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blastoma may present in this way Careful inquiry will usually disclose that neurologic symptoms compatible with intracranial tumor growth had preceded the onset of hemorrhage Needless to say, a thorough search should be made in these circumstances for evidence of intracranial tumor or of secondary tumor deposits in other organs, particularly the lungs The term mycotic aneurysm designates an aneurysm caused by a localized bacterial or fungal in ammation of an artery (Osler introduced the term mycotic to describe endocarditis, but its proper current use is to describe fungal infection) With the introduction of antibiotics, mycotic aneurysms have become less frequent, but they are still being seen in patients with bacterial endocarditis and in intravenous drug abusers Peripheral arteries are involved more often than intracranial ones; about two-thirds of the latter are associated with subacute bacterial endocarditis due to streptococcal infections In recent years, the number of mycotic aneurysms due to staphylococcal infections and acute endocarditis appears to have increased The usual pathogenic sequence is an embolic occlusion of a small artery, which may announce itself clinically by an ischemic stroke, with cells in the CSF Later, or as the rst manifestation, the weakened vessel wall gives way and causes a subarachnoid or brain hemorrhage The mycotic aneurysm may appear on only one artery or several arteries, and the hemorrhage may recur A consensus regarding the treatment of mycotic aneurysm has not been reached The underlying endocarditis or septicemia mandates appropriate antibiotic therapy and, in at least 30 percent of cases, healing of the aneurysm can be observed in successive arteriograms with this approach alone Treatment should continue for at least 6 weeks Some neurosurgeons believe in excising an accessible aneurysm if it is solitary and the systemic infection is under control Some mycotic aneurysms do not bleed, and in our view medical therapy takes precedence over surgical therapy The pathologic entity called brain purpura (pericapillary encephalorrhagia), incorrectly referred to as hemorrhagic encephalitis, consists of multiple petechial hemorrhages scattered throughout the white matter of the brain The clinical picture is that of a diffuse encephalopathy, but diagnosis is essentially pathologic Blood does not appear in the CSF, and the condition should not be confused with a stroke It is virtually impossible to establish the diagnosis during life, but the pathologic appearance is unique and highly characteristic The lesions in brain purpura are always small, 01 to 20 mm in diameter, and are con ned to the white matter, particularly the corpus callosum, centrum ovale, and middle cerebellar peduncles Each lesion is situated around a small blood vessel, usually a capillary In this para-adventitial area, both the myelin and axis cylinders are destroyed, and the lesion is usually though not always hemorrhagic Fibrin exudation, perivascular and meningeal in ltrates of in ammatory cells, and widespread necrosis of tissue are not observed In these respects brain purpura differs fundamentally from acute necrotizing hemorrhagic leukoencephalitis Usually the patient becomes stuporous and comatose without focal neurologic signs, and the CSF is normal The etiology of brain purpura is quite obscure It may complicate viral pneumonia, uremia, arsenical intoxication, and, rarely, metabolic encephalopathy and sepsis, or there may be no associated disease A degree of hemorrhage is to be expected in acute hemorrhagic leukoencephalitis (Hurst type), which represents an extreme form of acute disseminated encephalomyelitis (Chap 36), and in herpes encephalitis (Chap 33) In ammatory diseases of arteries and veins, especially polyarteritis nodosa, lupus erythematosus, and moyamoya disease, are.

This example includes the items Cost of Goods Sold and Revenue as totals (displayed at the two ends of the graph) The four interim values are displayed as deltas: Customer Rebates is therefore the difference between the previous value Cost of Goods Sold and the following value Overhead Costs, and so on

occasionally associated with cerebral hemorrhage Rupture of a vessel in these circumstances may be on the basis of hypertension or local vascular disease, and bleeding nearly always occurs into brain tissue rather than into the subarachnoid space Rarely, intracranial dissection of an artery (usually the vertebral) may allow some blood to escape into the subarachnoid space The other rare types of hemorrhage, listed in Table 34-9, are self-explanatory Hemorrhages of intraspinal origin, all of them rare, may be the result of trauma, AVM (the usual cause of nontraumatic hematomyelia), anterior spinal artery aneurysms, or bleeding into tumors Spinal subarachnoid hemorrhage from an AVM may simulate an intracranial subarachnoid hemorrhage, causing a stiff neck, headache, and even subhyaloid hemorrhages Subarachnoid hemorrhage in which interscapular or neck pain predominates should raise the suspicion of an aneurysm of the anterior spinal artery or of a spinal AVM or cavernous angioma Angiographic study of the radicular spinal vessels and the origins of the anterior spinal arteries from the vertebral arteries may disclose the source of bleeding Extradural and subdural spinal extravasations may be spontaneous (sometimes in relation to rheumatoid arthritis) but are far more often due to trauma, anticoagulants, or both Extradural spinal hemorrhage causes the rapid evolution of paraplegia or quadriplegia; diagnosis must be prompt if function is to be salvaged by surgical drainage of the hematoma These are discussed further in Chap 44

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