RI PT
above could not perfectly explain the things occurred in our case. Firstly, there was no descending transtentorial herniation and persistent vascular compression and stretching. And then reperfusion injury was not present due to decompressive
SC
craniectomy for intracranial hematoma and increased intracranial pressure. This case
M AN U
represents another type of secondary brainstem hemorrhage that is due to mild head injury and without the presence of brain herniation. Based on the progressive nature of mental state deterioration and increase of brainstem hematoma in the early stage of hospitalization, continuous injury to the local brainstem vasculature may exist. The
TE D
primary injury might be due to the instantaneous stretching of brainstem vessels at the moment of upward and downward movement during motor cycle accident. The momentary injury may lead to a cascade of local vascular responses which causes
EP
endothelial cell damage and increase of vascular permeability or even microvascular
AC C
rupture. Blood components, especially red blood cells, gradually leaked to the subarachnoid space and brainstem. 2 Generally speaking, traumatic brainstem hemorrhage, regardless of the type of
injury (primary or secondary), usually means a fatal event to most of the victims. However, traumatic brainstem hemorrhage does not readily warrant poor outcome and withdrawal of aggressive treatment. In rare circumstances, some patients might survive from secondary traumatic brainstem hemorrhage and experience a favorable
ACCEPTED MANUSCRIPT recovery.
1, 3, 5
In our opinion, those patients with good outcome might, in fact, have
experienced a relative focal and mild secondary brainstem injury. And nearly all of the cases of Duret hemorrhage with good outcome had experienced a rapid postoperative
RI PT
recovery, 1, 3, 5 which implies a mild and focal brainstem injury. In conclusion, we present a rare case of secondary traumatic brainstem hemorrhage that experienced a rapid and good recovery process. The mechanism is still obscure to
SC
us and need to be further studied. Although traumatic brainstem hemorrhage usually
M AN U
means a fatal event to most of the patients, some patients may experience a favorable recovery. This rare circumstance should be stressed in prognosis consultation and clinical management of this kind of patients.
TE D
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
EP
Consent
Written informed consents were obtained from the patient for publication of this
AC C
manuscript and any accompanying images. Copy of the written consent is available for review by the Editor of this journal.
References
ACCEPTED MANUSCRIPT 1. Stiver SI, Gean AD, Manley GT. Survival with good outcome after cerebral herniation
and
Duret
hemorrhage
caused
by
traumatic
head
injury.
J
Neurosurg.2009;110(6):1242-6.
RI PT
2.Parizel PM, Makkat S, Jorens PG, et al. Brainstem hemorrhage in descending transtentorial herniation (Duret hemorrhage). Intensive Care Med. 2002;28(1):85-8.
3.Ishizaka S, Shimizu T, Ryu N. Dramatic recovery after severe descending
SC
transtentorial herniation-induced Duret haemorrhage: a case report and review of
M AN U
literature. Brain Inj. 2014;28(3):374-7.
4.Meyer CA, Mirvis SE, Wolf AL, Thompson RK, Gutierrez MA. Acute traumatic midbrain
hemorrhage:
experimental
Radiology.1991 Jun;179(3):813-8.
and
clinical
observations
with
CT.
TE D
5.Nguyen HS, Doan NB, Gelsomino MJ, Shabani S, Mueller WM. Good outcomes in a patient with a Duret hemorrhage from an acute subdural hematoma. Int Med Case Rep J. 2016;9:15-8.
EP
6. Alexander E Jr, Kushner J, Six EG. Brainstem hemorrhages and increased
AC C
intracranial pressure: from Duret to computed tomography. Surg Neurol. 1982;17(2):107-10.
7. Andeweg J. Consequences of the anatomy of deep venous outflow from the brain. Neuroradiology. 1999;41(4):233-41.
Figure legends Figure 1a: Head CT 2 hours after the accident shows mild SAH at the interpeduncular
ACCEPTED MANUSCRIPT cistern. Figure 1b: Head CT 9 hours reveals brainstem hemorrhage adjacent to the previous SAH and increase of the primary SAH.
