Histological and biomechanical properties of systemic arteries in young and old Warmblood horses.

Arterial rupture is a well-recognized cause of sudden death in horses, which mainly affects older horses. The arterial wall is known to stiffen with age, although the underlying age-related histological and biomechanical changes remain unclear. The purpose of this study was to investigate the effect of aging by histological analysis of the arterial wall and examination of the arterial wall biomechanical properties using an inflation-extension test. Entire circular samples of the proximal and distal aorta, cranial and caudal common carotid, external iliac, femoral and median artery were collected from 6 young (6 years) and 14 old horses (≥15 years). Samples of all arteries were histologically examined and intima media thickness as well as area % of elastin, smooth muscle actin and collagen type I and III were determined. Older horses had a significantly larger intima media thickness and a significantly higher area % of smooth muscle actin compared to young horses. Samples of the proximal and distal aorta, the caudal common carotid and the external iliac artery were mechanically assessed using an in-house developed inflation-extension device with ultrasound analysis. Rupture occurred in a minority of arteries (8/78) at high pressures (between 250-300 mmHg), and mostly occurred in older horses (7/8). Pressure-area, pressure-compliance and pressure-distensibility curves were constructed. A significant difference in the pressure-area curves of the distal aorta, common carotid artery and external iliac artery, the pressure-compliance curves of the proximal aorta and carotid artery and the pressure-distensibility curve of the proximal aorta was observed between young and old horses. Results demonstrate an effect of age on the histological and biomechanical properties of the arterial wall, which might explain why arterial rupture occurs more often in older horses.

Possible Association Between Rupture and Intranidal Microhemodynamics in Arteriovenous Malformations: Phase-Contrast Magnetic Resonance Angiography-Based Flow Quantification.

OBJECTIVE: To examine a potential association between intranidal microhemodynamics and rupture using a phase-contrast magnetic resonance angiography (PCMRA)-based flow quantification technique in arteriovenous malformations (AVMs). METHODS: We retrospectively collected data on 30 consecutive patients with AVMs (23 unruptured and 7 ruptured). Based on PCMRA data, maximal (Vmax) and mean (Vmean) intranidal velocities were calculated. Logistic regression analysis was performed to assess factors associated with previous AVM rupture. RESULTS: All ruptures occurred within 6 months before PCMRA. The mean nidus volume was 4.7 mL. Eleven patients (37%) had deep draining vein(s), and 6 patients (20%) had a deep-seated nidus. The mean ± standard deviation Vmean and Vmax were 9.6 ± 2.8 cm/second and 66.7 ± 26.2 cm/second, respectively. The logistic regression analyses revealed that higher Vmax (P = 0.075, unit odds ratio [OR] = 1.05, 95% confidence interval [95% CI] = 1.00-1.10) was significantly associated with prior hemorrhage. The receiver-operating curve analyses demonstrated that a Vmean of 10.8 cm/second (area under the curve = 0.671) and Vmax of 90.2 cm/second (area under the curve = 0.764) maximized the Youden Index. A Vmax > 90 cm/second was significantly associated with AVM rupture both in the univariate (P = 0.025, OR = 9.0, 95% CI = 1.3-61.1) and multivariate (P = 0.008, OR = 51.7, 95% CI = 2.8-968.3) analyses. CONCLUSIONS: Presence of faster velocities in intranidal vessels may suggest aberrant microhemodynamics and thus be associated with AVM rupture. PCMRA-based velocimetry seems to be a promising tool to predict future AVM rupture.

Spontaneous rupture of immature gastric teratoma with hemoperitoneum in a newborn with 3-year follow-up.

