Acute type A aortic dissection requires prompt diagnosis and appropriate primary management. We report short-and long-term results of surgical and medical management of acute type A aortic dissection in our department and discuss optimal management for good results. From 1991 to 2000, 146 patients diagnosed with acute type A aortic dissection were admitted to our department. Of these, 32 (21.9%) died in the emergency room due mainly to cardiac tamponade. It was difficult to resuscitate patients who had suffered cardiopulmonary arrest due to acute aortic dissection. Surgery could be done on 101 patients. Prosthetic vascular graft replacements were done to resect entry sites in 99 patients. Hospital mortality in preoperatively critical patients (n=32) was 40.6% but only 14.5% in others (n=69). Overall actuarial survival at 5 years postoperatively was 68.5%. The extent of replaced aorta, either ascending or total arch, did not influence short-and long-term results. A clotted false lumen in the descending aorta following proxymal aorta replacement significantly reduced dissection-related events. Considering these facts, extended aorta replacement seems to be acceptable for resection of entry site in the aortic arch and ascending aorta replacement seems to be reasonable if the entry site is in the ascending aorta. Of the 38 patients (33.3%) with early thrombosed acute type A aortic dissection, 13 without dissection-related complications were treated nonsurgically and 25 were treated surgically. Excluding critical cases, in-hospital mortality and event-free occurrence in surgically treated cases were significantly better than those in nonsurgically treated cases, indicating that the appropriateness of the widely used nonsurgical treatment for thrombosed cases should be reconsidered.

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To evaluate the protective effect of hypothermia in severe subarachnoid hemorrhage (SAH), we induced mild brain hypothermia by surface cooling in 16 patients with WFNS Grade V SAH immediately after resuscitation and diagnosis by computed tomography (CT). Between April 1999 and September 2000, 10 men and 6 women between 50 and 72 years old (average 63.1), were studied. Those over 75 years and with no brain stem reaction, obvious hypoxemia, hypotension, or huge hematoma in the dominant cerebral hemisphere were excluded. The level of consciousness assessed by the Glasgow Coma Scale (GCS) was 3 in 8 (including 2 resuscitated from cardiopulmonary arrest), 4 in 1, 5 in 3, and 6 in 4. Four patients showed massive intracerebral or subdural hematoma associated with deviation of midline structure and 4 showed intraventricular hematoma with cast formation. All but 1 showed pupillary abnormality. Blood glucose exceeded 160mg/dl in 13. Median time from onset to arrival was 33min, cerebral angiography 86min, and surgery 174min. Core patient temperature reached 35.1°C just before surgery, 34.1°C at the beginning of microsurgery, and 33.6°C before leaving the operating room. After complete obliteration of an aneurysm by clipping and external decompression, patients were maintained under mild hypothermia at 33-34°C for 48 hours or more. Patient outcome as assessed by the Glasgow Outcome Scale at 6 months was as follows: good recovery (GR) in 2, moderate disability (MD) in 2, severe disability (SD) in 8, persistent vegetative state (VS) in 2, and death (D) in 1. No mortality related to hypothermia was encountered. Poor outcome was mostly related to primary brain damage, 3 caused by intracerebral hematoma, 1 by brain herniation, 1 by hypoxic damage, 3 by rerupture of the aneurysm before surgery, and 1 by delayed ischemia due to cerebral vasospasm. Overall outcome of consecutive 22 patients with Grade V SAH, including 6 without immediate brain hypothermia, was favorable (GR+MD) in 22.5% and unfavorable (SD+VS+D) in 77.3% of patients. In the comparison with a historical cohort of 24 patients with Grade V SAH between January 1998 and March 1999, decrease of VS+D and increase of SD were significant. Immediate induction of mild hypothermia possibly reduces primary brain damage and improves outcome in patients with WFNS Grade V SAH.

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Since 1997, all junior residents at our hospital serve 2 shifts of 24-hour-prehospital emergency practice on ambulance duty while working at our Emergency Center for 4 months of their rotation. The station, including crew, is designated by the Osaka City Fire Department. This training is given to decrease the gap between an emergency scene and a hospital, especially for new residents to be able to recognize and respond to prehospital emergencies and to experience leading a medical team. Evaluation was done by resident reports and a questionnaire to ambulance crew chiefs. Most reports from residents indicated their awareness of being a physician facing a patient at the scene and recognized the actual activities of ambulance crews. Results showed that ambulance chiefs gathered medical information from residents while together 24 hours and that residents were very helpful as physicians throughout ambulance duty. Our results show that we should continue ambulance duty training for all new junior residents.

