[Acute penetrating neck trauma presenting with laryngotracheal injury].

Laryngotracheal injuries are serious complications in the case of penatrating neck trauma which may not commonly in Japan. In the last several decades, many authors have discussed method for accurate evaluation and immediate airway management for patient with laryngotracheal injury. But, standardization of the treatment is still controversial about mandatory exploration or selective exploration. We report 4 cases with fresh laryngotracheal injury due to penetrating neck trauma including 3 suicide attempt patients. In these cases, laryngotracheoplasty used by absorbable material was performed within 8 hours after trauma. Two cases of suicide attempt patients underwent tracheostomy at the lower level of the laryngotracheal injury. After these treatment, fiberoptic bronchoscopy was performed to evaluate the airway for 3 cases except 1 who was dead because of hemorrhagic shock on arrival. In 2 cases, the suture filament existed in the lumen of the larynx and trachea, there were no major granulation in the site of repairment and no infection. Three cases were extubated successfully and discharged without major airway problem. Two cases have psychiatric disease such as depression, so we must consider their psychiatric background in the future. In conclusion, penetrating laryngotracheal trauma, we should consider that serious airway injury may be hidden under the superficial small wounds. Also, rapid local wound exploration and laryngotracheoplasty is important for life-saving, and fiberoptic bronchoscopy is effective to prevent early respiratory complications and has value in the evaluation.

Ileal adenomyoma accompanied by primary peritonitis: report of a case.

We report herein the case of a 52-year-old woman who presented with severe abdominal pain and a 2-week history of a yellow vaginal discharge. An emergency operation was performed for localized peritonitis attributed to acute perforated appendicitis. There were no findings to indicate the cause of peritonitis, but by chance, a submucosal tumor was found in the ileum 2m from Bauhin's valve. Appendectomy and wedge resection of the ileum with the submucosal tumor were carried out. The peritonitis was considered to have been idiopathic from bacterial and molecular biological examination of the ascites. Pathological, immunohistochemical, and flow cytometrical findings of the resected ileal submocosal tumor indicated a diagnosis of ileal adenomyoma with no malignancy, which suggested metaplasia of the pancreaticobiliary to gastric epithelium.

Improving clinical outcomes from acute subdural hematomas with the emergency preoperative administration of high doses of mannitol: a randomized trial.

OBJECTIVE: To evaluate clinical outcomes and postoperative physiological findings for comatose patients with acute subdural hematomas who received preoperative high-dose mannitol (HDM) versus conventional-dose mannitol treatment. METHODS: One hundred seventy-eight adult patients with non-missile, traumatic, acute, subdural hematomas were prospectively and randomly assigned to receive emergency, preoperative, intravenous HDM treatment (91 patients), compared with a control group treated with a lower preoperative mannitol dose (87 patients). RESULTS: Preoperative improvement of abnormal pupillary widening was significantly more frequent in the study group than in the control group of patients (P < 0.0001). Preoperative HDM treatment was also associated with significantly better clinical outcomes at 6-month follow-up evaluations (P < 0.01). Postoperative physiological findings revealed statistically significant between-group differences, with higher intracranial pressure and lower cerebral extraction of oxygen (relative cerebral hyperperfusion) in the control group, compared with the HDM group. Postoperative global brain ischemia (abnormally low arteriojugular lactate difference values) was rare and was detected in 2.2 and 3.4% of the patients in the study and control groups, respectively. CONCLUSION: Emergency preoperative HDM administration was associated with improved clinical outcomes for patients with acute subdural hematomas. Preoperative improvement of abnormal pupillary widening and better postoperative control of intracranial hypertension and associated relative cerebral hyperperfusion seemed to be relevant factors associated with improved outcomes.

Transorbital penetrating injury by a chopstick--case report.

A one-year-old boy presented with orbitocranial penetrating injury by a chopstick. Neurological examination did not reveal abnormal findings. Skull radiography did not reveal any sign of fracture and there were no abnormal findings. Initially, computed tomography (CT) of the head did not reveal any intracranial lesions. However, bone window CT showed a well-defined low-density abnormality measuring 2.5 cm in length in the right orbit and parasellar region. Magnetic resonance imaging clearly revealed a low-intensity structure extending from the orbit to the prepontine area. Surgical exploration was emergently performed and the wooden fragment was removed. The postoperative course was uneventful. Transorbital penetrating injury by a wooden foreign body is relatively rare. The wound may be superficial and trivial. Major neurological deficit does not usually manifest immediately, so the penetrating injury may be overlooked. If the foreign body is retained in the orbit and cranium, severe infectious complications may occur later.

