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Druelle A, Blatteau JE, Daubresse Duchadeuil L, Morin J, Roffi R, Dufresne PL, Lehot H, Castagna O. Case report: Reassessing guidelines for safe resumption of diving after spinal decompression sickness: insights from a challenging case. Front Med (Lausanne) 2024; 11:1347465. [PMID: 38784237 PMCID: PMC11111850 DOI: 10.3389/fmed.2024.1347465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
Background Recreational divers who have experienced Spinal Decompression Sickness (DCS) often aspire to return to their diving activities. Traditionally, it is recommended to observe a waiting period of several months before contemplating a return to unrestricted diving, particularly when clinical symptoms are absent, spinal cord Magnetic Resonance Imaging shows no anomalies, and the evaluation for Patent Foramen Ovale (PFO) returns negative results. Methods This article presents a compelling case study involving a 51-year-old recreational scuba diver who encountered two episodes of spinal decompression illness within a two-year timeframe. Notably, the search for a PFO produced negative results. The primary objective of this article is to underscore the critical importance of a meticulously planned approach to resuming diving after DCS incidents, emphasizing the potential for recurrence and the essential preventive measures. Conclusion We delve into the intricate decision-making process for returning to diving, emphasizing the significance of clinical evaluations, PFO assessments, spinal cord Magnetic Resonance Imaging, and the absence of clinical symptoms. By recognizing the risk of recurrence and the need for proactive prevention measures, we provide recommendations for both medical professionals and divers, with the ultimate goal of enhancing safety and informed decision-making within the diving community.
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Affiliation(s)
- Arnaud Druelle
- Ste Anne Military Hospital (HIA Ste Anne), Service de médecine hyperbare et d’expertise plongée (SMHEP), Toulon, France
| | - Jean-Eric Blatteau
- Ste Anne Military Hospital (HIA Ste Anne), Service de médecine hyperbare et d’expertise plongée (SMHEP), Toulon, France
| | - Lucile Daubresse Duchadeuil
- Ste Anne Military Hospital (HIA Ste Anne), Service de médecine hyperbare et d’expertise plongée (SMHEP), Toulon, France
| | - Jean Morin
- Ste Anne Military Hospital (HIA Ste Anne), Service de médecine hyperbare et d’expertise plongée (SMHEP), Toulon, France
| | - Romain Roffi
- Ste Anne Military Hospital (HIA Ste Anne), Service de médecine hyperbare et d’expertise plongée (SMHEP), Toulon, France
| | | | - Henri Lehot
- Ste Anne Military Hospital (HIA Ste Anne), Service de médecine hyperbare et d’expertise plongée (SMHEP), Toulon, France
| | - Olivier Castagna
- Ste Anne Military Hospital (HIA Ste Anne), Service de médecine hyperbare et d’expertise plongée (SMHEP), Toulon, France
- Underwater Research Team-ERRSO, Military Biomedical Research Institute-IRBA, Toulon, France
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Peppas S, Palaiodimos L, Nagraj S, Kokkinidis DG, Tiwari N, Kharawala A, Mojadidi MK, Mojaddedi S, Ntaios G, Faillace RT, Tobis JM. Right-to-Left Shunt in Divers with Neurological Decompression Sickness: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2023; 11:1407. [PMID: 37239692 PMCID: PMC10217987 DOI: 10.3390/healthcare11101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023] Open
Abstract
OBJECTIVE The aim of this study was to assess the association between the presence of a right-to-left shunt (RLS) and neurological decompression sickness (NDCS) and asymptomatic brain lesions among otherwise healthy divers. BACKGROUND Next to drowning, NDCS is the most severe phenotype of diving-related disease and may cause permanent damage to the brain and spinal cord. Several observational reports have described the presence of an RLS as a significant risk factor for neurological complications in divers, ranging from asymptomatic brain lesions to NDCS. METHODS We systematically reviewed the MEDLINE, Embase, and CENTRAL databases from inception until November 2021. A random-effects model was used to compute odds ratios. RESULTS Nine observational studies consisting of 1830 divers (neurological DCS: 954; healthy divers: 876) were included. RLS was significantly more prevalent in divers with NDCS compared to those without (62.6% vs. 27.3%; odds ratio (OR): 3.83; 95% CI: 2.79-5.27). Regarding RLS size, high-grade RLS was more prevalent in the NDCS group than the no NDCS group (57.8% versus 18.4%; OR: 4.98; 95% CI: 2.86-8.67). Further subgroup analysis revealed a stronger association with the inner ear (OR: 12.13; 95% CI: 8.10-18.17) compared to cerebral (OR: 4.96; 95% CI: 2.43-10.12) and spinal cord (OR: 2.47; 95% CI: 2.74-7.42) DCS. RLS was more prevalent in divers with asymptomatic ischemic brain lesions than those without any lesions (46.0% vs. 38.0%); however, this was not statistically significant (OR: 1.53; 95% CI: 0.80-2.91). CONCLUSIONS RLS, particularly high-grade RLS, is associated with greater risk of NDCS. No statistically significant association between RLS and asymptomatic brain lesions was found.
