A 49-year-old man with pulmonary edema and cardiogenic shock due to acute inferior myocardial infarction was successfully treated with percutaneous transluminal coronary angioplasty supported by percutaneous cardiopulmonary bypass. Emergency diagnostic coronary angiography revealed nearly complete obstruction in segment (seg) 2 of the right coronary artery (RCA), 99% stenosis with delayed filling of contrast medium in seg 6 of the left anterior descending artery (LAD), and hypoplasty of the circumflex artery except in seg 12 with 75% stenosis. Both the LAD and seg 12 arteries provided fairly good collateral circulation to segs 3 and 4, while the septal branches of the LAD were poorly perfused by the conus branch of the RCA. The shock in this case was pathophysiologically characterized as pump failure of the functioning heart due to multivessel disease, which affected the infarcted but stunned inferior myocardium and the severely acute ischemic anterior myocardium. Percutaneous cardiopulmonary bypass support was instituted because of poor left ventricular function revealed by echocardiogram (ejection fraction≤30%) and the high risk of hemodynamic collapse during angioplasty in segs 2 and 6 even with the combined use of intraaortic balloon counterpulsation and administration of cathecholamine. It is concluded that cardiopulmonary bypass can safely be instituted percutaneously to hemodynamically stabilize a patient in cardiogenic shock and facilitate potentially life-saving emergency complex coronary angioplasty.
Three patients with clinical and investigative features suggestive of septic cavernous sinus thrombosis are reported. Case 1: A 53-year-old woman developed headache, severe edema of the conjunctiva, proptosis and ophthalmoplegia with high fever following respiratory tract infection. CSF examination showed pleocytosis (11, 842/cmm; 49% polymorphs) and its culture revealed Streptococcus milleri. In spite of vigorous antibiotic treatment, she had hemiparesis and personality change as a sequela. Case 2: A 37-year-old man with a three-month history of dental infection developed high fever, proptosis and severe edema of the conjunctiva, and fell into coma. The spinal fluid contained 13, 672 white cells/cmm (91% polymorphs) with no sugar. He died on the 5th hospital day. Carotid angiograms of cases 1 and 2 demonstrated narrowing of the intracavernous portion of the internal carotid artery. Case 3: A 42-year-old man with a history of paranasal sinusitis developed headache, high fever, blephaloptosis and ophthalmoplegia. Plain skull radiograph showed opacity of the sphenoid sinus. The spinal fluid contained 764 white cells/cmm (49% polymorphs). In spite of antibiotic treatment, he died on the 13th hospital day. At autopsy the brain showed severe edema and the cavernous sinus contained pus. Culture of the pus revealed α-Streptococcus. We propose early diagnosis and aggressive antibiotic treatment of this disease.
We present a case of traumatic dissecting aneurysm of the vertebral artery associated with fracture of the cervical spine. The patient was a 73-year-old man who received head and neck injuries in an automobile accident. He was immediately brought to our hospital by ambulance following a short period of unconsciousness. The patient became alert and was orientated at the time of admission. Slight swelling on the left side of the neck was noted. Neurological examination revealed left Wallenberg's syndrome and swallowing disturbance. Roentgenograms and cervical CT confirmed transverse fracture of the axis. CT scan showed no intracranial lesion and angiography demonstrated a dissection of the left vertebral artery. T2-weighted MRI indicated a high intensity area in the left lateral medulla. Ten days later, angiography was carried out again and showed complete occlusion of the left vertebral artery at the origin of the dissection. The patient's condition was stable during observation and anticoagulation therapy was carried out. He became asymptomatic after a few weeks. Traumatic dissecting aneurysm of the vertebral artery is rare, and its diagnosis is quite difficult. When cerebrovascular disorder is suspected after trauma, early diagnosis and proper treatment should be conducted prior to the onset of semi permanent neuro-deciduation.
We describe a case of acute subdural hematoma, successfully treated by burr-hole opening and subdural tapping. The patient was a 55-year-old man who fell from the third floor of his house and suffered a head injury. On admission, he was semicomatose, and a computed tomography (CT) scan showed a right acute subdural hematoma and brain contusion. During preparation for the craniotomy, the patient's neurological state deteriorated. Transcranial Doppler (TCD) examination showed a decrease in mean flow velocity (MFV) in the right middle cerebral artery (MCA) and an increase in the pulsatility index (PI), which means an increase in intracranial pressure and a decrease in cerebral perfusion pressure. The patient was therefore subjected to burr-hole opening and subdural tapping in the right parietal region on the spot, and about 100ml of semiliquid subdural hematoma was drained off. At this time, the both MFV and PI according to TCD had improved. A craniotomy was then performed, and the subdural hematoma was totally evacuated. A postoperative CT scan revealed a contralateral epidural hematoma. Therefore a second craniotomy was performed, and the epidural hematoma was totally evacuated. After surgery, the patient's neurological condition improved to a confused state. Our experience in this case suggests that assessment of intracranial pressure by TCD and subdural tapping in the emergency room prior to craniotomy in the operating room, are beneficial in emergency cases of acute subdural hematoma.