Formation of a Large Fusiform Aneurysm near a Medullary Infarction Caused by Dissection of the Posterior Inferior Cerebellar Artery

Infarction of the posterior inferior cerebellar artery (PICA) can lead to ischemic stroke in the lateral medullary oblongata. PICA dissection can also elicit an ischemic event in this region, but its detection on radiological images is difficult because of the small diameter of the vessel. We report a case of Wallenberg syndrome due to PICA dissection in a 48-year-old man, which was difficult to diagnose on first admission. He reported sudden onset of sensory disturbance on the right side of his face, ataxic gait, and headache. Brain magnetic resonance imaging (MRI) revealed a fresh cerebral infarct in the right lateral medulla oblongata. Magnetic resonance angiography (MRA) performed at the time of his admission showed no cerebral vessel abnormalities. An MRI study 18 months after the event revealed a fusiform aneurysm on the lateral medullary segment of the PICA, which was extremely close to the cerebral infarct. We concluded that the infarct was due to PICA dissection because of the sudden onset of symptoms and because the infarcted territory of the occluded penetrating branch of the dissecting aneurysm was consistent with Wallenberg syndrome. The aneurysm was trapped and an occipital artery-PICA bypass was placed. At the latest follow-up, 1 year after the procedure, he had no neurological symptoms. Imaging findings at the time of his first admission indicated that the PICA was intact. However, 18 months later, MRI revealed enlargement of an aneurysm at the site of the dissection. A cerebral infarct with headache may indicate PICA dissection.

Experience Using Gentian Violet-Free Dyes for Tissue Visualization

BACKGROUND

 Gentian violet ink is used as a skin marker in various surgical procedures, including neurosurgery. The dye is also used to visualize the edges of blood vessels during bypass surgery. However, gentian violet ink carries the risks of carcinogenicity and venous injury, which causes microvascular thrombosis. In this study, we compare the gentian violet-free dye C.I. Basic Violet 4 (BV4) and gentian violet. The usefulness, in terms of color, and formation of microvascular thrombosis in anastomosis were compared.

METHODS

 We used the gentian violet-free dye in 20 cases involving 3 vascular anastomoses. The bone cutting lines on the bone surface, superior temporal artery, and middle cerebral artery were drawn using BV4 and gentian violet ink.

RESULTS

 The colors of BV4 and gentian violet ink were similar. No thrombus formation was observed at the vascular anastomosis when using BV4.

CONCLUSION

 BV4 can be used similarly to gentian violet ink. No adverse effects such as thrombus formation in microvascular anastomosis were experienced when BV4 was used.

Evaluation of Ethyl Violet as an Alternative Dye to Crystal Violet to Visualize the Vessel Wall during Vascular Anastomosis

Crystal violet (CV) ink has been used as a skin marker worldwide. It has been reported to be useful for vessel wall visualization of microvascular anastomoses. Contrastingly, it has been found to be carcinogenic and inhibit migration and proliferation of venous cells. In some countries, its use in the medical field has been restricted. Therefore, it is necessary to consider alternatives to CV. In this present study, we compared the time required for the anastomosis of a 0.8-1 mm diameter vessel in the chicken wrist artery using CV and a CV-free dye (ethyl violet; EV). The surgeon, microscope, and anastomosis microsurgical tools were standardized for comparison. CV and EV were changed for each anastomosis. The same surgeon performed 30 anastomoses using each dye. No visually obvious differences were noted in the vascular transections with CV and EV. As per the results, no statistically significant difference was observed in the time required for anastomosis using CV and EV. EV conforming to California Proposition 65 may be an effective alternative to CV for vascular visualization of microvascular anastomoses. However, further studies on the effectiveness of the EV in clinical cases are needed.