Among the subtypes of germ cell tumors, teratomas are the most frequent in the pediatric population and commonly occur in the sacrococcygeal region and the gonads. Less than 1% of all teratoma are found in abdominal organs including the stomach, liver, and kidney. Gastric teratomas are very rare tumors predominantly found in infants. Moreover, an immature gastric teratoma is exceptionally rare. Here, we present a case of immature gastric teratoma with spontaneous rupture in a newborn who was preoperatively diagnosed with neuroblastoma. On the first day after birth, the neonate presented with progressive abdominal distension accompanying respiratory distress. A firm mass was detected during a physical examination of the abdomen. An emergency exploratory laparotomy revealed hemoperitoneum resulting from a rupture of the tumor located in the posterior wall of the gastric antrum. Complete resection of the tumor and gastroduodenostomy were performed. The pathology evaluation revealed a grade 3 immature gastric teratoma with no malignant components. The patient was treated with adjuvant chemotherapy to prevent recurrence, since the tumor was ruptured in the abdominal cavity and the level of alpha-fetoprotein was decreased but still remained high above the normal range after surgery. In conclusion, physicians should be aware of the existence of gastric teratoma as the differential diagnosis of a huge abdominal mass in infants, especially neonates. Complete surgical removal of the tumor and long-term follow-up has been adopted as the standard management for immature gastric teratoma, although there has been controversy with adjuvant chemotherapy.

Failed angioembolization of a ruptured liver hemangioma complicated by iatrogenic injury of subclavian vein during catheter insertion.

In this study, we report a case of failed angioembolization of a ruptured liver hemangioma complicated by iatrogenic injury of the subclavian vein during catheter insertion. A 30-year-old woman experienced blunt trauma upon falling from her bed. Laceration of a seemingly preexisting hepatic hemangioma was diagnosed. No other injury was detected during a preoperative diagnostic workup. Subclavian vein catheterization was performed, followed by angioembolization to control bleeding due to the ruptured hemangioma. After angioembolization, the patient's systolic blood pressure and hemoglobin levels were 70 mmHg and 5.3 g/dL, respectively. She underwent emergency laparotomy. During the surgery, a large volume of blood in the abdominal cavity due to profuse bleeding from the ruptured hemangioma was observed. Because of a hemothorax found on chest radiography, we performed thoracoscopy, which revealed a large volume of blood in the right thoracic cavity and perforation of the subclavian vein by the catheter. After the damage-control surgery, the patient recovered safely. In this case, ruptured liver hemangioma complicated by subclavian vein catheter-related injury was treated safely using damage-control surgery. The catheter-related injury could be identified and treated using thoracoscopy.

Headache in Ruptured Intracranial Dermoid Cysts.

PURPOSE OF REVIEW: Intracranial dermoid cysts are benign, rare mass-occupying lesions of the central nervous system arising from the neuroectodermal cell lines. While rupture of intracranial dermoid cysts is rare, it can present with a variety of clinical manifestations. To explore the headache manifestations among patients with ruptured intracranial dermoid cysts. To our knowledge, limited studies focusing on headache due to the intracranial dermoid cysts rupture have been published to date. A literature review was done through PubMed/Medline. Articles within the past 10 years were reviewed. Articles in languages other than English were excluded. RECENT FINDINGS: Rupture of intracranial dermoid cysts could have various manifestations including headache, seizure, and meningitis. Depending on the location of the cyst, headache secondary to the rupture of the intracranial dermoid cysts could present in different ways. A detailed systematic literature review of headache presentations due to intracranial dermoid cysts rupture is provided.

Reconstruction and repair of atraumatic extensor tendon ruptures in rheumatoid wrists: Less extension lag after direct repair than interposition tendon grafting.

The purpose of this study was to investigate the outcomes of extensor tendon repair involving the original stump in atraumatic extensor tendon rupture of rheumatoid wrists. For this study, 16 cases were reviewed involving 14 patients with rheumatoid arthritis. A total of 52 ruptured tendons impacted 36 fingers; 51 tendons were repaired in 35 fingers. The ruptured tendon stumps were repaired either directly by end-to-end suture or by free interposition tendon graft. The 8- to 10-strand core suture method was used for direct repair with a looped 4-0 nylon suture. In all patients, the extensor retinaculum was released and repaired under the tendons. Postoperatively, a volar splint with the wrist and fingers extended was applied for 3 to 4 weeks, followed by a removable splint and gentle active flexion until 6 weeks. The mean follow-up period was 32 months. All fingers recovered active metacarpophalangeal (MCP) joint extension, including independent and active extension of the little finger. Overall, the mean extension lag at the MCP joint was 1.7°. The mean fingertip-to-palm distance with the MCP joint flexed was 0.24mm. The mean extension lag at the MCP joint was significantly greater after interposition tendon grafting (3.2°) than after direct repair (0°). There was no significant difference in the mean fingertip-to-palm distance between direct repair (0.38mm) and interposition tendon grafting (0.13mm). No re-rupture or additional extensor tendon rupture was observed. Repair of the original extensor tendon stump yields satisfactory outcomes and appears to be a viable alternative to tendon transfers in patients with rheumatoid wrists with atraumatic extensor tendon ruptures. Direct repair reduces postoperative extension lag without a significant difference in flexion deficit when compared with interposition tendon grafting.

