Efficacy of endovascular surgery for the treatment of acute epidural hematomas.

BACKGROUND AND PURPOSE: Recent advances in the equipment and technology for endovascular surgery have led to an increasing number of patients undergoing this procedure to treat various lesions. The purpose of this study was to investigate the efficacy of early-stage endovascular surgery to treat growing acute epidural hematomas (AEDHs). METHODS: Over a period of 2.5 years, endovascular intervention was performed in nine patients with AEDHs, as shown by the extravasation of contrast medium and the recognition of growing hematomas on CT scans. Embolization was performed by using catheters superselectively advanced with a microguidewire until it reached the area just before the bleeding point. RESULTS: In all nine cases, bleeding from the middle meningeal artery ceased immediately after treatment, and further surgical intervention was avoided. In three of five patients with additional lesions, surgical intervention was also conducted to treat an acute subdural hematoma (two patients) or a contusion hematoma (one patient); in two cases, these lesions were located on the contralateral side. CONCLUSION: In patients with thin AEDHs in the early stage, angiography followed by endovascular intervention allows for conservative treatment. Notable clinical benefits can be achieved in patients with complicated, multiple lesions.

Hepatocellular injury with hyperaminotransferasemia after cresol ingestion.

A 42-year-old man attempted suicide by ingesting about 150 mL of a saponated cresol solution containing about 50% cresol. His serum aminotransferase concentrations were elevated, and a coagulopathy was present at the time of admission, 15 hours after ingestion. The hyperaminotransferasemia and coagulopathy worsened on the second day, but resolved thereafter with supportive therapy. Histologic examination of a biopsy specimen obtained on the 14th day demonstrated focal dropout of hepatocytes (which were replaced by reticulin and collagen fibers), ballooning or hydropic degeneration of hepatocytes, and rapid regeneration with small hepatocytes in the periportal zones as well as in the centrilobular zones. A rapid onset of illness with periportal hepatocellular injury is inconsistent with damage due to a hepatotoxic metabolite of p-cresol produced by cytochrome P450, which has been suggested by studies in vitro. A direct transient noxious effect mediated via the portal or arterial circulation may be involved in hepatic injury after cresol ingestion.

Acute massive pulmonary thromboembolism associated with risperidone and conventional phenothiazines.

To assess the contribution of antipsychotic medication in Japanese patients suffering acute massive pulmonary thromboembolism, records of patients with idiopathic pulmonary thromboembolism associated with antipsychotic medication who were seen in a Japanese Emergency Center from January 1996 to December 2000 were reviewed. Age, gender, physical status, clinical presentation, antiphospholipid antibody, outcome, psychiatric profile, and antipsychotic medication use were examined. Seven patients had acute pulmonary thromboembolism associated with antipsychotic drug use, representing 44% of all patients with idiopathic pulmonary thromboembolism. The 7 patients developed symptoms in the early morning. More women than men were affected. In 5 cases, chlorpromazine and other phenothiazines had been prescribed, whereas in 2 cases, risperidone, a mixed serotonin 5HT(2A) and dopamine D(2) receptor antagonist, had been taken for 40 days and 6 days, respectively. In 4 cases, including the patients taking risperidone, antiphospholipid antibodies were not present. Although statistically significant conclusions can not be drawn from this study, the data suggest that patients receiving risperidone, as well as conventional phenothiazines, are at risk for acute pulmonary thromboembolism, even if otherwise healthy. Strong affinity for the 5HT(2A) receptor of the novel antipsychotic may increase coagulability and the risk of thromboembolism.

Transient diffuse cerebral hypoperfusion in Tc-99m HMPAO SPECT of the brain during withdrawal syndrome following acute barbiturate poisoning.

A 29-y-old man had taken small daily doses of barbiturates as hypnotics (50 mg pentobarbital, 30 mg phenobarbital) for 4y with no evident intoxication. When he attempted suicide by ingestion of 15 g amobarbital, treatment with charcoal hemoperfusion resulted in rapid disappearance of drug from the blood. Generalized convulsions and delirium ensued; these were responsive to phenobarbital. An electroencephalogram (EEG) showed diffuse 5-Hz theta activity. Tc-99m hexamethylpropyleneamineoxime (HMPAO) single photon emission computed tomographic (SPECT) imaging of the brain demonstrated a diffuse bilateral decrease in blood flow to the cerebral cortex. These investigations were performed interictally on day4 without sedative drugs, prior to initiation of anticonvulsants, and at a time when barbiturates were no longer detected in the serum. An EEG on day 15 no longer showed abnormal slowing. On the other hand, Tc-99m HMPAO SPECT of the brain demonstrated residual cerebral hypoperfusion on day 20, with nearly full recovery of cerebral perfusion on day 51. Barbiturate withdrawal syndrome is presumed to require a history of abuse; however in patients with a history of treatment with barbiturates physicians treating acute barbiturate poisoning should be alert for the possibility of barbiturate withdrawal syndrome even in the absence of barbiturate abuse.

