[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.

[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.

[Surgical treatment for spontaneous hemopneumothorax complicated by delayed re-bleeding: a case report].

A 34-year-old man was admitted to the hospital due to spontaneous hemopneumothorax. A chest tube drainage was performed, and hemorrhagic plueral effusion of 1,600 ml was drained. Because of this, the patient was transferred to the emergency center of our hospital. Following a blood transfusion, we continued to treat conservatively for nine days, because no more bleeding was recognized. On day ten, the patient suddenly started bleeding again, thus, an emergency operation was performed. At the operation under a thoracoscope, a bleeding point was ligated with surgical clip, however, it was difficult to remove blood clots that were attached with the lung surface, it was impossible to continue the thoracoscopic surgery. If re-bleeding occurs after the acute phase, problems may arise from conservative treatment. So, early surgical treatment should be considered.

Posttraumatic intestinal stenosis presenting as a perforation: report of a case.

A 78-year-old woman was admitted to the hospital after falling into a ditch approximately 1 m deep and sustaining a blunt abdominal trauma with a left femur fracture. On the tenth day after admission, symptoms of a small bowel obstruction occurred. A nasogastric tube was inserted, and the symptoms thus improved. She sometimes complained of abdominal pain during the 12 months after the fall, but recovered with conservative management. The next year, she was readmitted to the hospital for a pin extraction of the left femur bone. During this admission, 15 months since her admission after her fall, she again complained of abdominal pain. Abdominal pain increased with a muscular defense, and abdominal X-rays revealed free air. She was referred to our hospital with a diagnosis of perforative peritonitis, and emergency surgery was performed. Upon laparotomy, circumferential stenoses of the small bowel were recognized in the proximal segments about 40cm, 80cm, and 100cm from the ileocecal region. In addition, a perforation and prominent dilatation of the bowel segment was observed just proximal to the stenosis about 100cm from the ileocecal region. She underwent a small intestinal resection at two sites. There were no findings of an intestinal specific ulcer, such as Crohn's disease, intestinal tuberculosis, or malignancy, based on the results of a histopathological examination.

[Thoraco-abdominal impalement injury with diaphragmatic injury: a case report].

A 60-year-old man was admitted to our hospital because of impalement injury due to traffic accident. Chest X-ray on admission revealed normal lung field. CT scans of the chest and abdomen revealed slight pneumothorax and intra-abdominal organ protruding from abdominal cavity. An emergency operation was performed. Diaphragmatic injury was not detected during the abdominal procedure. On exploring the back wound, we found a laceration of 8 cm in diameter in the diaphragm and repaired it. Impalement injuries which have aspects of both blunt and penetrating trauma are uncommon. Accordingly, wound exploration and debridement of fistulous tract are necessary. In the case of thoraco-abdominal injuries by impalement, one should bear in mind the existence of diaphragmatic injury even with normal diaphragmatic shadow on chest X-ray.

The hNT human neuronal cell line survives and migrates into rat retina.

The present studies were undertaken to determine if hNT cells can survive in the vitreous of the eye and migrate into the retina. The hNT neuronal cell line represents a uniform source of human tissue that may be of use in retinal grafts. hNT cells stored in liquid nitrogen were thawed and labeled with the fluorescent dye 1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine perchlorate (DiI). Thirty thousand cells in 1 microL were injected epiretinally in rat. At survival times of 3, 14, 28, or 56 days, retinal sections were examined quantitatively by epifluorescence to reveal DiI-labeled cells. hNT cells survived in the vitreous at all time points without evidence of vascularization. At 3 days, essentially no hNT cells were found in deep retina, and only very few were attached to retina. At days 14, 28, and 56, hNT cells were found to cluster on the vitreal/retinal interface, and in deeper layers. The clusters of hNT cells took on the shape of a funnel at 14 days, and inverted funnel at 28 days, and by 56 days, populated the photoreceptor layer as a stratum. It is possible that hNT cells took on the morphology and function of photoreceptors. These results suggest that hNT cells injected epiretinally survive in the vitreous at least 56 days, migrate to the retinal/vitreous interface, and may migrate through the retina. This system permits the independent and quantitative evaluation of survival and migratory trophic responses.

[A case of recurrent bronchogenic cyst 15 years after initial operation].

