Carbon Monoxide Poisoning with Reversible Hemiparesis: Case Reports

Carbon monoxide (CO) is a tasteless, odorless, and non-irritating but highly toxic gas. CO intoxication is not uncommon in South Korea. Clinical presentations of CO poisoning varied according to the sources of CO, the patient's environment, job, and suicidal intention. We report on two cases of CO intoxication presenting hemiparesis. After hyperbaric oxygen therapy, initial neurologic deterioration of the two patients showed improvement. Emergency physicians should understand the possible-neurologic presentations of CO intoxication and make a proper decision regarding treatment.

Magnetic Resonance Imaging for the Prediction of Delayed Neuro-psychiatric Sequelae in Patients with Carbon Monoxide Poisoning

PURPOSE: Delayed neuropsychiatric sequelae (DNS) encompass a broad spectrum of neurological deficits, cognitive impairments, and affective disorders which commonly occur after a recovery from acute carbon monoxide (CO) poisoning. The early identification of patients with a high risk of DNS might improve their quality of care. Thus, we studied the role of magnetic resonance imaging (MRI) for the prediction of DNS. METHODS: This retrospective study included 41 patients with CO poisoning from January 2009 to June 2012. Magnetic resonance imaging (MRI) was performed within seven days after CO poisoning. Positive MRI findings were defined as focal or diffuse signals in fluid-attenuated inversion recovery (FLAIR), diffusion weighted imaging (DWI), and T2 weighted imaging (T2WI). DNS was considered present when patients had clinical symptoms and signs of DNS within 3 months after CO poisoning. Clinical and biohumoral data were collected; univariate and multivariate statistical analyses were performed to identify the predictive role of MRI for DNS. RESULTS: DNS occurred at a rate of 58.5%, with abnormal MRI findings associated with the development of DNS in the multivariate analysis. The sensitivity of MRI to DNS was 82.6%. In contrast, a normal MRI was seen in eighteen patients (43.9%). MRI revealed abnormalities in the deep white matter (41.5%), globus pallidus (34.1%), cerebral cortex (12.2%), medial temporal lobe (MTL)/hippocampus (7.3%), and cerebellum (4.9%). Among the MRI abnormalities revealed, lesions in the deep white matter were significantly associated with DNS development. Abnormal findings of the globus pallidus, cerebral cortex, MTL/hippocampus, and cerebellum were not associated with DNS development. CONCLUSION: This study demonstrates the utility of early MRI for the prediction of DNS. Future studies will be required to ascertain the prevention of DNS with hyperbaric treatment in CO poisoning.

Clinical Features of Spontaneous Isolated Superior Mesenteric Artery Dissection

PURPOSE: Spontaneous isolated superior mesenteric artery dissection (SISMAD) is defined as superior mesenteric artery (SMA) dissection without an associated aortic dissection. SISMAD is an uncommon mesenteric ischemia, but can lead to death if not recognized early. Here, we present our experience on features characterizing SISMAD in an early period and review imaging findings. METHODS: Twelve symptomatic SISMAD patients who received conservative treatment between March 2005 and February 2012 were included in this study. Their clinical characteristics, imaging findings, treatment methods and outcomes were retrospectively analyzed. A diagnosis of SISMAD was confirmed by multidetection computed tomography (MDCT) and computed tomographic (CT) angiography. RESULTS: All patients complained of severe (6 patients) or moderate abdominal pain (6 patients), and 4 patients complained of radiating back pain at the same time. Eight patients had an acute onset (< or =3 days) of abdominal pain, and 4 patients had a chronic onset of the abdominal pain. The abdominal pain was located in the upper abdomen in 7 patients and in the periumbilical area in 5 patients. Angiographic types of SISMAD were classified into Sakamoto's type I (3 patients), type II (1), type III (4), and type IV (4). The dissection occurred within 3 cm from the orifice of the SMA in 9 patients (75%). The angiographic type of SISMAD was not associated with clinical symptoms and treatment methods. Ten out of 12 patients were treated with conservative management such as expectation and anticoagulation. Aneurysmal dilation of the SMA was noted in 4 patients, and 2 patients out of these 4 underwent surgical operations due to persistent abdominal pain and a growing aneurysm. No patients had a recurrence of symptoms and lesion progression on follow-up CT angiography. CONCLUSION: Patients with an acute onset of severe abdominal pain or chronic persistent abdominal pain should be suspicious of SISMAD and CT angiography should be performed.

Moderate Head Injury: Predictors of a Repeat CT Scan

PURPOSE: A moderate head injury (Glasgow coma scale 9-13) has the large variability of severity, which accounts for the wide variability in the progression of lesions and in outcomes. Computed tomography (CT) is the standard diagnostic method for head injury, and repeat CTs (RCTs) are often obtained in order to monitor for progression of intracranial lesions. The purpose of this study was to suggest guidelines for RCT for moderate head injury. METHODS: In this study we reviewed data for 219 patients with moderate head injury who were admitted to our hospital via the emergency department between January 2004 and December 2009. The main outcome was worse progression of the intracranial lesions on RCT and neurosurgical intervention. Univariate and multivariate analyses were done for clinical variables to identify risk factors for progression of intracranial lesions and neurosurgical operations. RESULTS: On RCT, progression of injury was seen in 30.1% of patients, and neurosurgical intervention was performed in 14.6% of patients. Sixty percent of CT progression and ninety percent of neurosurgical intervention were occurred in patients with neurological deterioration. Independent risk factors associated with neurosurgical operation were coagulopathy (OR=13.275), amount of intracranial hemorrhage (OR=8.539), Marshall diffuse injury type of III/IV (OR=4.455), and skull fracture (OR=4.495). CONCLUSION: Routine repeat CT is necessary within 6 hour and 24-48 hour post-injury in patients with moderate head injury and without neurological deterioration.

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.