1/71. Carotid endarterectomy and intracranial thrombolysis: simultaneous and staged procedures in ischemic stroke.PURPOSE: The feasibility and safety of combining carotid surgery and thrombolysis for occlusions of the internal carotid artery (ICA) and the middle cerebral artery (MCA), either as a simultaneous or as a staged procedure in acute ischemic strokes, was studied. methods: A nonrandomized clinical pilot study, which included patients who had severe hemispheric carotid-related ischemic strokes and acute occlusions of the MCA, was performed between January 1994 and January 1998. Exclusion criteria were cerebral coma and major infarction established by means of cerebral computed tomography scan. Clinical outcome was assessed with the modified Rankin scale. RESULTS: Carotid reconstruction and thrombolysis was performed in 14 of 845 patients (1.7%). The ICA was occluded in 11 patients; occlusions of the MCA (mainstem/major branches/distal branch) or the anterior cerebral artery (ACA) were found in 14 patients. In three of the 14 patients, thrombolysis was performed first, followed by carotid enarterectomy (CEA) after clinical improvement (6 to 21 days). In 11 of 14 patients, 0.15 to 1 mIU urokinase was administered intraoperatively, ie, emergency CEA for acute ischemic stroke (n = 5) or surgical reexploration after elective CEA complicated by perioperative intracerebral embolism (n = 6). Thirteen of 14 intracranial embolic occlusions and 10 of 11 ICA occlusions were recanalized successfully (confirmed with angiography or transcranial Doppler studies). Four patients recovered completely (Rankin 0), six patients sustained a minor stroke (Rankin 2/3), two patients had a major stroke (Rankin 4/5), and two patients died. In one patient, hemorrhagic transformation of an ischemic infarction was detectable postoperatively. CONCLUSION: Combining carotid surgery with thrombolysis (simultaneous or staged procedure) offers a new therapeutic approach in the emergency management of an acute carotid-related stroke. Its efficacy should be evaluated in interdisciplinary studies.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
2/71. Midbrain infarction: a rare presentation of cryptococcal meningitis.A 20-year-old farmer who had headache and fever for 1 month, suddenly developed left hemiplegia, tremor in left arm and titubation followed by deep coma. Cranial CT scan revealed an infarction in right crus of midbrain. His CSF revealed 66 mg/dl protein, 10 lymphocytes/mm3, and 70 mg/dl glucose. CSF was positive for cryptococcal antigen. He improved following i.v. amphotericin 0.5 mg/kg and fluconazole 200 mg daily, continued for 6 and 12 weeks respectively. Infarctions though rare in cryptococcal meningitis should be considered in patients with chronic meningitis with vasculitis.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
3/71. Perioperative stroke associated with postoperative epidural analgesia.A patient with an epidural catheter for postoperative analgesia developed a stroke in association with a hypotensive episode resulting from a bolus of local anesthetic. After undergoing resection for femoral chondrosarcoma under epidural anesthesia, the patient received a continuous infusion of epidural morphine for postoperative analgesia. lidocaine 1% (10 mL in divided doses) was administered through the catheter for breakthrough pain. The patient experienced a hypotensive episode and was noted to have a motor and cortical sensory deficit of the left arm and leg 8 hours after the hypotensive episode. Clinical presentation and subsequent workup were consistent with a watershed infarction. The patient recovered full neurologic function before discharge. Postoperative hypotension from epidural analgesia may be associated with stroke; however, a cause-and-effect relationship usually cannot be established with certainty.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
4/71. Heterotopic ossification in childhood and adolescence.Heterotopic ossification, or myositis ossificans, denotes true bone in an abnormal place. The pathogenic mechanism is still unclear. A total of 643 patients (mean age, 9.1 years) admitted for neuropediatric rehabilitation were analyzed retrospectively with respect to the existence of neurogenic heterotopic ossification. The purpose of this study was to obtain information about incidence, etiology, clinical aspect, and consequences for diagnosis and therapy of this condition in childhood and adolescence. Heterotopic ossification was diagnosed in 32 patients (mean age, 14.8 years) with average time of onset of 4 months after traumatic brain injury, near drowning, strangulation, cerebral hemorrhage, hydrocephalus, or spinal cord injury. The sex ratio was not significant. In contrast to what has been found in adult studies, serum alkaline phosphatase was not elevated during heterotopic ossification formation. A persistent vegetative state for longer than 30 days proved to be a significant risk factor for heterotopic ossification. The incidence of neurogenic heterotopic ossification in children seems to be lower than in adults. A genetic predisposition to heterotopic ossification is suspected but not proven. As a prophylactic regimen against heterotopic ossification we use salicylates for those patients in a coma or persistent vegetative state with warm and painful swelling of a joint and consider continuous intrathecal baclofen infusion and botulinum toxin injection for those patients with severe spasticity. We prefer to wait at least 1 year after trauma before excision of heterotopic ossification.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