There are few reports on the postoperative recurrence of bronchogenic cysts. We conducted a re-operation on a 57-year-old man with a bronchogenic cyst 15 years after an initial operation. His history showed an earlier operation for a bronchogenic cyst at the age of 42 at another hospital. 15 years after this initial operation, he suffered from common cold like symptoms, and was referred to our hospital, because of an abnormal shadow on his chest X-ray. A chest CT and MRI revealed an oval tumor just under the right intermediate bronchus. We suspected it was a recurrence of the bronchogenic cyst, and an operation was performed. The cyst was firmly adhered to the lung, and at the upper site of the cyst, a region adjacent to the intermediate bronchus was adhered to the bronchial wall. The histological findings were similar to those of 15 years previously. The cyst wall lined with pseudostratified columnar ciliary epithelium with muscular layer, which led to a diagnosis of a bronchogenic cyst. Congenital cysts, including bronchogenic cysts, are considered to originate in abnormal primordia. If there are remaining abnormal primordia, a recurrence of the disease can occur.

[Re-expansion pulmonary edema after emergency thoracotomy for spontaneous hemopneumothorax: a case report].

A 44-year-old man was admitted to out hospital complaining of chest pain and increasing dyspnea. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the left hemothorax. Following blood transfusion because of 2,000 ml hemorrhagic pleural fluid, emergent surgery was carried out. At operation, a bleeding artery originating from the apex of the thoracic cavity and a bulla on the upper lobe were noticed. After extubation of endotracheal tube, he offered severe dyspnea with hypoxia. The chest X-ray showed figure of pulmonary edema in the left lower lobe. Patient was managed by oxygen, steroid, and urinastatin. On the 3rd operative day, pulmonary edema was disappeared. It should be kept in the mind that the re-expansion pulmonary edema occurred in patients with spontaneous hemopneumothorax of less than 3 days of duration.

[Cerebral infarction due to bacterial emboli associated with methamphetamine abuse].

The number of stimulant-drug addicts has recently been on the rise again, and they are being increasingly encountered in the emergency room. There are also frequent reports of cerebrovascular disorders complicating drug toxicity. These cerebrovascular disorders have included subarachnoid hemorrhage, intracranial hematoma, and a few cases of cerebral infarction. Here, we report the case of a 37-year-old male with drug toxicity, consciousness disorder, and hyperthermia. He was in a coma with a temperature of 43.1 degrees C and blood pressure of 58/35 mmHg when brought to our hospital. His condition worse rapidly deteriorated, and he died the same day. Cerebral infarction caused by gram-positive bacillus embolism, not necrotizing angiitis, was found at autopsy. Because drug addicts, especially stimulant-drug addicts, tend to inject themselves drug under unsanitary conditions, the possibility of this type of complication is always present. This is the first such case ever reported, and is therefore regarded as a rare complication of stimulant-drug intoxication.

[A case report of spontaneous hemopneumothorax].

A 55-year-old man was admitted to the private hospital with chief complaints of left chest pain and increasing dyspnea. Chest X ray on admission revealed a collapsed lung and an air fluid line in the left hemothorax. A chest tube drainage was carried out, but hemorrhagic pleural fluid of 1,000 ml was drainaged. So was the patient transferred to our hospital for surgical treatment. Following blood transfusion because of hemorrhagic pleural fluid of 1,500 ml, urgent surgery was carried out. At the operation under thoracoscope, the bleeding from the apex of the thoracic cavity was noted. The bleeding was controlled with endoscopic surgical clip. As it was, however, very difficult to remove massive blood clots under endoscopic surgery, a small thoracotomy was carried out in addition to the thoracoscopic surgery, then the bulla in the apex of left lung was resected and also removed a large amount of blood clots.

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.

[A successful management of acute ruptures of the right atrium and left ventricle due to blunt trauma].

It is difficult to save a patient with acute cardiac free wall rupture due to blunt trauma; only 9 patients abroad and 2 patients in Japan are reported to have survived rupture of the left ventricle. A 30-year-old female was injured in a motor-vehicle accident. Distension of the neck vein, chest X-P and echocardiograms suggested cardiac tamponade due to cardiac rupture. After relieving the cardiac tamponade by left thoractomy, ruptures at the apex of the left ventricle and two sites in the right atrium could be repaired by median sternotomy, and the patient survived the injury. Cardiac rupture should be suspected in all cases of blunt trauma, and the early diagnosis of cardiac tamponade is a key to patient survival. Echocardiography is especially convenient and useful for the diagnosis of this condition. Repair should be performed by median sternotomy and the potential necessity for cardiopulmonary bypass should not be ignored.

[2 cases of the tension pneumopericardium following blunt chest trauma resulting in the cardiac tamponade].

A 63-year-old man (case 1) was brought to our emergency unit following a high speed collision. He developed fatal cardiopulmonary arrest shortly after arrival despite resuscitation efforts. Tension pneumopericardium was revealed by chest X-ray and CT examination. An 18-year-old man (case 2) was admitted after a motorcycle accident. Pneumopericardium was noted on admission chest X-ray and CT examination. He developed cardiac tamponade after the examination. He was intubated and mechanically ventilated after the subxiphoid pericardial drainage. Pneumopericardium following blunt chest trauma is realized with tracheobronchial, pulmonary or esophageal injury. The clinical significance of pneumopericardium is the development of tension pneumopericardium resulting into cardiac tamponade. In a patient with traumatic pneumopericardium who requires mechanical ventilatory support, continuous pericardial drainage should be considered. In addition, tension pneumopericardium may occur in patients with breathing spontaneously as in our cases. In these cases, careful observation and immediate subxiphoid pericardial drainage are required.

