Three patients with acute subdural hematoma (SDH) caused by a ruptured intracranial aneurysm were admitted in a comatose state with signs of cerebral herniation. In one patient, while the SDH was evacuated by an emergency craniotomy, cerebral angiography was performed. Aneurysmal neck clipping was performed during the same operation. The man made a good recovery. In the other patients, while the SDH was irrigated by emergency trepanation, cerebral angiography was performed. These hepatomas were inoperable and the 2 patients died the day after admission. Several recent reports have suggested that SDH evacuation with craniotomy and aneurysmal neck clipping should be conducted simultaneously. However, the start of a one-stage operation for SDH and ruptured aneurysm is usually delayed several hours due to the need for preoperative examinations including angiography. A portable digital imaging system (PDIS) showing real time subtraction images is useful for finding critical vascular anomalies. The authors emphasize that a one-stage operation can be started within 50 minutes after admission by using a PDIS.
This is the first report of an aorto-caval fistula resulting from an inflammatory abdominal aortic aneurysm (IAAA) in Japan. A 78-year-old man was admitted to a local hospital with dyspnea and leg pains. Angiography revealed an aorto-caval fistula adjacent to the aortic bifurcation. He was transferred to our institute for surgical repair on the 19th day after the onset. On admission he was in shock due to “high output cardiac failure”. His cardiac index was 6.20l/min/m2 and his systemic vascular resistance index was 606dyn·sec/cm5/m2. The IAAA was exposed at the operation. The fistula was closed by using the anterior wall of the aneurysm as a patch. The aneurysm was replaced with an aorto-iliac graft. Most aorto-caval fistulas result from rupture of an atherosclerotic abdominal aortic aneurysm. Only six cases of aorto-caval fistulas resulting from an IAAA have been reported. None of the patients had symptoms of cardiac failure. Ours is the first case of an aorto-caval fistula resulting from an IAAA with symptoms of cardiac failure.
A 54-year-old man developed transient cardiac arrest due to malignant hyperthermia (MH) during clipping of a cerebral aneurysm. He was found to have unruptured middle cerebral artery aneurysms on both sides. At the first operation, on the left aneurysm, anesthesia was induced by thiopental and vecronium and maintained by isoflurane, nitrous oxide and oxygen. He suddenly developed cardiac arrest soon after an arrythmia of grade 3 A-V block which occurred 6.5 hours after the operation had started. Fortunately the heart recovered after 20 minutes of cardiopulmonary resuscitation. After this accident, the rectal temperature rose to 41.5°C with the manifestation of macro hematuria, metabolic acidosis, and elevation of the levels of serum enzymes GOT, LDH, and CPK. At this point, we suspected MH. Five weeks after the first operation, the second operation, on the right aneurysm was performed. Before anesthesia, dantrolene sodium was administered and a percutaneous pacemaker was inserted intravenously. Balance anesthesia was induced and the second operation was completed uneventfully. We should keep in mind that dantrolene should always be prepared and injected immediately under general anesthesia whenever MH is suspected.
Patients with traumatic transection of the thoracic aorta are now more frequently seen in the Emergency Department due to an increase in the number of high-speed motor vehicle collisions and improvements in the Emergency Medical System. Although transection of the aorta is usually fatal, patients who survive long enough to undergo surgery have a good prognosis. In this report, two cases of complete thoracic aortic transection are described. Both patients were involved in motor vehicle collisions. The first, a 52-year-old woman, underwent emergent angiography and aortic repair within 3 hours of admission. The second patient, a 39-year-old man, underwent hepatic lobectomy immediately after admission, and aortic repair the following day. In the setting of complete thoracic aortic transection with multisystem trauma, a flexible strategy is probably the most important measure impacting survival.