Area-selective stimulus-provoked seizures in post-anoxic coma.

We describe the case of a 70-year-old patient in whom hemiconvulsive seizures occurred during metabolic derangement, multiple stroke and post-anoxic coma following cardiac arrest. We employed the methods of clinical and EEG evaluation and CT brain scan. We found that hemiconvulsive seizures were provoked following a light tactile stimulus in the left-trigeminal area and occasionally a strong tapping in the right-trigeminal area. We conclude that this type of stimulus-provoked seizure is extremely rare and could be explained by diffuse and severe brain damage.

Area-selective stimulus-provoked seizures in post-anoxic coma.

We describe the case of a 70-year-old patient in whom hemiconvulsive seizures occurred during metabolic derangement, multiple stroke and post-anoxic coma following cardiac arrest. We employed the methods of clinical and EEG evaluation and CT brain scan. We found that hemiconvulsive seizures were provoked following a light tactile stimulus in the left-trigeminal area and occasionally a strong tapping in the right-trigeminal area. We conclude that this type of stimulus-provoked seizure is extremely rare and could be explained by diffuse and severe brain damage.

"Band aid" surgery: upper sternal split incision for valve surgery in adults. A modified technique.

A limited 10 cm upper sternotomy to the level of the third right intercostal space with preservation of the entire length of the left half of the sternum (quarter sternotomy) allows: 1) exposure for aortic valve surgery; 2) utilization of standard equipment and cannulation techniques; 3) preservation of both internal thoracic arteries and 4) early discharge from the hospital. Three patients, all female, aged 45, 62 and 67, two with severe aortic insufficiency and one with severe aortic stenosis, underwent replacement. In two, a St. Jude's valve and in one, a Baxter pericardial valve were used. In addition, aortic decalcification-endarterectomy was carried out in one and re-exploration in another. All patients were discharged at 4 days, impressed by their "Band-Aid Surgery". Improved patient mobility and earlier recovery of ventilatory function are possibly related to this more stable form of limited sternotomy.

Low-dose amiodarone-related complications after cardiac operations.

OBJECTIVE: High-dose preoperative amiodarone therapy has been implicated as a risk factor for serious complications after cardiac operations. To investigate the effect of preoperative low-dose amiodarone treatment on early postoperative outcome after cardiac operations, we prospectively studied 88 patients. METHODS: Forty-four patients were receiving amiodarone (mean daily dose +/- standard deviation, 205 +/- 70 mg/day) and 44 patients were controls matched in pairs. The following parameters were recorded after the operation in all patients: (1) the ratio of oxygen tension to inspired oxygen fraction on arrival in the intensive care unit and 2, 4, 6, 10, 14, 18, and 22 hours thereafter; (2) the occurrence of acute respiratory distress syndrome; (3) early postoperative cardiac complications; and (4) the type and number of inotropic agents or vasopressors (or both) needed. RESULTS: No difference in the ratio of oxygen tension to inspired oxygen fraction was noted at the various time intervals between amiodarone-treated patients and control patients. Overall, only one patient had acute respiratory distress syndrome in the amiodarone group, but he had multiple other factors known to predispose to acute lung injury. Several cardiac complications, such as pulmonary edema, temporary pacing, and need for intraaortic balloon pump counterpulsation, were observed more frequently in amiodarone-treated patients than in control patients. In addition, amiodarone-treated patients required more frequent inotropic support (73% vs 43%, p = 0.003) and more inotropic drugs or vasopressors (or both) per patient than did control patients (1.4 +/- 1.1 vs 0.6 +/- 0.8, p = 0.002). CONCLUSION: Preoperative low-dose amiodarone therapy does not seem to be related to significant postoperative lung toxicity, but it is associated with various cardiac complications and an increased need for more intense inotropic support after cardiac operations. These findings may be related to the drug's depressant effect on the myocardium.

Prevention of perioperative neurological dysfunction. A six year perspective of cardiac surgery.

Neurological dysfunction following cardiac surgical procedures is now well recognized. In order to minimise this serious complication, we instituted various protocols related to the potential causes of perioperative stroke such as: (1) components and use of the heart-lung machine; (2) air embolization; (3) intrinsic cerebro-vascular disease; (4) atheroemboli from the ascending aorta and (5) clot emboli from the left ventricle. We employed certain methods of operation of the heart-lung machine, air evacuation manoeuvres and a pharmacological brain protection protocol. These protocols were applied in a series of 1487 consecutive cardiac surgical procedures performed between 1984 and 1989; 127 patients died (8.54% mortality) and 16 patients (1.08%) suffered major neurological syndromes. Among the latter patients, 4 distinct groups were identified. Group A consisted of 6 patients who remained unresponsive after operation. In group B were 6 patients who awakened after operation but had clinical evidence of focal cerebral infarction. Group C included 3 patients who were initially intact neurologically but in whom neurological deficits developed later. Group D contained 1 patient who had severe mental aberration but no focal neurological deficits. Causative factors, including atheromatous embolism, perioperative hypotension and air embolism, were suspected in 12 of these 16 patients (75%) in groups A, B and C. The outcome was poor for unresponsive patients and 9 out of the 16 died or remained comatose (56.6%).