AC C
EP
TE D
M AN U
SC
RI PT
Figure 1c: Head CT 4 days later shows further increase of the brainstem hemorrhage.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
1. Secondary brainstem hemorrhage often develops during descending transtentorial herniation, which is known as Duret hemorrhage. 2. Secondary brainstem hemorrhage is always considered a fatal and irreversible event. 3. In rare circumstances, some patients might survive from secondary traumatic brainstem hemorrhage and experience a favorable recovery. 4. The mechanism is still obscure to us and need to be further studied.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
CT: Computed tomography SAH: subarachnoid hemorrhage GCS: Glasgow Coma Scale
S1878-8750(17)30923-3
DOI:
10.1016/j.wneu.2017.06.031
Reference:
WNEU 5902
To appear in:
World Neurosurgery
Received Date: 8 April 2017 Revised Date:
2 June 2017
Accepted Date: 5 June 2017
Please cite this article as: Hou K, Zhao J, Gao X, Zhu X, Li G, Delayed brainstem hemorrhage secondary to mild traumatic head injury: report of a case with good recovery, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.06.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Delayed brainstem hemorrhage secondary to mild traumatic head injury: report
of a case with good recovery AUTHORS: Kun Hou MS1, Jinchuan Zhao MS1, Xianfeng Gao MS1, Xiaobo Zhu
RI PT
M.D.1, Guichen Li MS2 DEPARTMENTAL and INSTITUTIONAL AFFLIATIONS:
1
Department of
Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin,
SC
2
M AN U
China
Kun Hou and Jinchuan Zhao contribute equally to this manuscript and they are co-first authors. #
Corresponding Author:
TE D
Guichen Li, Department of Neurology, The First Hospital of Jilin University, 3302 Jilin Road, Changchun 130031, China
EP
Email: [email protected]; Tel: +8618704479380; Fax: +86043184808174
AC C
Conflict of interest: The authors declare that they have no conflict of interest. Presentation at a conference: None
ACCEPTED MANUSCRIPT Delayed brainstem hemorrhage secondary to mild traumatic head injury: report
of a case with good recovery Introduction
RI PT
Traumatic brainstem hemorrhage, which occurs in 1-10% of closed head injuries, is commonly classified as the primary type and secondary type.
1
While primary
traumatic brainstem hemorrhage results from injury at the moment of impact,
SC
secondary traumatic brainstem hemorrhage occurs at a later stage after the primary
M AN U
head injury. In clinical practice, secondary traumatic brainstem hemorrhage often develops during descending transtentorial herniation due to raised intracranial pressure, which is known as Duret hemorrhage.
1-4
Duret hemorrhage is always
considered a fatal and irreversible event. However in rare circumstances, victims of 1, 3, 5
To our knowledge, secondary
TE D
Duret hemorrhage could gain favorable outcomes.
brainstem hemorrhage due to mild traumatic head injury without descending transtentorial herniation has never been reported. In this report, we present a case of
EP
delayed brainstem hemorrhage secondary to a relatively mild traumatic head injury
AC C
that experienced a rapid and favorable recovery. Case report
A 48-year-old man was admitted for a motor cycle accident. He was a smoker and
had alcoholic abuse for more than 20 years. Head computed tomography (CT) 2 hours after the accident revealed mild subarachnoid hemorrhage (SAH) at the interpeduncular cistern (Figure 1a). Physical examination on admission showed a Glasgow Coma Scale (GCS) score of 14 (E4, V4, M6). Nine hours after the accident
ACCEPTED MANUSCRIPT his mental state began to decline. His GCS score declined to 10 (E2, V3, M5). Head CT revealed brainstem hemorrhage adjacent to the previous SAH and increase of the primary SAH (Figure 1b). A digital substraction angiography was performed with no
RI PT
positive finding of vascular anomaly and evident cerebral vasospasm. CT performed one day after the accident showed no extension of the brainstem hemorrhage. Two days later his mental state gradually recovered. He could obey command and correctly
SC
answer some easy questions until on the fourth day after the accident that his mental
M AN U
state declined once again. Physical examination showed a GCS score of 10 (E2, V3, M5). An emergent CT revealed further increase of the brainstem hemorrhage (Figure 1c). His mental state never deteriorated anymore and further CT showed no increase of the brainstem hemorrhage and SAH. He experienced a rapid and favorable
Discussion
TE D
recovery. His Glasgow Outcome Scale score was 5 at 3 months’ follow-up.
As nearly all of the reported cases of secondary brainstem hemorrhage were
EP
secondary to descending transtentorial herniation, Duret hemorrhage was always 1, 2
The pathogenesis of
AC C
considered the synonym of secondary brainstem hemorrhage.
secondary brainstem hemorrhage is still obscure to us, although it has been noticed for decades.
6
Generally speaking, there was no consensus on the origin (arterial or
venous) of Duret hemorrhage. Some authors believed that stretching and disruption of the paramedian pontine perforating arteries during brainstem downward movement lead to hemorrhaging.
1
While some other authors insisted that veins may be
compressed more easily than arteries, and hemorrhagic transformation of an area of
ACCEPTED MANUSCRIPT venous ischemia may also contribute to Duret hemorrhage.
