When cardiac hypokinesis in myocardial infarction is analyzed by means of phase analysis of radionuclide (RI) angiography, there are some cases in which the amount of regional wall movement of the left ventricle does not so decline, but the phase delay of regional wall movement is great. Hence, a simulation experiment was performed with a computer to evaluate the influences of regional phase delay on cardiac work. It was assumed that the radius of the model of the left ventricle varies from 3 cm in the late diastolic phase to 2 cm in the late systolic phase, and that in the initial 1/3 time of diastole, the radius alters by 90% of the change. One cardiac cycle (360 degrees) was divided into 60 fractions (1 fraction = 6 degrees), 0 degree being the end of diastole and 180 degrees the end of systole. An ischemic area was supposed to cover S% of the whole volume of the left ventricle, its amount of regional wall movement being P% of the normal area, and the phase delay being R degrees. By varying S, P and R, and taking weighted means of volume curves and normal ones, their assumed volume curves of the left ventricle were computed. Stroke volume (SV) and ejection fraction (EF) obtained from these curves were compared to those obtained from the normal curves, and were expressed in percentage (%SV, %EF). The influences of the changes of S, P and R on the volume curve and on the cardiac work were examined. Then the count curves of the left ventricle (LV) were obtained by gated RI angiography in 22 cases of myocardial infarction and 8 healthy controls, and LV regional wall movements were examined by means of the Fourier analysis. The circular volume was partitioned from the center into eight sections on the LV image of LAO 45 degrees, and the amount of wall movement and the phase delay of each section were evaluated from the count curves of each section. The following results were obtained. %SV and %EF declined with sole occurrence of regional phase delay. Occurrence of the regional phase delay flattened the slope of the volume curve of the initial diastolic phase and formed shoulders on this curve. This was observed also on the count curves actually determined from cases with myocardial infarction. When regional wall movement was markedly decreased, the influence of the regional phase delay on the pattern of the volume curve was slight even if the phase delay was extensive.(ABSTRACT TRUNCATED AT 400 WORDS)
In Japan, pulmonary thromboembolism (PTE) is rare and the therapy of this disease, especially the thrombolytic therapy, has not been established yet. We studied the effect of thrombolytic therapy by urokinase (UK) in eighteen patients with PTE. We also compared the results with those in Europe and the United States. Eighteen patients (male 7, female 11) were 27 yo to 77 yo (mean 55 yo). Seven cases were mild and 11 cases were moderate to severe. The initial dosage of UK administration was 2.4 x 10(5) to 7.2 x 10(5) IU with the mean of 4.1 x 10(5) IU, which was approximately the double of those in Europe and the US. The duration of UK therapy was 1 to 9 days with the mean of 4.8 days. It was longer than in Europe and the US (12-24 hours). Total amount of UK in each case ranged 4.8 x 10(5) to 42 x 10(5) IU (mean 19.3 x 10(5) IU) with the daily dosage of 4.0 x 10(5) IU in average. They were almost half of those in Europe and the US. Clinical signs and laboratory findings subsided in 1-7 day by UK administration in 14 cases (87%) with the reduction of defects on perfusion lung scans and all of these cases survived. No severe complications were found in any cases. We conclude that the thrombolytic therapy with UK in Japan might be acceptable from the results of this present study. However, the prospective study of thrombolytic therapy on a larger scale remains to be done in the future.
Cerebral vasospasm is an unelucidated complication of subarachnoid hemorrhage. Various treatments exist against cerebral vasospasms however, consensus on the optimal treatment is lacking. We use clazosentan, which is used to prevent cerebral vasospasm, with multidrug combinations. In this study, we aimed to clarify the initial results of using clazosentan in multidrug combinations in the real world. We retrospectively investigated 54 patients who were treated for subarachnoid hemorrhage and received clazosentan. We compared the results of these patients on the basis of two groups: those with good outcomes (modified Rankin scale score: 0–3) and poor outcomes (4–6) at discharge. Among the patients, poor outcome was observed in 19 patients (35.2 %). Angiographic vasospasms occurred in 10 patients (good outcome [n = 6] vs. poor outcome [n = 4]; p = 0.73), and symptomatic vasospasms occurred in 4 patients (n = 2 vs. n = 2, p = 0.61). The incidence of pleural effusion (28.6 % vs. 73.7 %, p < 0.01) and the mean daily fluid balance (303.5 mL/day vs. 785.4 mL/day, p < 0.01) were higher in the poor outcome group. Pleural effusion and high positive balance may be associated with poor outcome. However, the number of cases examined was small; therefore, further large-scale studies with a bigger sample size are needed.
