Acetazolamide to treat symptomatic ruptured arachnoid cysts: illustrative cases.

BACKGROUND: Arachnoid cysts are benign, often asymptomatic intracranial mass lesions that, when ruptured, may cause seizures, raised intracranial pressure, hemorrhage, and/or loss of consciousness. There is no widely agreed upon treatment, and there is debate as to whether a nonoperative or surgical approach is the best course of action. The carbonic anhydrase inhibitor acetazolamide may be an effective nonoperative approach in treating ruptured arachnoid cysts. OBSERVATIONS: The Pediatric Neurosurgery Clinical Database at BC Children's Hospital from 2000 to 2020 was queried, and four pediatric patients who were treated with acetazolamide after presentation with a ruptured middle cranial fossa arachnoid cyst were identified. All patients showed some degree of symptom improvement. Three of the patients showed complete reabsorption of their subdural collections in the ensuing 6 months. One patient had an inadequate response to acetazolamide and required surgical management. LESSONS: Acetazolamide is a safe and reasonable primary treatment option in pediatric patients with ruptured middle cranial fossa arachnoid cysts, and it may help avoid the need for surgery.

Doxycycline sclerotherapy for post-traumatic inguinal lymphocele in a child.

Lymphoceles are abnormal collections of lymphatic fluid caused by a disruption in the lymphatic channels and leakage of lymph. This most commonly occurs after surgical procedures, but occasionally lymphoceles may be the result of trauma, more commonly penetrating trauma. Lymphoceles resulting from blunt trauma are rare in both adults and children. In the adult population, there are few published case reports, and management principles vary. To date, there are no reports of traumatic lymphoceles in the paediatric population, and therefore there is no precedent for treatment. Here, we report the case of a young boy who developed an inguinal lymphocele from a bicycle handle bar injury which was successfully treated with doxycycline sclerotherapy.

Assessment of a modified technique for air delivery during fluoroscopic-monitored pneumatic intussusception reduction.

BACKGROUND: Intussusception is one of the most common causes of acute abdominal emergency in children. Image-monitored pressure reduction is the first line of treatment. OBJECTIVE: We report on a modified technique of air delivery during fluoroscopic-monitored pneumatic intussusception reductions, and compare it with an established technique. MATERIALS AND METHODS: We modified the Shiels intussusception reduction device so that the air used for intussusception reduction is delivered not by the device's insufflator bulb, but rather by the hospital medical air supply system, eliminating the need for continuous pumping of the insufflator bulb during the procedure. Subsequently, we retrospectively compared sequential fluoroscopy-monitored pneumatic intussusception reduction procedures performed in patients younger than 18 years using either the standard or modified devices, evaluating technical procedure parameters (i.e. median procedure time length, fluoroscopy time length and radiation dose) and patient outcomes (i.e. number of complete intussusception reductions, number of incomplete intussusception reductions, number of intussusception recurrences within 3 days of the procedure, number of procedures followed by surgery). RESULTS: We found no statistically significant differences between procedures performed with the standard and modified techniques. CONCLUSION: The device modification allows for increased operator comfort. Evaluated procedure parameters and patient outcomes appear similar to those of the standard technique.

Noninvasive detection of risk for emotion-provoked myocardial ischemia.

OBJECTIVES: To test an easily administered, noninvasive technology to identify vulnerability to mental stress ischemia. BACKGROUND: Myocardial ischemia provoked by emotional stress (MSI) in patients with stable coronary artery disease (CAD) predicts major adverse cardiac events. A clinically useful tool to risk stratify patients on this factor is not available. METHODS: Patients with documented CAD (n = 68) underwent single photon emission CT myocardial perfusion imaging concurrent with pulse wave amplitude assessment by peripheral arterial tonometry (PAT) during a mental stress protocol of sequential rest and anger stress periods. Heart rate and blood pressure were assessed, and blood was drawn for catecholamine assay, during rest and stress. MSI was defined by the presence of a new perfusion defect during anger stress (n = 26) and the ratio of stress to rest PAT response was calculated. RESULTS: Patients with MSI had a significantly lower PAT ratio than those without MSI (0.76 +/- 0.04 versus 0.91 +/- 0.05, p = .03). An ROC curve for optimum sensitivity/specificity of PAT ratio as an index of MSI produced a sensitivity of 0.62 and a specificity of 0.63. Among patients taking angiotensin converting enzyme (ACE) inhibitors, the sensitivity and specificity of the test increased to 0.86 and 0.73, respectively; 90% of patients without MSI were correctly identified. CONCLUSIONS: PAT in concert with ACE inhibition may provide a useful approach to assess risk for MSI. Future studies should help determine how best to utilize this approach for risk assessment in the clinical setting.

C-reactive protein and vulnerability to mental stress-induced myocardial ischemia.

Myocardial ischemia provoked in the laboratory during mental stress (MSI) in patients with stable coronary artery disease (CAD) predicts subsequent clinical events. The pathophysiology of MSI differs from that of exercise ischemia, and the mechanisms tying MSI to poor prognosis are not known. C-reactive protein (CRP) is a risk marker for cardiovascular events in patients with CAD, but little is known regarding the relationship of CRP to MSI. The purpose of this study was to examine the association of CRP to risk of MSI in CAD patients. Eighty-three patients with stable CAD underwent simultaneous single-photon emission computed tomography (SPECT) imaging with technetium-99m tetrofosmin myocardial perfusion imaging (MPI) and transthoracic echocardiography (TTE), at rest and during MS induced by laboratory mental stress. Serum CRP levels were measured 24 h after MS. MSI was defined by the presence of a new perfusion defect on SPECT and/or new regional wall motion abnormality on TTE during MS. Of the 83 patients, 30 (36%) developed MSI. There was no difference in gender, sex, BMI, histories of diabetes, hypertension, smoking, lipid profile, medications used (including statins, beta-blockers, ACE inhibitors, and aspirin), or hemodynamic response during MS between those with and without MSI. In univariate logistic regression analysis, each unit (1 mg/L) increase in CRP level was associated with 20% higher risk of MSI (OR 1.2, 95% CI 1.01-1.39, P=.04). This relationship remained in multivariate models. These data suggest that levels of CRP may be a risk marker for MSI in patients with CAD.

Late postpartum eclampsia as an obstetric complication seen in the ED.

Preeclampsia is a complication of pregnancy associated with hypertension and proteinuria. Preeclampsia may be associated with grand mal seizures and is termed eclampsia. Historically, eclampsia occurring more than 48 hours after delivery, known as late postpartum eclampsia, was thought to be uncommon; however, recent evidence suggests that its incidence is increasing. In addition, the presentation of late postpartum preeclampsia-eclampsia may differ from that occurring during the pregnancy. This contributes to difficulty in diagnosing late postpartum preeclampsia-eclampsia in an emergency department setting. We report 2 cases of late postpartum eclampsia presenting 8 days after delivery, which highlight the unique features of this disorder and discuss some of the difficulties in managing these patients. Greater awareness and knowledge of this disorder by ED physicians should improve outcomes in these potentially life-threatening cases.