Pneumomediastinum and Subcutaneous Emphysema after High Pressure Air and Sand Injection Injury to the Upper Arm

We present a rare case of a 47-year-old man who developed pneumomediastinum and subcutaneous emphysema after a high pressure hose accidentally injected air and sand particles into his right upper arm. On presentation, he complained of dyspnoea and chest pain. He had palpable subcutaneous emphysema extending from the upper arm to his neck, face, and trunk. Plain X-ray films and computed tomography showed pneumomediastinum and subcutaneous emphysema, but no sand particles. Conservative treatment was done with close observation, and serial radiographs were obtained. There was complete resolution of the mediastinal and subcutaneous air after about two weeks with no evidence of infection. This was an extremely rare case of pneumomediastinum and severe subcutaneous emphysema occurring after accidental air injection injury to the upper arm. With regard to how air entered the mediastinal cavity, possible pathways are discussed. (Hong Kong j.emerg.med. 2014;21:51-54)

Usefulness and Problems of Intraosseous Infusion with the Bone Injection Gun™ Using Simulators Under Confined Space Conditions

Introduction

It is important to have a venous line for infusion as an emergency treatment for patients suffering from crush syndrome or bleeding under confined space (CS) conditions in disaster medicine. However, it is not easy to for Emergency Life-Saving Technicians (ELSTs) to establish a venous line in such settings. Although previous studies have described the use of mechanical intraosseous (IO) devices and IO access while wearing chemical protection gears, problems for the use of IO devices under CS conditions have not been considered. This study aimed to investigate usefulness and problems of using a Bone Injection Gun™ (BIG) for IO infusion by ELSTs and rescue workers in CS conditions.

Methods

The time required and success rate for IO infusion using a BIG in a manikin leg were measured, and for administering intravenous infusion in a manikin arm using either rescue gloves or plastic gloves by ELSTs or rescue workers under CS conditions.

Results

Wearing rescue gloves, ELSTs were significantly faster in placing intraosseous infusion (IOI) compared with rescue workers. The success rate of the placement was not significantly different between ELSTs and rescue workers whether or not they wore rescue or plastic gloves.

Conclusions

Although the finite usefulness of IOI with BIG under CS conditions is indicated, some problems such as the timing of removal of the IOI and difficulty in finding the location of the trocar needle after activating BIG are pointed out. Therefore, there are rooms to consider using IOI with BIG under CS condition. (Hong Kong j.emerg. med. 2014;21:23-30)

Cardiopulmonary haemodynamic changes after severe head injury

Haemodynamic studies were performed by pulmonary artery catheter in 15 patients with severe head injury. To our knowledge, few data are available about the detailed haemodynamic changes after head injury using pulmonary artery catheter. All patients were assessed by the Glasgow Coma Scale, computed tomography and intracranial pressure monitoring. We divided the patients into hypotensive and normotensive groups. All patients showed a high pulmonary vascular resistance and a high pulmonary capillary wedge pressure, probably due to pulmonary vasoconstriction. In the hypotensive group, the two major changes were a marked decrease of the cardiac index and a slight increase of systemic vascular resistance. The low cardiac index was the result of heart failure secondary to myocardial dysfunction. In contrast, the normotensive group was characterized by a high systemic vascular resistance that was induced by generalized vasoconstriction. Increased intracranial pressure is initially associated with an increase of the cardiac index and systemic vascular resistance, so patients with severe head injury also suffer from profound circulatory disturbance.

Intracisternal neurinoma of the C1 posterior root

We report a rare intracisternal C1 posterior root neurinoma in a 35-year-old man without neurofibromatosis who presented with headache, nuchal pain, bilateral motor weakness of the upper extremities, and numbness in the right distal upper extremity. CT and MRI study showed a 20-mm intracisternal lesion at the foramen magnum. At surgery, there was an anastomosis between the C1 posterior root and a spinal accessory nerve at the site of the tumor; the root from the collateral sulcus of this C1 root was absent. Postoperatively, the patient remains free of symptoms. Foramen magnum neurinomas have been described as accessory nerve tumors. We present new anatomical consideration regarding this lesion.

