Contralateral Mirror Image Spreading in Post-Stroke Complex Regional Pain Syndrome

The long-term prognosis of complex regional pain syndrome is difficult to predict because of its unclear pathophysiology. The syndrome can spontaneously spread to other regions in the body. We report a case in which a complex regional pain syndrome that occurred in a 75-year-old male patient after a stroke spread to the opposite side.

Which Neural Tract Plays a Major Role in Memory Impairment After Multiple Cerebral Infarcts? A Case Report

Injury to the thalamocortical tract (one in the Papez circuit) that leads to memory impairment following brain injury is very rare. In this study, we present a case of partial injury to the thalamocortical tract that causes memory impairment after concurrent thalamic and hippocampal infarct. A 20-year-old male complained of memory impairment 1 month after partial injury to the thalamocortical tract. Using a probabilistic diffusing tensor tractography, it was found that the right thalamocortical tract was thinner than the left thalamocortical tract. However, all other neural tracts including the fornix, cingulum, and mammillothalamic tract were intact on both hemispheres. Therefore, the memory impairment in this patient was considered as being due to thalamic infarct based on the observation that the fornix from hippocampal infarct was intact. This case suggests that the assessment of lesions in the neural tracts of the Papez circuit might be useful for understanding the mechanism of memory impairment following cerebral infarction.

Functional Improvement Following Revision Surgery in a Patient with the Dual Disability of a Complicated Residual Limb and Contralateral Hemiplegia: A Case Report

The number of reported cases with dual disability is increasing for the past few decades. Currently, dual disability of lower limb amputation and motor weakness after stroke became a strong issue in public concern. The functional levels of patients have shown in the wide range from independent community ambulation to non-ambulation. Thus, it indicates that favorable outcomes for dual disability may depend upon adopted rehabilitative strategies. We present the case of a man with left below-knee amputation and severe right-sided weakness following a huge putaminal hemorrhage. He had suffered from extreme pain and misfit of the prosthetic socket and the complicated residual limb for three years prior to the stroke. Forty days post-stroke, we performed a revision surgery to resolve the complications of bony overgrowth, verrucous hyperplasia, and neuroma and applied an ankle foot orthosis (AFO). Two years post-stroke, he was able to ambulate outside his home and negotiate stairs using a cane. This is the first case with the dual disability of lower limb amputation and contralateral hemiplegia to undergo revision surgery. The results suggest that an early revision surgery and use of an AFO are crucial for achieving a higher level of mobility in such cases.

Retraction: Aortic Dissection and Rupture in a Child

No abstract available.

Aortic Dissection and Rupture in a Child

After developing sudden severe chest pain, an 11-year-old boy presented to the emergency room with chest pain and palpitations and was unable to stand up. The sudden onset of chest pain was first reported while swimming at school about 30 minutes prior to presentation. Arterial blood pressure (BP) was 150/90 mmHg, heart rate was 120/minute, and the chest pain was combined with shortness of breath and diaphoresis. During the evaluation in the emergency room, the chest pain worsened and abdominal pain developed. An aortic dissection was suspected and a chest and abdomen CT was obtained. The diagnosis of aortic dissection type B was established by CT imaging. The patient went to surgery immediately with BP control. He died prior to surgery due to aortic rupture. Here we present this rare case of aortic dissection type B with rupture, reported in an 11-year-old Korean child.

Is Stem Cell-Based Therapy Going on or Out for Cardiac Disease?

Acute myocardial infarction and subsequent heart failure are leading causes of death worldwide. Stem cell-based therapies have improved cardiac function in recent clinical trials, but cardiomyocyte regeneration has not been demonstrated in human hearts. Angiogenesis and restoration of cardiac perfusion have been successfully performed using bone marrow derived stem cells and other adult stem cells. Resident cardiac stem cells are known to differentiate into multiple heart cell types, including cardiomyocytes. Furthermore, induced pluripotent stem cells are a focus of research due to the great potential for customized stem cell therapy.

Isolated Pulmonary Arterial Hypertension-Janus' Faces of Hyperthyroidism

We describe a 54-year-old woman with isolated pulmonary arterial hypertension accompanied by hyperthyroidism due to Graves' disease. Her pulmonary artery hypertension resolved spontaneously after restoration of euthyroidism. This case suggests that hyperthyroidism should be considered a reversible cause of pulmonary arterial hypertension.

Right Atrial Lipoma Presenting with Angina

We report a case of a cardiac lipoma arising from the free wall of right atrium, which was diagnosed as the presumed source of angina by compressing the right coronary artery in a 54-year-old woman. Surgical excision of the tumor was performed well. She continues to do well for six months without angina.

