Embolismo cerebral durante vuelo comercial: reporte de caso / Cerebral embolism during commercial flight: case report

RESUMEN Presentamos el caso de un varón de 25 años con antecedentes de consumo de marihuana y tabaco, que durante viaje en vuelo comercial a Cusco presentó disnea, pérdida de conciencia y estado epiléptico. Arribó a esta ciudad presentando hipotensión arterial, murmullo pulmonar abolido, sin recuperación de conciencia. La tomografía de tórax reveló bullas pulmonares y la tomografía mostró neumoencéfalo, diagnosticándose embolia gaseosa cerebral. La hipoxemia asociada a convulsiones y pérdida de conciencia en una persona joven durante el vuelo no es un evento común. La pérdida de la presión en la cabina durante el ascenso parece ser el evento desencadenante en pacientes con enfermedad pulmonar.

ABSTRACT We present the case of a 25-year old man with a history of marijuana and tobacco consumption who, during a commercial flight to Cusco, presented dyspnea, loss of consciousness, and epileptic condition. He arrived in this city presenting arterial hypotension, abolished pulmonary murmur, with no recovery of consciousness. The thorax tomography revealed lung bullae and the tomography showed pneumocephalus. He was diagnosed with cerebral gas embolism. Hypoxemia associated with seizures and loss of consciousness in a young person during a flight is not a common event. Loss of cabin pressure during climb appears to be the triggering event in patients with lung disease.

Intermittent loss of consciousness during cesarean section under spinal anesthesia: a case report / Perda intermitente de consciência durante cesariana sob raquianestesia: relato de caso

Abstract Loss of consciousness during spinal anesthesia is a rare but scary complication. This complication is generally related to severe hypotension and bradycardia, but in this case, the loss of consciousness occurred in a hemodynamically stable parturient patient. We present a 31 years-old patient who underwent an emergency cesarean section. She lost consciousness and had apnea that started 10 minutes after successful spinal anesthesia and repeated three times for a total of 25 minutes, despite the stable hemodynamics of the patient. The case was considered a subdural block, and the patient was provided with respiratory support. The subdural block is expected to start slowly (approximately 15-20 minutes), but in this case, after about 10 minutes of receiving anesthesia, the patient suddenly had a loss of consciousness. After the recovery of consciousness and return of spontaneous respiration, the level of a sensory block of the patient, who was cooperative and oriented, was T4. There were motor blocks in both lower extremities. Four hours after intrathecal injection, both the sensory and motor blocks ended, and she was discharged two days later with no complications. Hence, patients who receive spinal anesthesia should be closely observed for any such undesirable complications.

Resumo A perda de consciência durante a raquianestesia é uma complicação rara, mas assustadora. Essa complicação geralmente está relacionada à grave hipotensão e bradicardia, mas, neste caso, a perda de consciência ocorreu em uma paciente parturiente hemodinamicamente estável. Apresentamos o caso de uma paciente de 31 anos, submetida a uma cesariana de emergência. A paciente perdeu a consciência e apresentou apneia que teve início 10 minutos após a raquianestesia bem-sucedida e repetiu o episódio três vezes por 25 minutos, a despeito de sua hemodinâmica estável. O caso foi considerado como um bloqueio subdural e a paciente recebeu suporte respiratório. Espera-se que o bloqueio subdural inicie lentamente (aproximadamente 15-20 minutos), mas, neste caso, cerca de 10 minutos após a anestesia, a paciente repentinamente perdeu a consciência. Após a recuperação da consciência e o retorno da respiração espontânea, a paciente que estava orientada e cooperativa apresentou nível de bloqueio sensorial em T4. Havia bloqueio motor em ambas as extremidades inferiores. O bloqueio sensório-motor terminou quatro horas após a injeção intratecal e a paciente recebeu alta hospitalar dois dias depois, sem complicações. Considerando o exposto, os pacientes que recebem raquianestesia devem ser atentamente observados para quaisquer complicações indesejáveis.

Lifetime Prevalence of Transient Loss of Consciousness in an Urban Russian Population / Prevalência de Perda de Consciência Temporária em População Russa Urbana

