Delayed cardiac tamponade caused by a staple line after wedge resection of the lung

An 80-year-old woman was diagnosed with an adenocarcinoma of the left lower lobe, clinical stage IA3. Taking the patient’s age and medical history into consideration, a wedge resection was performed. After the resumption of rivaroxaban on postoperative Day 3, the patient suddenly developed cardiac tamponade on postoperative Day 5. A drainage tube was placed by pericardiocentesis, and the haemodynamics recovered immediately. No recurrence of cardiac tamponade was observed. The confluence of staple lines is a risk factor for tissue damage. Some covering is recommended, especially when the stapling line contacts the pericardium on the left side.     

Prolonged somatic survival of clinically brain-dead adult patient

A 43-year-old woman suffered clinical brain death after severe head injury. The patient met the criteria for the diagnosis of clinical brain death on Day 3. Aggressive hemodynamic and respiratory managements coupled with triple hormone therapy were performed at the family's request, resulting in continued cardiac activity for a prolonged period. Spinal reflexes and automatisms were observed until cardiac arrest. Ventilatory support was discontinued on Day 168, when cardiac death was confirmed, and her kidneys and eyeballs were removed for transplantation. The patient survived for 165 days after the diagnosis of clinical brain death, which is an extremely prolonged period of somatic support for an adult patient after brain death. An extensive and informed discussion on the end-of-life treatment of clinically brain-dead patients is urgently required in Japan to establish treatment guidelines for such patients.     

Heparin-induced thrombocytopenia and thrombosis following subarachnoid hemorrhage. Case report

The authors present a case of heparin-induced thrombocytopenia and thrombosis (HITT) that occurred after aneurysmal subarachnoid hemorrhage (SAH), and they review the relevant literature. An immune-mediated syndrome, HITT is characterized by moderate thrombocytopenia and paradoxical vascular thromboses. Although it has been estimated in prospective studies that HITT occurs in between 1 and 3% of patients receiving heparin, it is underrecognized in the neurosurgical literature. In the present case, a 49-year-old woman underwent clipping of a right posterior communicating artery aneurysm after suffering a Hunt and Hess Grade III SAH. She had an uncomplicated postoperative course with good clip positioning and no vasospasm observed on a cerebral angiogram obtained on Day 7. On Day 23, the patient developed a right hemiparesis and experienced a grand mal seizure. A head computerized tomography scan revealed a hemorrhagic infarct in the left middle cerebral artery distribution. Repeated cerebral angiograms did not show vasospasm. She was thrombocytopenic (platelet count as low as 46 x 10(9)/L on Day 28 compared with 213 x 10(9)/L on Day 1) and had been receiving heparin flushes to maintain intravenous catheter patency. An assay for HITT-associated antibodies was positive. The heparin flushes were discontinued and the platelet count recovered (121 x 10(9)/L). She improved neurologically, but was left with a significant right hemiparesis at discharge. This patient had assay-proven heparin-induced thrombocytopenia despite minimal exposure to heparin. Because there was no evidence of vasospasm or other factors to account for her delayed hemorrhagic infarction, an HITT-related disorder seemed most likely. Despite a large body of literature describing HITT in nonneurosurgical patients, only three previous neurosurgical cases have been published. This case report may serve to heighten awareness of this disorder.     

Dissecting aneurysm of the posterior inferior cerebellar artery--studied by serial angiography]