Therapeutic effects of milnacipran, a serotonin and noradrenaline reuptake inhibitor, on post-stroke depression

Depression is common after stroke. While several reports have been published on the use of antidepressants such as selective serotonin reuptake inhibitors and tricyclics for the treatment of post-stroke depression (PSD), no previous study has examined the use of a selective serotonin and noradrenaline reuptake inhibitor (SNRI) for this condition. The present study investigated the efficacy and safety of milnacipran, a SNRI, for the treatment of PSD. A 6-week open study was conducted in 12 patients (two males and 10 females) aged 53-88 years. All patients were diagnosed with major or minor depressive disorder according to DSM-IV, where onset was subsequent to a cerebral infarction or haemorrhage (stroke). Severity of depression was assessed using the 21-item Hamilton rating scale for depression (HAM-D). The maximum total daily dose of milnacipran was in the range of 30-75 mg b.i.d. Three patients experienced side-effects, but none of the side-effects were serious. Two patients dropped out of the study. At the end of the study, 58.3% (7/12) of the total patient population and 70% (7/10) of the patients completing the study were in remission (a final HAM-D score of less than 7 and no longer meeting criteria for major or minor depression). These results suggest that milnacipran may be an effective treatment for PSD.

Three-dimensional CT angiography of intracranial vasospasm following subarachnoid haemorrhage

We evaluated the usefulness of three-dimensional CT angiography (3D-CTA) in the diagnosis of intracranial vasospasm following subarachnoid haemorrhage (SAH) in 13 patients suspected of having vasospasm on clinical grounds. The intracranial vessels were clearly shown by 3D-CTA in 12 patients. 3D-CTA revealed spasm in the vessels of nine patients. Catheter angiography performed in seven of these patients immediately after 3D-CTA confirmed vasospasm. A low-attenuation area was seen on CT in the other two patients, representing an ischaemic lesion due to the spasm. In nine patients, a second 3D-CTA was performed using the same technique 1 week after the first, showing no vasospasm. Initial 3D-CTA revealed no vasospasm change in three patients. Following 3D-CTA, one of these had conventional angiography, which also demonstrated no spasm.

[Changes of arterial ketone body ratio (AKBR) in patients with intracerebral hemorrhage]

The arterial ketone body ratio (AKBR) is considered to be an accurate index of the functional reserve of the liver, and the validity of this idea has been confirmed in the field of abdominal surgery. We found low AKBR value intracerebral hemorrhage patients and discussed the clinical significance of this finding in this paper. Twenty-five patients with intracerebral hemorrhage treated at our institution were included in this study. Their ages ranged from 42 to 86 years old (average 68.5 years). There were 13 cases of putaminal hemorrhage and 12 cases of thalamic hemorrhage. Evacuation of the hematoma or ventricle drainage was performed in 20 of these cases within 3 days after symptoms of intracerebral hemorrhage appeared. There were 12 cases with intraventricular hemorrhage. The outcome of these patients was as follows; 17 cases survived, eight cases died. We collected blood samples on days 1, 2, 3, 7 and 10 after the onset of symptoms (day 0) and measured the following: 1, beta-hydroxybutyrate; 2, acetoacetate; 3, epinephrine; 4, norepinephrine. On day 0 total ketone body levels were higher (246.3 +/- 231.7 mumol/l), AKBR values (0.60 +/- 0.18) were significantly lower than in the control group (2.05 +/- 1.35) (p < 0.001). However, both epinephrine and norepinephrine levels were significantly higher, 638.4 +/- 229.0 pg/ml and 1036.5 +/- 288.2 pg/ml, respectively. The AKBR value was 0.76 +/- 0.19 on day 1, 1.04 +/- 0.30 on day 2, and increased thereafter. In addition, the relation between sequential changes of AKBR in patients with intraventricular hemorrhage and outcome were also discussed. AKBR values are known to decrease not only in cases of hepatic failure, but in cases in which the liver energy charge is reduced, such as shock and hypoxemia, but no investigations have ever been performed to determine whether AKBR is altered in cerebrovascular disease. In this study, we found that AKBR values were lower in intracerebral hemorrhage, presumably due to reduced hepatic blood flow causes by increased levels of epinephrine and norepinephrine. In addition, our findings suggest that the fluctuations in AKBR values correlated with the outcome of intracerebral hemorrhage patients.