Abstract Background: Most international studies on epidemiology of transient loss of consciousness (TLC) were performed many years ago. There are no data about the lifetime prevalence of TLC in Russia. Objective: To identify the lifetime prevalence and presumed mechanisms of TLC in an urban Russian population. Methods: 1796 individuals (540 males [30.1%] and 1256 females [69.9%]) aged 20 to 69 years (mean age 45.8 ± 11.9 years) were randomly selected and interviewed within the framework of multicentre randomised observational trial. Results: The overall prevalence of TLC in the studied population was 23.3% (418/1796), with the highest proportion (28%) seen in 40-49 year age group. TLC was significantly more common in women than in men (27.5% vs 13.5%). The mean age of patients at the time of the first event was 16 (11; 23) years, with 333 (85%) individuals experiencing the first episode of TLC under 30 years. The average time after the first episode of TLC was 27 (12; 47) years. The following mechanisms of TLC were determined using the questionnaire: neurally-mediated syncope (56.5%), arrhythmogenic onset of syncope (6.0%), nonsyncopal origin of TLC (1.4%), single episode during lifetime (2.1%). Reasons for TLC remained unidentified in 34% cases. 27 persons (6.5%) reported a family history of sudden death, mainly patients with presumably arrhythmogenic origin (24%). Conclusion: Our findings suggest that the overall prevalence of TLC in individuals aged 20-69 years is high. The most common cause of TLC is neurally-mediated syncope. These data about the epidemiology can help to develop cost-effective management approaches to TLC.

Resumo Fundamento: A maioria dos estudos internacionais sobre epidemiologia da perda de consciência temporária (PCT) foi realizada há muitos anos. Não há dados sobre sua prevalência ao longo da vida na Rússia. Objetivo: Identificar a prevalência ao longo da vida e os supostos mecanismos da PCT em uma população russa urbana. Métodos: 1.796 indivíduos (540 homens 30,1% e 1.256 mulheres 69,9%) com idade entre 20 e 69 anos (idade média, 45,8 ± 11,9 anos) foram selecionados aleatoriamente e entrevistados no contexto de um estudo multicêntrico randomizado observacional. Resultados: A prevalência global de PCT na população estudada foi 23,3% (418/1.796), sendo a mais alta proporção (28%) observada na faixa etária de 40-49 anos. PCT foi significativamente mais comum nas mulheres (27,5% vs 13,5%). A idade média dos pacientes por ocasião do primeiro evento foi 16 (11; 23) anos, com 333 (85%) indivíduos experienciando o primeiro episódio de PCT antes dos 30 anos. O tempo médio após o primeiro episódio de PCT foi 27 (12; 47) anos. Os seguintes mecanismos de PCT foram determinados usando-se um questionário: síncope neuromediada (56,5%), síncope de origem arritmogênica (6,0%), PCT de origem não sincopal (1,4%), episódio único durante a vida (2,1%). A causa de PCT não foi identificada em 34% dos casos, sendo que 27 pacientes (6,5%) relataram história familiar de morte súbita, principalmente aqueles com PCT de suposta origem arritmogênica (24%). Conclusão: Nossos achados sugerem uma alta prevalência global de PCT em indivíduos com idade entre 20 e 69 anos. A causa mais comum de PCT é a síncope neuromediada. Esse dado sobre a epidemiologia pode contribuir para o desenvolvimento de abordagem custo-efetiva para PCT.

Silvery hair with bronze-tan in a child: A case of Elejalde disease.

A 5-year-old boy was admitted for severe neurological impairment including hypotonia and loss of consciousness without preceding febrile illness. On examination, he had silver colored hair and bronze-tan over photo-exposed body parts. He was born of consanguineous parents and three of his elder siblings, who died in early childhood, had similar colored hair. Complete blood count and serum immunoglobulin levels were within normal limits. Peripheral blood smear did not show any cytoplasmic granules in neutrophils. Cerebro-spinal fluid examination did not reveal any abnormality. Light microscopic examination of the hair revealed irregular clumping of the melanin throughout the shafts. The patient died on the second day following admission. A clinical diagnosis of Elejalde disease was made. The clinical and genetic overlapping of the three silvery-hair syndromes has been discussed.

A case of left atrial myxoma: anaesthetic management.

Left Atrial Myxomas are notorious for their varied presentations. We describe one such case which initially presented with hemiparesis and seizures and was diagnosed as cerebral infarction and treated accordingly and decompression craniotomy with hinge flap was done for raised ICP and impending brain herniation. The main cause was a left atrial myxoma, which was diagnosed only in follow up. The myxoma has embolised to give rise to cerebral infarction. The LA myxoma was then successfully operated under general anaesthesia and Cardiopulmonary bypass (CPB).

Macroscopic T wave alternans in long QT syndrome.

A 6 year old girl was admitted with recurrent episodes of loss of consciousness. ECG showed prolonged QT interval and macroscopic T Wave alternans. Identification of this ECG pattern is important since it can lead to potentially lethal arrhythmias.