Factors of Cardiopulmonary Resuscitation Outcome for In-hospital Adult Patients / 대한구급학회지

BACKGROUND: The purpose of this study was to evaluate the factors of cardiopulmonary resuscitation (CPR) outcome for in-hospital adult patients, acquiring data with standardized reporting guideline of in-hospital cardiopulmonary resuscitation in Korea. METHODS: All adult cardiac arrest patients from July 2004 to December 2006 in this general hospital were included. Their clinical spectrums were reviewed retrospectively using Utstein-style based template. RESULTS: For the study time period, one hundred and forty-two patients underwent cardiac arrest in this hospital. 136 patients were performed CPR. Return of spontaneous circulation (ROSC) occurred in 42 cases, and 15 patients were survived to hospital discharge. A shorter CPR time and a lower Simplified Acute Physiology Score II (SAPS II) were significant for survivor to hospital discharge (p<0.01). Sex, age, and location in cardiac arrest were not attributed to survival to hospital discharge. CONCLUSIONS: In-hospital CPR patients, the high rate of ROSC and survival to hospital discharge were associated to the cause of arrest, shorter time of CPR, and lesser severity of disease (SAPS II). This result can be a great implication of survivor from CPR in-hospital adult patients in Korea. Further evaluation with consistent data acquisition of CPR using Utstein-style would contribute to improve CPR practice and outcome.

An Unusual Case of Exercise-Induced Idiopathic Brugada Electrocardiographic Pattern

An exercise-induced idiopathic Brugada electrocardiographic pattern during the effort phase is very rare. A 42-year-old male visited our cardiology clinic for chest discomfort. He has been treated for myocardial infarction 2 months ago. He underwent a treadmill test according to the Bruce protocol. Typical coved-type ST-segment elevation was found during the effort phase, and it gradually recovered after the exercise. The ST-segment elevation appeared to be unrelated to hypervagotonia. This elevation was not induced by a pharmacological test with flecainide. A significant ventricular arrhythmia was not induced by programmed ventricular stimulation. Hence, we discharged the patient without implantation of an implantable cardioverter defibrillator.

Delayed Rupture of Mycotic Hepatic Artery Aneurysm in a Patient with Infective Mitral Endocarditis-First Case in Korea

Mycotic aneurysms of the hepatic artery are usually caused by mycotic infection in patients suffering with bacterial endocarditis. Mycotic aneurysms have become very rare recently due to early intensive antibiotic treatment for infective endocarditis. Despite of the non-specific symptoms, these aneurysms show a high possibility of sudden death if thye ruptured. Therefore, early detection and surgical repair of aneurysms are very important. We report here on a case of hepatic artery mycotic aneurysm that presented as sudden shock and rupture.

Comparison of Impedance Cardiography with Thermodilution of Hemodynamic Parameters in Critically Ill Patients / 대한구급학회지

BACKGROUND: To evaluate the feasibility of noninvasive hemodynamic monitoring (impedance cardiography, ICG) in critically ill patients, we compared this technique with simultaneous invasive monitoring with a pulmonary artery thermodilution catheter. METHODS: A prospective observational study was done comparing invasive monitoring and noninvasive monitoring in 12 critically ill patients. The cardiac output (CO), the stroke volume (SV) and the systemic vascular resistance (SVR) measured by using a standard thermodilution pulmonary artery catheter technique were compared with the corresponding measurements simultaneously using an ICG. RESULTS: The value of CO, SV and SVR measured by ICG were closely correlated to those by the thermodilution methods [r: 0.659 (p<0.01), 0.536 (p<0.01), 0.738 (p<0.01)]. CONCLUSIONS: ICG can provide hemodynamic information previously available only by invasive monitoring with a thermodilution catheter.

Serum Levels of Advanced Glycation End Products Are Associated with In-Stent Restenosis in Diabetic Patients

The formation of advanced glycation end products (AGEs), in various tissues has been known to enhance immunoinflammatory reactions and local oxidant stresses in long standing diabetes. Recently, AGEs have been reported to play a role in neointimal formation in animal models of arterial injury. We attempted to determine whether the serum levels of AGEs are associated with coronary restenosis in diabetic patients. Blood samples were collected from diabetic patients with coronary artery disease undergoing stent implantation and the serum levels of AGEs were analyzed by the fluorescent intensity method. The development of in-stent restenosis (ISR) was evaluated by a 6-month follow-up coronary angiography. A total of 263 target lesions were evaluated, in 203 patients. The ISR rate in the high-AGE (> 170 U/ml) group (40.1%) was significantly higher than in the low-AGE group (< or =170 U/ml) (19.6%) (p < 0.001). Furthermore, multivariate analysis revealed that a high level of serum AGEs is an independent risk factor for the development of ISR (odds ratio, 2.659; 95% CI, 1.431-4.940; p=0.002). The serum levels of AGEs constitute an excellent predictive factor for ISR, and should be one of the guidelines for medical therapy and interventional strategy to prevent ISR in diabetic patients.