[Postoperative three-dimensional CT angiography (3D-CTA) in evaluation of proximal clipping for ruptured vertebral aneurysms]

At present, intra-arterial angiography remains the gold standard for most cerebrovascular problems. Recently, three-dimensional computed tomographic angiography (3D-CTA) has been reported as a screening method for the diagnosis of cerebrovascular disease. This imaging modality uses the information obtained on a contrast-enhanced CT scan to generate three-dimensional images of the cerebrovascular system. We performed 3D-CTA in the preoperative and postoperative evaluation of patients undergoing proximal clipping of ruptured vertebral artery aneurysms in addition to conventional cerebral angiography. In this study, the value of 3D-CTA after proximal clipping of ruptured vertebral artery aneurysm was evaluated retrospectively. Six patients were examined with a spinal CT (HITACHI CT-W 3000) after intravenous bolus injection of 100 ml contrast material (Iohexhol 300 mgI/ml) at the rate of 2 ml/s with a 25 second pre-scanning delay. The images of 3D-CTA were reconstructed using a new 3D-volume-render (Voxel Transmission) technique. The ages of the six patients ranged from 33 to 61 years and five cases were males and one case was female. Only one patient had a saccular aneurysm and the other five had fusiform aneurysms. Two patients underwent emergency operations within 4 days, and the other four had delayed operations. The outcome was good recovery in five cases and severe disability in one case. Postoperative conventional cerebral angiography demonstrated no delineation of the aneurysms in five cases. These results correspond well to postoperative 3D-CTA. Postoperative conventional cerebral angiography could not be performed in only one patient, but the aneurysm was visualized on the third postoperative 3D-CTA. Proximal clipping is still one of the therapeutic options for ruptured vertebral aneurysms, but some reports emphasized the possibility of rebleeding after proximal clipping of vertebral artery aneurysms. The rebleeding occurred within 1 week after proximal clipping in 6 of 9 cases (66.7%), and the prognoses were extremely poor. Therefore, in patients selected for proximal clipping, it is necessary to undertake postoperative evaluation of the aneurysm within one week after proximal clipping. 3D-CTA is minimally invasive and can be easily performed repeatedly, even if the patients are in a poor condition. In conclusion, 3D-CTA is very useful especially for evaluation of ruptured vertebral artery aneurysms following proximal clipping.

[Evaluation of three-dimensional CT angiography (3D-CTA) for the diagnosis of cerebral vasospasm]

We evaluated the usefulness of three-dimensional CT angiography (3D-CTA) for the diagnosis of cerebral vasospasm following subarachnoid hemorrhage (SAH). Eleven patients with SAH who were suspected of having cerebral vasospasm on the basis of their clinical symptoms were examined by 3D-CTA with a spiral CT scanner after an intravenous bolus administration of contrast medium. 3D-CTA revealed vasospastic changes of the cerebral vessels in eight patients. Conventional angiography was performed in six patients immediately after the 3D-CTA examination, and demonstrated the cerebral vasospasm. In eight patients, a second 3D-CTA was performed with the same technique one week after the first 3D-CTA examination. The second 3D-CTA showed the cerebral vessels without vasospastic change. In conclusion, 3D-CTA is a promising, minimally invasive strategy for the assessment of cerebral vasospasm.

[Changes in arterial ketone body ratio (AKBR) in subarachnoid hemorrhage patients]

