Operative Timing in Patients with Traumatic Acute Subdural Hematomas

PURPOSE: Acute traumatic subdural hematoma (SDH) increases after severe traumatic brain injury (TBI) and leads to high mortality. The time to operation is a correctable prognostic factor in TBI, but the timing of hematoma evacuation still remains controversial. We assessed the correlation between operative timing and mortality in traumatic acute SDH. METHODS: We conducted a retrospective study over an 8-year period in 163 surgical patients with acute traumatic SDH. Information was obtained about demographic, clinical, and radiological findings, surgical management, and mortality at discharge. RESULTS: Overall, 85 patients (52.1%) died, and 47 patients (28.8%) showed good recovery. The patients who underwent earlier surgery were more likely to have severe head injury. The time to operation in patients that died was shorter than patients with good recovery. The mean time for evacuation [Ed-Is this the same as time to surgery, or is this specifically when the hematoma was removed? Please clarify.] was 351.7+/-220.5 minutes in patients who died and 395.5+/-363.3 minutes in patients with good recovery. Patients undergoing surgery within 4 hours of injury had a mortality rate of 54.4% versus 50.9% receiving surgery after 4 hours. But the risk ratio for time spent to surgery increased until 240 minutes and then decreased. Logistic regression on patients with 240 minutes until surgery showed that the probability of death increased with time to surgery. CONCLUSION: Patients who undergo surgery within 180 minutes after injury have a lower probability of death than those with delayed surgery.

Acute Cardiac Ischemia in Young Adults: Characteristics and Risk Factors

PURPOSE: Acute cardiac ischemia under the age of 45 years is uncommon. This study was to evaluate the prevalence of various risk factors, the angiographic characteristics, and the prognosis in young patients with acute cardiac ischemia compared with that in older patients. METHODS: A review was retrospectively done of 554 patients with acute cardiac ischemia from January 2002 to December 2002. The patients were divided into two groups: patients under 45 years old (75 patients) and patients over 45 years old (479 patients). The clinical features which were compared between the two groups were demographic features, risk factors (cigarette smoking, history of hypertension and diabetes, hypercholesterolemia, hypertriglyceridemia, and family history of ischemic cardiac disease), coronary angiographic findings, and prognosis. RESULTS: The incidence of acute cardiac ischemia in patients under 45 years old was 13.5% (75/554). Three clinical risk factors, a history of cigarette smoking, a positive family history coronary artery disease, and hypertriglyceridemia, were significantly more prevalent in the young patients. Angiographically, normal or minimal coronary obstructions were more frequently found in the young patients, and significant coronary obstructions were more frequently found in the older patients. However the incidences of single-vessel disease and multi-vessel disease between young patients and older patients were not different. Young patients with acute cardiac ischemia do not have a more favorable prognosis than older patients. CONCLUSION: Acute cardiac ischemia is found in young patients with less extensive disease, but young patients do not have a more favorable prognosis than older patients.

Effect of Fibrinolytic Therapy in Reperfusion of the Coronary Artery on the Prognosis in Acute Myocardial Infarction

PURPOSE: The most significant advance in treatment of acute myocardial infarction is reperfusion therapy with fibrinolytics and percutaneous coronary intervention (PCI). The aim of this study was to assess the efficacy of reperfusion and the clinical outcomes of patients with acute myocardial infarction (AMI) who underwent fibrinolytic therapy. METHODS: A retrospective chart review was done for 226 patients with acute myocardial infarction who met the criteria for fibrinolytic therapy. We compared the thrombolysisin-myocardia-infarction (TIMI) flow in angiography of the infarct-related artery and the clinical outcomes between patients with and without fibrinolytic therapy. Also we analyzed the effects of fibrinolytics in various treatment modalities. The clinical outcomes included the 30-day mortality, repeat AMI/unstable angina, and coronary artery bypass graft (CABG). RESULTS: Angiography after fibrinolytic therapy revealed TIMI grades 0/1, 2, or 3 flow in 15.1%, 21.4%, and 63.5% of vessels, respectively, but in patients without fibrinolytic therapy those percent were 35.0%, 26.0%, and 39.0%, respectively. A significantly increased mortality was seen in patients with lower TIMI grade flow (11.1%, 0%, and 0.8% with TIMI grade 0/1, 2 and 3, respectively, p =0.001). The 30-day mortality were significantly lower in patients with fibrinolytic therapy than in patients without fibrinolytic therapy, particularly in patients with TIMI grade 0-2 flow. There was no significant difference in the 30-day mortality and the clinical outcomes among patients with fibrinolytic therapy, emergency PCI, and delayed PCI. CONCLUSION: Fibrinolytic therapy improved the TIMI flow in angiography and reduced the 30-day mortality.

Diagnostic Value of Cardiac STATus(TM) for Diagnosing Acute Cardiac Ischemia in Patients with Acute Chest Pain in an Emergency Settings

PURPOSE: The purpose of this study was to investigate the usefulness of a qualitative bedside test for detection of cardiac troponin I (Cardiac STATus(TM)) in evaluating patients with acute chest pain in emergency settings. MATERIAL AND METHODS: In 147 patients who had chest pain without ST-segment elevation on their electrocardiograms, we evaluated the sensitivity and the specificity of the new, rapid, bedside troponin I assay for acute myocardial infarction (AMI) and acute cardiac ischemia (ACI). Patients whose samples were taken at least 4 hours after the onset of pain were selected. RESULTS: Cardiac STATus(TM) was positive in 28 patients (19.0%). Among 31 patients with AMI, Cardiac troponin I was positive in 19 (61.3%) patients. Among 95 patients with ACI, Cardiac STATusT M was positive in 24 patients (25.3%). The results were false positive in 12/31 patients (38.7%) for AMI and in 71/119 patients (59.7%) for ACI. The negative predictive value of the Cardiac STATus(TM) was 90.5% for AMI and 65.0% for ACI. During the 30 days of follow-up, there were 4 deaths and 12 cases of non-fatal AMI. Cardiac troponin I proved to be independent predictor of cardiac events. CONCLUSION: In contrast to its excellent specificity (0.92), the sensitivity (0.61) of the Cardiac STATus(TM) assay was poor. Thus, we conclude that this test is not highly sensitive for early detection of myocardial-cell injury. Negative test results were associated with low risk, but did not allow safe discharge of patients with chest pain from the emergency setting. Positive results of Cardiac STATus(TM) were associated with unfavorable outcomes.