The Multiple Combined Oral Platelet Aggregation Inhibitors of Aspirin, Ticlopidine and Cilostazol after PCI

BACKGROUND AND OBJECTIVES: Along with intracoronary stenting, medications, such as Ca++ channel blocker, nitric oxide and some platelet aggregation inhibitors, have contributed to the reduction of coronary restenosis. However, restenosis still remains as a challenging dilemma, with a frequency of 20-50%. Aspirin and ticlopidine are known as a standard anti-platelet regimen following PCI, but cilostazol is a comparably effective drug, which has a different mechanism to that of ticlopidine. It is unknown if the triple combination of aspirin, ticlopidine and cilostazol could further reduce adverse events and restenosis. SUBJECTS AND METHODS: The clinical and angiographic data, which had been collected after PCIs at Wallace Memorial Baptist Hospital, between Jan. 2000 and Dec. 2001, were retrospectively analyzed. The patients had taken either aspirin+ ticlopidine or aspirin+ticlopidine+cilostazol, and the clinical observation and follow-up angiography was completed for 6 months. There were 111 (66 males) and 87 (male:57) in the aspirin+ticlopidine and aspirin+ ticlopidine+cilostazol groups, respectively. The rates of major adverse cardiovascular events (MACE) and restenosis were compared during the follow-up period. RESULTS: The frequency of MACE was similar, without a significant increase in the side effects during the follow-up period. The restenosis and target lesion revascularization (TLR) rates were significantly decreased in the triple combination therapy group (37.2% vs. 21.9%, p=0.006, 29.8% vs. 14.1%, p=0.008). CONCLUSION: This study showed that this triple combination of platelet aggregation inhibitors is a good combination therapy for the reduction of restenosis. It is suggested that these effects were probably due to more potent platelet inhibition by the multi-directional mechanism in addition to coronary vasodilation effect.

Wide QRS tachycardia during treatment with class ic antiarrhythmic agents in a patient with atrial fibrillation: report of 2 cases / 대한내과학회지

Wide QRS tachycardia may represent a rare proarrhythmic effect of some antiarrhythmic agents. Class Ic antiarrhythmic agents produce rate- dependent ventricular conduction slowing due to use-dependent sodium channel blockade, causing QRS prolongation in cases with an increased heart rate. The authors describe two cases of atrial flutter with 1:1 atrioventricular conduction exhibiting a wide QRS tachycardia while on therapy using flecainide and propafenone, and the difficulty in interpreting the ECG.

Wide QRS tachycardia during treatment with class ic antiarrhythmic agents in a patient with atrial fibrillation: report of 2 cases / 대한내과학회지

Wide QRS tachycardia may represent a rare proarrhythmic effect of some antiarrhythmic agents. Class Ic antiarrhythmic agents produce rate- dependent ventricular conduction slowing due to use-dependent sodium channel blockade, causing QRS prolongation in cases with an increased heart rate. The authors describe two cases of atrial flutter with 1:1 atrioventricular conduction exhibiting a wide QRS tachycardia while on therapy using flecainide and propafenone, and the difficulty in interpreting the ECG.

Upregulation of extracellular matrix metalloproteinase inducer (EMMPRIN) and gelatinases in human atherosclerosis infected with Chlamydia pneumoniae: The potential role of Chlamydia pneumoniae infection in the progression of atherosclerosis

Chlamydia pneumoniae infection implicated as an important etiologic factor of atherosclerosis, especially in coronary artery disease (CAD), was found in vitro to be associated with the induction of matrix metalloproteinases (MMPs). An extracellular matrix metalloproteinase inducer (EMMPRIN)/membrane-type 1 matrix metalloproteinase (MT1-MMP) system which induces and activates MMPs,is suggested to be functional and were upregulated in the failing myocardium. However, the upstream regulation of MMPs by C. pneumoniae within atheroma itself remains unclear. We evaluated the seroepidemiologic study of C. pneumoniae infection in CAD patients (n = 391) and controls (n = 97) and performed histopathological and in vitro analysis in atherosclerotic vascular tissues obtained from patients with seropositive to C. pneumoniae (n = 20), by using immunochemistry for C. pneumoniae, EMMPRIN/MT1-MMP, MMP-2, and MMP-9. The seropositive rates of both anti-C. pneumoniae IgG and IgA were 56.7% in CAD group and 43.3% in control group (P =0.033). Seropositive rate was increased in subgroups of CAD patients without conventional coronary risk factors compared to those with conventional risk factors. Immunoreactivities of EMMPRIN, MT1-MMP, MMP-2, and MMP-9 were increased in the atheromatous plaque itself, predominantly in immunoreactive macrophages/mononuclear cells to C. pneumoniae. Furthermore, Western blot analysis showed that EMMPRIN and MMP-2 were detected more prominently in atherosclerotic tissues infected with C. pneumoniae compared to control tissues. Zymographic analysis revealed that activities of MMP-2 and MMP-9 were more increased in atherosclerotic tissues infected with C. pneumoniae compared to control tissues. The present study demonstrated upstream regulation of MMPs can be induced by C. pneumoniae within atheromatous plaque itself. These findings help to understand the potential role of C. pneumoniae in the progression of atherosclerosis.