[Penetrating lung and diaphragmatic injuries with no abnormal finding of chest X-ray: a case report].

A case of penetrating lung and diaphragmatic injuries with no abnormal findings of chest X-ray is reported. A 76-year-old man was admitted to our hospital due to penetrating chest trauma. A simple X-ray film of the chest on admission revealed no abnormal finding. An emergency operation was performed. On exploring the back open wound, we found a laceration of 7 cm in diameter in the right diaphragm and lung laceration. Then we repaired primarily with absorbable material. The postoperative course was uneventful, and the patient was discharged 12 days later. Penetrating truncal traumas can result in diaphragmatic injury. Sometimes the clinical and roentgenographic findings are unreliable. If the diagnosis is missed, a diaphragmatic injury may occur delayed diaphragmatic hernias within hours to years. Accordingly, initial wound exploration are important for the diagnosis of diaphragmatic injury in avoiding serious complications.

Regional cerebral blood flow after status epilepticus.

Two patients with status epilepticus due to specific conditions were examined using MRI and stable Xe/CT CBF. [Case 1] A 30-year-old woman developed a grand mal seizure during delivery. She was comatose, and MRI revealed abnormal high intensity areas bilateral basal ganglia, compatible with eclampsia. Regional CBF was decreased in bilateral occipital lobes and right basal ganglia. Six days after onset. Regional gray matter flow was increased, especially in the thalami and basal ganglia. [Case 2] The patient is a 31-year-old male diagnosed with temporal lobe epilepsy since 10 years. At the onset, he had a prolonged right hemiconvulsion followed by generalized tonic-clonic convulsion. MRI 13 days after onset showed left hemispheric edematous swelling of gray matter. Stable Xe/CT 3 weeks after onset demonstrated increased cortical CBF corresponding to edematous area. The results suggested that regional CBF decreased immediately after status epilepticus and then increased for 1-3 weeks in the interictal period. We speculate that the energy debt incurred during prolonged seizure causes relative ischemic condition in the neurons, with the increase in CBF resulting from accelerated energy production for a long period.

Hippocampal damage in the human brain after cardiac arrest.

BACKGROUND AND PURPOSE: Very few reports are available on changes in the human hippocampus after cardiac arrest. The objective of this study was to investigate if specific hippocampal volume losses can be demonstrated in the human brain following reperfusion after cardiac arrest. METHODS: We assessed the volumes of the hippocampal formation (HF) and temporal lobe excluding HF (TL) as the contrast using magnetic resonance (MR)-imaging-based volumetry in 11 vegetative patients after cardiac arrest and in 22 healthy controls of similar age, sex and body size distribution. The measured volumes were normalized for differences in the head size among subjects by dividing by the total intracranial volume (TICV). The MR images of the 11 patients were obtained between days 8 and 21 after cardiac arrest. RESULTS: The observed volumes of HFs and TLs of both patient and control groups were as follows: right HF volume (HFV): 2.67 +/- 0.19 (mean +/- SD, cm(3)) in patients versus 3.89 +/- 0.44 in controls; left HFV: 2.72 +/- 0.17 versus 3.74 +/- 0.35; right TL volume (TLV): 73.37 +/- 6.54 versus 80.08 +/- 7.62, and left TLV: 72. 45 +/- 6.77 versus 78.59 +/- 6.68. The normalized indices (HFV/TICV and TLV/TICV) were as follows: right HF: 0.0021 +/- 0.0002 (mean +/- SD) in patients versus 0.0031 +/- 0.0001 in controls, p < 0.0001, left HF: 0.0022 +/- 0.0002 versus 0.0030 +/- 0.0001, p < 0.0001, right TL: 0.058 +/- 0.002 versus 0.064 +/- 0.004, p = 0.0007, and left TL: 0.058 +/- 0.002 versus 0.062 +/- 0.004, p = 0.0014. The HFV-TLV ratios (HFV/TICV divided by TLV/TICV) of both groups were: right HFV-TLV ratio: 0.037 +/- 0.004 in patients versus 0.049 +/- 0. 004 in controls, p < 0.0001, left HFV-TLV ratio: 0.038 +/- 0.004 versus 0.048 +/- 0.004, p < 0.0001. CONCLUSIONS: The patient group had HFs that were 26.8-30.6% smaller than those of the control group, but in the patient group, the TLs slightly decreased in size by only 7.8-8.2% of the volume of those in the control group within 21 days after cardiac arrest. The volume reductions in the bilateral HFs of patients after cardiac arrest were significantly larger than those in the bilateral TLs. We speculate that this specific rapid hippocampal shrinkage reflects its greater vulnerability to global brain ischemia.