We report the case of a 34-year-old male with cerebellar hemorrhagic infarction caused by a dissecting aneurysm of the left posterior inferior cerebellar artery (PICA). The patient suffered from a headache and vomiting for two days and was transferred to our hospital with sudden deterioration of consciousness. On admission, he was semicomatose. A CT scan revealed hemorrhagic infarction in the left cerebellum and upward herniation. The emergency operation for posterior fossa decompression was performed. Postoperatively, his consciousness level improved promptly and he had no neurological deficits except for slight gait disturbance. The first vertebral angiography was performed on Day 27. It showed a sausage-like dissecting aneurysm of the left distal PICA. We planned conservative therapy with careful observation because of there being no indication for an operation. Serial angiography was performed and demonstrated the regression of the dissecting aneurysm on Day 258. Dissecting aneurysms of the distal PICA are rare and their natural history is not well understood. Conservative therapy for vertebrobasilar dissecting aneurysms has often been reported. We suggest that conservative therapy with serial angiography is the treatment of choice especially for ischemic-type dissecting aneurysms. We review 17 cases of dissecting aneurysm of the distal PICA in this study.     

High-dose chemotherapy followed by peripheral blood stem cell transplantation in advanced extragonadal germ cell tumor--a case report]

We reported the experience of high-dose chemotherapy (HDC) combined with peripheral stem cell transplantation (PBSCT) in 29 years-old man with advanced retroperitoneal germ cell tumor accompanied with left supraclavicular lymph node metastases, who obtained complete remission after comprehensive treatment. The initial levels of serum AFP, hCG and beta-hCG were high at 30.2 ng/ml, 14,000 mIU/ml and 66 ng/ml, respectively. After 3 courses of chemotherapy (BEP regimen), while left supraclavicular lymph node swelling was disappeared, the retroperitoneal mass lesion persisted on CT scan. Not all of 3 markers fell to the normal range. After myelosuppressive chemotherapy (etoposide 500 mg/m2 Day 1-3), PBSCs were collected by two consecutive apheresises on Day 17 and 18. In total, 19.5 x 10(6)/kg CD 34 positive cells were obtained. The patient underwent PBSCT (all CD 34 positive cells were infused) on Day 0 following HDC (CBDCA 250 mg/m2/day, etoposide 300 mg/m2/day, IFM 1.5 g/m2/day, Day-7(-)-3, respectively). He became severely leukopenic and thrombopenic with nadir of 200/microliter on Day 6 and 2 x 10(4)/microliter on Day 2, respectively. By administration of platelet transfusion and G-CSF, the white blood cell counts and thrombocyte counts recovered to 6,400/microliter and 4.1 x 10(4)/microliter on Day 10, respectively. Microbiologically enterocolic and respiratory tract infections occurred with elevated body temperature (> 40 degrees C). Antibiotic and antimycotic treatments were continued until disappearance of all clinical and microbiological evidence. He was kept for 10 days in clean room. After HDC, all markers fell to the normal range, but the retroperitoneal residual mass still persisted. Resection of the residual mass and retroperitoneal lymph node dissection were performed with pathological examination revealing tissue necrosis without viable cell. The patient has survived with no sign of the disease for 9 months.     

Argatroban usage for anticoagulation for ECMO on a post-cardiac patient with heparin-induced thrombocytopenia

We report a post-Norwood Stage I patient requiring ECMO support using Argatroban as an anticoagulant following diagnosis of heparin-induced thrombocytopenia (HIT). A 2.6 kg female was born with hypoplastic left heart syndrome and underwent a Norwood Stage I operation on day 4 of life. The patient weaned off cardiopulmonary bypass with no complications and was routinely placed on a ventricular assist device (VAD) for 3 days. Heparin was infused at a rate of 16-32 IU/ kg/h to maintain an ACT of 160-180 seconds. Two days after VAD termination, the patient was placed on continuous veno-veno hemofiltration (CVVH). Shortly after CVVH, the patient was diagnosed with HIT and placed on an Argatroban infusion. Five days later, a VAD and subsequent ECMO was used because of decreasing left ventricular function, gross body edema, and poor renal function. This case report summarizes the use of Argatroban during VAD and ECMO support for a patient diagnosed with HIT.     

Severe left ventricular failure after double lung transplantation: pathophysiology and management.

