Among the late postoperative complications of the acute dissection of aorta, the fistula between dilated distal aorta and pulmonary parenchym is so rare that only few case have been reported sporadically. Although the aortopulmonary fistula is one of a fatal condition that needs prompt surgical intervention, with an appropriate management it is well controllable condition. Early diagnosis and urgent surgical intervention is the only way to prevent catastrophic hemorrhage. We experienced a surgical management of aortoplumonary fistula which occurred between upper lobe of the left lung and distal aortic dilatation of previous aortic bypass graft which was performed for Debakey type I acute aortic dissection.
Aorta ; Aortic Aneurysm ; Dilatation ; Early Diagnosis ; Fistula* ; Hemorrhage ; Lung ; Postoperative Complications ; Transplants

Posterior reversible encephalopathy syndrome (PRES) involves predominantly posterior subcortical white matter and cortex. PRES is associated with an abrupt and severe increase in blood pressure or administration of various immuno-suppresants. We present a 18-year-old female with PRES. She was admitted to our hospital with seizures. She had been suffering from acute hypertension (170/100 mmHg) associated with acute renal failure. Brain MRI showed reversible biparietal cortical and subcortical edema. We report a case of hypertension-induced PRES associated with acute renal failure. (J Korean Neurol Assoc 19(5):541~543, 2001)
Acute Kidney Injury ; Adolescent ; Blood Pressure ; Brain ; Edema ; Female ; Humans ; Hypertension ; Magnetic Resonance Imaging ; Posterior Leukoencephalopathy Syndrome* ; Seizures

The authors present a case of rapidly progressing eosinophilic granuloma (EG) of the skull without hemorrhage after minor trauma. A 6-year-old boy presented with a soft mass on the midline of his forehead. He had a surgery for EG 19 months ago. One month earlier, computed tomography (CT) and bone scans were performed to evaluate the possible recurrence of EG, and there was no evidence of recurrence in CT. However, a slightly increased uptake in the bone scan was noted on the midline of the forehead. A rapid growing mass developed in a new spot after a minor trauma 7 days before the patient arrived at the clinic. His physical examination was unremarkable, except for a non-tender, soft, and immobile mass. A plain skull X-ray and CT showed a lytic bony defect on the midline of the frontal bone. Magnetic resonance imaging showed a 1.4 cm sized enhancing mass. Surgical resection and cranioplasty were done. The role of trauma in the development of EG is unclear. However, our case suggests that minor trauma is an aggravating factor for EG formation. Careful observation with regular follow-up is necessary in patients with EG after minor trauma.
Child ; Craniocerebral Trauma ; Eosinophilic Granuloma* ; Forehead ; Frontal Bone ; Hemorrhage ; Humans ; Magnetic Resonance Imaging ; Male ; Physical Examination ; Recurrence ; Skull*

Reports of traumatic leptomeningeal cysts (TLMC) are rare in adults. The standard treatment approach is craniectomy with careful exposure of the intact dural edges, followed by duroplasty. However, occasionally, the location of the TLMC makes achieving watertight duroplasty impossible. Herein, we report the case of a 28-year-old male who presented with a soft growing mass on the vertex of his head 16 months after the head trauma. Upon enhanced CT examination, a bony defect involving both the inner and outer table of the cranium was observed close to the sagittal sinus, and a well-defined cystic mass, 5 cm in diameter, was nested within the defect. The risks associated with extension craniotomy were high because the lesion was located superficial to the sagittal sinus, we opted to use fibrinogen-based collagen fleece (TachoCombR(R)) to repair the dural defect. Two months after surgery, the patient remained asymptomatic with a good cosmetic result. In cases like ours, when the defect is near the major sinuses and the risk of rupturing the sinus during watertight dural closure is high, fibrinogen-based collagen fleece (TachoComb(R)) is an effective alternative approach to standard dural suture techniques.
Adult ; Arachnoid Cysts ; Collagen ; Cosmetics ; Craniocerebral Trauma ; Craniotomy ; Head ; Humans ; Male ; Skull ; Skull Fractures ; Suture Techniques

