ABSTRACT
Coronary artery aneurysms are rare in the general population. There are no randomized control trials to guide the therapy at this moment. We present a case of a 52-year-old male who was recovering from addiction and was sober for past five years. He came to the hospital with typical chest pain. There were ST segment depressions in leads III and AVF. The second troponin was found to be elevated. The impression was non-ST-segment elevation myocardial infarction. He was started on subcutaneous enoxaparin and underwent left heart catheterization which revealed dilated ectatic coronary arteries with aneurysmal dilatation. In addition, there was sluggish blood flow and several blood clots mainly in the left circumflex artery. No intervention was performed and the patient was started on heparin drip which was transitioned to warfarin on discharge. The echocardiogram revealed an ejection fraction of 35% with anterior and inferoseptal wall dyskinesia. Echocardiogram at one-year follow-up showed improved ejection fraction of 50% with similar wall dyskinesia. Coronary artery aneurysms are treated with medical management with or without invasive approach. Invasive management is conducted in people with stenosis and can be achieved by coronary artery bypass graft or covered stents.
ABSTRACT
BACKGROUND: The use of decompressive craniectomy (DC) has been studied in the setting of different conditions, including traumatic brain injury, subarachnoid hemorrhage, and malignant middle cerebral artery (MCA) infarction. The rationale of this study is to determine the functional outcome after DC in patients with malignant MCA infarcts. METHODS: A longitudinal cohort study was performed based on patients diagnosed with malignant MCA territory infarction admitted to the Neurosurgery Department of a tertiary care hospital in Islamabad, Pakistan between July 2015 and November 2016. All patients had a clinical diagnosis of stroke according to the World Health Organization (WHO) stroke criteria. RESULTS: A total of 34 patients participated in this study, out of which 20/31 (64.5%) were males while 11/31 (35.5%) were females with a mean age of 51.61 ± 13.96 years. The mean time from diagnosis to surgery was 60.61 ± 49.83 hours. Out of 31 patients, 18 (58.1%) had a right middle cerebral artery infarct (RMCAI) and 13 (41.9%) had a left middle cerebral artery infarct (LCAI). Logistic regression was applied to assess the association between the type of MCA infarct with the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (mBI) scores, and upper and lower limb motor power. However, the logistic regression model was not statistically significant χ2 (4) = 3.896, p = 0.866. There was a statistically significant mild improvement of neurological scores and upper and lower motor power over a course of six months, but the overall functional outcome was poor with mBI < 60 and mRS > 4 (p < 0.001) with total mortality of 8.7%. CONCLUSION: Decompressive craniectomy is a life-saving surgery that appears to benefit patients with malignant MCA infarcts of either the dominant or non-dominant cerebral hemisphere. Decompressive craniectomy results in mild improvements in neurological scores but still poor functional outcome after six months.