[A case with traumatic internal carotid artery dissection in which the extent of the pseudolumen was defined by MR angiography].

We report a 29-year-old male with traumatic internal carotid artery (ICA) dissection who presented with cerebral ischemia developed after removal of a left acute subdural hematoma and external decompression. CT scans 4 days after the operation showed infarctions of the distribution of the bilateral cerebral hemispheres. Cerebral angiography on the 11th hospital day demonstrated narrowing of the extracranial internal carotid artery at C1-C2 vertebral levels. Slight arterial dilatation and retention of the contrast medium were found just above the narrowing segment, which was suspected to be a pseudolumen. Three D time-of flight MRA showed an intramural hematoma corresponding to the narrowing on the angiography. Original axial MRA images showed that narrowing of the lumen was surrounded by a crescent hematoma and that two flow velocity areas were in the area distal to the narrowing. High flow seemed to be ordinary artery flow rate. The low flow area, including turbulent flow, led to the retention of contrast medium mimicking a pseudolumen. Precise MRA imaging will bring us an accurate diagnosis of extracranial carotid dissections.

Bilateral chronic subdural hematomas resulting in unilateral oculomotor nerve paresis and brain stem symptoms after operation--case report.

An 85-year-old male presented with bilateral chronic subdural hematomas (CSDHs) resulting in unilateral oculomotor nerve paresis and brainstem symptoms immediately after removal of both hematomas in a single operation. Initial computed tomography on admission demonstrated marked thick bilateral hematomas buckling the brain parenchyma with a minimal midline shift. Almost simultaneous removal of the hematomas was performed with the left side was decompressed first with a time difference of at most 2 minutes. However, the patient developed right oculomotor nerve paresis, left hemiparesis, and consciousness disturbance after the operation. The relatively marked increase in pressure on the right side may have caused transient unilateral brain stem compression and herniation of unilateral medial temporal lobe during the short time between the right and left procedures. Another factor was the vulnerability of the oculomotor nerve resulting from posterior replacement of the brain stem and stretching of the oculomotor nerves as seen on sagittal magnetic resonance (MR) images. Axial MR images obtained at the same time demonstrated medial deflection of the distal oculomotor nerve after crossing the posterior cerebral artery, which indicates previous transient compression of the nerve and the brain stem. Gradual and symmetrical decompression without time lag is recommended for the treatment of huge bilateral CSDHs.

Surgical treatment of internal carotid artery anterior wall aneurysm with extravasation during angiography--case report.

A 54-year-old female presented subarachnoid hemorrhage from an aneurysm arising from the anterior (dorsal) wall of the internal carotid artery (ICA). During four-vessel angiography, an extravasated saccular pooling of contrast medium emerged in the suprasellar area unrelated to any arterial branch. The saccular pooling was visualized in the arterial phase and cleared in the venophase during every contrast medium injection. We suspected that the extravasated pooling was surrounded by hard clot but communicated with the artery. Direct surgery was performed but major premature bleeding occurred during the microsurgical procedure. After temporary clipping, an opening of the anterior (dorsal) wall of the ICA was found without apparent aneurysm wall. The vessel wall was sutured with nylon thread. The total occlusion time of the ICA was about 50 minutes. Follow-up angiography demonstrated good patency of the ICA. About 2 years after the operation, the patient was able to walk with a stick and to communicate freely through speech, although left hemiparesis and left homonymous hemianopsia persisted. The outcome suggests our treatment strategy was not optimal, but suture of the ICA wall is one of the therapeutic choices when premature rupture occurs in the operation.

Haemangioma calcificans presenting as intracranial haemorrhages during pregnancy.