Patients undergoing bilateral lung transplantation for end-stage pulmonary hypertension may experience various complications. We describe a patient who underwent transplantation for chronic pigeon breeder's disease, who had secondary pulmonary hypertension and deteriorated right heart function, and who developed severe left heart failure during the weaning phase after successful double lung transplantation. The patient was stabilized with catecholamines and an intra-aortic balloon pump. Left heart function increased within 7 days and normalized at Day 18. Otherwise, the post-operative course was uneventful.     

Successful treatment of tachycardia-induced cardiomyopathy with LVAD in a 12-year-old boy

Tachycardia-induced cardiomyopathy is an unusual cardiac disease that is life-threatening if tachycardia is not controlled. We report a 12-year-old boy who suffered from ectopic left atrial tachyarrhythmia that was refractory to medications and caused tachycardia-induced cardiomyopathy with severe heart failure. The patient required a left ventricular assist device (ABIOMED BVS5000 [ABIOMED Inc, Danvers, MA]) as a bridge to recovery. Tachycardia was finally controlled with flecainide while the patient was on left ventricular assist device support. The device was successfully explanted after 28 days of support. The temporary use of a left ventricular assist device was necessary to maintain a good hemodynamic status during the treatment of pharmacological refractory tachycardia, and it allowed a successful bridge to recovery.     

Delayed epistaxis resulting from external carotid artery injury requiring embolization: a rare complication of transsphenoidal surgery: case report

OBJECTIVE AND IMPORTANCE: Delayed epistaxis resulting from trauma to branches of the external carotid artery is an infrequent but potentially serious complication of transsphenoidal surgery. We report two cases of severe, delayed epistaxis in patients who had undergone transsphenoidal surgery. In both cases, noninvasive treatment failed, necessitating endovascular intervention. CLINICAL PRESENTATION: The first patient, a 52-year-old woman with a prolactinoma, underwent a second transsphenoidal resection 18 months after the first surgery. She was readmitted on postoperative Day 15 with massive epistaxis. The second patient, a 40-year-old woman, had undergone two transsphenoidal surgeries, 14 years apart, for an adrenocorticotropic hormone-secreting adenoma. She was readmitted with massive epistaxis on postoperative Day 17. INTERVENTION: Both patients were initially treated with nasal balloon packing but experienced recurrent hemorrhage when the balloon was deflated, necessitating referral to the interventional radiology department for embolization. At arteriography, the first patient was found to have a pseudoaneurysm of the medial branch of the left internal maxillary artery, which was subsequently embolized. Arteriography in the second patient revealed an abnormally dilated midline branch of the right internal maxillary artery in the nasal septum; this vessel was occluded at arteriography. CONCLUSION: Delayed massive epistaxis is a rare but significant complication of transsphenoidal surgery. Injury to branches of the external carotid artery, along with injury to the internal carotid artery, should be suspected in patients who present with delayed epistaxis after transsphenoidal surgery. Angiography performed in patients with refractory bleeding should include selective external carotid injections. Epistaxis that is refractory to anterior and posterior nasal packing may be effectively treated with endovascular embolization.     

Lobar torsion complicating bilateral lung transplantation.

We report a case of left lower lobe torsion in a patient who had undergone bilateral lung transplantation for alpha(1)-antitrypsin deficiency. The patient experienced acute pulmonary hypertension and hypoxemia on post-operative Day 3 and the chest X-ray showed bilateral alveolar infiltrates and a new focal consolidation of the left lower lobe. Fiberoptic bronchoscopy showed complete obstruction of the left lower lobe bronchus and abnormal rotation of the left upper lobe bronchus suggesting torsion, which was confirmed by pulmonary angiography and ultimately at thoracotomy. The possibility of acute lobar torsion should be considered in lung transplant recipients who demonstrate evidence of acute respiratory insufficiency in the early post-operative period.     

