Cerebral fat embolism (CFE) is a serious complication of long-bone fractures. We reported a case of CFE observed throughout the clinical course by magnetic resonance imaging (MRI) studies. A 23-year-old man suffered a left femoral fracture in a traffic accident and lapsed into a coma 23 hours after injury. Brain computed tomography (CT) did not show any abnormality 8 hours after coma, but MRI showed multiple high-intensity spotty lesions in cerebral white matter in T2 weighted images (T2WI). Four days after onset, these positive lesions became much clearer and spread. Although most disappeared in the subacute clinical stage, local highintensity lesions were still observed in T2WI, apparently local brain edema and ischemic infarctions. CFE is reported to exert 3 characteristic manifestations -- local brain edema, ischemic infarction, and hemorrhagic infarction. These patterns and localization appear to be correlated with clinical outcome. We conducted MRI studies to clarify the status and location of CFE, and found that T2WI, inversion recovery T1 (IRT1) and gradient echo T2*weighted images (T2*WI) studies are useful in CFE detection and status assessment.
We report a patient with severe liver injury and traumatic rupture of the aorta successfully managed by staged operation. A 40-year-old man injured in a motor vehicle accident was taken to a hospital in hemorrhagic shock. Chest roentogenography showed left hemothorax and widening of the upper mediastinum. Abdominal computed tomography (CT) showed type III b liver injury and periaortic hematoma. Abdominal packing and coil embolization were conducted for the liver injury. The patient was transferred to our hospital because aortography showed a pseudoaneurysm of the proximal descending aorta. On admission, the hemodynamic state was relatively stable, and we decided to conduct delayed repair of the traumatic aortic injury due to hypothermia-acidosis-coagulopathy syndrome. The second operation was performed 48 hours after the initial operation. Prosthetic graft replacement was conducted for the aortic injury, and hepatorrhaphy for the liver injury. The patient was discharged on day 70 after the second operation. Urgent surgical treatment is necessary for traumatic rupture of the aorta. However, in severe injury to other organs, repair of the aortic injury should be considered after hemorrhage from other organs is controlled or hypothermia-acidosis-coagulopathy syndrome improves.
Distigmine bromide is an anticholinesterase used to treat urinary retention. We describe a case of life-threatening cholinergic crisis induced by a usual oral dose of distigmine bromide for postoperative urinary retention. An 82-year-old man with mild chronic renal failure was transferred to our emergency room due to cholinergic crisis accompanied by cyanosis, hypotension, and consciousness disturbance. The patient was 10mg/day of distigmine bromide orally administered for 2 days. The patient's serum cholinesterase decreased to 3IU/l. Mechanical ventilation, fluid resuscitation, and inotropic support were started. A few days after admission, despite continuous low serum cholinesterase, his toxic symptoms almost disappeared. Extubation was done, and the patient had an event-free recovery. The possibility of cholinergic crisis should be considered when patients with renal failure are given distigmine bromide. During cholinergic crisis, toxic symptoms do not parallel serum cholinesterase. Cholinergic crisis should thus be treated while carefully observing clinical symptoms.