The arterial ketone body ratio (AKBR) is considered an accurate index of the functional reserve of the liver, and its validity has been confirmed in the field of abdominal surgery. We found low AKBR values subarachnoid hemorrhage patients and discuss the clinical significance of this finding in this paper. Twenty-eight patients with subarachnoid hemorrhage treated at our institution were included in this study. Their ages ranged from 26 to 81 years old (average: 61.5 years). According to the WFNS classification 12 cases were grade I, II, or III, and 16 were grade or IV V. Surgical clipping was performed in 23 of these cases, within 2 days after symptoms of subarachnoid hemorrhage appeared. There were eight cases of symptomatic vasospasm and three cases of re-ruptured aneurysm. Outcome was classified according to the Glasgow Outcome Scale (GOS) as: good recovery (GR), moderately disabled (MD), severely disabled (SD), vegitative survival (VS), and dead (D). Using these criteria, the outcome of these patients was as follows: GR or MD in 10 cases, SD or VS in 8 case, and D in 10 cases. Ten healthy adults were chosen as controls. We collected arterial blood samples on days 1, 2, 3, 7, 10 and 14 after the onset of symptoms (day 0) and measured the following: 1, beta-hydroxybutyrate; 2, acetoacetate; 3, epinephrine; and 4, norepinephrine. On day 0 total ketone body levels were higher (165.6 +/- 119.9 mumol/l), and AKBR values (0.65 +/- 0.24) were significantly lower than in the control group (2.50 +/- 1.09) (p < 0.001), while both epinephrine and norepinephrine levels were significantly higher, 506.5 +/- 200.3 pg/ml and 899.5 +/- 221.4 pg/ml, respectively. The AKBR value was 0.90 +/- 0.27 on day 1, 1.11 +/- 0.4 0 on day 2, and increased thereafter. The average AKBR value exceeded 1.0 on day 2 in the ten GR and MD cases. In the SD and PVS cases, however, it exceeded 1.0 on day 3, but in the D patients it never exceeded 1.0 and instead was significantly lower. AKBR values are known to decrease not only in hepatic failure, but in cases in which the liver energy charge is reduced, such as shock and hypoxemia, but no investigations have ever been performed to determine whether AKBR is altered in cerebrovascular disease. In this study, we found that AKBR values were lower in subarachnoid hemorrhage, presumably due to the reduced hepatic blood flow caused by the increased levels of epinephrine and norepinephrine. In addition, our findings suggested that the fluctuations in AKBR values were correlated with the outcome of subarachnoid hemorrhage patients.

[Anterior pituitary functions in patients with severe head injuries treated with moderate hypothermia]

Eleven patients with severe head injuries were treated by artificial moderate hypothermia (32.0-33.0 degrees C). Measurement of the serum levels of anterior pituitary hormones (LH, FSH, TSH, and PRL) and the response of these hormones to the respective releasing hormones was done in the 11 patients before and during hypothermia. All 11 patients were under GCS 5. Those with brain death during hypothermia were excluded. Moderate hypothermia was performed for 3-7 days and involved cooling to 32.0-33.0 degrees C (Jugular venous blood temperature). The peak value of LH, FSH, TSH and PRL to administration of TRH or LH-RH during hypothermia were significantly lower than those before hypothermia, while basal values of those hormones were not affected by this treatment. These findings suggested that anterior pituitary function were suppressed by moderate hypothermia.

Arteriovenous malformation associated with moyamoya disease: case report

A rare case of arteriovenous malformation associated with moyamoya disease is reported. In this case, an interesting angiographic change was obtained during the follow-up period. The feeding artery from the internal carotid artery gradually disappeared as the moyamoya disease progressed, and a new feeding artery appeared from the external carotid artery.

Effect of U74006F on neurologic function and brain edema after fluid percussion injury in rats

The effect of the 21-aminosteroid U74006F, an inhibitor of iron-dependent lipid peroxidation, on neurologic outcome and cerebral edema was evaluated in adult male Sprague-Dawley rats subjected to a fluid percussion temporal brain injury followed by 45 min of hypoxia (PaO2 = 30.0 mm Hg). The rats were divided randomly into five groups. Bolus injections of a control drug or U74006F (1.0, 3.0, 10.0, or 30.0 mg/kg) were given 3 min and 3 h after the injury. Twenty-four hours after the injury, the neurologic status was evaluated, the rats were killed, and brain water content was determined by microgravimetry. U74006F did not significantly reduce brain water content at any dose level, nor did it affect rotorod walking or activity scores. However, rats treated with U74006F at a dose of 10.0 mg/kg had significantly better motor function scores (p < 0.05) than rats in the control group. These findings demonstrate the usefulness of U74006F as a cerebroprotective agent in this model of experimental head injury.

Evaluation of 2,3,5-triphenyltetrazolium chloride staining to delineate rat brain infarcts

BACKGROUND AND PURPOSE

Accurate and reproducible determination of the size and location of cerebral infarcts is critical for the evaluation of experimental focal cerebral ischemia. The purpose of this study was to compare intracardiac perfusion of 2,3,5-triphenyltetrazolium chloride with immersion of brain tissue in 2,3,5-triphenyltetrazolium chloride to delineate brain infarcts in rats.

