Search Results (6)

Approximately 795,000 people experience new or recurrent strokes in the United States each year; between 10 to 20% of these are spontaneous intracerebral hemorrhages (ICH). Uncontrolled hypertension is not only the most common cause of ICH but also a major risk factor for hematoma expansion. Resistant hypertension, defined as persistently elevated blood pressure despite the use of three or more antihypertensives of different classes, is common in patients with ICH. A long-acting calcium channel blocker, angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), and a thiazide diuretic are generally considered the mainstay for the treatment of resistant hypertension. However, due to the risk of hyponatremia and worsening cerebral edema, thiazide diuretics should be avoided during the first few weeks of ICH. Recent evidence supports the use of a mineralocorticoid receptor antagonist. While resistant hypertension may be idiopathic, a workup of secondary causes should be pursued. Adequate and timely control of elevated blood pressure remains one of the main cornerstones of treatment in patients with ICH. Previous studies have revealed that resistant hypertension in patients with ICH is associated with longer ICU stays, a higher risk of recurrent stroke, and can contribute to renal, cardiac, and neurologic complications. This emphasizes the need for early initiation of oral antihypertensives and adequate blood pressure control at hospital discharge. Landmark studies have shown that early lowering of SBP to 130–150 mm Hg with smooth, sustained BP control is safe and may improve functional outcomes in patients with mild to moderate ICH. After initiating oral antihypertensives with a calcium channel blocker, an ACEi or ARB beta-blocker, and a mineralocorticoid receptor antagonist to maximally tolerated doses, the next line of antihypertensive treatment should be tailored to the patient’s co-morbidities, and may include a beta-blocker, central alpha agonist, hydralazine, and minoxidil. In this review, we discuss the epidemiology of resistant hypertension in ICH and its molecular basis, diagnostic workup, and acute and long-term treatment. We present novel mechanisms implicated in hypertensive ICH, including ferroptosis, neuroinflammation, the CNS–gut microbiome axis, and novel therapeutics. We also propose a simple algorithm for the optimal pharmacological management of resistant hypertension in ICH. Full article

Background: Kidney dysfunction is common in intracerebral hemorrhage (ICH), but it is unclear whether reduced estimated glomerular filtration rate (eGFR) on admission is an independent driver of short-term outcomes or a marker of overall vulnerability. Methods: In this single-center retrospective study, we analyzed the data of consecutive patients with spontaneous ICH. Results: Among 276 patients, 92 (33.3%) presented with eGFR < 60 mL/min/1.73 m² on admission. Only 17/92 (18.5%) had documented pre-existing chronic kidney disease (CKD). Acute kidney injury (AKI) occurred more often in patients with eGFR < 60 mL/min/1.73 m² than in those with eGFR ≥ 60 mL/min/1.73 m² (25.0% vs. 10.3%). In survival models, eGFR ≥ 60 mL/min/1.73 m², predicted higher 90-day survival in the baseline model (OR 3.031, p = 0.013) but was attenuated after adjustment for age and premorbid modified Rankin Scale (mRS) and was no longer independent after additional adjustment for laboratory markers. Across all models, the National Institutes of Health Stroke Scale (NIHSS) score, hematoma volume, and history of coronary artery disease remained robust predictors. Higher leukocyte count predicted lower survival, whereas higher hemoglobin predicted higher survival. Among survivors, favorable functional outcome was independently associated with lower NIHSS, younger age, lower premorbid mRS, and absence of documented CKD. Admission eGFR category was not independently associated. Conclusions: Reduced admission eGFR primarily reflects baseline frailty and systemic derangement rather than an independent determinant of short-term survival after full adjustment, whereas documented CKD is more informative for disability among survivors. AKI occurs more frequently in patients presenting with reduced eGFR, supporting close renal monitoring in acute ICH. Full article

Background and Clinical Significance: Spontaneous renal hematoma, also known as Wunderlich syndrome (WS), is a rare disease characterized by the acute onset of spontaneous renal hemorrhage into the subcapsular, perirenal, and/or pararenal spaces without a history of prior trauma. WS can be a life-threatening condition due to hemorrhagic shock; consequently, prompt diagnosis and a therapeutic approach are essential for favorable outcomes. Treatment ranges from conservative management to surgical intervention. The most common etiologies are neoplasms and vascular diseases, but WS can also be observed in patients undergoing hemodialysis. In patients with end-stage renal disease (ESRD), especially those on hemodialysis, acquired cystic kidney disease and renal cell carcinoma are among the primary causes of WS. Although less common, WS can develop in dialysis patients even in the absence of traditional (primary) risk factors. In general, patients with chronic kidney disease (CKD) have a paradoxical hemostatic profile, likely explaining their higher tendency to bleed, so WS can occur without existing predisposing factors. The multifactorial pathogenesis in these patients includes functional platelet abnormalities, intimal arterial fibrosis, chronic inflammation, and oxidative stress associated with ESRD. The use of hemodialysis-related antithrombotic medications could serve as another contributing factor increasing the risk of bleeding. Case Presentation: We present a case report of a 62-year-old male on chronic dialysis who developed sudden right-sided lumbar pain and hematuria during dialysis without evidence of prior trauma. Imaging revealed a large subcapsular hematoma of the right kidney. Further investigations did not reveal additional risk factors in this instance; however, his routinely used hemodialysis-related antithrombotic medications were potentially a contributing factor. Despite conservative treatment, his condition worsened, and the hematoma enlarged, requiring emergency nephrectomy. Postoperatively, his condition gradually improved. Conclusions: This case highlights the importance of considering WS in hemodialysis patients, even without the presence of traditional risk factors, as well as including WS in the differential diagnosis of acute abdominal pain. Full article

