Acute aortic dissection provoked by sneeze: a case report

The response of the abdominal viscera and the contraction of the intercostal muscles during the respiratory phase of sneezing increases intrathoracic pressure, which may lead to several complications. However, there are no reports in the literature concerning aortic dissection after sneezing. We report a patient in whom the development of dissection was secondary to sneezing, although hypertension was present as a risk factor, and we discuss the relationship between sneezing and aortic dissection. To our knowledge, this is the first report of aortic dissection provoked by sneezing in the literature.     

Emergency Bedside Ultrasound Diagnosis of Superior Mesenteric Artery Dissection Complicating Acute Aortic Dissection

Background

A timely diagnosis of aortic dissection is associated with lower mortality. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, there is limited literature regarding the use of bedside ultrasound to identify superior mesenteric artery dissection, a known high-risk feature of aortic dissection.

Objective

Our aim was to present a case of superior mesenteric artery dissection identified by bedside ultrasound and review the utility of bedside ultrasound in the diagnosis of aortic emergencies.

Case Report

We report a case of superior mesenteric artery dissection found on emergent bedside ultrasound in a 46-year-old male complaining of abdominal pain with a history of cocaine abuse and prior aortic dissection. Bedside ultrasound in the emergency department revealed an intimal flap in the descending aorta with extension into the superior mesenteric artery prompting early surgical consultation before computed tomography because of concern for acute mesenteric ischemia.

Conclusion

Superior mesenteric artery dissection is a high-risk feature of aortic dissection and can be identified with emergent bedside ultrasound.     

Serum D-dimer is a sensitive test for the detection of acute aortic dissection: a pooled meta-analysis

Acute aortic dissection is a rare but devastating condition with high mortality. Unfortunately, there is no sensitive screening indicator of disease in common use. The objective of this study was to assess the sensitivity and utility of the serum D-dimer as a test for acute aortic dissection. A pooled analysis was performed of all original research studies testing the sensitivity of serum D-dimer for acute aortic dissection. A search of MEDLINE, EMBASE, and the Cochrane Register using the terms “aortic dissection” and “d-dimer” was made of all English language publications. All original reports of consecutively enrolled patients with acute aortic dissection and a measured serum D-dimer were included. Case reports were excluded. A value of 0.5 microgram per milliliter was defined as the threshold for a positive D-dimer. The primary outcome was the pooled sensitivity of the D-dimer test for acute aortic dissection. There were 21 original reports of patients with acute aortic dissection and D-dimer measurements. Eleven studies were included and a total of 349 acute aortic dissection patients were described. The sensitivity of the D-dimer test was 327/349, 94% (95% confidence interval 91–96), and the point estimate was essentially unchanged in a sensitivity analysis, 183/192, 95% (95% confidence interval 91–98). Specificity ranged from 40% to 100%. Serum D-dimer is sensitive for acute aortic dissection and potentially represents a useful test for patients who present with a low likelihood of this disease.     

An Unrecognized Presentation of Cocaine-Associated Pneumomediastinum in the Prehospital Setting

Cocaine abuse is associated with a significant number of emergency medical services (EMS) calls and emergency department visits every year. The medical complications of recreational cocaine use are diverse, involving almost any body organ, and vary greatly according to the substance used and the route by which is taken. Previous reports have associated cocaine abuse with serious pulmonary complications, including barotrauma. The occurrence of barotrauma is directly related to the way cocaine is consumed. The majority may manifest clinically with subcutaneous emphysema, chest pain, and neck pain. We report a case of cocaine-induced pneumomediastinum in the prehospital environment that masqueraded as an allergic reaction. Prehospital providers should be alert for clinical manifestations suggestive of barotrauma in cocaine users.     

