Recent papers have reported the effectiveness of local intraarterial thrombolysis (LIT) on acute occlusion of major cerebral arteries, especially on middle cerebral artery occlusion (MCO), but it is not fully accepted in internal carotid artery occlusion (ICO). ICO, particularly with poor collateral flow, may be fatal if recanalization is not be achieved. At our institute, 32 LITs were performed with alteplase in the last 5 five years and the efficacy of LIT has been studied for ICO in 15 and MCO for 17 of these cases. Compared to MCO, ICO proved worse conscious state and lower regional cerebral blood flow (rCBF) in the middle cerebral artery area measured by xenon-enhanced computed tomography. There is no significant difference between groups on recanalization or intracranial hemorrhage. The percentage of brain death was 60% in ICO and 18% in MCO, and mortality in hospital was 80% and 41% (p<0.05). Although ICO is fatal, with successful LIT, recanalization without intracranial hemorrhage, patients escape brain death. This is statistically significant (p<0.05) in ICO patients but not in MCO patients. Conclusion: ICO patients are more severely compromised than MCO patients in consciousness, rCBF of the ischemic area and mortality. A significant relationship between the result of LIT and clinical outcome has been proven only in ICO.

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Lipopolysaccharide (LPS) is thought to be the causal agent of paralytic ileus in sepsis. We have reported that contraction of taenia caecum isolated from guinea pigs is suppressed by LPS. In the present study, we tried to create a new experimental method for the study of intestinal paralysis induced by LPS with continuously recorded changes in the movement of taenia caecum of conscious guinea pigs. Laparotomy was performed under pentobarbital anesthesia in guinea pigs, and a microforce transducer was sutured on taenia caecum. After operation, the guinea pigs were allowed to eat and drink freely. Four days later, LPS (E. coli, O111:B4) was injected into the abdominal cavity, and the movement of taenia caecum was recorded. Changes in body temperature after the administration of LPS were measured successively. Intestinal contraction movements in conscious guinea pigs were recorded in a stable manner for many hours. The characteristic relaxing action of taenia caecum was that it peaked between 2 and 4 hours after administration of LPS and that it was dependent on the LPS-dose. Body temperature changed in good correlation to the tension of taenia caecum. The above results suggest that the novel method, monitoring the intestinal movement of conscious guinea pigs, is a useful experimental model for the study of intestinal paralysis due to endotoxicosis.

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It has been reported that diffuse brain injury patients with primary brainstem lesions have a poor prognosis. Predicting the existence of brainstem injury at hospital arrival is problematic in actual clinical practice. We conducted magnetic resonance imaging (MRI), to visualize brainstem lesions clearly, and retrospectively analyzed predictive factors of brainstem lesions by stepwise multiple logistic regression analysis of patient characteristics, neurological findings, laboratory data, and CT findings at arrival in each case. We compared 24 patients with brainstem lesion and 60 without using MRI obtained less than 3 weeks after admission. Items investigated were blood pressure immediately after hospital arrival, arterial blood gas analysis, existence of abnormal respiration, blow direction, GCS, light reflex, oculocephalic reflex, corneal reflex, intracranial pressure, jugular venous oxygen saturation, and CT findings such as existence of subarachnoid hemorrhage at the suprasellar cistern, perimesencephalic cistern and convexity, lesions on the thalamus and basal ganglia, gliding contusion, intraventricular hemorrhage and Traumatic Coma Data Bank classification. Independent predictive factors of primary brainstem lesion included impaired light reflex (odds ratio: 2.269), subarachnoid hemorrhage at convexity (odds ratio: 3.592) and suprasellar cistern (odds ratio: 2.458), and Traumatic Coma Data Bank group III (odds ratio: 11.062).

