Fetal middle cerebral artery Doppler waveforms in twin-twin transfusion syndrome

The aim of this study was to compare the fetal middle cerebral artery (MCA) Doppler waveforms in growth-retarded twin fetuses with (n = 11) and without (n = 24) twin-twin transfusion syndrome (TTTS). Umbilical artery (UA) and fetal MCA Doppler velocity waveforms were recorded on admission. The mean values of the UA pulsatility index (PI) of smaller twin fetuses with and without TTTS were significantly higher than those of normal singleton pregnancies. The mean values of the MCA PI of smaller twin fetuses in the TTTS group (+0.7 +/- 1 SD) were significantly higher than those of normal singleton pregnancies on admission, and these levels did not markedly change following amniocentesis. On the other hand, the values of the MCA of the growth-retarded fetuses without TTTS (-0.9 +/- 1 SD) were significantly lower than those of normal singleton pregnancies. Our findings suggest that measurement of fetal MCA PI is a useful method to assess growth-retarded fetuses in monochorionic twin pregnancies. Copyright Copyright 1999 S. Karger AG, Basel     

Nonpenetrating traumatic injury of the thoracic aorta and left subclavian artery; report of a case

Nonpenetrating traumatic injury of the thoracic aorta and/or its major branch is usually fatal and the treatment of this condition carries extremely high risk because of associated visceral organ injuries. Accurate diagnosis have been difficult. However, recently developed multi-slice helical computed tomography (CT) is highly sensitive in early detection of precise location of injury and associating injuries of other organs. Here we report our case with combined thoracic aortic and left subclavian artery injuries, diagnosed by 3-dimensional (3-D) CT and treated successfully.     

The treatment of refractory edema

The principle therapy for edema should be targeted to the treatment of the primary disease. However, supportive care is required in most of cases. When effective circulating blood volume is increased, the use of a diuretic medicine is the main treatment strategy. Nevertheless, it is not enough to prevent respiratory and cardiovascular failure in some patients and immediate blood purification therapy, such as extracorporeal ultrafiltration method (ECUM), is required. When the cardiac function is poor, continuous therapy such as continuous hemodiafiltration (CHDF) or continuous hemofiltration (CHF) could be selected with stable circulatory effect. Furthermore, plasma exchange or low density lipoprotein (LDL) apheresis could be a candidate for refractory nephroses, such as primal focal segmental glomerulosclerosis and can induce partial or complete remission.     

A reappraisal of rhythmic coma patterns in children

OBJECTIVE: This study was designed to determine the prevalence of rhythmic coma patterns in comatose children and to ascertain the prognostic significance of reactive rhythmic coma patterns. METHODS: We retrospectively analyzed and classified electroencephalogram (EEGs) in comatose children between two months and 18 years of age during the period 1996 - 2003 according to modified Young's classification. Outcome at one-year was scored according to the Paediatric Cerebral and Overall Performance Category Scale. Outcomes were compared using Fisher's exact test and Mann-Whitney test. RESULTS: Analysis of 63 electroencephalogram (EEG) records in 38 patients showed rhythmic patterns in 19 records (30.2%; 9 alpha, 4 spindle, 4 theta and 2 beta coma patterns, total number of children = 14). Aetiology and outcome of alpha coma patterns and other rhythmic coma patterns were similar. In five children, one type of rhythmic pattern changed to another. Records with reactive rhythmic coma 66.7% (6/9), were associated with favourable outcome. Sixty percent of the records (6/10 records in seven children) with non-reactive pattern were associated with unfavourable outcome. This clinically significant difference did not reach statistical significance (lower Paediatric Cerebral and Overall Performance Category Scale score p= 0.14; favourable outcome p=0. 19). CONCLUSION: Rhythmic coma patterns in comatose children are not uncommon. Aetiology, reactivity and outcome of individual patterns are similar and thus make the rhythmic coma patterns distinct EEG signatures in comatose children. There was a clinically significant better outcome with reactive rhythmic coma patterns.     

Recurrent intractable seizures in children with cortical dysplasia adjacent to dysembryoplastic neuroepithelial tumor