DeBakey Ⅰ型主动脉夹层无深低温停循环杂交手术的护理

目的探讨Debakey Ⅰ型主动脉夹层无深低温停循环杂交手术的护理经验。方法对12例Debakey Ⅰ型主动脉夹层患者行无深低温停循环杂交手术的治疗和护理配合进行回顾性分析。结果 12例患者手术成功,术后并发症少,治愈出院。结论加强无深低温停循环杂交手术的围手术期观察和进行有效护理,有利于手术治疗成功,并发症少,促进患者早日康复。     

Aortic dissection: a dreaded disease with many faces

Aortic dissection is a relatively uncommon but catastrophic illness classically thought to present with acute, sharp, chest pain with radiation to the back. However, aortic dissection can manifest in a number of different ways that include congestive heart failure, inferior myocardial infarction, stroke, focal pulse and neurologic deficits, abdominal pain, or acute renal failure. According to some studies, only about 80% of patients with type A dissection present with severe anterior chest pain, and only about 60% describe their pain as being sharp. Another series reports that treating clinicians fail to initially entertain the diagnosis of aortic dissection in up to 35% of cases. Many patients later found to have aortic dissection are initially suspected to have other conditions such as acute coronary syndrome, pericarditis, pulmonary embolism, or even cholecystitis. In this article we present a case of an unusual presentation of aortic dissection and a review of this condition.     

Cocaine use and acute myocardial infarction

Cocaine use in the United States is widespread, affecting more than 30 million Americans. Although many of these persons do not seek healthcare, the overriding cause for hospitalization is cocaine-associated chest pain. Because only a minority of these patients suffer myocardial injury, it is important to exclude even rarer life-threatening causes for chest pain, such as aortic dissection or pneumothorax. Following that, a thorough knowledge of the pathophysiology and existing literature helps to provide cost-effective care, which focuses resources on those patients most likely to suffer complications. Regardless of the severity of complications, referral to cocaine detoxification programs, counseling, social support, and outpatient follow-up care for modification of cardiac risk factors is a fundamental component of long-term patient care.     

Aortic dissection presenting as uniocular blindness

A patient presented with uniocular blindness and headache, which was initially suspected to be subarachnoid hemorrhage. The patient had a seven-year history of diabetes mellitus, hypertension and hypothyroidism, as well as a two-year history of congestive cardiac failure with aortic regurgitation. Upon autopsy, the patient was diagnosed with aortic dissection. There are no other known reports of such a presentation. This case demonstrates that aortic dissection can present without any classical features, and hence it is important to consider the possibility of dissection in patients with long-standing hypertension and acute neurologic symptoms associated with pain.     

The diagnosis of aortic dissection by emergency medicine ultrasound

A series of five cases of aortic dissection are presented that were diagnosed by emergency physicians using ultrasound to search the abdominal and thoracic aorta for pathology. Aortic dissection is a vascular emergency with a high morbidity and mortality, yet its presentation can be varied and subtle. This article reports the use of Emergency ultrasound in a series of five aortic dissections discovered with a limited, yet timely viewing of the aorta and heart by emergency physicians.     