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Objective: We retrospectively reviewed 29 cases of hypertensive cerebellar hemorrhage treated conservatively or surgically in the last 10 years to determine the relationship between therapeutic options and outcome in different clinical settings. Materials and Methods: Of the 29, 15 were treated conservatively and 14 surgically. We looked at differences in age, consciousness on arrival, and hematoma size and location, to determine the relationship between ventricular hematoma perforation, incidence of acute hydrocephalus, and final outcome. Results: Mean age was significantly higher in the surgical group (group S), at 69.1 years, than in the conservatively treated group (group C), at 65.9 years. The mean Glasgow Coma Scale on admission was statistically significant at 14.0 in group C and 10.1 in group S, significantly different, hematomas were larger in group S, and vermisic hemorrhages were 2 times more frequent than hemispheric hemorrhages in group S, but equally frequent in group C. Fourth ventricular perforations were more common than acute hydrocephalus in group S. Group C outcome was favorable at 86% with good or moderate disability on the Glasgow Outcome Scale, but poor group S outcome was 87% severely disabled or death. We concluded that the prognosis of hypertensive cerebellar hemorrhage mainly depends on the volume of the initial hematoma. Cases requiring usually premised a poor outcome, indicating that treatment must focus on measures to prevent the hematoma from developing from the onset.

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We report a 26-year-old woman suffering from sepsis due to severe pneumonia successfully managed with sufficient irrigation of airpassages under differential lung ventilation (DLV). The patient had attempted suicide by jumping from a building, sustaining a unilateral pulmonary contusion, multiple rib fractures with hemothorax, liver injury, pelvic fracture, and open fractures of the lower leg. Although we successfully treated the multiple injuries, she went into septic shock due to severe bacterial pneumonia in the lung opposite the contused one. Both sputum and blood culture revealed Pseudomonas aeruginosa. Her condition did not improve despite antibiotic therapy specific to the organism. Frequent bronchoscopy with sufficient irrigation of the left bronchial tree appeared necessary to drain transbronchial pus. DLV was used to avoid hypoxemia and prevent the spread of infection to the opposite lung during irrigation. This airway management from day 21 after injury ameliorated bacterial infection and enabled her to recover from sepsis. DLV was maintained for 26 days and replaced by conventional ventilation through a single lumen tube. DLV thus was beneficial in sepsis due to severe unilateral pneumonia.

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We report a sudden death due to meningococcal meningitis type B. A previously healthy 40-year-old man was transferred to our emergency center with cardiopulmonary arrest and a 2-day history of severe headache and chills. Cardiopulmonary resuscitation was unsuccessful. Brain computed tomography (CT) showed brain edema and mildly dilated ventricles. A culture of the cerebrospinal fluid was positive for Neisseria meningitidis. Autopsy to determine the cause of death showed the most marked pathological change to be myocardial microabscesses in the cardiac conduction system. No change was seen in other parts of the myocardium nor was any sign of congestive heart failure found. No cerebral herniation or adrenal hemorrhage were noted. Death was thus probably acute damage to the cardiac conduction system. We suggest that patients with meningococcal meningitis be observed carefully for the development of fatal arrhythmia.

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We report 2 cases in which transcatheter arterial embolization (TAE) was successful in treating blunt thoracic trauma. Case 1: A 23-year-old man was found by chest computed tomography (CT) to have multiple rib fractures and lung hematoma. Hemorrhage from a chest tube was estimated at more than 1000ml. We immediately conducted bronchial and intercostal angiography and found stains suggesting hemorrhage. We conducted TAE for these arteries, successfully controlling hemorrhage. Ensuing surgery confirmed the success of TAE. Case 2: A 58-year-old man was found by chest CT to have multiple rib fractures and lung hematoma. Hemorrhage from an endotracheal tube was estimated at more than 100ml/hr. Bronchial angiography showed stains suggesting hemorrhage. TAE of the bronchial artery enabled hemorrhage from the tracheal tube to be controlled. Both cases showed TAE to be successful in avoiding lung resection and thus useful in blunt thoracic trauma treatment.

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