Hemorrhagic infarctions

Lyden PD, Zivin JA, Clark WA, Madden K, Sasse KC, Mazzarella VA, Terry RD, Press GA. Tissue plasminogen activator-mediated thrombolysis of cerebral emboli and its effect on hemorrhagic infarction in rabbits. Neurology. 1989 39 703-708. 

Recombinant t-PA has also been approved for use in acute ischemic stroke within 3 hours of symptom onset. In patients without hemorrhagic infarct or other contraindications, this therapy has been demonstrated to provide better outcomes in several randomized clinical trials. The recommended dose is 0.9 mg/kg, not to exceed 90 mg, with 10% given as a bolus and the remainder during a 1 hour infusion. Streptokinase has been associated with increased bleeding risk in acute ischemic stroke when given at a dose of 1.5 million units, and its use is not recommended in this setting. 

Anticoagulants are sometimes used in the overall treatment of PVE even though there are risks of intracerebral hemorrhage or hemorrhagic infarction. Countering this risk, however, is the risk of major thromboembolic complications involving the central nervous system that may occur in die absence of continued anticoagulant therapy. 

Pituitary apoplexy (hemorrhagic infarction presenting with sudden severe headache, often followed by pituitary... 

Mokri B, Silbert PL, Schievink WI et al (1996) Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery. Neurology 46 356-359 Molina CA, Montaner J, Abilleira S et al (2001) Timing of Spontaneous Recanalization and Risk of Hemorrhagic Transformation in Acute Cardioembolic Stroke. Stroke 32 1079-1084 Molina CA, Alvarez-Sabin J, Montaner J et al (2002) Thrombolysis-related hemorrhagic infarction a marker of early reperfusion, reduced infarct size, and improved outcome in patients with proximal middle cerebral artery occlusion. Stroke 33 1551-1556... 

Thrombotic thrombocytopenic purpura is a rare acute or subacute disease in adults, rather similar to the hemolytic uremic syndrome in children, in which there is systemic malaise, fever, skin purpura, renal failure, hematuria and proteinuria. Hemorrhagic infarcts caused by platelet microthrombi occur in many organs in the brain they may cause stroke-like episodes (Matijevic and Wu 2006) although more commonly there is global encephalopathy. The blood film shows thrombocytopenia, hemolytic anemia and fragmented red cells. The differential diagnosis includes infective endocarditis, idiopathic thrombocytopenia, heparin-induced thrombocytopenia with thrombosis, systemic lupus erythematosus, non-bacterial thrombotic endocarditis and disseminated intravascular coagulation. 

Table 10.3. Rates of infarction, primary hemorrhage or hemorrhagic infarction on CT scan among subjects with probable or definite transient ischemic attack or minor stroke in the Oxford Vascular Study (OXVASC)...

Fig. 29.4. Axial CT (a) and T2-weighted MR brain (b) slices in a patient with deep cerebral venous thrombosis with bilateral deep hemorrhagic infarction.

TNFa is primarily responsible for a laboratory phenomenon known as the localized hemorrhagic Shwartzman reaction in which repeated injection of LPS into a solid tissue leads to hemorrhagic infarction. This occurs because LPS-induced TNFa secretion by macrophages can stimulate endothelial ceils to release PGs, IL-6, and other mediators that cause coagulation, clotting, and obstruction of local blood supply,... 

It is related to abnormal endothelial reactivity that leads to intravascular deposition of fibrin with subsequent end-organ damage. Most maternal deaths are due to central nervous system complications, but the liver may also be the target of injury. The injury to the liver is ischemic. Modest elevations in ALT and AST occur, typically 4 to 10 times the upper reference limit. Hepatic complications, including hemorrhage, infarction, and fulminant hepatic failure, may occur and necessitate early delivery... 

Note Hemorrhagic infarct leads to erythrocyte degradation and hemosiderin deposition. e. Clinical manifestations depend on affected artery... 

FLAIR image (c) shows high and low signal at the posterior left temporal lobe corresponding to hemorrhagic infarct... 

Molina, C.A., et al.. Thrombolysis-related hemorrhagic infarction a marker of early reperfusion, reduced infarct size, and improved outcome in patients with proximal middle cerebral artery occlusion Stroke, 2002. 33(6) p. 1551-6. 

Fisher, M. and R.D. Adams, Observations on brain embolism with special reference to the mechanism of hemorrhagic infarction. J Neuropathol Exp Neurol, 1951. 10(1) p. 92-4. 

Ogata, J., et al.. Hemorrhagic infarct of the brain without a reopening of the occluded arteries in cardioembolic stroke. Stroke, 1989. 20(7) p. 876-83. 

Calandie, L., J.F. Ortega, and E Bermejo, Anticoagulation and hemorrhagic infarction in cerebral embolism secondary to rheumatic heart disease. Arch Neurol, 1984. 41(11) p. 1152-4. 

Reperfusion dysrhythmia or hemorrhagic infarction can result if thrombolytics break up the clot after an MI. The major complication using thrombolytics is hemorrhage. The hemorrhage is stopped by using aminocaproic acid (Amicar) to inhibit plasminogen activation. The use of heparin with thrombolytic medications is commonly done and can prevent formation of new clots but requires intensive care and close monitoring of the patient. 

Diquat is not taken up by pulmonary alveolar cells and does not cause pulmonary fibrosis, but is associated with gastrointestinal fluid sequestration, renal failure, and cerebral and brainstem hemorrhagic infarctions. 

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