Levamisole in cocaine: Unexpected news from an old acquaintance

Levamisole is a pharmaceutical with anthelminthic and immunomodulatory properties that was previously used in both animals and humans to treat inflammatory conditions and cancer. Levamisole has been identified as a cocaine adulterant in the United States since 2003. By 2009, the United States Drug Enforcement Administration (DEA) estimated that 69% of the cocaine seized contained levamisole. The first case reports of complications related to levamisole in cocaine users were published in 2009. The objectives of this article are to review the literature regarding the full spectrum of possible complications related to levamisole use for medical purposes, to review the current scope of levamisole-induced complications in cocaine users and to discuss the pharmacological properties that might explain the motivation behind the large-scale adulteration of cocaine with levamisole. Literature review revealed that significant complications were quickly reported when levamisole was used in inflammatory conditions. By 1976, several cases of leukopenia and agranulocytosis were reported. Recurrence with re-exposure was well described and agranulocytosis spontaneously reversed upon discontinuation of therapy. Vasculitis secondary to levamisole treatment was first reported in 1978 and mostly manifests as leukocytoclastic vasculitis, cutaneous necrotising vasculitis and thrombotic vasculopathy without vasculitis. These findings typically, but not invariably, involve the ear lobes. Discontinuation of levamisole therapy was again a critical part of the treatment. Various neurological side effects were described with levamisole therapy, the most concerning complication being multifocal inflammatory leukoencephalopathy (MIL). Literature review identified 203 unique cases of complications in cocaine users that can be attributed to levamisole adulteration. The two principal complications reported are haematological (140 cases of neutropenia) and dermatological (84 cases). Even though these complications can occur in isolation, many cases displayed both simultaneously. No formal case of leukoencephalopathy in the setting of cocaine use has been reported so far. A striking phenomenon is the apparent high level of recurrence (27.1%) of symptoms in cocaine users after re-exposure to cocaine that is presumably adulterated. The importance of accurately identifying levamisole-induced complications is therefore critical for symptomatic patients as discontinuation of exposure is fundamental and as a correct diagnosis prevents unnecessary and potentially dangerous use of other treatment modalities like powerful immunosuppressive therapy. Literature review suggests that levamisole might have the advantages of enhancing noradrenergic neurotransmission by inhibiting reuptake, by inhibiting MAO and/or COMT, by acting on ganglionic nicotinic receptors and by being partially metabolized into an amphetamine-like compound. It could also increase endogenous opioids and increase dopamine concentration in the cerebral reward pathway. These potential effects make levamisole an interesting choice as a cocaine adulterant. It seems unlikely that levamisole use as a cocaine adulterant will soon reach an end. More information is needed about the diagnosis and treatment of levamisole-induced complications, and the efforts of the medical and public health community is needed to face this challenging problem.     

Levamisole in cocaine: unexpected news from an old acquaintance

Levamisole is a pharmaceutical with anthelminthic and immunomodulatory properties that was previously used in both animals and humans to treat inflammatory conditions and cancer. Levamisole has been identified as a cocaine adulterant in the United States since 2003. By 2009, the United States Drug Enforcement Administration (DEA) estimated that 69% of the cocaine seized contained levamisole. The first case reports of complications related to levamisole in cocaine users were published in 2009. The objectives of this article are to review the literature regarding the full spectrum of possible complications related to levamisole use for medical purposes, to review the current scope of levamisole-induced complications in cocaine users and to discuss the pharmacological properties that might explain the motivation behind the large-scale adulteration of cocaine with levamisole. Literature review revealed that significant complications were quickly reported when levamisole was used in inflammatory conditions. By 1976, several cases of leukopenia and agranulocytosis were reported. Recurrence with re-exposure was well described and agranulocytosis spontaneously reversed upon discontinuation of therapy. Vasculitis secondary to levamisole treatment was first reported in 1978 and mostly manifests as leukocytoclastic vasculitis, cutaneous necrotising vasculitis and thrombotic vasculopathy without vasculitis. These findings typically, but not invariably, involve the ear lobes. Discontinuation of levamisole therapy was again a critical part of the treatment. Various neurological side effects were described with levamisole therapy, the most concerning complication being multifocal inflammatory leukoencephalopathy (MIL). Literature review identified 203 unique cases of complications in cocaine users that can be attributed to levamisole adulteration. The two principal complications reported are haematological (140 cases of neutropenia) and dermatological (84 cases). Even though these complications can occur in isolation, many cases displayed both simultaneously. No formal case of leukoencephalopathy in the setting of cocaine use has been reported so far. A striking phenomenon is the apparent high level of recurrence (27.1%) of symptoms in cocaine users after re-exposure to cocaine that is presumably adulterated. The importance of accurately identifying levamisole-induced complications is therefore critical for symptomatic patients as discontinuation of exposure is fundamental and as a correct diagnosis prevents unnecessary and potentially dangerous use of other treatment modalities like powerful immunosuppressive therapy. Literature review suggests that levamisole might have the advantages of enhancing noradrenergic neurotransmission by inhibiting reuptake, by inhibiting MAO and/or COMT, by acting on ganglionic nicotinic receptors and by being partially metabolized into an amphetamine-like compound. It could also increase endogenous opioids and increase dopamine concentration in the cerebral reward pathway. These potential effects make levamisole an interesting choice as a cocaine adulterant. It seems unlikely that levamisole use as a cocaine adulterant will soon reach an end. More information is needed about the diagnosis and treatment of levamisole-induced complications, and the efforts of the medical and public health community is needed to face this challenging problem.     