Prognostic models for neurological functional outcomes in aneurysmal subarachnoid hemorrhage patients with intracranial hematoma.

OBJECTIVES: Current guidelines paid little attention to a unique severe disease about intracranial hematoma owing to aneurysm rupture. We attempted to explore the predictive factors for prognosis in these poor patient population. PATIENTS AND METHODS: One hundred twenty-one aneurysmal subarachnoid hemorrhage combined with intracerebral hematoma patients discharged between 2013 and 2016 were reviewed in this retrospective study. Unfavorable outcome was defined as a modified Rankin Scale (mRS) score of 3, 4, 5, or 6 at 6 months. Multivariable logistic regression was performed to evaluate the association of unfavorable outcome with preoperative and postoperative clinical characteristics. RESULTS: Of 121 patients with intact follow-up data, 34 (28.10 %) had an unfavorable prognosis. The preoperative prognostic model included patients' age, respiratory rate, Hunt-Hess scale, red cell distribution width, and serum sodium at admission. The postoperative prognostic model included patients' age, respiratory rate, red cell distribution width, serum sodium, postoperative delayed cerebral ischemia, and pulmonary infection. Both preoperative and postoperative prognostic models had excellent discrimination with Area Under The Curve (AUC) of 0.864 (P < .001) and 0.898 (P < .001), respectively. CONCLUSION: In clinical practice, we should pay more attention to those old patients with worse admission Hunt-Hess score, presenting deep-slow respiratory and lower serum sodium. Reduction of postoperative delayed cerebral ischemia and pulmonary infection might improve outcomes after aneurysmal SAH with intracerebral hematoma.

Spontaneous splenic rupture: a rare first presentation of diffuse large B cell lymphoma.

Spontaneous splenic rupture (SSR) is a rare but potentially life-threatening entity. It can be due to neoplastic, infectious, haematological, inflammatory and metabolic causes. An iatrogenic or an idiopathic aetiology should also be considered. Depending on the degree of splenic injury and the haemodynamic status of the patient, it can be managed conservatively. A 61-year-old man presented to the emergency department with an acute abdomen, hypovolaemic shock and clotting abnormalities. However, his focused assessment with sonography for trauma showed no evidence of an aortic aneurysm, rupture or dissection. Further investigation with a CT angiogram aorta confirmed a subcapsular splenic haematoma with free fluid in the pelvis and a mass in the superior pole of the spleen. He was diagnosed with an SSR. He was initially managed non-operatively. However, his repeat CT showed an enlarging haematoma and he underwent embolisation of his splenic artery. Ultrasound-guided core biopsy of his splenic mass confirmed the diagnosis of diffuse large B-cell lymphoma. This paper will discuss the clinical presentation, differential diagnosis and management of SSR. Furthermore, it provides an important clinical lesson to maintain a high index of clinical suspicion for splenic injury in patients presenting with left upper quadrant abdominal pain radiating to the shoulder. This case also reinforces the importance of close observation and monitoring of those individuals treated conservatively for signs of clinical deterioration.

Predictive ability of admission neutrophil to lymphocyte ratio on short-term outcome in patients with spontaneous cerebellar hemorrhage.