1, 7
Besides, surgical
decompression may promote Duret hemorrhage by the way of reperfusion injury. 1 However, our patient represents a unique case, because the hypotheses mentioned
RI PT
above could not perfectly explain the things occurred in our case. Firstly, there was no descending transtentorial herniation and persistent vascular compression and stretching. And then reperfusion injury was not present due to decompressive
SC
craniectomy for intracranial hematoma and increased intracranial pressure. This case
M AN U
represents another type of secondary brainstem hemorrhage that is due to mild head injury and without the presence of brain herniation. Based on the progressive nature of mental state deterioration and increase of brainstem hematoma in the early stage of hospitalization, continuous injury to the local brainstem vasculature may exist. The
TE D
primary injury might be due to the instantaneous stretching of brainstem vessels at the moment of upward and downward movement during motor cycle accident. The momentary injury may lead to a cascade of local vascular responses which causes
EP
endothelial cell damage and increase of vascular permeability or even microvascular
AC C
rupture. Blood components, especially red blood cells, gradually leaked to the subarachnoid space and brainstem. 2 Generally speaking, traumatic brainstem hemorrhage, regardless of the type of
injury (primary or secondary), usually means a fatal event to most of the victims. However, traumatic brainstem hemorrhage does not readily warrant poor outcome and withdrawal of aggressive treatment. In rare circumstances, some patients might survive from secondary traumatic brainstem hemorrhage and experience a favorable
ACCEPTED MANUSCRIPT recovery.
1, 3, 5
In our opinion, those patients with good outcome might, in fact, have
experienced a relative focal and mild secondary brainstem injury. And nearly all of the cases of Duret hemorrhage with good outcome had experienced a rapid postoperative
RI PT
recovery, 1, 3, 5 which implies a mild and focal brainstem injury. In conclusion, we present a rare case of secondary traumatic brainstem hemorrhage that experienced a rapid and good recovery process. The mechanism is still obscure to
SC
us and need to be further studied. Although traumatic brainstem hemorrhage usually
M AN U
means a fatal event to most of the patients, some patients may experience a favorable recovery. This rare circumstance should be stressed in prognosis consultation and clinical management of this kind of patients.
TE D
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
EP
Consent
Written informed consents were obtained from the patient for publication of this
AC C
manuscript and any accompanying images. Copy of the written consent is available for review by the Editor of this journal.
References
ACCEPTED MANUSCRIPT 1. Stiver SI, Gean AD, Manley GT. Survival with good outcome after cerebral herniation
and
Duret
hemorrhage
caused
by
traumatic
head
injury.
J
Neurosurg.2009;110(6):1242-6.
RI PT
2.Parizel PM, Makkat S, Jorens PG, et al. Brainstem hemorrhage in descending transtentorial herniation (Duret hemorrhage). Intensive Care Med. 2002;28(1):85-8.
3.Ishizaka S, Shimizu T, Ryu N. Dramatic recovery after severe descending
SC
transtentorial herniation-induced Duret haemorrhage: a case report and review of
M AN U
literature. Brain Inj. 2014;28(3):374-7.
4.Meyer CA, Mirvis SE, Wolf AL, Thompson RK, Gutierrez MA. Acute traumatic midbrain
hemorrhage:
experimental
Radiology.1991 Jun;179(3):813-8.
and
clinical
observations
with
CT.
TE D
5.Nguyen HS, Doan NB, Gelsomino MJ, Shabani S, Mueller WM. Good outcomes in a patient with a Duret hemorrhage from an acute subdural hematoma. Int Med Case Rep J. 2016;9:15-8.
EP
6. Alexander E Jr, Kushner J, Six EG. Brainstem hemorrhages and increased
AC C
intracranial pressure: from Duret to computed tomography. Surg Neurol. 1982;17(2):107-10.
7. Andeweg J. Consequences of the anatomy of deep venous outflow from the brain. Neuroradiology. 1999;41(4):233-41.
Figure legends Figure 1a: Head CT 2 hours after the accident shows mild SAH at the interpeduncular
ACCEPTED MANUSCRIPT cistern. Figure 1b: Head CT 9 hours reveals brainstem hemorrhage adjacent to the previous SAH and increase of the primary SAH.
AC C
EP
TE D
M AN U
SC
RI PT
Figure 1c: Head CT 4 days later shows further increase of the brainstem hemorrhage.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
1. Secondary brainstem hemorrhage often develops during descending transtentorial herniation, which is known as Duret hemorrhage. 2. Secondary brainstem hemorrhage is always considered a fatal and irreversible event. 3. In rare circumstances, some patients might survive from secondary traumatic brainstem hemorrhage and experience a favorable recovery. 4. The mechanism is still obscure to us and need to be further studied.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
CT: Computed tomography SAH: subarachnoid hemorrhage GCS: Glasgow Coma Scale