DeBakeyⅢ型主动脉夹层腔内修复治疗并发症的处理与分析

目的 总结近年来我科DeBakeyⅢ型主动脉夹层腔内修复治疗的经验,重点探讨围术期发生的并发症及其预防与处理.方法 回顾性分析自2009年1月至2011年1月的2年间我科完成49例DeBakeyⅢ型主动脉夹层腔内修复治疗患者的临床资料.结果 无术后近期死亡、无截瘫.严重的并发症有昏迷2例(4.1％)、内漏2例(4.1％)、上肢缺血2例(4.1％).新发近端夹层1例.术后多数患者存在不同程度发热.结论 腔内修复治疗能够降低夹层治疗的病死率,但严重并发症不容忽视.降低逆行性夹层、急性脑供血不足、内漏等并发症可以进一步改善患者的预后,提高生存质量.     

DeBakeym型主动脉夹层腔内修复治疗并发症的处理与分析

目的总结近年来我科DeBakey III型主动脉夹层腔内修复治疗的经验,重点探讨围术期发生的并发症及其预防与处理。方法回顾性分析自2009年1月至2011年1月的2年间我科完成49例DeBakey III型主动脉夹层腔内修复治疗患者的临床资料。结果无术后近期死亡、无截瘫。严重的并发症有昏迷2例（4．1％）、内漏2例（4．1％）、上肢缺血2例（4．1％）。新发近端夹层1例。术后多数患者存在不同程度发热。结论腔内修复治疗能够降低夹层治疗的病死率,但严重并发症不容忽视。降低逆行性夹层、急性脑供血不足、内漏等并发症可以进一步改善患者的预后,提高生存质量。     

Painless aortic dissection presenting as hoarseness of voice: cardiovocal syndrome: Ortner's syndrome.

Most of the neurological manifestations of the aortic dissection are due to neuronal ischemia secondary to either extension of the dissection process into a branch artery, or compression of an artery by the false lumen of the dissecting aortic hematoma. However, the enlarging false lumen may directly compress on an adjacent nerve, causing neuronal injury resulting in neurological symptoms. This may particularly take place when a distal intimal tear does not decompress the false lumen, resulting in formation of an expanding blind pouch. About 10% of aortic dissections are painless and may present with symptoms secondary to the complications of the dissection. Although cardiovocal syndrome, or Ortner's syndrome (hoarseness of voice due to involvement of recurrent laryngeal nerve in cardiovascular diseases) has been described with aortic dissection, it has not been reported as an initial presenting feature of this disorder. This report describes the first case of painless aortic dissection presenting with hoarseness of voice, the cardiovocal syndrome. The hoarseness remained the only symptom throughout the entire course of the disease. The aortic dissection was not suspected initially. During surgical exploration, the recurrent laryngeal nerve was found compressed by the false lumen at the level of aortic arch. Aortic root replacement was performed successfully, resulting in complete resolution of the hoarseness. The neurological manifestations of aortic dissection, and the cardiovocal syndrome, are discussed.     

Aortic Dissection Presenting as Isolated Lower Leg Ischemia

Background: Aortic dissections that present only with symptoms of lower extremity ischemia are rare. Few case reports exist documenting this phenomenon. Objectives: We report an unusual case of aortic dissection presenting as unilateral lower extremity pain. Case Report: A 56-year-old man presented with left lower extremity pain of 1 h duration. He had no associated complaints. Doppler imaging revealed decreased flow in the left iliac artery, thus, initial treatment with anticoagulation was begun for presumptive obstruction. Subsequent imaging with arteriography revealed a Stanford type A/DeBakey type 1 aortic dissection. This was confirmed by computer-assisted tomography angiography, and the patient was taken to surgery for repair. Conclusion: It is important to consider the connection between lower extremity symptoms and possible aortic dissection.     