As one of the prototypical intracranial hemorrhage (ICH), spontaneous cerebellar hemorrhage (SCH) is treated with different strategies by comparing with supratentorial hemorrhage (SH). Additionally, SCH patients usually suffer from worse prognosis than patients with other types of ICH. It is well documented that the unique anatomic structures of posterior cranial fossa lead to a higher risk for brainstem compression and/or brain edema in SCH patients. Recently, neutrophil to lymphocyte ratio (NLR) was reported to possess an excellent predictive ability for the prognosis of patients with ICH, and most of those cases are SH. Thus, the potential association between NLR and the prognosis of SCH patients remains to be elucidated. Here, we aim to assess the predictive role of admission NLR and other available inflammatory parameters for the outcomes of patients with SCH.All patients with acute SCH admitting to West China Hospital from February 2010 to October 2017 were retrospectively enrolled. According to the absolute neutrophil count, absolute lymphocyte count, white blood count and absolute monocyte count extracted from electronic medical records, NLR was calculated. The multivariable logistic regression analysis was applied to analyze the associations between disease outcome and laboratory biomarkers. The comparisons of predictive powers of each biomarker were assessed by receiver operating curves (ROCs). The spearman analyses and multiple linear analyses were also conducted to identify the independent predictors for admission NLR.Admission NLR independently associated with 30-day status (odds ratio [OR] 1.785, 95% confidence interval [CI] 1.463-2.666, P <.01) and exhibited a better predictive value (AUC 0.751, 95% CI 0.659-0.830, P <.001) with the best predictive cutoff point of 7.04 in 62 patients with unfavorable outcomes. Moreover, absolute neutrophil count, absolute lymphocyte count, presence of intraventricular hemorrhage (IVH) and Glasgow coma scale (GCS) score were also correlated with admission NLR, respectively.Admission NLR is a potential marker to independently predict the 30 days functional outcome of SCH patients. Based on our results, systemic inflammation in admission might be considered as an important player in participating the pathological process of patients with SCH.

A Spontaneous Cervical Epidural Hematoma Mimicking a Stroke: A Challenging Case.

BACKGROUND: A spontaneous cervical epidural hematoma (SCEH) is a rare occurrence, with < 500 cases reported to date. Clinically, it usually presents with quadriparesis, but in extremely rare cases it can present with hemiparesis or hemiplegia, and can easily be misdiagnosed as stroke. The cervical epidural hematoma by itself is an urgent condition that requires a quick and accurate diagnosis and a prompt surgical treatment. CASE REPORT: We present a case where an SCEH mimicked the much more frequent condition of a stroke, and discuss the importance of diagnostics procedures that help differentiate SCEH from acute cerebral infarction. The patient's history of neck pain and spondylosis render this case more challenging. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Considering that the emergency tissue plasminogen activator treatment for acute cerebral infarction can worsen the state of an SCEH patient, or even lead to permanent damage or death, it is of great importance to rapidly and accurately differentiate these two conditions.

Mechanical complications in patients with ST-segment elevation myocardial infarction: A single centre experience.

BACKGROUND: The study aims to assess characteristics and outcomes of patients suffering a mechanical complication (MC) after ST-segment elevation myocardial infarction (STEMI) in a contemporary cohort of patients in the percutaneous coronary intervention era. METHODS AND RESULTS: This retrospective single-center cohort study encompasses 2508 patients admitted with STEMI between March 9, 2009 and June 30, 2014. A total of 26 patients (1.1%) suffered a mechanical complication: ventricular septal rupture (VSR) in 17, ventricular free wall rupture (VFWR) in 2, a combination of VSD and VFWR in 2, and papillary muscle rupture (PMR) in 5 patients. Older age (74.5 ± 10.4 years versus 63.9 ± 13.1 years, p < 0.001), female sex (42.3% versus 23.3%, p = 0.034), and a longer latency period between symptom onset and angiography (> 24h: 42.3% versus 16.2%, p = 0.002) were more frequent among patients with MC as compared to patients without MC. The majority of MC patients had multivessel disease (77%) and presented in cardiogenic shock (Killip class IV: 73.1%). Nine patients (7 VSR, 2 VFWR & VSR) were treated conservatively and died. Out of the remaining 10 VSR patients, four underwent surgery, three underwent implantation of an occluder device, and another three patients had surgical repair following occluder device implantation. All patients with isolated VFWR and PMR underwent emergency surgery. At 30 days, mortality for VSR, VFWR, VFWR & VSR and PMR amounted to 71%, 50%, 100% and 0%, respectively. CONCLUSIONS: Despite advances in the management of STEMI patients, mortality of mechanical complications stays considerable in this contemporary cohort. Older age, female sex, and a prolonged latency period between symptom onset and angiography are associated with the occurrence of these complications.

