stunned myocardium(気絶心筋)の概念は短時間の虚血後,再灌流されると一時的に心筋収縮機能は低下するが,数日後に改善がみられるとされている。われわれは心肺蘇生により心拍再開が得られた後の心筋にも同様の病態が関与していると考え,心拍再開後の心機能の回復過程について検討した。対象は過去5年間に当センターで扱った心肺停止例のうち,心エコーを用いて経時的に心機能を評価し得た47例。性別は男性36例,女性11例で平均年齢は61.5±16.3歳であった。方法は心拍再開後に心エコーを経時的に記録し,M-モードエコーグラムよりTeichholzの方法により左室駆出分画(EF)を求め,心肺停止から心拍再開までの時間(心停止時間)とEFの回復過程との関係について検討した。結果は心肺停止例の心停止時間は1～60分であり,平均では24.6±14.6分であった。心停止時間と心拍再開後1日以内のEFの関係では心停止時間が5分未満ではEFは69.2±10.9%, 5～30分未満では62.1±10.4%, 30分以上では57.9±11.0%で,心停止時間が長い程心機能の有意な低下がみられた。つぎに心拍再開後の心機能の経時的回復過程では,1日以内,2～3日後,7～15日後のEFはそれぞれ61.1±11.8%, 60.5±9.0%, 67.6±9.2%と心機能は3日以後に有意な回復がみられた。さらに心停止時間が30分未満の群と30分以上の群でEFの変化を比較すると30分未満の群では有意に回復がみられたが,30分以上の群では差はなかった。また年齢とEFの相関はみられなかった。結論として心拍再開後の心機能は心停止時間が長いほど低下がみられ,心拍再開後の心機能の回復には数日を要し,心停止時間が長い例では心機能の回復も悪かった。以上より心拍再開後後の心筋もstunned myocardiumの病態が存在するものと推察された。

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目的:左主幹部(LMT)梗塞は,病院到着前に心肺停止(CPA)に陥る例や病院到着時すでにショックに陥っている例が多く,その心電図所見と予後の関係は明らかでない。そこで本研究の目的はLMT梗塞の急性期心電図所見を分析し,その予後を明らかにすることとした。方法:対象は来院時心肺停止症例を含め緊急冠動脈造影(CAG)を施行した急性心筋梗塞(AMI) 414例のうち,LMTが閉塞していた10例とした。そして,この10例の収容時および心拍再開時の心電図所見と予後の関係を検討した。結果:死亡率は70% (7/10)で,その死因はLOSが6例,心破裂が1例であった。収容時または心拍再開時の心電図所見と予後の関係は,narrow QRS波形では75% (3/4)が生存し,wide QRS波形では全例(6/6)が死亡した。そして,このwide QRS波形のV1誘導はrR'型が4例,R型は2例であった。総括: wide QRSを呈したLMT梗塞は最重症AMIであり全例が死亡した。そして,このQRS波形はV1誘導がrR'またはR型右脚ブロックパターンを呈する特徴を有していた。一方,narrow QRSを呈したLMT梗塞例は,その後の再灌流療法などの治療が功を奏すると予後は比較的良好となった。

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A 19-year-old woman, status post an uneventful pregnancy and delivery, developed a severe migranous headache and visual loss at 2 hours post partum. Computed tomography demonstrated ischemia and edema in the bilateral parietooccipital cortices. Magnetic resonance imaging (MRI) ruled out cerebral sinus thrombosis. Magnetic resonance imaging angiography (MRA) did not reveal remarkable abnormal findings in the major arteries. Cerebral angiography revealed circulation disorder of the bilateral posterior cerebral arteries in the capillary phase. The patient recovered with conservative therapy. The ischemic lesion associated with eclampsia often affects the parieooccipital cortices and basal ganglia. In such cases, the ischemic lesions are often reversible, and the symptoms resolve quickly, usually within a week. Conservative therapy is warranted when major artery stenosis or venous thrombosis can be excluded. Careful follow-up is essetial, however, as cases in which the vasospasm worsened and the patient died have been reported.

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Two cases of HELLP syndrome are reported. Case 1: A 23-year-old primigravid woman, presented at 35 weeks' gestation with uterine contractions and vaginal bleeding. Her laboratory data showed elevated liver enzymes and low platelet count. She was suspected to have HELLP syndrome, and an emergency cesarean section was performed with delivery of a 2, 090g female infant. After delivery, jaundice and oliguria were noticed and the mother lost conscious due to severe hypoglycemia. A glucose infusion, a large volume of fresh frozen plasma and protease inhibitors were administered intravenously. She regained consciousness quickly and recovered without neurological deficits. Case 2: A 31-year-old woman, para 3, gravida 4, complained of nausea, vomiting and epigastralgia. Her blood pressure was elevated and laboratory data showed elevated liver enzymes, low platelet count and hemolysis. She was diagnosed as having HELLP syndrome and an emergency cesarean section was performed with delivery of a 1, 024g male and a 924g female infant. After delivery, oliguria was noticed and platelet count dropped to as low as 18, 000/mm³. This patient also received a large volume of fresh frozen plasma and protease inhibitors. These two cases showed high levels of maternal plasma endothelin in the first postoperative week and case 2 showed elevated tissue polypeptide antigen. These two mediators may play an important role in this syndrome.

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We present a case of pure puffer fish poisoning who developed prolonged ataxia without persistent muscle weakness. Impaired peripheral nerve conduction was suggested to be the cause of the prolonged ataxia. A 40-year-old male, a licensed puffer fish chef, tasted a piece of puffer fish liver when his stomach was empty. Approximately 20 minutes later he recognized numbness in the fingers and lips, the onset of generalized muscle weakness and paresthesia. He was admitted to our hospital for the management of progressive motor weakness one hour after ingestion. Spontaneous breathing disappeared 90 minutes after ingestion. After six hours of mechanical ventilation, spontaneous breathing resumed. Motor paralysis and paresthesia improved within 20 hours, while dizziness persisted for several days, which was not attributable to alcohol in this case. Neurological examination showed prolonged ataxia; he could not stand on one foot until the third hospital day. Serial peripheral nerve conduction velocity studies revealed decreased conduction velocities. In particular, conduction velocities of the sensory nerve were more seriously impaired and required a longer recovery time as compared to those of the motor nerve. Since tetrodotoxin does not affect the central nervous system, such prolonged ataxia in puffer fish poisoning is presumably attributable to decreased peripheral nerve conduction velocities.

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We report a case of post-traumatic delayed stricture of the small bowel. An 11-year-old girl wearing a 2-point seat belt while riding as a passenger in a car was injured. Her demonstrable injuries were an L3 Chance fracture and contused seat belt scar in the lower abdomen. Symptoms of bowel obstruction began 9 days after the injury but then improved. On the 21st day, symptoms of bowel obstruction worsened rapidly, necessitating surgery. Four annular stricture lesions were revealed. Three were resected and one was treated conservatively. Mesenteric injury was slight. Histological findings were Ul-IV and no ischemic change. The time elapsed from the injury to the appearance of these symptoms was approximately 12 days. Laparotomy is important in considering resection. The main causes of this disease are circulatory disorders and inflammatory adhesions, but in our case the source was an organic change in the curative course of small bowel injury.

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