Ruptured vertebral artery dissecting aneurysm associated with parent artery occlusion

A 63-year-old hypertensive man presented with vertebral artery (VA) dissection manifesting as subarachnoid hemorrhage located mainly in the posterior fossa. Left vertebral angiography on the day of hemorrhage showed complete occlusion of the left VA. Right vertebral angiography showed retrograde filling of the distal portion of the left VA and the left posterior inferior cerebellar artery, and a "double lumen"-like finding in the left VA. He was managed conservatively. Follow-up angiography on Day 29 showed spontaneous recanalization of the occlusive lesion and an almost normal arterial configuration. T2-weighted magnetic resonance (MR) imaging on Day 45 revealed multiple infarctions in the brainstem. T1-weighted MR imaging showed a high intensity area, suggestive of intramural hematoma, in the left VA. He was transferred to another hospital in a persistent vegetative state.     

Left Ventricular Assist for Pediatric Patients With Dilated Cardiomyopathy Using the Medos Vad Cannula and a Centrifugal Pump

Ventricular assist devices for small pediatric patients are expensive and commercially unavailable in Taiwan. We used the Medos ventricular assist device cannula (Medos, Aachen, Germany) and a centrifugal pump to support pediatric patients with dilated cardiomyopathy and decompensated heart failure. From January 2007 to December 2008, three pediatric patients with dilated cardiomyopathy were supported using a centrifugal pump as the left ventricular assist device. The Medos arterial cannula was sutured to the ascending aorta, and the Apex cannula was fixed into the left ventricular apex. When the patient was weaned off of cardiopulmonary bypass, the left ventricular assist device pump was started. The pump flow was gradually titrated according to the filling status of the left ventricle. All the left ventricular assist devices were successfully implanted and functioned well. Two patients on extracorporeal membrane oxygenation had severe lung edema before left ventricular assist device implantation. Both patients required extracorporeal membrane oxygenation for the postoperative period until the pulmonary edema was resolved. Among the three patients, two successfully bridged to heart transplantation after support for 6 and 11 days, respectively. The first patient (10 kg) expired due to systemic emboli 30 days after left ventricular assist device support. In summary, these results suggest that the Medos ventricular assist device cannula and a centrifugal pump is an option for temporary left ventricular assist device support in patients with intractable heart failure and as a bridge to heart transplantation.     

The Treatment of Bovine Collagen Allergy with Cyclosporin

BACKGROUND: Bovine collagen is currently the most common substance used in soft-tissue augmentation. Although patients should undergo routine skin testing for allergy to bovine collagen prior to treatment, hypersensitivity reactions may rarely still occur. Previously, there have been no reliable methods of treatment for these reactions, and physicians could only reassure patients that the reaction would slowly disappear. OBJECTIVE. The use of oral cyclosporin in a patient with hypersensitivity to bovine collagen was evaluated. METHODS: A patient with an allergic reaction to implanted bovine collagen was started on cyclosporin 175 mg p.o. bid (5 mg/kg/day) after no improvement was seen after treatment with oral and topical steroids. The cyclosporin was started on Day 23 of the allergic reaction. RESULTS: Improvement in the itching and redness was noted by Day 28 of the allergic reaction, and complete clinical resolution of the allergic reaction was noted on Day 41. On Day 47, the cyclosporin was stopped without recurrence of symptoms. The patient did not experience side effects from cyclosporin, and her blood pressure and renal function remained normal. CONCLUSION: This case report shows that oral cyclosporin A may be a safe and effective treatment for bovine collagen hypersensitivity.     