The purpose of this study was to identify the pathologic features that predict postoperative outcome in children with cortical dysplasia adjacent to dysembryoplastic neuroepithelial tumors. We reviewed the records of children with dysembryoplastic neuroepithelial tumor who underwent epilepsy surgery and who had at least 1 year of surgical follow-up. We divided the dysembryoplastic neuroepithelial tumors into three pathology classes (simple, complex, and nonspecific), categorized adjunctive cortical dysplasia into four types, and compared histopathology with seizure outcomes. We identified 26 children with dysembryoplastic neuroepithelial tumors. Dysembryoplastic neuroepithelial tumors were complex in 19 patients (73%), simple in 6 (23%), and nonspecific in 1 (4%). Cortical dysplasia was adjacent to dysembryoplastic neuroepithelial tumors in 18 patients. Six patients had type IA cortical dysplasia, 5 had type IB, 3 had type IIA, and 1 had type IIB. The 3 remaining patients had repeated surgeries; of these, 2 patients had cortical dysplasias of type IA/IB and 1 was type IIA/IIB. Eight (39%) of 18 patients with dysembryoplastic neuroepithelial tumors and cortical dysplasia required further surgery for recurrent intractable seizures (P < .05), whereas none of 8 patients without cortical dysplasia required additional surgery. Of 13 patients with type I cortical dysplasia, only 4 had a poor seizure outcome, whereas all 5 patients with type II had a poor seizure outcome postoperatively (P < .05). Children with dysembryoplastic neuroepithelial tumor and cortical dysplasia often had recurrent intractable seizures postoperatively and required further epilepsy surgery. Cortical dysplasia adjacent to dysembryoplastic neuroepithelial tumor can play a role in the epileptogenicity of dysembryoplastic neuroepithelial tumor. Complete resection of a dysembryoplastic neuroepithelial tumor and its adjacent cortical dysplasia should be considered.     

Identifying the primary epileptogenic hemisphere from electroencephalographic (EEG) and magnetoencephalographic dipole lateralizations in children with intractable epilepsy

We used electroencephalographic (EEG) and magnetoencephalographic dipole lateralizations to identify the primary epileptogenic hemisphere in 41 children with intractable localization-related epilepsy. We compared EEG and magnetoencephalographic dipole lateralizations, EEG ictal onsets, and magnetic resonance images (MRIs). Concordant lateralization of EEG and magnetoencephalographic dipoles (> 50% of each lateralizing to the same hemisphere) occurred in 34 patients, with EEG ictal onsets in the same hemisphere in 23 (68%) and concordant MRI lesions in 23 (68%). Focal resection in 16 of 20 patients resulted in a good surgical outcome. Of the seven children with nonconcordant magnetoencephalographic and EEG lateralizations, one (14%) had EEG ictal onset and one (14%) had MRI lesions that lateralized; none had surgery. The relationship between lateralized EEG and magnetoencephalographic dipoles forecasts surgical candidacy. Concordant lateralizations predict good seizure control after surgery by identifying the primary epileptogenic hemisphere. Discordant lateralizations signify an undetermined epileptogenic hemisphere and contraindicate surgery without further testing.     

Endocutter no-knife and extraparenchymal control of the main hepatic veins for major hepatectomy

BACKGROUND/AIMS: Extraparenchymal control of the main hepatic veins (ECHV) and use of vascular staplers are now considered as effective methods to prevent intraoperative hemorrhage and duration of hepatic transection. The aim of the present preliminary study was to investigate whether extraparenchymal control of the hepatic veins combined with inflow occlusion and a new articulating linear stapler without a knife (Endocutter no-knife) were effective for major hepatectomy. METHODOLOGY: Twenty patients with hepatic malignant disease underwent major hepatectomies in which 4 or more Couinaud's segments were removed. Extraparenchymal control of the hepatic veins and Endocutter no-knife were used in 7 (Recent group) of the 20 patients after June 2003. Hemihepatic devascularization before hepatic transection, and intermittent hepatic inflow occlusion were also performed in these 7 patients. In the other 13 (Previous group) patients before June 2003, major hepatectomy was performed under only intermittent hepatic inflow occlusion. Intraoperative blood loss volume, transfusion of packed red blood cells, and duration of hepatic transection were compared between the Recent group and Previous group. RESULTS: Estimated blood loss and number of intraoperative blood transfusion were significantly smaller in the Recent group than in the Previous group. Duration of hepatic transection was also significantly shorter in the Recent group than in the Previous group. CONCLUSIONS: The present preliminary study showed that extraparenchymal control of the hepatic veins and Endocutter no-knife are useful for major hepatectomy.     

Intrauterine therapy for the acutely enlarging fetal cystic hygroma

Enlarged fetal cystic hygroma is known to cause life-threatening complications such as fetal hydrops and neonatal respiratory difficulty. A 28-year-old Japanese woman, gravida 0, presented with fetal cystic hygroma at 23 weeks of gestation. There were no other structural malformations or hydrops detected by ultrasonographic examination. In addition, the karyotype was diagnosed as normal through amniotic fluid analysis. The cystic lesion showed acute enlargement and intrauterine sclerotherapy using OK-432 was performed at 26 weeks. The size of the cyst initially decreased, which was followed by a gradual increase. A viable 3,098 g male infant was delivered by cesarean section at 37 weeks without any other complications. The infant had no clinical difficulty during the neonatal period and later underwent a surgical removal of the remaining cystic lesion. Cases of fetal cystic hygroma showing acute enlargement without other complications are considered good candidates for intrauterine therapy to prevent subsequent complications.