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Affiliation(s)
- Spyros Peppas
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Leonidas Palaiodimos
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Sanjana Nagraj
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Damianos G. Kokkinidis
- Section of Cardiovascular Medicine, Yale University/Yale New Haven Hospital, New Haven, CT 06520, USA
| | - Nidhish Tiwari
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Amrin Kharawala
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Mohammad K. Mojadidi
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Sanauallah Mojaddedi
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 382 21 Larissa, Greece
| | - Robert T. Faillace
- Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Jonathan M. Tobis
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA
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Wu X, Ya J, Zhou D, Ding Y, Ji X, Meng R. Pathogeneses and Imaging Features of Cerebral White Matter Lesions of Vascular Origins. Aging Dis 2021; 12:2031-2051. [PMID: 34881084 PMCID: PMC8612616 DOI: 10.14336/ad.2021.0414] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/14/2021] [Indexed: 01/10/2023] Open
Abstract
White matter lesion (WML), also known as white matter hyperintensities or leukoaraiosis, was first termed in 1986 to describe the hyperintense signals on T2-weighted imaging (T2WI) and fluid-attenuated inversion recovery (FLAIR) maps. Over the past decades, a growing body of pathophysiological findings regarding WMLs have been discovered and discussed. Currently, the generally accepted WML pathogeneses mainly include hypoxia-ischemia, endothelial dysfunction, blood-brain barrier disruption, and infiltration of inflammatory mediators or cytokines. However, none of them can explain the whole dynamics of WML formation. Herein, we primarily focus on the pathogeneses and neuroimaging features of vascular WMLs. To achieve this goal, we searched papers with any type published in PubMed from 1950 to 2020 and cross-referenced the keywords including “leukoencephalopathy”, “leukoaraiosis”, “white matter hyperintensity”, “white matter lesion”, “pathogenesis”, “pathology”, “pathophysiology”, and “neuroimaging”. Moreover, references of the selected articles were browsed and searched for additional pertinent articles. We believe this work will supply the robust references for clinicians to further understand the different WML patterns of varying vascular etiologies and thus make customized treatment.
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Affiliation(s)
- Xiaoqin Wu
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jingyuan Ya
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,4Division of Clinical Neuroscience, Queen's Medical Center School of Medicine, the University of Nottingham, Nottingham NG7 2UH, UK
| | - Da Zhou
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- 3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,5Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | - Xunming Ji
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Meng
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
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Blatteau JE, Morin J, Roffi R, Druelle A, Sbardella F, Castagna O. Clinical problem solving: Mental confusion and hypoxaemia after scuba diving. Diving Hyperb Med 2020; 50:181-184. [PMID: 32557423 DOI: 10.28920/dhm50.2.181-184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/29/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION We report a case of a diving accident associating both cerebral symptoms and signs of respiratory impairment after two dives. The objective is to describe the process for obtaining the diagnosis. CASE REPORT A 52-year-old man experienced mental confusion associated with hypoxaemia after surfacing. All decompression procedures were fully respected. The diver had a spatio-temporal disorientation accompanied by a marked tendency to fall asleep spontaneously. He had no dyspnoea and no cough, but crepitations at both lung bases were found with oxygen saturation at 80%. CONCLUSIONS In this clinical case, cerebral magnetic resonance imaging and chest computed tomography scan helped to exclude other pathology that would have necessitated urgent transfer rather than urgent hyperbaric treatment. The imaging is particularly useful in case of cerebral and respiratory symptoms following scuba diving.