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The United States Center for Disease Control and Prevention (CDC) questions the effectiveness of tacky mats in preventing nosocomial infection (Guideline for preventioin of surgical site infection, 1999), but in Japan, this mat use remains conventional at the Intensive Care Unit (ICU) entrance. In April 2001, we discontinued tacky mat use after surveying the infection of ICU patients from January to March 2001 (group A) during use and from April to June 2001 (group B) after discontinuation. We studied total mat cost at our hospital and ICU. The survey was conducted based on the National Nosocomial Infection Surveillance System (NNIS) guideline. We examined device-related infection such as catheter-related bloodstream infection (BSI), ventilator-associated pneumonia (VAP), and urinary tract infection related to the urethral catheter (UTI). We investigated the APACHE (acute physiology and chronic health evaluation) II score, average ICU stay, and device utilization rate. No significant difference was seen in average ICU stay, APACHE II score, the device utilization rate, and total number of ICU stays between group A and B. The occurrence of BSI, VAP, and UTI did not differ significantly between groups. This data indicated that the tacky mat at the ICU entrance is ineffective, and wastes money. For our hospital, tacky mat cost reached to 4.5 million yen/year in 2000, reduced to 1.5 million yen/year in 2001. The money is now used education on infection control. Eduction and raised awareness are thus important for prevention of nosocomial infection.

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A 52-year-old man was admitted after sustaining a gunshot wound to the head. The patient had been ambulant at the time of impact but collapsed suddenly and was comatose upon admission. Brain computed tomography (CT) scans revealed an acute subdural hematoma with marked midline shift; an emergency evacuation of the hematoma and craniectomy were performed. He recovered neurologically and underwent cranioplasty using autologous bone two weeks after the initial surgery, but he developed a wound infection and subdural empyema, necessitating another debridement surgery. Cranioplasty using a ceramic bone was performed two months after the debridement, and he was discharged with no neurological deficits. Gunshot wounds to the head have a higher rate of postoperative infection than closed head injuries; thus, debridement to remove as much bony and missile fragments as possible is important.

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Percutaneous dilational tracheostomy (PDT) has become an appropriate alternative to conventional surgical tracheostomy and has gained worldwide acceptance. Multiple publications in recent years have reported the efficacy and relative safety of this approach. However, PDT is not always feasible or practicable, and problems can occur. With the more widespread use of PDT, the uncommon but serious complications of pneumothoraces and mediastinal emphysema resulting from posterior tracheal wall perforation are more often seen. A 16-year-old female suffering from head injury underwent PDT. On the morning after surgery, the patient developed subcutaneous emphysema, decreased arterial saturation, and decreased breath sounds in both sides of the chest. Tension pneumothoraces and mediastinal emphysema associated with PDT were documented radiographically. Thoracostomy tubes were inserted, followed by immediate clinical improvement. Iatrogenic posterior tracheal wall perforation is a complication of PDT, not generally associated with open tracheostomy. This serious complication occurs because of technical errors committed during the PDT insertion. The use of concurrent endoluminal visualization to confirm proper needle insertion and placement, avoidance of excessive force, and proper patient selection have been identified as factors vital to performing PDT in a safe and controlled fashion. Concurrent endoluminal visualization by bronchoscopy is essential in reducing the technical complications of PDT insertion.

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Drug-induced toxic epidermal necrolysis (TEN) is a rare, but severe disease, resembling widespread second-degree burns. We report on two cases of TEN. Case 1: A 53-year-old woman presented with a skin rash in the clinical course of severe acute pancreatitis. She was diagnosed as having TEN, affecting 90% of her body surface area (BSA). She was transferred to our ICU, presenting with respiratory and renal dysfunction, and severe sepsis. She was treated in a similar manner as treatment for severe burns and underwent 6 plasma exchange series. However, the infection became uncontrollable and the skin lesion showed no improvement. She died of multiple organ failure (MOF) on the 61st ICU day. Case 2: A 34-year-old man was admitted to our ICU with a diagnosis of TEN, affecting 40% of his BSA. We performed 3 plasma exchange series. The skin lesion and general condition gradually improved, and he was transferred to a general ward on the 17th ICU day. Current evidence suggests that keratinocytes is died through apoptosis in TEN and that Fas-Fas ligand interactions are involved in TEN pathophysiology. We studied the serum soluble Fas ligand (sFasL), and evaluated the time course of sFasL concentrations in these 2 cases. Serum concentrations of sFasL in Case 1 were sustained at a high level, whereas those in Case 2 gradually decreased. The sFasL concentration may be related to the severity and clinical course of TEN.

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