Crystal Methamphetamine‐Associated Cardiomyopathy: Tip of the Iceberg?

Abstract

Background.?Crystal methamphetamine has become a drug of widespread use. Previous reports describe myocardial infarction, pulmonary edema, and aortic dissection related to methamphetamine use. Cardiomyopathy due to methamphetamine exposure has been rarely described. Methods.?We identified 1640 patients admitted in a 4‐yr period with a primary or secondary diagnosis of cardiomyopathy. We excluded patients with known cause of cardiomyopathy other than substance abuse. We found 120 patients had a diagnosis of substance abuse, including 21 patients with methamphetamine use. We retrospectively reviewed the medical records of these 21 crystal methamphetamine users. Results.?Nineteen (84%) underwent echocardiography with consistent findings of dilated cardiomyopathy and global ventricular dysfunction. Of five who had a nuclear myocardial perfusion study, none had evidence of ischemia or infarct. Of six who underwent cardiac catheterization, only one had evidence of coronary stenosis. Conclusion.?Methamphetamine use appears to produce cardiomyopathy in some users. The pathogenesis is probably similar to that of cocaine and catecholamine‐induced cardiomyopathy. Cellular, animal, and clinical data support the link between methamphetamine exposure and myocardial pathology.     

累及弓部分支的B型主动脉夹层患者原位开窗腔内治疗的护理

目的探讨累及弓部分支的Stanford B型主动脉夹层患者原位开窗腔内治疗的临床护理对策。方法回顾性分析解放军总医院血管外科2012年1月至2013年7月收治的9例累及弓部分支的B型主动脉夹层近端锚定区不足患者采用腔内原位开窗技术治疗的临床资料,总结护理要点。结果所有患者支架置入均一次成功,夹层原发破口完全封闭,无内漏发生,围术期无死亡病例。1例患者出现声音轻微嘶哑,其余患者无相关并发症发生。9例患者的平均住院天数为(12±2)d,均痊愈出院。结论加强累及弓部分支的Stanford B型主动脉夹层近端锚定区不足患者原位开窗腔内治疗的围术期护理,有助于提高患者的手术耐受性、有效预防并发症的发生。     

Radiological diagnosis and classification of antegrade and retrograde Stanford type A intimal intussusception

Intimal intussusception is an uncommon variation of aortic dissection, resulting from circumferential detachment and stripping of the intima in the setting of a Stanford type A dissection. The resultant tube of detached intima may prolapse either antegrade into the aortic lumen or retrograde into the left ventricular cavity. We classify these forms of dissection as antegrade and retrograde Stanford type A intimal intussusception. We present two cases with intimal intussusception and a review of the current literature. The majority of previous cases have been reported in the cardiology and cardiothoracic surgical literature, with few previous radiological reports.     

主动脉夹层围手术期的处理

目的：总结主动脉夹层外科围手术期处理的临床经验。方法：117例主动脉夹层手术患者,术后入重症监护室（ICU）进行系统监护。根据主动脉夹层特点,予以相应的治疗,积极防治可能出现的并发症。结果：住院病死3例,一过性脑功能紊乱11例,脑血管意外6例,血管吻合口出血开胸止血5例,声音嘶哑2例,肾功能衰竭1例。结论：加强以神经、呼吸、循环为重点的各系统监护,维持内环境稳定,积极防治各系统并发症,是主动脉夹层患者术后顺利康复的保障。     

主动脉夹层患者术后谵妄危险因素和预测模型的研究进展

术后谵妄是主动脉夹层患者常见并发症之一,发生率较高,危害性较强。该研究对主动脉夹层患者术后谵妄的类型和特征、危险因素及风险预测模型进行综述,以期为临床医护人员尽早识别主动脉夹层患者谵妄风险,制订有效预防管理方案,改善患者生存结局提供参考。