Erythrocyte transfusion causes immunosuppression after total hip replacement

A prospective study of 34 patients undergoing total hip replacement was done to determine whether homologous erythrocyte transfusion causes postoperative immunosuppression. In the transfused patient group (14 patients), there was a reduction in CD3+ and CD3+4+ cell numbers at Day 2, returning to preoperative levels by Day 7. In contrast, in the untransfused patient group (20 patients), there was no significant depression in these lymphocyte subgroups at Day 2 and an increase in total lymphocyte, CD3+, CD3+4+, and CD3+4-8- cell numbers at Day 7. In both patient groups there was postoperative leukocytosis, granulocytosis, and monocytosis at Days 2 and 7, with no significant change in postoperative B (CD19+) cell numbers, natural killer cells, or the minor T cell populations of CD3+4+8+ and CD3+25+. The lymphocyte functional test of Candida recall was significantly impaired at Day 7 in the transfused patient group, where Candida recall is a memory T cell response to an antigen extracted from the yeast Candida Albicans. These findings suggest that homologous erythrocyte transfusion after hip replacement surgery causes cell mediated immune suppression. The main clinical implication of the current study is that perioperative homologous erythrocyte transfusion may place patients at greater risk of infectious complications, including infection of the prosthesis.     

Transaortic inflow and outflow cannula for centrifugal mechanical assistance

A specific cannula allowing single site transaortic inflow and outflow cannulation for centrifugal assist devices is described. The cannula is inserted through a straight 18 mm collagen coated Dacron tube anastomosed to the anterior aspect of the ascending aorta. The inflow conduit of the cannula is positioned into the left ventricle through the aortic valve, and the end hole of the outflow conduit is positioned in the ascending aorta. The cannula was evaluated in vivo in 3 adult pigs by the institution of a centrifugal pump for left ventricular support. Optimal flow varied between 5 and 6 L/min and mean aortic pressure between 55 and 70 mm Hg throughout the 3 days of left ventricular support. Recently, we employed this cannula in a patient who was not able to be weaned from cardiopulmonary bypass for the institution of left ventricular support using a centrifugal pump. The cannula provided effective inflow and outflow drainage with an optimal flow of 5.2 L/min throughout the 72 h of support. The patient was successfully weaned from support on the fourth postoperative day. This rational transaortic approach of cannulation using this specific cannula is a refined implantation technique which allows direct left ventricular inflow drainage, reduces the time of implantation, spares left ventricular myocardium, avoids bleeding that is sometimes encountered at other cannulation sites, and avoids compression of the heart by cannulas.     

Reversible cortical auditory dysfunction caused by cerebral vasospasm after ruptured aneurysmal subarachnoid hemorrhage and evaluated by perfusion magnetic resonance imaging. Case report

A 52-year-old woman developed subarachnoid hemorrhage (SAH) caused by a ruptured right internal carotid artery (ICA) aneurysm. Because of the aneurysm configuration, the authors decided to delay surgery and instead undertook serial imaging studies of the aneurysm. The patient remained alert but developed acute bilateral deafness on Day 7. Audiological examination and auditory brainstem responses suggested that the hearing disturbance was cortical in origin. Three-dimensional computed tomography (CT) angiography showed severe vasospasm in the right middle cerebral artery (MCA) and moderate vasospasm in the left ICA and MCA. Three-tesla magnetic resonance (MR) imaging was performed 2 days after the onset of symptoms. Diffusion-weighted and T2-weighted MR images showed an acute infarction in the right insular cortex caused by vasospasm. Perfusion-weighted MR imaging, particularly mean transit time mapping, revealed hypoperfusion in both temporal lobes including the auditory cortex and right auditory radiation. The vasospasm was treated with induction of mild hypertension and hypervolemia. Follow-up MR images, 3D CT angiograms, and audiometry performed 2 weeks after the first examination showed recovery of vasospasm and resolution of perfusion abnormality and hearing disturbance. On Day 26, the aneurysm was successfully occluded with clips and the patient was discharged with no deficits. To the authors' knowledge, this is the first reported case of reversible cortical auditory dysfunction purely due to bilateral cerebral vasospasm detected using perfusion MR imaging after SAH.     

