Neurologic complications of sit-ups associated with the Valsalva maneuver: 2 case reports

Henle fibre layer haemorrhage: clinical features and pathogenesis

BACKGROUND

To describe the clinical presentation and characteristic imaging features of deep retinal haemorrhages primarily located in the Henle fibre layer (HFL) of the macula. The spectrum of aetiologies and a comprehensive theory of pathogenesis are presented.

METHODS

This is a retrospective, multicentre case series evaluating eyes with retinal haemorrhage in HFL. Clinical features, underlying aetiology, systemic and ocular risk factors, visual acuity, and multimodal imaging including fundus photography and cross-sectional and en face optical coherence tomography (OCT) are presented.

RESULTS

Retinal haemorrhages localised to HFL in 33 eyes from 23 patients were secondary to acute blunt trauma to the head (n=2), eye (n=1) and trunk (n=1), ruptured intracranial aneurysm (Terson's syndrome, n=3), general anaesthesia (n=1), epidural anaesthesia (n=1), hypertension with anaemia (n=1), decompression retinopathy (n=1), postvitrectomy with intraocular gas (n=1), retinal vein occlusion (n=7), myopic degeneration (n=2), macular telangiectasia type 2 (n=1), and polypoidal choroidal vasculopathy (n=1). Defining clinical features included deep retinal haemorrhage with feathery margin and petaloid pattern radiating from the fovea. OCT demonstrated characteristic hyper-reflectivity from the haemorrhage delineated by obliquely oriented fibres in the Henle layer. Spontaneous resolution of HFL haemorrhage occurred after 3 months in 15 patients with follow-up.

CONCLUSION

The characteristic petaloid-shaped, deep intraretinal haemorrhage with a feathery margin localised to HFL is associated with various disorders. The terminology 'Henle fiber layer hemorrhage (HH)' is proposed to describe the clinical and OCT findings, which may result from abnormal retinal venous pressure from systemic or local retinovascular disorders affecting the deep capillary plexus or from choroidal vascular abnormalities.

Intraoperative Valsalva maneuver: a narrative review

The Valsalva maneuver (VM) involves expiratory effort against a closed mouth and/or glottis in the sitting or supine position with the increased intraoral and intrathoracic pressure raised to 40 mmHg for 15-20 sec after which the pressure is suddenly released and the breathing restored to normal. Complex cardiovascular and other physiologic changes occur during the VM. The VM has been used for diagnostic and therapeutic reasons as well as intraoperatively during specific surgical procedures. Although the VM is usually safe, rare complications have been reported. This review examines the published literature surrounding the VM and explores the physiologic changes that occur during its performance. Attempts have been made to understand its intraoperative uses and complications and how these can be prevented.

Spontaneous cervical epidural hematoma presenting as brown-sequard syndrome following repetitive korean traditional deep bows

Spontaneous cervical epidural hematoma (SCEH) is an uncommon cause of acute nontraumatic myelopathy. SCEH presenting as Brown-Sequard syndrome is extremely rare. A 65-year-old man had motor weakness in the left extremities right after his mother's funeral. He received thrombolytic therapy under the impression of acute cerebral infarction at a local hospital. However, motor weakness of the left extremities became aggravated without mental change. After being transferred to our hospital, he showed motor weakness in the left extremities with diminished pain sensation in the right extremities. Diagnosis of SCEH was made by cervical magnetic resonance imaging. He underwent left C3 to C5 hemilaminectomy with hematoma removal. It is important for physicians to be aware that SCEH can be considered as one of the differential diagnoses of hemiplegia, since early diagnosis and management can influence the neurological outcome. We think that increased venous pressure owing to repetitive Korean traditional deep bows may be the cause of SCEH in this case.

Spinal epidural hematoma after stretch exercise: a case report

Spinal epidural hematoma (SEH) is a rare but serious condition. Common causes of SEH include spinal fracture, spinal trauma, and invasive spinal procedures such as lumbar puncture, epidural anesthesia, or myelography. A few previous reports have suggested that SEH could be caused by minor triggers such as spinal manipulation therapy or spontaneously in rare cases. A 60-year-old man, immediately after stretch exercise, developed severe back cervicodynia and rapidly progressive weakness of left arm from SEH. He was treated by decompression laminectomy and evacuation of the hematoma. However, the upper extremity weakness did not completely resolve. The standard treatment remains timely surgical decompression and evacuation of the hematoma. Thus, early diagnosis and treatment can confer a significant prognostic advantage to patients with SEH. Based on the finding that SEH was caused by a mild mechanical trigger and neurologic deficits remained in this patient, this report highlights its diagnostic difficulty as well as the importance of rapid treatment. Emergency physicians should consider SEH among the differential diagnosis in patients with sudden-onset back pain with symptoms and signs of spinal cord compression.

Intraperitoneal rupture of mature cystic ovarian teratoma secondary to sit-ups

A case of general peritonitis caused by sudden perforation of a mature cystic ovarian teratoma is presented. The clinical course consisted of progressive abdominal tenderness after a 1600-m run and 12 subsequent sit-ups. An exploratory laparotomy revealed massive ascites and a 10-cm linear perforation over the dome of the tumor, probably caused by a sharp elevation of intra-abdominal pressure generated during the sit-ups. Neither peritoneal granulomatous reaction nor inflammatory adhesions to adjacent bowel loops were found. A search of the English literature did not reveal any similar case.

Bilateral Subdural Hematomas in an Adult With Hereditary Factor VII Deficiency: A Complication of Sit-ups and Inversion?

