Using trepanation and surgical drainage, we successfully treated epidural and subdural empyema caused by acute frontal sinusitis. An 11-year-old girl admitted for fever and right hemiparesis was found in head MRI to have epidural empyema of the left frontopolar region and subdural empyema of both the left convexity and interhemisphere following acute frontal sinusitis. Antibiotics started immediately after admission and frontal sinusectomy proved effective for the epidural but not subdural empyema, necessitating radical surgery on hospital day 10. Two trepanations were made on the left frontal convexity and posterior paramedian portion and drainage tubes placed at each empyema site after sufficient irrigation. Subdural empyema thereafter diminished to where the patient could be discharged, mobile, with mild right hemiparesis on day 38. We speculated that the infection route was from the acute frontal sinusitis to intracranial lesions, with epidural empyema possibly developing via direct extension through communicating veins and the perivascular space of the posterior wall of frontal sinus. Subdural empyema may have been caused by retrograde thrombophlebitis of cortical bridging veins. If conservative therapy for subdural empyema is not successful, immediate surgical drainage is recommended.
In the 4 years since Japan's organ transplantation law went into effect, 22 organ procurements have taken place. To analyze problems in organ procurement from brain-dead donors, we reviewed the diagnosis of brain death and organ procurement in our 3 cases. 1) Although it signing and presentation of a donor card (“living will”) is generally regarded expression of definite intent of organ donation, this intent is not always fully discussed by family members. Procedures must proceed carefully until final decision-making for organ donation by family members. 2) To maximize respect for “living wills” in organ donation, we must reduce time taken for brain death diagnosis and organ procurement under legal guidelines and ensure organ viability. 3) The excellent results with organ transplantation surgery should be emphasized to improve organ transplantation awareness among potential donors.
A 32-year-old man was compressed between two boards and suffered a pancreatic injury and acute blurring of vision. He was treated conservatively at a local hospital and transferred to our hospital on the 10th day following his injury. His corrected visual acuity was 0.08 for his right eye and 0.3 for his left. An ophthalmoscopy revealed multiple cotton-wool exudates and retinal hemorrhages, while a fluorescein angiography examination showed staining of the vessel walls and minor leakage along the vessels. We diagnosed the patient as having Purtscher's retinopathy and managed the patient by observation. Endoscopic retrograde pancreatography and computed tomography examinations revealed a disruption of the main pancreatic duct and a right renal infarction. A caudal pancreatectomy and a right nephrectomy were therefore performed on the 18th day after the injury. The visual acuity improved to 0.8 in the right eye and 1.0 in the left eye 5 months after the injury. Purtscher's retinopathy is characterized by a sudden loss of vision after a head, chest or abdominal injury and is associated with cotton-wool exudates and retinal hemorrhages in the posterior pole. No effective treatments have been reported, but the prognosis is typically considered to be good. Emergency doctors should be aware of this disease as a cause of blurred vision resulting from extraocular injury.
Proximal occlusion or trapping combined with EC-IC (extracranial intracranial arterial) bypass is the treatment of choice for giant fusiform aneurysms if the parent vessel cannot be reconstructed by clipping. Combining endovascular treatment and bypass surgery is a viable alternative. We report a young man with mild right hemiparesis following a second episode of basal ganglia hemorrhage and subarachnoid hemorrhage. 3D-CT showed a left ruptured, partially thrombosed giant M1 fusiform aneurysm. He underwent STA-MCA bypass with attempted M1 reconstruction and, a week later, attempted total coil occlusion of the M1 aneurysm. Only the ruptured point at the distal M1 was occluded, however, resulting in temporary mild right hemiparesis and aphasia. A month later, when he was to undergo a second coil procedure, angiography showed spontaneous, complete obliteration of the M1 aneurysm, so no further endovascular procedure was attempted. The treatment of M1 giant fusiform aneurysms and the mechanism of spontaneous thrombosis of the aneurysmal sac after bypass and distal occlusion are discussed. Combined distal bypass and endovascular obliteration of the aneuysmal sac with coils is a variable alternative if vascular reconstruction is difficult or not possible.