Venous drainage patterns in perimesencephalic nonaneurysmal subarachnoid hemorrhage

OBJECTIVE: The precise etiology of perimesencephalic nonaneurysmal subarachnoid hemorrhage (P-SAH) has not yet been determined. We decided to compare the venograms of patients with P-SAH with those of patients with aneurysmal SAH (A-SAH) to examine the relationship between P-SAH and venous drainage patterns. METHODS: We retrospectively studied 18 patients with P-SAH during the past 10 years and 112 patients with ruptured A-SAH during the past 4 years by reevaluating their venograms for possible abnormalities in venous structures, particularly focusing on the basal vein of Rosenthal (BVR). Anatomical variants were classified into three types according to the drainage pathway. RESULTS: The location and drainage pathway of the BVR proved to be a significantly more primitive configuration in patients with P-SAH than in those with A-SAH (P<0.05). On the other hand, physical action including components of the Valsalva maneuver were the cause of nine cases of P-SAH (69.2%) in this case profile. The occurrence rate was significantly higher in the P-SAH group than in the A-SAH group (14.3%) (p<0.05). CONCLUSION: Our data suggest that failure of longitudinal anastomoses between the primary primitive veins as well as excessive strenuous exertion including components of the Valsalva maneuver plays an important predisposing role in the etiology of P-SAH.     

Conscious sedation and amnesic effect of intravenous low-dose midazolam prior to spinal anesthesia

BACKGROUND: The pain associated with spinal puncture is severe, and the memory of this uncomfortable procedure often deters patients from undergoing the procedure again. Therefore, it is important to make the patient as comfortable as possible when this procedure is performed. METHODS: We administrated a low-dose (1-2.5 mg) of midazolam intravenously several minutes before conducting a spinal-tap in 200 patients undergoing elective surgery of the lower limb. The dose of midazolam used was based on the patient's age and weight, and we investigated remaining of a memory concerning the spinal-tap procedure and side effects of midazolam at the end of surgery. RESULTS: Memory of the spinal-tap procedure remained in 14.0%, 1.9%, and 32.7% of the patients who had received benzodiazepine preoperatively and in 25.0%, 40.0%, and 60.9% of the patients who hadn't received benzodiazepine preoperatively in the age group <60, 60-70, and > or =70 years, respectively. No patient experienced severe respiratory depression, but an excessive sedation or restlessness was experienced in 1.6%, 4.8%, and 5.2% of the patients. CONCLUSIONS: In the patients aged <70 years, intravenous administration of 0.023-0.044 mg x kg(-1) of midazolam was very effective in preventing a bad memory concerning the spinal-tap procedure; however, it is important to note that the number of side effects associated with this procedure increases in patients aged > or =60 years.     

Significance of ductal plate malformation in the postoperative clinical course of biliary atresia

Purpose

Ductal plate malformation (DPM) is one of the etiologic theories for the development of biliary atresia (BA). In this study, we investigated the significance of DPM in the postoperative clinical course of BA, especially as a predictive factor of jaundice clearance.

Methods

Between 1988 and 2005, 31 patients with uncorrectable BA underwent hepatoportoenterostomy and steroid therapy. Immunohistochemistry was used to characterize biliary structures using cytokeratin 19. Specimens were defined as DPM-positive if a concentric cellular arrangement was detected. This retrospective study included comparisons of preoperative characteristics, the postoperative jaundice period, and cumulative steroid doses between patients with and without DPM.

Results

Of the 31 patients with uncorrectable BA, 25 (80.6%) became jaundice-free. Ductal plate malformation was detected in 11 (35.5%) of the 31. Between the 2 groups, there were no differences in preoperative characteristics or in the postoperative jaundice-free rate. Among those who became anicteric, the postoperative jaundice period was 145.3 ± 69.9 days in the DPM-positive group (n = 9) and 81.8 ± 44.7 days in the DPM-negative group (n = 16) (P < .05). The total administered steroids were 149.7 ± 78.2 and 95.0 ± 60.2 mg/kg, respectively (P = .09).

Conclusion

Ductal plate malformation may disturb bile flow and require more steroid to improve bile drainage. Therefore, the presence of DPM in the liver predicts poor bile flow after hepatoportoenterostomy in infants with BA.     

Feasibility of percutaneous radiofrequency ablation for intrathoracic malignancies: a large single-center experience

BACKGROUND: Radiofrequency ablation (RFA) has become an accepted alternative for treating intrathoracic malignancies; however, the incidence and characteristics of peri- and postprocedural complications are not well described. The purpose of the study was to assess the safety and technical feasibility of percutaneous RFA in unresectable intrathoracic malignancies. METHODS: Percutaneous RFA was performed in patients with intrathoracic malignancies between June 2001 and December 2004. In total, 366 tumors were treated in 137 patients in 211 sessions. All patients were nonsurgical candidates or had refused surgery. Three hundred and thirty-six lesions were subjected to RFA for the treatment of metastases and 30 lesions for primary lung carcinoma. RESULTS: Although no procedural mortality occurred, 2 patients died during the course of the study because of intractable pneumothorax and massive hemoptysis (0.9%). The overall major complication rate was 17.1% (pneumothoraces requiring tube drainage in 25, pleuritis in 6, pleural effusion requiring tube drainage in 4, lung abscess in 1, and intrapulmonary hemorrhage with hemothorax in 1). Minor complications included pneumothoraces not requiring tube drainage in 108 sessions, pleural effusion without drainage in 34, hemosputum in 9, nausea and/or vomiting in 3, subcutaneous emphysema in 3, cough in 2, skin burn in 2, atelectasis in 1, and subileus in 1. High fever and/or chest pain were seen in 33.8% and 39.3% of patients, respectively. CONCLUSIONS: With over 200 procedures, RFA appears to be a safe and minimally invasive option with negligible mortality and little morbidity in selected patients with unresectable intrathoracic malignancies.     

Traumatic aortic regurgitation caused by a detached commissure

Case reports of traumatic aortic regurgitation caused by detached commissures are rare. We report a case of a 56-year-old man involved in a traffic accident. During his hospitalization for subdural hematoma and pulmonary contusion, he began to suffer from heart failure. He was operated on under diagnosis of severe aortic regurgitaion. The commissure between the left and the noncoronary cusps was largely detached from the aortic wall, which was easily estimated to be the cause of the prediagnosed left cusp prolapse. His aortic valve was replaced, and his postoperative course was uneventful.