1/26. 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) |
2/26. Large cerebral vessel disease in sickle cell anaemia.An 18 year old male with documented sickle cell disease was admitted to the hospital for the final time in coma. cerebral angiography revealed multiple stenotic lesions of the large cerebral vessels. The pathology of this large vessel involvement is demonstrated and the potential contribution of large as opposed to small cerebral vessel disease in the neurological manifestations of sickle cell anaemia is discussed.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
3/26. hyphema associated with pupillary dilation in a patient with exfoliation glaucoma and warfarin therapy.PURPOSE: To describe an unusual hemorrhagic complication associated with pupillary dilation in a patient with exfoliation glaucoma taking anticoagulation therapy. methods: A 78-year-old woman with bilateral exfoliation glaucoma who was receiving warfarin, 2 mg daily, for systemic anticoagulation developed acute visual loss in the right eye several hours after pupillary dilation. RESULT: Examination disclosed bilateral advanced exfoliation glaucoma, localized vascularized iridolenticular adhesions in the right eye, and a 4-mm layered hyphema in the right eye. CONCLUSION: patients with exfoliation glaucoma and vascularized posterior synechiae who are receiving anticoagulation therapy are at increased risk for visually significant spontaneous hyphema after pupillary dilation.- - - - - - - - - - ranking = 8keywords = coma (Clic here for more details about this article) |
4/26. Normal-tension glaucoma with reversed ophthalmic artery flow.PURPOSE: To describe a case of normal-tension glaucoma with bilateral complete occlusion of the internal carotid artery. methods: A 58-year-old man who had a 2-year history of normal-tension glaucoma in the left eye presented with ocular ischemic syndrome. To evaluate the orbital circulation, cerebral angiography and color Doppler imaging were performed. RESULTS: cerebral angiography showed bilateral complete occlusion of the internal carotid artery and collateral blood supply through the right and left ophthalmic arteries, in which the flow was reversed. Moreover, color Doppler imaging revealed lower blood flow velocities in the left central retinal and short posterior ciliary arteries, suggesting a steal phenomenon. CONCLUSION: Normal-tension glaucoma in the present case may be caused by chronic reduction of retrobulbar blood flow resulting from a steal phenomenon.- - - - - - - - - - ranking = 7keywords = coma (Clic here for more details about this article) |
5/26. Nonketotic hyperglycemic hyperosmolar coma. Report of neurosurgical cases with a review of mechanisms and treatment.Seventy-eight critically ill patients who died while on the neurosurgical service were studied retrospectively to establish the prevalence of nonketotic hyperglycemic hyperosmolar coma (NHHC). All the patients had been comatose before death, and all underwent necropsy. Criteria for the diagnosis of NHHC included moderate-to-severe hyperglycemia with glucosuria, absence of significant acetonuria, hyperosmolarity with dehydration, and neurological dysfunction. This study revealed seven cases of unequivocal NHHC (9%), and six of hyperosmolarity but with incomplete records. Five of the seven confirmed cases of NHHC demonstrated no evidence of cerebral edema transtentorial herniation, or brain-stem damage, and showed central nervous system (CNS) lesions compatible with survival. Fatal complications of this syndrome, such as acute renal failure, terminal arrhythmias, and vascular accidents, both cerebral and systemic, were common in this series. The mechanism of coma in NHHC is believed related to shifts of free water from the cerebral extravascular space to the hypertonic intravascular space, with subsequent intracellular dehydration, accumulation of metabolic products of glucose, and brain shrinkage. It is uncertain whether injury to specific areas in the CNS is a predisposing factor to the development of NHHC. Factors documented to be significant in its development include nonspecific stress to primary illnesses, hyperosmolar tube feedings, dehydration, diabetes and mannitol, Dilantin, or steroid administration.- - - - - - - - - - ranking = 7keywords = coma (Clic here for more details about this article) |
6/26. Acute extrapyramidal syndrome in mild ornithine transcarbamylase deficiency: metabolic stroke involving the caudate and putamen without metabolic decompensation.A 6-year-old male with partial ornithine transcarbamylase (OTC) deficiency had acute and rapidly progressive symmetrical swelling of the head of the caudate nuclei and putamina. Clinical presentation was ataxia and dysarthria progressing to seizures and coma; these symptoms gradually resolved with supportive management. Although he had been recently treated for mild hyperammonemia, there was no evidence of acute metabolic decompensation prior to presentation, and plasma ammonia and amino acids were consistent with good metabolic control. This case is novel in that the neurological insult affected the neostriatum of the basal ganglia and the episode occurred in the absence of an apparent metabolic abnormality, unique observations in a patient with OTC deficiency. CONCLUSION: This case suggests that the pathophysiology of metabolic stroke is complicated. It also argues for an evaluation for metabolic stroke in patients with known inborn errors of metabolism who present with unusual neurological symptoms in the absence of biochemical abnormalities. Similarly, this case suggests that patients presenting with unexplained neurological insults might benefit from an evaluation for an inborn error of metabolism.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
7/26. 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) |
8/26. Traumatic internal carotid artery occlusion--case report.A 20-year-old male was admitted comatose immediately after a motorcycle accident. Initial computed tomography demonstrated traumatic subarachnoid hemorrhage, and the diagnosis of traumatic internal carotid artery occlusion was established by angiography. Conservative management improved his symptoms, but eventually he died from delayed traumatic apoplexy. Traumatic internal carotid artery occlusion is relatively rare, but is serious and requires early diagnosis and treatment. For patients with severe head trauma and vascular occlusion, anticoagulants are contraindicated, and frequent follow-up angiography is recommended.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
9/26. cerebrospinal fluid cytokines in salmonella urbana encephalopathy.We present a case report of encephalopathy associated with salmonella urbana infection in a child. A 5-year-old boy was admitted to our clinic with convulsions and coma. cerebrospinal fluid (CSF) interleukin-6 (IL-6) and IL-8 were elevated at onset and were decreased within normal limit on the fifth day. Residual neurological deficits included severe mental deficits and spastic tetraplegia. High levels of CSF proinflammatory cytokines might be related to central nervous system (CNS) disease activity. Although encephalopathy is a rare complication of non-typhi salmonella infection, it should be borne in mind as an occasionally serious and potentially lethal disease.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
10/26. Intracardiac rhabdomyosarcoma: transesophageal echocardiographic findings and diagnosis.Transesophageal echocardiography (TEE) was performed on a 41-year-old woman who presented with a cerebrovascular accident. TEE confirmed the presence of a morphologically bizarre biatrial tumor with precarious, vigorous motion throughout the cardiac cycle. Surgical intervention was decided on, and the patient underwent cardiac surgery for tumor excision 16 hours after TEE. Intraoperative frozen section diagnosis was spindle cell sarcoma, and subsequent immunohistochemical analysis showed the tumor to be a rhabdomyosarcoma. The data are presented here, and the role of TEE to establish a preoperative diagnosis of intracardiac tumor is discussed.- - - - - - - - - - ranking = 6keywords = coma (Clic here for more details about this article) |
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