5/71. Traumatic basilar artery occlusion caused by a fracture of the clivus--case report.A 56-year-old man presented with a rare traumatic basilar artery occlusion caused by a fracture of the clivus. He fell from the height of 2 meters and immediately fell into a coma. Head computed tomography (CT) revealed an open depressed fracture, an acute epidural hematoma 1 cm thick in the left middle frontal fossa, and a longitudinal fracture of the clivus. Emergency removal of the hematoma was performed with cranioplasty. Head CT 8 hours 50 minutes after injury showed infarctions in the brain stem, cerebellum, and occipital lobes. cerebral angiography revealed occlusion of the basilar artery in the middle part of the clivus. The patient died after 3 days. autopsy revealed that the basilar artery was trapped in the clivus fracture site. Vertebrobasilar artery occlusion due to trapping in a clivus fracture has a very poor prognosis. diagnosis is difficult and generally only confirmed at autopsy. cerebral angiography is recommended in a patient in a deep coma without massive brain contusion at the early stage of head injury to identify the possibility of vertebrobasilar artery occlusion in a clivus fracture.- - - - - - - - - - ranking = 2keywords = coma (Clic here for more details about this article) |
6/71. Sudden coma from acute bilateral internal carotid artery territory infarction.Six patients with bilateral internal carotid artery occlusion who presented with sudden loss of consciousness, quadriplegia, and initially intact brainstem reflexes are described. They soon lost brainstem reflexes and died within 3 days. The presumed causes of internal carotid artery occlusion were atherothrombosis in three patients and cardiogenic embolism in the others. This catastrophic stroke syndrome mimics severe brainstem stroke and has an extremely poor prognosis.- - - - - - - - - - ranking = 4keywords = coma (Clic here for more details about this article) |
7/71. Metastatic chondrosarcoma to the lung with extension into the left atrium via invasion of the pulmonary veins: presentation as embolic cerebral infarction.We present a case of metastatic chondrosarcoma to the lungs that invaded the left inferior pulmonary vein, extended into the left atrium and presented with an embolic cerebral infarct. CT findings included a large mass in the left lower lobe associated with enlargement of the left inferior pulmonary vein and a lobular filling defect in the left atrium. Systemic arterial embolization and obstruction of the mitral valve may be prominent features of pulmonary tumors that have invaded the pulmonary veins.- - - - - - - - - - ranking = 5keywords = coma (Clic here for more details about this article) |
8/71. Extensive bihemispheric ischemia caused by acute occlusion of three major arteries to the brain.An 86-year-old woman developed cardioembolic stroke three times. In the last one, she fell into sudden coma and fatal outcome due to acute occlusion of bilateral internal carotid arteries (ICAs) and the basilar artery. diffusion-weighted magnetic resonance imaging (MRI) delineated brain ischemia in the whole bilateral cerebral hemisphere soon after the stroke onset. Signal intensity of the brain parenchyma increased in whole the hemisphere. Especially, all the cortical rims glittered. This is the first report of the cardioembolic stroke due to simultaneous occlusion of the three major arteries to the brain.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
9/71. diffusion-weighted imaging in acute bacterial meningitis in infancy.Bacterial meningitis is frequently fatal or leads to severe neurological impairment. Complications such as vasculitis, resulting in infarcts, should be anticipated and dealt with promptly. Our aim was to demonstrate the complications of meningitis by diffusion weighted imaging (DWI) in patients who deteriorated despite therapy. We studied 13 infants between the ages of 1 day and 32 months who presented with symptoms ranging from fever and vomiting to seizures, encephalopathy and coma due to bacterial meningitis, performing MRI, including DWI, 2-5 days after presentation. Multiple infarcts were found on DWI in 12 of the 13, most commonly in the frontal lobes (in 10). Global involvement was seen in four children, three of whom died; the fourth had a very poor outcome. In one case abnormalities on DWI were due to subdural empyemas. We diagnosed vasculitis in three of five patients studied with MRA. We think DWI an important part of an MRI study in infants with meningitis. Small cortical or deep white-matter infarcts due to septic vasculitis can lead to tissue damage not easily recognized on routine imaging and DWI can be used to confirm that extra-axial collections represent empyemas.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
10/71. temporal muscle haematoma as a cause of suboptimal haemicraniectomy: case report.OBJECTIVE: To call attention to an unusual complication of decompressive haemicraniectomy in the treatment of malignant haemispheric infarction. METHOD: We describe a case in which partial decompression occurred despite large craniectomy. Complete decompression followed resection of the temporal muscle. Pertinent literature is briefly reviewed. CASE DESCRIPTION: A 55-year old woman developed massive right middle cerebral artery infarction evolving to cerebral haerniation in 40 hours. Decompressive haemicraniectomy without cortical excision was unable to revert coma and decerebrate posturing because of a massive temporal muscle haemorrhage with persistent contralateral deviation of midline structures. Muscle resection was followed by adequate external haerniation of the affected haemisphere and fast recovery. Cranioplasty was succesfully performed 22 days later, following gradual regression of cerebral oedema. CONCLUSION: There is an increasing perception of the need to operate patients with massive middle cerebral or internal carotid artery territory infarctions before the development of coma and cerebral haerniation. The most common factor leading to inadequate surgical decompression is small size craniectomy. The case reported calls attention to temporal muscle bleeding as an additional complication of craniectomy.- - - - - - - - - - ranking = 2keywords = coma (Clic here for more details about this article) |
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