Conduction system abnormalities in rat embryos induced by maternal hyperthermia.

Maternal hyperthermia induces severe malformations in the central nervous system (CNS) in both humans and laboratory animals. These phenomena are accompanied by apoptotic cell death, especially in the developing CNS. Cardiovascular malformations in conjunction with skeletal and CNS abnormalities have been reported in embryos of laboratory animals. In rats, hyperthermic treatment at 43 degrees C for 15 min at day 9 of pregnancy induced various severe external malformations in embryos, such as exencephaly, spina bifida, microphthalmia, anophthalmia, facial cleft or defect, generalized edema, and cardiovascular abnormalities. Examination of the embryonic heart revealed abnormal formation of the conduction system. Although hyperthermia causes marked hemodynamic defects, we could not obtain direct proof of a link between hemodynamic alteration by hyperthermia and malformations of the conduction system.

Acute liver failure following intravenous methamphetamine.

A 41-y-o Pakistani man presented with psychosis, hyperthermia, rhabdomyolysis, and liver dysfunction approximately 6 h after i.v. injection of methamphetamine. Serum concentrations of methamphetamine and amphetamine on admission were 0.30 microg/mL and 0.04 microg/mL, respectively. Total serum bilirubin and alanine aminotransferase concentrations peaked on the 3rd hospital day at 8.6 mg/dL and 4155 IU/L, respectively, and gradually returned to normal with supportive care. The patient had no evidence of infectious hepatitis or intake of other drugs. Histologic examination of a liver biopsy specimen obtained on the 11th d showed confluent necrosis and ballooning degeneration in centrilobular zones. No inflammatory changes were seen in portal tracts. Liver damage can be a complication of illicit methamphetamine use, even in patients without viral infection or intake of other drugs.

Blockade of bradykinin B(2) receptor suppresses acute pancreatitis induced by obstruction of the pancreaticobiliary duct in rats.

1. The involvement of bradykinin (BK) B(2) receptor in acute pancreatitis induced by pancreaticobiliary duct ligation was investigated in rats. 2. The activities of amylase and lipase in the serum, the water content of the pancreas, and vacuolization of the acinar cells were significantly increased 2 h after obstruction of the duct in Sprague-Dawley rats. 3. Elevated serum amylase activity, increased pancreatic oedema, and damage of the pancreatic tissue were significantly less marked in plasma kininogen-deficient, B/N-Katholiek rats than in the normal strain, B/N-Kitasato rats 2 h after the ligation. 4. Obstruction of the pancreaticobiliary duct augmented the level of (1-5)-BK (Arg(1)-Pro(2)-Pro(3)-Gly(4)-Phe(5)), a stable BK metabolite, in the blood from 73.0+/-21.7 pg ml(-1) at 0 h to 149.8+/-38.0 pg ml(-1) at 2 h after the induction of pancreatitis in SD rats. 5. Administration of a BK B(2) receptor antagonist, FR173657 (100 mg kg(-1), p.o.) or Hoe140 (100 nmol kg(-1), s.c.), reduced the elevation of amylase and lipase activities in the serum and of pancreatic water content in a dose-dependent manner. The effective attenuation of oedema formation and vacuolization by the antagonists was also confirmed light-microscopically. In contrast, treatment with gabexate mesilate or indomethacin did not cause significant suppression of the pancreatitis. 6. These findings suggest a possible involvement of kinin B(2) receptor in the present pancreatitis model. Furthermore, they point to the potential usefulness of the B(2) receptor in clinical acute pancreatitis.

Treatment outcome of nonclostridial gas gangrene at a Level 1 trauma center.

OBJECTIVE: To evaluate the results of treatment of nonclostridial gas gangrene at a Level 1 trauma center. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS: Seven patients with nonclostridial gas gangrene were studied. The average age of all patients at the time of admission was 40.3 years (range 14 to 67 years). RESULTS: Three of seven patients had posttraumatic infection, and the remaining four were strongly associated with underlying diseases: diabetes mellitus in three and paraplegia as the result of a spinal cord injury in two. The time of symptom onset was clearly defined in four cases, and the average interval between symptom onset and transfer to our hospitals was six days (range 2 to 10 days). Surgical debridement was performed immediately on admission in six patients (86 percent). A triple antibiotic regimen consisting of penicillin, gentamicin, and clindamycin was used initially in all patients. In three patients, hyperbaric oxygen therapy was also used. The overall mortality rate was 42.9 percent (three of seven patients). In these patients, the interval from onset of symptom to transfer to our hospital was ten days in one patient, which was longer than average, and was not accurately known in the other two patients. CONCLUSION: Nonclostridial gas gangrene is extremely rare but life-threatening. The greatest pitfall for the emergency department physician is failure to suspect it clinically. Aggressive treatment, including surgical debridement and intravenous antibiotics with or without hyperbaric oxygen therapy, must be initiated immediately to minimize morbidity and mortality.