Enhancement of neutrophil chemiluminescence after elective gastrointestinal surgery

Neutrophil count and luminol-dependent chemiluminescence were measured pre-operatively and on the second, sixth and ninth days after operation in nine patients undergoing major, elective gastrointestinal surgery. The aim of the study was to test the hypothesis that elective surgery as a form of injury has no prolonged deleterious effect on neutrophil activity in non-septic patients. A significant increase in neutrophil count was demonstrated in all patients at Day 2 (P less than 0.01) and Day 9 (P less than 0.01). Neutrophil chemiluminescence increased on Day 2 and Day 6, the increase on Day 6 being significant (P less than 0.02). In the first 9 days after elective gastrointestinal surgery, a biphasic neutrophilia occurs and the metabolic response of neutrophils to an opsonized particle is not impaired. These data would support the hypothesis that major elective surgery has no deleterious effects on neutrophil activity, and indeed that neutrophil activity may be enhanced.     

AngioJet rheolytic thrombectomy for thrombotic myocardial injury in a 15-year-old cystic fibrosis patient during lung transplantation

We report on an acute myocardial injury caused by thrombotic emboli during off-pump bilateral sequential lung transplantation in a 15-year-old female patient with end-stage cystic fibrosis. A few minutes after reperfusion of the right (second sequential) allograft, the patient developed hemodynamic collapse, including hypotension, acute akinesis of the anterior and lateral myocardial walls, and severe mitral regurgitation. Thrombus was noted within the left atrium and ventricle on intraoperative transesophageal echocardiogram. After emergent cannulation for cardiopulmonary bypass, the patient underwent left cardiac catheterization with AngioJet rheolytic thrombectomy and removal of the clot from the distal left anterior descending coronary artery. Reperfusion was established without the need for stent placement or further intervention. The patient required short-term life support with venoarterial extracorporeal membrane oxygenation.     

The use of a biventricular assist device for postcardiotomy profound biventricular failure

A 58-year-old woman who could not be weaned from cardiopulmonary bypass was treated with a biventricular assist device (BVAD) using a centrifugal pump for the left side and a pneumatic pulsatile pump for the right side. At the initiation of the BVAD support, predominant right ventricular failure was recognized and therefore weaning was begun from the left side. The left ventricular assist device was discontinued after 87 h and the patient was finally weaned from the right ventricular assist device after 205 h. Despite the complete recovery of cardiac function, the patient developed renal failure followed by an intractable infection and died of multiple organ failure on the 59th postoperative day (POD).     

Coagulopathy as a complication of kidney biopsies in paediatric systemic lupus erythematosus patients with antiphospholipid syndrome

Children with systemic lupus erythematosus (SLE) generally undergo a pretreatment kidney biopsy. However, some of these patients, especially those with antiphospholipid syndrome (APS), may experience serious coagulopathic complications. We report herein two cases of paediatric SLE with APS in which, despite normal blood test results, the disparate coagulopathic complications of haemorrhage and embolism developed following a kidney biopsy. Case 1 was, an 8‐year‐old male in whom, primary APS was initially diagnosed. Fourteen months later SLE was diagnosed. Based on a percutaneous kidney biopsy, International Society of Nephrology and the Renal Pathology Society (ISN/RPS) class III‐A lupus nephritis was histologically diagnosed. On post‐biopsy Day 9, a giant haematoma in the fascia of the left kidney developed and was accompanied by changes in the vital signs. Case 2, a 13‐year‐old male, initially received the diagnosis of SLE with APS and underwent two courses of pulse methylprednisolone therapy. His coagulation abnormalities improved, and a percutaneous needle kidney biopsy was performed, leading to the histological diagnosis of ISN/RPS class III‐A lupus nephritis. Furthermore, thrombotic microangiopathy was also detected in the renal histopathology. On post biopsy Day 6, the patient experienced right leg pain. A contrast CT and lower extremity ultrasonography detected a massive deep vein thrombosis and partial left pulmonary artery thrombosis. A kidney biopsy in children with SLE and APS can cause lethal coagulopathic complications, and the risks to such patients should be weighed carefully before the procedure is performed.