[A case of Hangman's fracture associated with vertebral arteriovenous fistula treated with trapping].

A case of a traumatic vertebral arteriovenous fistula associated with a hangman's fracture is reported. A 45-year-old male fell down about 2 meters and struck his parietooccipital region against the ground. Profuse nasal bleeding developed. He was transferred to a local hospital, where his respiration was ataxic and blood pressure was low. After intubation, he was transferred to our emergency department. Cervical x-p revealed fracture of C1, C2 and subluxation of C2 body. Because of uncontrollable nasal bleeding, the bilateral maxillary arteries were embolized with spongel. At this time, right vertebral angiograms demonstrated a vertebral arteriovenous fistula with an pseudoaneurysm located at C2 level. On the 13th hospital day, direct balloon occlusion of the fistula was attempted; this could not be achieved because the subclavian and vertebral arteries were tortuous and the balloon catheter could not be introduced to the level of the fistula in the vertebral artery. The patient was only observed until follow-up angiogram on the 24th hospital day revealed enlargement of the pseudoaneurysm. We performed trapping of both the proximal and distal ends of the involved vertebral artery; from C5 to C1. Postoperative course was uneventful, hangman's fracture was fixed with a Halo vest. Four months after operation, fistula and pseudoaneurysm were not opacified on angiogram. We believe that transvascular techniques are the treatment of choice for vertebral arteriovenous fistulas. However, as the next best thing, we can use trapping for the patient whose vessels are too tortuous to introduce the balloon catheter to the involved vessel.

[Traumatic primary brain stem injury and ambient cistern hematoma evaluated with magnetic resonance imaging].

Traumatic hemorrhage in the ambient cistern is thought to be an indirect indication of brain stem injury. In many cases such brain stem lesions cannot be clearly demonstrated by conventional CT scans. Magnetic resonance imaging (MRI) provides a more sophisticated display of the brain stem with improved contrast resolution of structures not appreciated on CT. We present four patients with traumatic ambient cistern hematoma on CT. They showed consciousness disturbance at the initial neurological examination and a Glasgow Coma Scale (GCS) of 7-10. All patients had hemothorax or clavicular fracture ipsilateral to the ambient cistern hematoma that suggested a severe mechanical force from the same direction. Axial, coronal and sagittal MRI scans were obtained with a super-conductive 1.5 T unit (Picker) within 6 days after trauma. Two standard pulse sequences were used; (1) Spin-echo (TR/TE = 500/20) or Inversion Recovery (TR/TI/TE = 3300/600/30) to obtain T1-weighted information and (2) Spin-echo (TR/TE = 2000/100) to obtain T2-weighted information. In case 1 (3-year-old girl) the hematoma which was thought to be located in the ambient cistern on CT was found to be present in the subpial region in the tegmentum on MRI. On T2 weighted image, a high signal intensity area was seen in the perifocal area. This area was demonstrated as a low density area on CT. This patient has remained in a persistent vegetative state 6 months after trauma. In case 3 (31-year-old man) CT demonstrated no abnormal findings in the brain stem. MRI demonstrated a high intensity area in the right cerebral peduncle and left tegmentum.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of intracerebral AVM fed by the anterior ethmoidal artery].

Only 27 cases of dural AVM fed by the anterior ethmoid artery have been reported in the literature. Their nidi were usually in the dura mater. In our case, the nidus was located in the brain parenchyma, although its feeder was the dural artery. A 75-year-old man was admitted to our department because of disturbed consciousness. CT scan showed intracerebral hemorrhage in the left frontal region with ventricular perforation, and subarachnoid hemorrhage in the suprasellar cistern. Left carotid angiography revealed an AVM in the anterior cranial fossa, fed by the anterior ethmoidal artery and drained by a cortical vein, which was dilated with some vascular sacs. A left frontal craniotomy was performed. The subcortical hematoma was removed, and then, after retracing the frontal lobe, two feeders penetrating the dura mater were identified and clipped. The nidus of the AVM with aneurysmal vascular dilatation could be seen on the cortical surface. It was coagulated and removed en-bloc. Histologically, the malformation consisted of thickened dilated veins and distorted small arteries. Postoperative angiography revealed no vascular anomaly. The patient was discharged with mild aphasia and mild right hemiparesis.