METHODS

After 6, 24, or 48 hours of ischemia induced by permanent middle cerebral artery occlusion, some rats were perfused with 2,3,5-triphenyltetrazolium chloride; other rats were given an overdose of barbiturates, after which brain sections were immersed in 2,3,5-triphenyltetrazolium chloride. Coronal sections were taken 4, 6, and 8 mm from the frontal pole, and infarct areas in perfused and immersed sections were compared; subsequently, the same sections were stained with hematoxylin and eosin.

RESULTS

In rats subjected to 24 or 48 hours of occlusion, areas of infarction were clearly defined with both 2,3,5-triphenyltetrazolium chloride staining techniques, and the infarct sizes correlated well with the results of hematoxylin and eosin staining (r = 0.85-0.94).

CONCLUSIONS

These results demonstrate that intracardiac perfusion of 2,3,5-triphenyltetrazolium chloride is an accurate, inexpensive, and efficient staining method to detect infarcted tissue 24 and 48 hours after the onset of ischemia in rats.

[Clinical value of bedside ultrasonography in craniectomized patients]

Twenty-five patients underwent bedside ultrasonographic examination through a postoperative skull defect, and the images were compared with axial computed tomography (CT) scans. The patients included 12 with cerebrovascular disease, two with brain tumor, one with a brain abscess, and 10 with head injury. Clear ultrasonographic images were obtained in all patients except one who had undergone a suboccipital craniectomy. Ultrasound was most useful when hydrocephalus was present, in which cases, regardless of the cause, hypo-echoic dilated third and lateral ventricles were demonstrated. In one case, it was decided to emplace a ventriculoperitoneal shunt on the basis of the results of serial sonography, which documented ventricular enlargement. Intracerebral hematomas also were identified by ultrasonography. Acute hematomas, such as subarachnoid blood clots persisting after clipping of an aneurysm, appeared as hyper-echoic images, whereas, late hematomas were depicted as hypo-echoic images. In one case, a recurrent brain tumor was depicted as a hyper-echoic mass. In multiple-trauma patients with head injury who were too unstable to be moved for CT scanning, ultrasound was extremely useful. So-called "delayed traumatic intracerebral hematoma" was identified in two cases subsequent to removal of an acute subdural hematoma. These results that serial ultrasonographic examination of the lateral ventricles through a craniectomy can supplement CT scanning in the evaluation of hydrocephalus and is also useful in evaluating cerebrovascular disease, brain tumors, infection, and head injury.

[Traumatic subarachnoid hemorrhage in acute severe head injury]

Traumatic subarachnoid hemorrhage (TSAH) is a frequent occurrence resulting from acute severe head injury. Computerized tomography (CT) accurately identifies the region, extent and nature of TSAH following trauma. But, to our knowledge, there have been few series detailing the characteristics of TSAH in acute severe head injury. The purpose of this study is to describe the findings, nature and prognosis of TSAH. Over a six and a half year period between April 1977 and September 1983, 414 severely head injured patients were examined by CT within 24 hours of the injury in the Department of Neurological Surgery and Critical Care Medicine, Nippon Medical School. Among them, 97 (23.4%) patients showed the appearance of TSAH in the Sylvian fissures, tentorium cerebelli, cortical sulci, basal cisterns and interhemispheric fissures. Conscious state on admission was defined using the Glasgow Coma Scale (GCS) and clinical outcome was defined using Glasgow Outcome Scale. There were 77 men and 20 women, ranging from 4 months to 83 years in age (means 44.3 years). TSAH therefore appears to be seen in all age groups, but especially in middle age groups. The GCS on admission was 8 or less in all cases; the GCS was 8 in 10 cases, 7 in 7 cases, 6 in 15 cases, 5 in 16 cases, 4 in 23 cases, 3 in 26 cases. The lower GCS scores, the more frequently TSAH was identified, and 67% of the patients had a GCS of 6 or less.(ABSTRACT TRUNCATED AT 250 WORDS)

A model of brain abscess: septic homologous blood clot emboli in rats

Brain abscesses in rats were produced by intra-arterial injection of septic homologous blood clot emboli. The production rate was 100% and the histopathological features closely resembled those seen in other animal models and in spontaneously occurring brain abscesses in humans. This small-animal model may be useful for systematic study of the development of brain abscesses as well as for evaluation of various therapeutic procedures.