Carotid angioplasty and stenting (CAS) for carotid stenosis has been increasingly used as an alternative treatment in patients not eligible for surgery. Even though CAS can be performed relatively simply in many cases, various complications can occur. We report four cases of CAS using the Carotid Wallstent, which were complicated by delayed shortening of the stent, resulting in restenosis after successful CAS.
Angioplasty ; Carotid Arteries ; Carotid Stenosis ; Humans ; Stents

A 65-year-old woman with type 2 diabetes mellitus was found in an unresponsive state and she was admitted to our hospital. She was comatose on arrival. The bedside blood glucose level on admission was 15 mg/dl (normal range, 55-110 mg/dl). After emergency infusion with 50% dextrose, the blood glucose level rapidly normalized to 98 mg/dl, but there was no clinical improvement of her consciousness. Three days after admission, diffusion-weighted magnetic resonance imaging of the brain revealed bilateral temporal, occipital and frontal lobes lesions with high signal intensity. The patient's neurological condition did not change over the next 15 days. She died of pneumonia on the 30th day of hospitalization. DWI may be useful for detecting and making the differential diagnosis of hypoglycemic coma. Further, marked differences in the neuroimaging patterns of patients in a hypoglycemic coma are valuable prognostic predictors. We report here on a case of hypoglycemic coma with a poor outcome.
Aged ; Blood Glucose ; Brain ; Coma ; Consciousness ; Diabetes Mellitus, Type 2 ; Diagnosis, Differential ; Emergencies ; Female ; Frontal Lobe ; Glucose ; Hospitalization ; Humans ; Hypoglycemia ; Magnetic Resonance Imaging ; Neuroimaging ; Pneumonia

From May 1, 1993 to May 31 1995, the authers studied retrospectively 211 patients who underwent cardiovascular operation with cardiopulmonary bypass (CPB). Because we were interested in new development of ARF (prevalence, mortality rate, and main risk factors), we performed a multivariate statistical analysis about data of patients with preoperative serum creatinine values of less than 1.5 mg/dL. Normal renal function before operation (serum creatinine level less than 1.5 mg/dL) was registered in 198 (74%) patients. Of these, 27 (14%) patients showed postoperative renal complication, including 20 (10%) patients classified as renal dysfunction (serum creatinine level between 1.5 and 2.5 mg/dL) and 7 (4%) patients as acute renal failure (serum creatinine level higher than 2.5 mg/dL). The mortality rate was 5.8% in normal patients, 5% in patients with renal dysfunction, and 43% when acute renal failure developed (p=0.036). Indeed, the renal impairment proved to be an independent predictor of mortality (odd ratio 2.52~11.25), along with cardiovascular (odd ratio 4.20) and respiratory (odd ratio 2.18) complications. Multivariate analysis identified the following variables as independent risk factors for postoperative renal impairment : advanced age (odd ratio 1), need for emergency operation (odd ratio 3.78), low-output syndrome (odd ratio 3.66), respiratory complication (odd ratio 1.30), need for deep hypothermic circulatory arrest (odd ratio 1.4). The 13 patients (7%) with preoperative renal failure showed a significantly higher morbidity and mortality rate than those without renal complications before operation. We concluded that the likelihood of severe renal complications is resonably low in the patients undergoing cardiac operation without preexisting renal dysfunction, but associated mortality remains high. A prominant role of hemodynamic factor in the development of postoperative acute renal failure must be recognized during preoperative, intraoperative, and postoperative periods.
Acute Kidney Injury* ; Cardiopulmonary Bypass ; Circulatory Arrest, Deep Hypothermia Induced ; Creatinine ; Emergencies ; Hemodynamics ; Humans ; Mortality ; Multivariate Analysis ; Postoperative Period ; Renal Insufficiency ; Retrospective Studies ; Risk Factors

A 56-year old female underwent total aortic arch replacement March 1995, because of an expanding chronic Debakey type I aortic dissection. This aortic dissection had an intimal tear at the origin of the right carotid artery. Retrograde and antegrade propagation of dissection resulted in aortic arch blood flow separation and expanding pseudolumen to the abdominal aorta. Sudden anuria (ARF) developed 3 hours later postoperatively and renal doppler ultrasonography and aortography showed diminished blood flow of renal arteries. We performed balloon aortic dilatation but failed. She could be restored good renal flow after intimal flap fenestration resection and thrombectomy of the abdominal aorta. This patient could be discharged in a state of mild CRF after 2 months of ICU care for respiratory and renal failure.
Acute Kidney Injury* ; Anuria ; Aorta, Abdominal ; Aorta, Thoracic* ; Aortography ; Carotid Arteries ; Dilatation ; Female ; Humans ; Middle Aged ; Renal Artery ; Renal Insufficiency ; Thrombectomy ; Ultrasonography, Doppler

