Life-Threatening Bleeding from the Pubic Branch of the Inferior Epigastric Artery after Pubic Ramus Fracture

Isolated pubic ramus fracture with concurrent life-threatening bleeding caused by injury to the inferior epigastric artery (IEA) or its branches has rarely been reported and can frequently be overlooked. This paper reports two cases of isolated pubic ramus fracture with concomitant injury to the pubic branch of the IEA, causing serious bleeding and hemodynamic instability. Pelvic angiography showed leakage of contrast from the pubic branch of the IEA. The complication in both cases was successfully treated with transcatheter arterial embolisation.

Kernohan-Woltman Notch Phenomenon Caused by Acute Traumatic Subdural Haematoma

A 27-year-old man suffered from right hemiparesis after a closed head injury. Computed tomography (CT) revealed a right hemisphere subdural haematoma with midline structure shifted to the left. The CT finding was believed to be mislabeled because the site of haematoma did not correlate with an ipsilateral hemiparesis. Magnetic resonance imaging revealed a right transtentorial uncal herniation and a small lesion within left cerebral peduncle, suggesting Kernohan-Woltman notch phenomenon (KWNP). KWNP has been rarely seen in patients with acute traumatic subdural haemorrhage. Anatomical small maximum tentorial notch width is the possible anatomical factor predisposing our patient to this phenomenon. (Hong Kong j.emerg.med. 2014;21:116-119)

Hypertensive caudate hemorrhage prognostic predictor, outcome, and role of external ventricular drainage

BACKGROUND AND PURPOSE

The purpose of the present study was to analyze the outcome and outcome predictors of caudate hemorrhage and role of external ventricular drainage in acute hydrocephalus.

METHODS

Clinical data from 36 consecutive patients with hypertensive caudate hemorrhage was used in the present study. Age, gender, volume of parenchymal hematoma, hematoma in the internal capsule, initial Glasgow Coma Scale (GCS), hydrocephalus, severity of intraventricular hemorrhage, and hemorrhagic dilatation of the fourth ventricle were analyzed for effect on outcome. Effect of external ventricle drainage for hydrocephalus was evaluated by comparing preoperative and postoperative GCS scores.

RESULTS

By univariate analyses, poor outcome was associated with a poor initial GCS score (P=0.016), hydrocephalus (P<0.001), intraventricular hemorrhage severity (P<0.01), and hemorrhagic dilatation of the fourth ventricle (P=0.02). By multivariate analysis, stepwise logistic regression revealed that hydrocephalus was the only independent prognostic factor for poor outcome (P<0.001). Postoperative 48-hour GCS score was better than the preoperative score by use of paired-sample t test (P<0.001).

CONCLUSIONS

Hydrocephalus is the most important predictor of poor outcome. External ventricular drainage response for hydrocephalus was good in the present study, whereas an early decision should be made regarding preoperative neurological condition.

Early prediction of aphasia outcome in left basal ganglia hemorrhage

OBJECTIVES

The independent predictors of aphasia outcome for patients with left basal ganglia hemorrhage were evaluated.

PATIENTS AND METHODS

We included 140 patients of 1,036 patients with spontaneous intracerebral hemorrhage admitted to our hospital from January 1993 through December 1997. Aphasia was assessed using the aphasia scale of the Scandinavian stroke scale. Univariate and step-wise logistic regression analyses were performed to assess the relationships between the initial aphasia score, age, gender, blood volume, locations of hematoma and aphasia outcome.

RESULTS

Step-wise logistic regression analysis revealed that the following two factors were independently associated with the final aphasia outcome: initial aphasia score (P < 0.0001) and location of hematoma involving the posterior limb of the internal capsule (P = 0.004).

CONCLUSIONS

A particularly high likelihood of poor aphasia outcomes of patients with left basal ganglia hemorrhage are predicted in those who have poor initial aphasia score and whose brain computed tomography shows the hematoma involves the posterior limb of the internal capsule.

Klebsiella brain abscess in adults

BACKGROUND

We analyzed the clinical manifestations and therapeutic outcomes of Klebsiella brain abscesses.

PATIENTS AND METHODS

The clinical data of 15 patients with Klebsiella brain abscesses, retrospectively collected over a 14-year period, were studied.

RESULTS

The 15 patients included 13 cases of Klebsiella pneumoniae infection and two cases of Klebsiella oxytoca. All but one case were community-acquired infections. Locations of all of these abscesses were supratentorial. 12 cases involved a single abscess, and three involved multiple abscesses. Gas formation was also found in two cases (13%). Common predisposing factors included metastatic spread, chronic otitis media and neurosurgical procedures. Among these 15 patients, 11 were treated surgically and four received antibiotics alone. In total, 11 patients survived and four died, with an overall mortality rate of 26.7%.

CONCLUSION

The clinical presentations and therapeutic outcomes varied according to the different Klebsiella species. While debilitating diseases were common in K. pneumoniae infections, they were not common in K. oxytoca infection. And while metastatic septic abscess is a well-known, devastating complication of K. pneumoniae septicemia, usually seen as a brain abscess with a gas-forming appearance, all of these K. oxytoca infections had both otogenic infections and more favorable outcomes.

Atlantal stenosis: a rare cause of quadriparesis in a child. Case report

The authors report the case of a 3-year-old boy who suffered from quadriparesis and respiratory distress after failing to execute a somersault properly. Neuroimaging revealed spinal cord contusion with marked spinal canal stenosis at the level of the atlas. No subtle instability, occult fracture, or other congenital abnormalities were confirmed. Spinal cord contusion with marked canal stenosis is rare, and only several adult cases have been reported. Severe stenosis at the level of the atlas may predispose individuals to severe spinal cord contusion, as occurred in our patient after sustaining trivial trauma.

Changes of bilateral palmar skin temperature in transthoracic endoscopic T-2 sympathectomy

OBJECT

Transthoracic endoscopic T-2 sympathectomy is currently the treatment of choice for palmar hyperhidrosis (PH). Intraoperative monitoring of palmar skin temperature (PST) is often used to assess the adequacy of sympathetic ablation. The aim of this study was to investigate the time course of PST changes during the operation and to determine factors involved in the sympathetic modulation of the palmar skin blood flow.

METHODS

Eighty-one patients with PH underwent bilateral transthoracic endoscopic sympathectomy of T-2 in which continuous intraoperative PST monitoring was used. Palmar skin temperature data, recorded every 30 seconds throughout the operation, were plotted against time, and a graph of two PST curves was obtained in each case. A multiphasic curve pattern of great similarity was observed in nearly 70% of cases. Specific PST readings at different operative stages were collected and averaged for all cases. The trend of PST changes in response to different procedures during the operation was analyzed. It was found that unilateral procedures caused simultaneous bilateral PST alterations. In almost all cases, bilateral PST was dramatically lowered when unilateral skin incision and intercostal muscle dissection were performed. The temperature remained low until the T-2 sympathectomy was finished on one side. In addition, unilateral T-2 sympathectomy induced synchronous elevation of bilateral PST. However, the ipsilateral response was significantly stronger than that on the contralateral side.

CONCLUSIONS

Although intraoperative monitoring of PST is a reliable guide for surgeons performing endoscopic transthoracic sympathectomy, it is important to realize that PST fluctuates at different stages during the operation and that surgical procedures themselves can significantly influence PST readings. The PST data recorded at specific time points, therefore, can be misleading in terms of accuracy and the completeness of ablation of the target sympathetic ganglia, especially when the sympathetic trunk or ganglia are anatomically aberrant.