目的:発症直後(6時間以内)の急性大動脈解離の臨床像を明らかにし,診断を困難にする要因について検討する。対象:過去13年間の90症例(A型50例,平均年齢67歳,男/女=16/34,B型40例,62.6歳,23/17)のretrospective study。結果:最も重要な背景因子は高血圧症でA型33例(66%),B型28例(70.3%)に認められた。来院時主訴はB型では39例(97.5%,胸背部痛30例)が痛みを主訴としていたのに対し,A型では36例(72%,胸背部31例)にすぎず,17例は突然のcollapseを主訴としていた。来院時収縮期血圧はA型で有意に低く(93.5±30.1 vs 167±36.1mmHg),25例(50%)は90mmHg未満のショック状態であった。合併症はA型45例(90%,タンポナーデ23,大動脈弁閉鎖不全19,末梢動脈閉塞15,冠閉塞8他)に対し,B型9例(末梢動脈閉塞5,腎虚血3他)であった。心電図上,急性ST-T変化はA型の27例(55.1%),B型の9例(22.5%)に認めた。CT,エコーでの確診はA型32/37(86.5%),29/44(65.9%),B型37/39(94.9%),12/24(50%)であった。全体としてCTまたはエコーでA型の90%,B型の100%で確定診断を得た。A型の39%,B型の22.4%に急性期診断の問題を認め,心疾患,消化器疾患,脳血管障害などとの鑑別を要した。診断問題群における年齢,性,来院時血圧,四肢動脈閉塞,縦隔拡大,心電図変化,心不全,意識障害,タンポナーデ,大動脈弁閉鎖不全,痛みの有無の頻度は,診断に問題がなかった群と有意な差を認めなかった。結論:初期診断の問題とは,最初に診断に携わった医師が大動脈解離を疑うか否かの問題である。きわめて多彩な臨床像が初期診断を困難にしているが,突然の胸痛,意識障害,原因不明のショックなどでは必ず大動脈解離を念頭に置くべきである。
Acute brain swelling often occurs following external decompression but only rarely following drainage of cerebrospinal fluid (CSF). How can we predict acute brain swelling before external decompression or CSF drainage? It has been suggested that the mechanism of acute brain swelling involves an increase in cerebral blood volume (CBV) but this remains uncertain. A patient with acute brain swelling following head injury in whom intracranial pressure (ICP), jugular venous oxygen saturation (SjO2), and transcranial Doppler sonography (TCD) were serially monitored is presented, and the mechanism is discussed. A 17-year-old man was admitted to the emergency room following a traffic accident on a motorcycle. He was comatose with a score of 6 on the Glasgow coma scale. Pupils were anisocoric, and brain stem reflexes were absent except for the cough reflex. Computed tomography showed traumatic subarachnoid hemorrhage and acute hydrocephalus. Initial TCD showed that the brain was hyperemic. The ICP had increased to 50mmHg, despite barbiturate therapy. Therefore ventricular drainage was implemented via the anterior lateral ventricle to decrease ICP. Ventricular drainage was opened while ICP, SjO2, TCD were being serially monitored. At 4 minutes 30 seconds after opening the drainage, ICP suddenly increased, and SjO2 simultaneously decreased rapidly. There were no changes in TCD waveform during the first 4 minutes, change, indicating the absence of any significant increase in CBV. At that point ICP suddenly increased to 60mmHg, and the TCD waveform changed to systolic flow. Subsequent CT clearly revealed brain swelling. After that the ICP continued at 60∼70mmHg, but the SjO2 increased from 20% to 80%, and then decreased to 20% again. During the next stage, the SjO2 continued at 80∼90%. These changes were explained in terms of alternating periods of relative brain ischemia and brain hyperemia. Hyperemia and intracrnial hypertension were suspected prior to drainage, based on serial monitoring of TCD, ICP, and SjO2 upon admission. Presumably the sudden increase in cerebral perfusion pressure under these conditions caused the acute brain swelling. When brain hyperemia is suspected, it is important to control ICP gradually.
There have been few studies on mental stress caused by natural disasters from a neuroendocrinological viewpoint. In this study we examined five patients with physical injures as a result of the Hokkaido Nansei-oki earthquake and tsunami and evaluated stress over a two-week period after the disaster. Blood cortisol and catecholamines (epinephrine, norepinephrine, and dopamine) were measured as indices of acute stress reaction, and urine 17-OHCS, 17-KS-S and 17-KS-S/17-OHCS ratio, often used to evaluate psychosocial stress, were also measured as indices of “wear and tear”, “repair and recovery”and “distortion of adaptation”, respectively (the former two expressed as creatinine ratio, all three expressed as percentages of the mean values in a healthy 25-year-old group). Serum cortisol was increased in two of the five patients only on the 4th day after the disaster, while plasma catecholamines remained within normal limits. 17-OHCS increased (over 100%), 17-KS-S clearly decreased (below 50%), and the 17-KS-S/17-OHCS ratio markedly decreased (far below 50%) during the observation period in all of the patients, who experienced continuous mental and physical distress throughout the period. This reveals that disasters create intensive mental stress in which long-term care is indispensable to mental and psychological recovery, as well as physical recovery.
A 49-year-old woman with severe shock and metabolic acidosis was transferred to our hospital. She had no cardiac disease. The patient had been treated with salazopirine, steroid and parenteral hyperalimentation at a local hospital for ulcerative colitis for 3 years. One week ago, she experienced bilateral abductor paralysis. When the steroid dosage was decreased 2 days ago, she developed sudden shock and consciousness disturbance. Large-dose steroid therapy was administered, but her hemodynamic state failed to improve. On admission, her hemodynamics and metabolic acidosis deteriorated despite administration of large-dose catecholamines, sodium bicarbonate and fluid resuscitation. The patient showed characteristic clinical signs of shoshin beriberi, such as abductor paralysis, malnutrition and low output syndrome (LOS), and the cause of the shock was suspected to be shosin beriberi due to long-term parenteral hyperalimentation without vitamins. The patient was therefore put on assisted circulation by intra-aortic balloon pumping (IABP) and vitamin B1 (thiamine) therapy. Immediately after starting IABP, her hemodynamics, metabolic state, oxygenation and level of consciousness improved dramatically. Six hours later, her hemodynamics had stabilized, and administration of adrenaline was discontinued. The next day, she was weaned from IABP, and five days later, the patient was discharged from the ICU without any complications. It is concluded that IABP is useful in patients with catecholamine-resistant LOS such as shoshin beriberi until efficiency of the fundamental therapy.