A 33-year-old female with intracerebral haemorrhage during pregnancy, associated with subarachnoid and intraventricular haemorrhages, is presented. Intracranial haemorrhages during pregnancy are known to frequently result from cerebral aneurysms or arteriovenous malformations. We believe that this is caused by haemangioma calcificans and is noteworthy in considering the indications for surgical treatment for intracranial calcified lesions suggestive of cavernous haemangioma.

Specific changes in human brain after hypoglycemic injury.

BACKGROUND AND PURPOSE: Very few reports are available on serial changes in the human brain after severe hypoglycemic injury. The aim of this study was to investigate sequential neuroradiological changes in brains of patients after hypoglycemic coma compared with those after cardiac arrest previously studied with the same methods. METHODS: We repeatedly studied CT scans and MR images obtained at 1.5 T in four vegetative patients after profound hypoglycemia associated with diabetes mellitus. RESULTS: In all patients, consecutive CT scans showed symmetrical, persistent low-density lesions with transient enhancement in the caudate and lenticular nuclei and transient enhancement in the cerebral cortex 7 to 14 days after onset. Serial MR images consistently revealed symmetrical lesions of persistent hyperintensity and hypointensity on T1- and T2-weighted images, respectively, in the caudate and lenticular nuclei, cerebral cortex, substantia nigra, and/or hippocampus from 8 days to 12 months after onset. CONCLUSIONS: Repeated MR images revealed specific lesions in the bilateral basal ganglia, cerebral cortex, substantia nigra, and hippocampus, which suggests the particular vulnerability of these areas to hypoglycemia in the human brain. We speculate that the localized lesions represent tissue degeneration, including some combination of selective neuronal death, proliferation of astrocytic glial cells, paramagnetic substance deposition, and/or lipid accumulation. The absence of localized hemorrhages on MR images in hypoglycemic encephalopathy is in marked contrast to the presence of regional minor hemorrhages in postischemic-anoxic encephalopathy.

Rapid natriuresis and preventive hypervolaemia for symptomatic vasospasm after subarachnoid haemorrhage.

To prevent symptomatic cerebral vasospasm, we have used hypervolaemia (HV) or volume expansion in patients with aneurysmal subarachnoid haemorrhage (SAH) in recent years. In these patients we could not perform effective fluid and sodium (Na) replacement because of rapid and overwhelming water and Na loss. Although this phenomenon is characteristic under hypervolaemic states, we regard it important to elucidate the mechanism underlying initiation of vasospasm after aneurysmal SAH. Patients with aneurysmal SAH, operated on within 24 hours of onset, were analysed prospectively. We selected 17 patients in good pre-operative condition. Intravascular volume expansion was accomplished with plasma fractionate or albumin and crystalloid solutions in all patients. We divided the 17 patients into two groups; symptomatic spasm group (S-group) consisting of 4 cases developing transient ischaemic symptoms and non-symptomatic spasm group (NS-group) consisting of 13 cases. In S-group, rapid and marked natriuresis developed characteristically before the onset of ischaemic symptoms. The differences in daily Na balance between the two groups were significant on the 3rd and 5th days (p < 0.05). The mean cumulative Na balance in S-group during the 10 days of the study (-375 +/- 159 mEg) was higher than that of NS-group (-24.4 +/- 225 mEq) (p < 0.05). Rapid natriuresis preceded the development of ischaemic symptoms, and was important as a trigger for symptomatic vasospasm after SAH. We considered that hormonal disorders were implicated in this phenomenon, and atrial natriuretic peptide (ANP), antidiuretic hormone (ADH), renin, and aldosterone were each measured three times during the period, with no significant differences, found between the two groups. It was speculated that another potent natriuretic factor, similar to ANP, induced a rapid selective natriuresis resulting in symptomatic vasospasm.

[Dural AVF of the posterior fossa associated with sinus occlusion presenting as intracerebral hemorrhage: case report].

A 69-year-old man was admitted because of sudden onset of consciousness disturbance. Neurological examination on admission revealed slightly disturbed consciousness, sensory aphasia and right hemiparesis. CT scan disclosed a hematoma in the left posterior temporal lobe. Left carotid angiograms showed dural AVF of the transverse/sigmoid sinus fed mainly by the left occipital and posterior auricular arteries. On the angiograms the left sigmoid sinus was completely occluded. This was associated with retrograde venous flow into the cortical veins, the superior petrosal sinus and the contralateral traverse sinus. After stabilizing the condition, we totally resected the dural AVF including the left transverse sinus. The postoperative course was uneventful. Histopathological examination of the surgically resected specimen revealed that the dural A-V fistula per se existed in the sinus wall.