A 57-year-old man of northern Italian and Polish descent with a late-onset, mild form of hereditary factor VII deficiency developed bilateral intracranial subdural hematomas after performing sit-ups while he was in a head-down position on an inversion table. The pertinence of the Valsalva maneuver and increased intracranial venous and intraocular pressure associated with sit-ups and other exercises in the causation of subdural hematomas and other types of intracranial and ocular hemorrhage are discussed in this study.

Clopidogrel-induced spontaneous spinal epidural hematoma

The hemorrhagic side effects associated with the use of clopidogrel are within the acceptable range and occur mainly at skin or gastrointestinal sites. We report a case of spontaneous spinal epidural hematoma (SSEH) in a 60-yr-old woman who was treated with clopidogrel for frequent transient ischemic attacks. To our knowledge, this is the second reported case of clopidogrel-induced SSEH. The patient's symptoms and past history of clopidogrel use suggested the diagnosis and made the procedure proceed quickly to operate SSEH 9 hr after the onset of paraplegia. The outcome was excellent. Therefore, with the popularity of antiplatelet prescription, physicians should keep in mind and urgently treat this unusual but critical side effect.

Spinal cord injury in a 14-year-old male secondary to cervical hyperflexion with exercise

STUDY DESIGN

Case report.

OBJECTIVES

To present an interesting case of a 14-year-old male with acute paresis of upper extremities and progressive difficulty with lower extremities. The patient is a competitive wrestler and was performing his daily abdominal workout 'sit-ups' with hands interlocked behind his head. During the end and immediately following his abdominal workout, he felt progressive weakness in his upper extremities. He was rushed to the hospital within an hour and seen in the emergency room and admitted to the neurology service for a presumed thromboembolic event.

SETTING

New York, USA.

RESULTS

The patient was negative for any hematologic disease or coagulopathy. Magnetic resonance imaging was negative for any mass effect on the spinal cord and neurological examination revealed bilateral upper extremity paraparesis 3/5 and lower extremity spasticity and propioceptive dysfunction. The patient was treated with corticosteroids and rigid collar, follow-up examination at 3 months revealed resolution of symptoms.

DISCUSSION/CONCLUSION

The pathophysiology of central cord syndrome is thought to be primarily secondary to a hyperextension injury, which causes buckling of the ligamentum flavum and increasing spinal cord diameter which leads to cord compression. This syndrome is more commonly seen in the spondylotic elderly. This case involves a teenager with normal canal diameter; however, combining aggressive exercise with extreme cervical hyperflexion, one can plausibly account for an acute ischemic event or repetitive microinjury to the spinal cord.

Spontaneous spinal epidural hematoma: A case report

A 59-year-old man presented to the emergency department (ED) the day after a minor motor vehicle crash for evaluation of bilateral shoulder pain. He underwent ED evaluation for his back pain two more times before it was found that he had a spontaneous spinal epidural hematoma (SSEH). On the third visit, the patient had waxing and waning neurologic symptoms including lower extremity weakness and urinary retention. The diagnosis was made by MRI, and the patient was successfully treated with cervical hemilaminectomy at the cervicothoracic junction for evacuation of the epidural hematoma 5 days after the onset of back pain.

Acute hemodynamic effects of abdominal exercise with and without breath holding

OBJECTIVES

To compare the magnitudes of change in heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure, and rate-pressure product (RPP) during 3 abdominal exercises: straight partial sit-up (SPSU), oblique partial sit-up (OPSU), and the AbSculptor(R) sit-up; and to examine the effect of breath holding on these parameters.

DESIGN

Prospective, repeated measures.

SETTING

Autonomic research laboratory in a major medical center.

PARTICIPANTS

Fourteen normal male and female volunteers (age range, 24-37y; mean, 30.4y).

INTERVENTIONS

Hemodynamic parameters were recorded during each abdominal exercise performed with and without breath holding. Mean peak values were calculated for 1 minute before exercise, during exercise, and for 10 minutes after exercise.

MAIN OUTCOME MEASURES

Statistical analysis examined for differences in the hemodynamic changes among the 3 exercises under both conditions (with and without breath holding).

RESULTS

Heart rate, SBP, DBP, mean blood pressure, and RPP increased during all 3 exercises. The mean peak heart rate and RPP increases were greater for the OPSU than the AbSculptor (heart-rate increase, 21.1+/-6.6bpm vs 17.6+/-5.7bpm, P=.03; RPP increase, 36.9+/-15.5bpm.mmHg vs 29.4+/-10.1bpm.mmHg, P=.05). For all 3 exercises, breath holding significantly increased the hemodynamic parameter elevations during exercise, with the exception of heart rate (SBP, P<.001; DBP, P<.001; mean blood pressure, P<.001; RPP, P=.02). Quantitatively, breath holding during the OPSU resulted in the largest exercise-associated increases in heart rate (21.0+/-8.1bpm), mean blood pressure (22.2+/-16.4mmHg), and RPP (44.9+/-22.3bpm.mmHg). Postexercise, all hemodynamic parameters generally returned to baseline within several minutes.

CONCLUSION

When performing the OPSU, SPSU, or the AbSculptor exercises as used in this investigation, normal individuals exercising at low intensities may experience peak heart rate and mean blood pressure increases of 30bpm and 50mmHg, respectively. Voluntary breath holding significantly increased the peak blood pressure elevations and RPP for all 3 exercises, but particularly for the OPSU.