Background: Embolic cerebral infarction and infectious intracranial aneurysms (IIAs) are well-known central nervous system complications of infective endocarditis (IE). In this report, we describe a rare case of cerebral infarction caused by the occlusion of the M2 inferior trunk due to IE, followed by the rapid formation and rupture of IIA. Case Description: A 66-year-old woman was admitted to the hospital with a diagnosis of IE and embolic cerebral infarction after being brought to the emergency department with a 2-day history of fever and difficulty walking. After admission, she was immediately started on antibiotic therapy. Three days later, the patient suddenly became unconscious, and a head computed tomography (CT) scan showed massive cerebral hemorrhage and subarachnoid hemorrhage. Contrast-enhanced CT showed a 13-mm large aneurysm in the left middle cerebral artery (MCA) bifurcation. An emergency craniotomy was performed, and intraoperative findings revealed a pseudoaneurysm at the origin of the M2 superior trunk. Clipping was considered difficult, so trapping and internal decompression were performed. The patient died on the 11 th day after surgery due to the worsening of her general condition. The pathology of the excised aneurysm was consistent with a pseudoaneurysm. Conclusion: IE may cause occlusion of the proximal MCA and rapid formation and rupture of IIA. It should be noted that the location of IIA may be a short distance away from the occlusion site.
Objective: We investigated that the characteristics of serum catecholamine concentration at the hyper-acute phase of aneurysmal subarachnoid hemorrhage (SAH) and its relationship between patient outcome and delayed vasospasm. Methods: Patients with aneurysmal SAH (n=170) were prospectively enrolled between 2008 and 2011. Baseline demographic data and physiological parameters, including plasma concentrations of adrenaline (AD), noradrenaline (NA) and dopamine (DP) were evaluated. Results: On admission, plasma AD, NA and DP levels were significantly higher in patients with a poor clinical grade on admission (Hunt and Kosnik: IV-V), compared to those with a good clinical grade on admission (Hunt and Kosnik: I-III). AD showed a significantly high concentration immediately after the onset of SAH and then rapidly decreased. The levels of NA peaked within 6 hours after onset, then significantly decreased. The time course of the elevation of DP showed a similar trend to that of NA. The each catecholamine levels significantly correlated with each other. Multivariate analyses demonstrated age, poor clinical grade, plasma AD and NA levels were predictors of poor patient outcome. Poor clinical grade, Fisher scale and plasma AD level were predictors of the development of delayed vasospasm. Conclusion: The present study suggests that sympathetic activation in patients in the acute phase of SAH reflects the severity of SAH, and is closely related to the development of delayed vasospasm, leading to the subsequent immune response and inflammatory reactions. Suppressing catecholamine surge in hyper-acute phase may contribute to prevention of vasospasm and improvement of patient outcome.
Isolated-type intracranial dural arteriovenous fistulas (DAVFs) could hinder the effective use of the transvenous approach. Direct trans-sinus embolization (dTSE) with craniotomy remains the treatment method for isolated-type DAVFs. We report our experience in using a neurosurgical hybrid operating room (NHOR) to treat cases of isolated-type DAVFs by dTSE using a single burr hole. Between April 2007 and March 2017, 189 DAVFs were treated by an endovascular procedure at our institution. Among these cases, 27 patients (14.3%) had isolated-type DAVF and 7 patients (3.7%) were treated by dTSE. The procedure accuracy and invasiveness of dTSE were compared with those of the transvenous embolization (TVE) group. The NHOR was equipped with a biplane angiography system and used to perform 3D rotational angiography (3DRA). The burr hole site was precisely determined by 3DRA. Only one burr hole was made to expose the target sinus and allow for direct puncture. The target sinus was occluded by using coils and liquid embolic material. The NHOR allowed the accurate placement of the burr hole. Only a single burr hole and small skin incision (with minimal bleeding) were required for each dTSE case. The mean total contrast volume was significantly reduced in the dTSE group compared with that in the TVE group. Moreover, the dTSE group required shorter operation times and lower total radiation doses compared with the TVE group. Using dTSE could be performed with a single burr hole using a NHOR equipped with biplanar fluoroscopy. This approach is a minimally invasive and effective treatment for isolated-type DAVFs.
The trans-cell technique in stent-assisted coil embolization is a common treatment method for intracranial aneurysm. However, despite the frequency of its use, reports discussing its complications and their management are few. We describe a case of stent and microguidewire entanglement, which could not be removed, during treatment using the trans-cell technique. We discuss the mechanism of the entanglement and its management.A woman in her 40s was found to have an unruptured cerebral aneurysm with a maximum diameter of 5.9 mm located in the paraclinodal anterior process of the left internal carotid artery during a close examination of a headache. The aneurysm had an irregular shape and wide neck. Stent-assisted coil embolization was planned. Initially, the coil was embolized using a jailing technique, but the microcatheter was pushed out of the aneurysm during embolization. Thus, we attempted to switch to a trans-cell technique. However, during the process, the stent and microguidewire became entangled and could not be removed. Finally, when the stent slipped off, the entanglement was resolved and the microguidewire was retrieved. Fortunately, the patient was discharged home without postoperative complications.Once a stent and a microguidewire become entangled, safely releasing them is difficult. Thus, it is important to avoid this scenario from occurring.