Effects of intravenous nitroglycerin combined with dopamine on intracranial pressure and cerebral arteriovenous oxygen difference in patients with acute subarachnoid haemorrhage.

The effects of intravenous nitroglycerin (NTG) combined with dopamine on intracranial pressure (ICP) and cerebral arteriovenous oxygen difference (AVDO2) were studied in 11 patients with acute subarachnoid haemorrhage (SAH). The study was performed on Days 1 to 3 of SAH after aneurysmal clipping. Treatment consisted of an intravenous drip infusion of NTG in increasing incremental doses of 0.5, 1.0, 1.5, 2.0, and 2.5 micrograms/kg/min at one-hour intervals. Dopamine (5 to 10 micrograms/kg/min) was also given concurrently to maintain systemic blood pressure. ICP values before NTG administration ranged from 7 to 24 mmHg (mean. 11.91 +/- 5.30 mmHg). ICP began to increase immediately after the administration of NTG 0.5 microgram/kg/min and peaked at 14.64 +/- 5.93 mmHg 10 minutes after onset of infusion. Thereafter, ICP gradually returned to pretreatment levels. Increasing the dose of NTG failed to induce further significant rises in ICP. Mean AVDO2 before NTG administration was 4.69 +/- 0.62 ml/dl. This parameter showed no significant change during NTG infusion, although cerebral perfusion pressure decreased to between 75% to 94% of the control value after NTG administration. These results indicate that continuous NTG infusion combined with dopamine does not have adverse effects on ICP (the ICP increase is minimal and transient) and may even have beneficial effects on CBF in patients with acute SAH.

Changes in the basal ganglia and thalamus following reperfusion after complete cerebral ischaemia.

We report specific changes bilaterally in the basal ganglia and thalamus following reperfusion after complete cerebral ischaemia. A 69-year-old man, resuscitated after cardiac arrest, showed symmetrical low-density lesions in the head of the caudate nucleus and lentiform nucleus on CT. MRI revealed methaemoglobin derived from minor haemorrhage in the basal ganglia and thalamus, not evident on CT. We suggest that this haemorrhage results from diapedesis of red blood cells through the damaged capillary endothelium following reperfusion.

Specific changes in human brain following reperfusion after cardiac arrest.

BACKGROUND AND PURPOSE: Very few reports are available on serial changes in human brain after cardiac arrest. The primary objective of this study is to investigate sequential neuroradiological changes in patients remaining in a persistent vegetative state following resuscitation after cardiac arrest. METHODS: We repeatedly studied eight vegetative patients resuscitated from unexpected out-of-hospital cardiac arrest using computed tomographic (CT) scanning and high-field magnetic resonance (MR) imaging at 1.5 T. RESULTS: In seven of the eight patients, CT scans obtained between days 2 and 6 features symmetrical low-density lesions in the bilateral caudate, lenticular, and/or thalamic nuclei. These ischemic lesions were persistently of low density on serial CT scans. In these seven patients, MR images demonstrated what were thought to be hemoglobin degradation products derived from minor hemorrhages localized in the bilateral basal ganglia, thalami, and/or substantia nigra. Diffuse brain edema in the acute stage and diffuse brain atrophy in the chronic stage were consistent neuroradiological findings. No abnormal enhanced lesions were demonstrated by CT scans. CONCLUSIONS: The most characteristic findings on high-field MR images were symmetrical lesions in the bilateral basal ganglia, thalami, and/or substantia nigra with specific changes suggestive of minor hemorrhages that were not evident on CT scans. We speculate that these minor hemorrhages result from diapedesis of red blood cells in these regions during the reperfusion period through the endothelium disrupted by ischemia-reperfusion insult.

Acute obstructive hydrocephalus due to brain-stem edema caused by hyperosmotic insult. Case report.

The case of a 63-year-old man with acute obstructive hydrocephalus is presented. To the authors' knowledge, this is the first reported case of acute obstructive hydrocephalus associated with nonketotic hyperosmolar diabetic coma. It is believed that the plasma hyperosmolality resulted in osmotic endothelial injury leading to brain-stem edema.