ABSTRACT
A 65-year-old man suddenly developed severe headache, vertigo, and sensory disturbance of the right side. On the CT, a high density round mass was identified in the dorsal portion of the pons. The patient's level of consciousness decreased one hour later. A repeat CT showed diffuse subarachnoid hemorrhage and hydrocephalus. Angiography demonstrated a dural arteriovenous fistula (DAVF) at the craniocervical junction. The main feeding artery was the left C2 radicular artery, and the fistula was drained by a leptomeningeal vein that proceeded upward and had a venous ectasia in its distal portion. Transarterial embolization could not be performed because the feeding artery could not be cannulated using a microcatheter. 3D-CT angiography showed a single draining vein at the anterior portion of the left vertebral artery. Four weeks later, ventricular drainage was instituted following surgical disruption of the arteriovenous fistula's draining vein. Postoperative angiography demonstrated complete obliteration. In the present case, surgical clipping of the draining vein was safe and effective; surgical resection of the DAVF or cautery of the surrounding dura was not necessary. Intraoperative digital subtraction angiography (DSA) was as useful as the Doppler technique.
Subject(s)
Central Nervous System Vascular Malformations/complications , Subarachnoid Hemorrhage/etiology , Aged , Angiography, Digital Subtraction , Central Nervous System Vascular Malformations/diagnostic imaging , Central Nervous System Vascular Malformations/surgery , Cervical Vertebrae , Humans , Male , Skull , Subarachnoid Hemorrhage/diagnostic imaging , Tomography, X-Ray Computed , Treatment Outcome , Vascular Surgical ProceduresABSTRACT
BACKGROUND AND OBJECTIVES: The rapid cardiac troponin T (cTnT) test is widely used to detect myocardial necrosis in the emergency setting. This assay system is rapid and myocardial-specific, but the plasma cTnT concentration is difficult to determine quantitatively. A recently developed bedside cTnT and myoglobin (Mb) analyzer (CARDIAC system) was evaluated. METHODS: The new CARDIAC system was used to measure plasma cTnT and Mb levels, and serum levels of creatine kinase MB isoenzyme (CK-MB), cTnT and Mb were measured by conventional assays in 160 consecutive emergency patients with suspected acute myocardial infarction. RESULTS: The sensitivity of cTnT for identifying acute myocardial infarction was 76%, significantly higher than that of Mb (67%, p < 0.01) and CK-MB (54%, p < 0.05). The diagnostic sensitivities in patients admitted < or = 3 hr and 3-6 hr after onset were 52% and 65% for cTnT, 60% and 90% for Mb, and 36% and 50% for CK-MB, respectively. These sensitivities of Mb were significantly higher than those of CK-MB but not cTnT. However, the sensitivity of cTnT (100%) was significantly higher than that of Mb (58%, p < 0.01) and CK-MB (70%, p < 0.001) in patients admitted > 6 hr after onset. The specificities of cTnT, Mb and CK-MB were 96%, 76% (p < 0.001 vs cTnT and CK-MB) and 95%, respectively. Therefore, cTnT (86%) had significantly (p < 0.001) higher diagnostic accuracy compared with Mb (71%) and CK-MB (75%). Combination diagnosis using cTnT and Mb showed the highest sensitivity (86%) compared with cTnT (p < 0.05) and Mb (p < 0.001). The correlation coefficients between the levels measured by CARDIAC system and those by ordinary assays were 0.98 in cTnT and 0.97 in Mb. CONCLUSIONS: Bedside rapid quantitative assays of cTnT and Mb are useful as a point of care test for the diagnosis of acute myocardial infarction.