A Case of Primary Pericardial Hemagiopericytoma

Intracardiac hemangiopericytomas are rare tumors which originates from the pericyte in the external wall of capillaries. 1) The tumors are known to usually develop in the lower extremities, pelvic cavity and retroperitoneum, 2) but are very rare in the heart. 3) The symptoms and signs of a hemagiopericytoma depend on the size and location of the tumor. 2) A hemagiopericytoma has a high potential for local recurrence and metastasis, so regular follow-up is needed following surgical excision. 2) A 36-year-old man presented with shortness of breath and chest discomfort. Before operating, a chest CT scan showed that a compressive collapse of the left lung had developed next to a large mediastinal tumor. Because of impending respiratory failure due to collapse of the left lung, an operation was performed. The operation showed that the mediastinal tumor was a large loculated hemopericardium accompanied by pericardial bleeding. A hematoma evacuation with a pericardiectomy was performed, and the pathology of the thickened pericardial wall revealed a malignant hemangiopericytoma. The patient has followed up for 6 months without symptoms or sign of tumor recurrence following the radiation therapy.

A Case of Coronary Stenting in the Management of Myocardial Ischemia Caused by Myocardial Bridging

Myocardial bridging is defined as a condition where a segment of a major epicardial coronary artery running intramurally through the myocardium. Although this abnormality is usually regarded as an incidental finding at angiography, it has been associated with myocardial ischemia, infarction, and sudden death. Standard treatment involves beta-adrenergic receptor blockers, surgery with dissection of the overlying muscle fibers, or coronary artery bypass grafting. A few cases of the intracoronary stent implantation have been reported as an alternative treatment in individual patients with myocardial bridging. We report a case of intracoronary stenting in a severe systolic narrowing at the middle segment of the left anterior descending artery in a patient complaining of recurrent chest pain despite medical treatment.

Clinical utility of harmonic imaging in the detection of right to left shunt through patent foramen ovale by transthoracic contrast echocardiography

BACKGROUND: Paradoxical embolism through the patent foramen ovale (PFO) is a well-recognized mechanism for otherwise unexplained ischemic stroke. Although transthoracic contrast echocardiography (TCE) has been used frequently for noninvasive diagnosis of right to left shunt through PFO, its diagnostic accuracy appears limited, especially in patients with poor acoustic window. Since harmonic imaging (HI) can enhance the definition of contrast microbubbles, theoretical advantages of HI in the detection of right to left shunt through PFO using microbubbles can be considered. However, there are few data regarding the diagnostic efficacy of HI in the detection of right to left shunt through PFO. The purpose of this study was to compare the diagnostic value of transthoracic HI in the detection of right to left shunt through PFO in patients with stroke with that of fundamental imaging (FI). Methods: One hundred thirty-six consecutive patients with stroke (82 male, mean age:9) underwent TCE in both HI and FI and transesophageal echocardiography (TEE) during rest and Valsalva maneuver with intravenous administration of agitated saline. PFO was judged to be present if microbubbles appeared in the left atrium within 3 cardiac cycles of their appearance in the right atrium. TEE was regarded as the gold standard for assessing the diagnostic accuracy of TCE. Results: Right to left shunt through PFO was detected in 40 of 136 patients by TEE (29.4%). FI of TCE detected shunt through PFO in only 9 of 136 patients (6.6%). In contrast, HI detected shunt through PFO in 25 of 136 patients (18.4%). The overall sensitivity and specificity of FI and HI for detection of right to left shunt through PFO were 22.5%, 62.5% (p<0.05) and 100%, 100%, respectively. Valsalva maneuver during HI significantly increased the detection rate of shunt through PFO (during rest in 9 and during Valsalva maneuver in 25, p<0.05). CONCLUSION: HI with contrast microbubble injection significantly enhanced the detection of right to left shunt through PFO in patients with ischemic stroke compared with FI by transthoracic approach.