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Affiliation(s)
- Jean-Eric Blatteau
- Department of Diving and Hyperbaric Medicine, Sainte-Anne Military Hospital, Toulon, France.,Corresponding author: Professor Jean-Eric Blatteau, Service de Médecine Hyperbare et d'Expertise Plongée (SMHEP), Hôpital d'Instruction des Armées (HIA) Sainte-Anne, BP 600, 83800 Toulon cedex 9, France,
| | - Jean Morin
- Department of Diving and Hyperbaric Medicine, Sainte-Anne Military Hospital, Toulon, France
| | - Romain Roffi
- Department of Diving and Hyperbaric Medicine, Sainte-Anne Military Hospital, Toulon, France
| | - Arnaud Druelle
- Department of Diving and Hyperbaric Medicine, Sainte-Anne Military Hospital, Toulon, France
| | - Fabrice Sbardella
- Department of Radiology, Sainte-Anne Military hospital, Toulon, France
| | - Olivier Castagna
- Military Institute of Biomedical Research (ERRSO), Toulon, France
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Hartig F, Reider N, Sojer M, Hammer A, Ploner T, Muth CM, Tilg H, Köhler A. Livedo Racemosa - The Pathophysiology of Decompression-Associated Cutis Marmorata and Right/Left Shunt. Front Physiol 2020; 11:994. [PMID: 33013436 PMCID: PMC7497564 DOI: 10.3389/fphys.2020.00994] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/22/2020] [Indexed: 11/13/2022] Open
Abstract
Decompression sickness and arterial gas embolism, collectively known as decompression illness (DCI), are serious medical conditions that can result from compressed gas diving. DCI can present with a wide range of physiologic and neurologic symptoms. In diving medicine, skin manifestations are usually described in general as cutis marmorata (CM). Mainly in the Anglo-American literature the terms cutis marmorata, livedo reticularis (LR), and livedo racemosa (LRC) are used interchangeably but actually describe pathophysiologically different phenomena. CM is a synonym for LR, which is a physiological and benign, livid circular discoloration with a net-like, symmetric, reversible, and uniform pattern. The decompression-associated skin discolorations, however, correspond to the pathological, irregular, broken netlike pattern of LRC. Unlike in diving medicine, in clinical medicine/dermatology the pathology of livedo racemosa is well described as a thrombotic/embolic occlusion of arteries. This concept of arterial occlusion suggests that the decompression-associated livedo racemosa may be also caused by arterial gas embolism. Recent studies have shown a high correlation of cardiac right/left (R/L) shunts with arterial gas embolism and skin bends in divers with unexplained DCI. To further investigate this hypothesis, a retrospective analysis was undertaken in a population of Austrian, Swiss, and German divers. The R/L shunt screening results of 18 divers who suffered from an unexplained decompression illness (DCI) and presented with livedo racemosa were retrospectively analyzed. All of the divers were diagnosed with a R/L shunt, 83% with a cardiac shunt [patent foramen ovale (PFO)/atrium septum defect (ASD)], and 17% with a non-cardiac shunt. We therefore not only confirm this hypothesis but when using appropriate echocardiographic techniques even found a 100% match between skin lesions and R/L shunt. In conclusion, in diving medicine the term cutis marmorata/livedo reticularis is used incorrectly for describing the actual pathology of livedo racemosa. Moreover, this pathology could be a good explanation for the high correlation of livedo racemosa with cardiac and non-cardiac right/left shunts in divers without omission of decompression procedures.
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Affiliation(s)
- Frank Hartig
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | - Norbert Reider
- Department of Dermatology, University Clinic Innsbruck, Innsbruck, Austria
| | - Martin Sojer
- Department of Neurology, University Clinic Innsbruck, Innsbruck, Austria
| | - Alexander Hammer
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | - Thomas Ploner
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | | | - Herbert Tilg
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
| | - Andrea Köhler
- Department of Internal Medicine, University Clinic Innsbruck, Innsbruck, Austria
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Yanagawa Y, Omori K, Takeuchi I, Jitsuiki K, Ohsaka H, Ishikawa K. The on-site differential diagnosis of decompression sickness from endogenous cerebral ischaemia in an elderly Ama diver using ultrasound. Diving Hyperb Med 2019; 48:262-263. [PMID: 30517960 DOI: 10.28920/dhm48.4.262-263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 11/07/2018] [Indexed: 11/05/2022]
Abstract
Commercial or occupational breath-hold (BH) harvest divers along the coast and islands of Japan are collectively called Ama divers. Repetitive BH diving by Ama divers may place them at risk of developing neurological decompression sickness (DCS). We report a 74-year-old Ama diver who demonstrated right hemiparesis during an ascent after free diving at a depth of 5 metres' sea water. This report suggests the usefulness of on-site ultrasound for making a differential diagnosis of DCS from endogenous cerebral ischaemia. Further clinical studies of this management approach are warranted.
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Affiliation(s)
- Youichi Yanagawa
- Department of Acute Critical Care Medicine, Juntendo Shizuoka Hospital, Izunokuni City, Shizuoka Prefecture, Japan.,Corresponding author: 1129 Nagaoka, Izunokuni City, Shizuoka, Japan 410-2295,
| | - Kazuhiko Omori
- Department of Acute Critical Care Medicine, Juntendo Shizuoka Hospital, Izunokuni City, Shizuoka Prefecture, Japan
| | - Ikuto Takeuchi
- Department of Acute Critical Care Medicine, Juntendo Shizuoka Hospital, Izunokuni City, Shizuoka Prefecture, Japan
| | - Kei Jitsuiki
- Department of Acute Critical Care Medicine, Juntendo Shizuoka Hospital, Izunokuni City, Shizuoka Prefecture, Japan
| | - Hiromichi Ohsaka
- Department of Acute Critical Care Medicine, Juntendo Shizuoka Hospital, Izunokuni City, Shizuoka Prefecture, Japan
| | - Kouhei Ishikawa
- Department of Acute Critical Care Medicine, Juntendo Shizuoka Hospital, Izunokuni City, Shizuoka Prefecture, Japan
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