Background: This study investigated the clinical features, underlying causes, and management of patients with spontaneous perirenal hemorrhage (Wunderlich syndrome; WS). Methods: We retrospectively reviewed the records of patients hospitalized for WS at a single tertiary center between 2011 and 2024. All patients were evaluated for non-traumatic perirenal hemorrhage identified on computed tomography (CT) in the emergency department. Clinical variables, including age, underlying diseases, symptoms, hemodynamic instability, and hospitalization course, were analyzed. Laboratory test results, as well as radiological and pathological findings, were reviewed. Results: The study included 46 events from 38 patients, with a median (IQR) follow-up period of 32 (4–82) months. The most common presenting symptom was flank pain, observed in 44 cases (95.7%). Renal lesions, including visible tumors, were detected in 25 cases (54.3%), while 13 cases (28.3%) exhibited perirenal hematoma without a distinct lesion. Among seven patients with hemodynamic instability (systolic blood pressure < 90 mmHg), one underwent emergency embolization, and four required emergency surgical exploration. Surgical intervention was performed in 13 cases (28.3%), all involving nephrectomy, while radiologic embolization was attempted in seven cases (15.2%), with one patient later requiring delayed nephrectomy. The final diagnosis revealed renal cell carcinoma in eight cases (six patients), angiomyolipoma in 11 cases (six patients), renal cysts in six cases, acquired cystic kidney disease in six cases, sarcoma in three cases, perivascular epithelioid cell tumor in one case, lymphoma in one case, and chronic pyelonephritis in four cases; no specific disease was identified in six cases. During follow-up, six patients died; four of these deaths were directly related to WS or its underlying etiologies. Conclusions: WS is a potentially life-threatening condition, with benign or malignant renal masses being the most common causes. Although the advancement of interventional techniques has led to an increasing number of cases being conservatively managed, the possibility of renal malignancy should always be considered. Full article

Background/Objectives: Spontaneous chest wall hematomas are rare but potentially life-threatening complications, particularly in patients with multiple comorbidities such as those undergoing hemodialysis. This case report aims to highlight the significance of early diagnosis and appropriate management in preventing complications associated with this condition. Methods: We report the case of a 79-year-old man with end-stage renal disease on hemodialysis, presenting with a large spontaneous hematoma (18.7 × 13.1 × 9.6 cm) in the right upper chest wall. Initial interventions, including diagnostic imaging and transarterial angiography, did not detect active bleeding. Surgical exploration revealed bleeding from a branch of the lateral thoracic artery, which was managed through vessel ligation and hematoma drainage. Results: The hematoma was successfully managed through surgical intervention, with no postoperative complications such as infection, recurrent bleeding, or wound issues. The patient’s recovery was uneventful, and he was discharged in stable condition. This case underscores the role of microvascular fragility and uremic coagulopathy in the development of spontaneous bleeding in hemodialysis patients. Conclusions: This case emphasizes the importance of timely recognition and individualized management of spontaneous soft tissue bleeding in hemodialysis patients. Surgical intervention is necessary for large hematomas or cases of hemodynamic instability to ensure hemostasis and mitigate complications. Full article

Background and Objectives: Systemic lupus erythematosus (SLE) is a disease with multiple organ involvement, and spontaneous hemorrhage, especially perirenal hemorrhage, is rare. Case Presentation: We report the case of a 19-year-old teenager with SLE who experienced left flank pain and hypovolemic shock. Abdominal computed tomography revealed a large left retroperitoneal hematoma. Recurrent hypovolemic shock occurred despite the transcatheter arterial embolization of the left renal artery. Repetitive abdominal computed tomography results showed active hemorrhage. Result: An exploratory laparotomy was used to confirm descending colonic mesenteric artery bleeding, which was resolved. The patient needed temporary regular kidney replacement therapy for active lupus nephritis, which terminated one month after discharge. Conclusions: When patients with SLE experience acute abdominal pain, flank pain, or back pain combined with hypovolemia, there is a higher risk of bleeding due to spontaneous hemorrhage, which should be included in the differential diagnosis. Therefore, early diagnosis and adequate emergency intervention are necessary. Full article