Statistical analysis of astrocytic glioma

Fifty patients of both sexes of Astrocytic Glioma from Sheikh Zayed Hospital and Lahore General Hospital Lahore were included in this study. Ten normal brain tissues [control] were taken from accident cases. Out of 50 study cases there were 16 [32%] were low grade [I-II] Astrocytic Glioma and 34 [68%] were high grade Astrocytic Glioma. The male to female percentage was found out to be 26 [52%] and 24 [48%] respectively. Among the males, 11 [22%] were in grade I-II while 15 [30%] were in grade III-IV Astrocytic Glioma, while 5 [10%] females were in grade I-II and 19 [38%] were in grade No statistical sex difference was seen in the ratio of male and female who developed Astrocytic Glioma [P>0.05]. The ages of the patients ranged from 10 to 76 years with maximum number of cases in the age group 30-49 years. In this age group, 11 [22%] patients had grade I-II while 20 [40%] were in grade type of Astrocytic Glioma. The statistical difference of age in different groups was found to be highly significant, [P<0.01]. The most common presenting complaints were headache, vomiting, weakness of limbs, loss of orientation and giddiness. These were observed mainly in grade III-IV Astrocytic tumors. The complaints of difficulty in speech, papilloedema and fits were observed often with an almost equal ratio in all grades of Astrocytic Glioma. The loss of consciousness was observed only in Grade III-IV tumors. The most common site of Atstorcytic Glioma was Parietal lobe and Fronto-parietal lobe constituting 9 [18%] in grade I-II and 15 [30%] in grade HI-IV Astrocytic Gliomas, that is statistically significant, [P<0.05]. The most common site of Astrocytic Glioma was Parietal lobe, 17 out of 50 [7 in grade I-II and 10 in grade III-IV], while the second most common site of this tumor was Temproparietal region, [4 in grade I-II and 6 in grade III-IV]. There were 29 Astrocytic Gliomas in right lobe [10 in grade I-II, and 19 in grade III-IV], while 18 in left lobe [5 in grade I-II and 13 in grade III-IV]. This was statistically highly significant, [P<0.01]. High grade Astrocytic Glioma was also present in Thalamus, mid brain, and Interventricular septum

Greyout, blackout e perda de consciência induzida pelas aceleraçöes na Força Aérea Brasileira: um estudo em 1991-92 / Greyout, blackout and loss of conciousness induced by acceleration in the Brazilian Air Force: a study in 1991-92

A national survey wiyh high and medium performance aircraft pilots on the incidence of symptoms duee to + Gz acceleration has been performed, in order to make up a human centrifuge physiological training profile directed to the needs of the Brazilian Air Force pilots. Anonymous questionnaires were sent to flight Squadrons of F-5, AMX, Mirage F-103, Xavante AT-26 and Tucano T-27. They consisted of inquiries about the ocurrence of visual symptoms and/or loss of consciouness during + Gz maneuvers, and post G-LOC symptoms, 23 pilots (11.92 per cent) reported greyout and/or loss of peripheral vision; 40 (20.72 per cent) blackout; 20 (10,36 per cent) G-LOC. Those who reported LOC also reported post G-LOC symptons (100 per cent), being 16 (80 per cent) gradual and 4 (20 per cent) instantaneous. Incidence of G-LOC was not found to depend upon the type pf aircraf flown (p>0.05). Considering the pilots who reported G-LOC, 80 per cent were preceded by blackout, which could allow them to relieve + Gz load before they would reach their endpoint for the ocurrence of G-LOC. For these reasons we recommend intensive human centrifuge training periodically, similar to the hypocia-recognition symptoms test in the low-pressure chamber, not only for high performance aircraft pilots but as well as for any pilot who can perform aerobatics (thus exposing himself to the adverse effects of "pulling G"), in order for each pilot to recognize his consciousness endpoint when undergoing + Gz maneuvers, in a controlled and safe environment.

Malignant insulinoma presenting with recurrent episodic loss of consciousness.

A 57 year old male presented with episodic behavioural abnormalities and loss of consciousness for 2 years. His fasting blood glucose was 20 mg/dl and corresponding insulin level 119 uU/ml. His EEG showed intermittent rhythmic delta activity. Abdominal CT scan revealed an enhancing mass in the tail of the pancreas and secondaries in the liver. After distal pancreatectomy, resection of the left lobe of the liver and chemotherapy, the hypoglycaemic spells subsided. Histopathology revealed an islet cell tumour with metastases in the liver. Episodic neurobehavioural dysfunction should alert towards the possibility of hypoglycaemia.

Análisis clínico de 5 casos de intoxicación alcohólica en niños menores de 10 años / Alcohol intoxication in children younger than 10 years: a review of 5 cases

Se analizan cinco casos de intoxicación alcohólica en menores de 10 años egresados del Hospital de Temuco durante 1984-1986. La mayoría de los pacientes son de sexo masculino, residencia rural y la bebida fue ingerida con el consentimiento de los adultos responsables de ellos. En el cuadro clínico se destaca el compromiso de conciencia, hipertonía, trismus y convulsiones, las que sólo en un caso se relacionaron con hipoglicemia. La recuperación del estado psicomotor previa fue muy lenta en los menores de 3 años. Se comenta la necesidad de dar a conocer los peligros de la ingesta etílica infantil y de tener presente el diagnóstico de intoxicación alcohólica ante un paciente con compromiso de conciencia sin causa evidente