We report here on a case of acute aortic dissection after intravenous tissue plasminogen activator (t-PA) administration in a patient with acute ischemic stroke. A 75-year-old woman with a history of hypertension and diabetes mellitus presented with left hemiplegia and a decreased mentality. The admission studies revealed severe stenosis of the right middle cerebral artery and decreased cerebral perfusion. Initial chest radiography showed hypertensive cardiovascular changes and increased interstial markings on both lung fields. Cyanosis and cardiac arrest occurred 80 minutes after intravenous t-PA administration. Emergency cardiopulmonary resuscitation was done and chest CT showed a dissection involving the whole aorta and pericardial effusion due to bleeding. In spite of our earnest efforts, the patient died. It should be kept in mind that aortic dissection can occur after intravenous t-PA administration and an early clinical suspicion and diagnosis is needed to avoid this devastating complication.
Aged ; Aorta ; Cardiopulmonary Resuscitation ; Constriction, Pathologic ; Cyanosis ; Diabetes Mellitus ; Emergencies ; Female ; Heart Arrest ; Hemiplegia ; Hemorrhage ; Humans ; Hypertension ; Lung ; Middle Cerebral Artery ; Perfusion ; Pericardial Effusion ; Stroke ; Thorax ; Tissue Plasminogen Activator

OBJECTIVES: Supraorbital route through eyebrow incision, mini-pterional craniotomy, and midline interhemispheric route are most generally used methods for key hole surgery on anterior circulation aneurysm. Surgical route is determined according to aneurysm architecture and patient status. The approaching route can be selected according to the findings of 3-dimensional computed tomography (CT) angiography simulation. Prospective decision-making protocol, surgical technique of key hole surgery, and the results are presented in this paper. METHODS: 173 patients with anterior circulation aneurysms were treated by direct surgical neck clipping during last two years. Twenty patients of poor grade (Hunt-Hess grade IV,V) were treated by craniectomy with clipping. Decision making protocol was applied to 153 unruptured and good grade ruptured aneurysm patients. Simulation of key hole surgery was conducted by CT work station using conventional software InSpace (Siemens, Germany), and direction and shape of aneurysm was observed from the perspective of microsurgery. RESULTS: 113 ruptured and 40 unruptured aneurysms were secured through one of the three approaching routes. Supraorbital approach had been performed in 82 cases (unruptured 24, ruptured 58) while 64 cases were treated by mini-pterional craniotomy. Midline key hole surgery were carried out in seven distal anterior circulation aneurysms (DACA) using brain navigation system. After locating the aneurysm, supraorbital approach was applied to 46 cases involving anterior cerebral artery (ACA), 16 in internal carotid artery (ICA) and 20 in middle cerebral artery (MCA). Mini-pterional craniotomy was carried out in aneurysms located in ACA (9), ICA (18), and MCA (37). In most cases, the results of clipping were good. The average follow-up time was 16.7months (ranging 2 to 32months) and the results were cosmetically excellent. CONCLUSION: Simulating surgical approaches with 3-D CT angiography is a highly useful method for determining various surgical routes in anterior circulation aneurysm treatment. Therefore, minimally invasive and tailored surgical approaches are recommended since optimal route can be found through simulation. Thus, minimal invasive and tailored surgical approach is available through this method. These procedures have clear advantages; shorter surgical time and hospital stay, less operative trauma, reduced costs and less pain, and better cosmetic outcomes compared to standard craniotomy. Optimal surgical results are expected from minimally invasive and tailored surgical craniotomy.
Aneurysm ; Aneurysm, Ruptured ; Angiography ; Anterior Cerebral Artery ; Brain ; Carotid Artery, Internal ; Cosmetics ; Craniotomy ; Decision Making ; Eyebrows ; Follow-Up Studies ; Humans ; Length of Stay ; Microsurgery ; Middle Cerebral Artery ; Neck ; Operative Time