Incidence of Cardiac Dysfunction After Brain Injury.

INTRODUCTION: Cardiovascular complications in patients with subarachnoid hemorrhage are considered to be a neurally mediated process rather than a manifestation of coronary artery disease. AIM: The aim of study is to show the incidence and type cardiac complications after traumatic and spontaneous SAH. PATIENTS AND METHODS: The study had prospective character in which included 104 patients, with diagnosed subarachnoid hemorrhage (SAH), in the period from 2014 to 2017. Two groups of patients were formed. Group I: patients with SAH caused by the rupture of a brain aneurysm. Group II: patients with SAH after traumatic brain injury. RESULTS: Electrocardiogram (ECG) abnormalities was predominant after traumatic brain injury 74 %, with statistically significant difference atrial fibrillation 42.5 % (p = 0.043) and sinus bradycardia 31.4 % (p = 0.05). Hypertension are predominant in patients with spontaneous SAH with statistically significant difference (15 (27.7%) vs 36 (72%) p=0.034) and hypotension in group II (10 (18.5%) vs 2 (4%) p = 0.021 ) with traumatic SAH patients. The time in Intensive Care Unit (ICU) for traumatic SAH group was 6.1 ± 5.2 days and 3.9 ± 1.16 for spontaneous SAH group with statistical significance (p = 0.046). Respiratory support time was longer in traumatic SAH group (39.4 ± 23.44 vs. 15.66 ± 22.78) with p = 0.043. CONCLUSION: Cardiac dysfunction in patients with subarachnoid hemorrhage are considered to be a neurally mediated process rather than a manifestation of coronary artery disease. Early treatment of cerebral injury could be reduce incidence of cardiac complications after traumatic brain injury. Cardiac dysfunction in patients with SAH is still very high, despite substantial qualitative progress in their treatment.

Spontaneous rupture of seminoma in undescended testis with hemoperitoneum: a rare presentation.

Cryptorchidism is associated with increased risk of malignancy and infertility. We present a case of a 30-year-old man who presented to the Emergency Department of our tertiary care hospital with spontaneous intra-abdominal rupture of the seminoma in undescended testis with hemoperitoneum. This is a rare presentation of seminoma and emphasises the importance of scrotal examination in young men presenting with acute abdomen. Surgical management is the definitive treatment and should be instituted as soon as possible, after appropriate resuscitation.

Spontaneous bilateral quadriceps tendon rupture.

Spontaneous bilateral quadriceps tendon rupture is a rare finding in emergency departments. Thus, the pathophysiology is not well understood. Imaging for improved speed of diagnosis is rarely considered. We present a case of non-traumatic spontaneous bilateral quadriceps tendon rupture and examine current literature on the pathophysiology and imaging guidelines on the topic. The patient is a 49-year-old male that presented to the emergency department with bilateral thigh pain. He had been seen earlier with similar pain, but now presents with increased difficulty ambulating. The patient was found to have spontaneous rupture of bilateral quadriceps tendon. He was treated surgically and has been following with Orthopedic Surgery. Imaging in the emergency department included an ultrasound that showed tendon rupture. Spontaneous bilateral quadriceps tendon rupture is an uncommon finding in medicine and the emergency department. MRI remains the gold standard. However, clinical exam and ultrasound should be utilized for diagnosis of tendon rupture to hasten treatment.

Spontaneous splenic rupture as a rare complication of G-CSF injection.

Splenic rupture is an infrequent and underdiagnosed side effect of granylocyte colony-stimulating factor (G-CSF). We report the case of a 54-year-old woman with brain and bone metastasis in a lung adenocarcinoma who was admitted for faintness 28 days after a G-CSF injection. Abdominal CT scan confirmed the diagnosis of splenic rupture. A conservative treatment was chosen using a peritoneal cleansing during laparoscopic surgery. Clinicians should be aware of this rare toxicity as it could be severe, but easily reversible using appropriate surgical treatment. Even if prognosis remains poor for patients with lung cancer, invasive procedures could be considered in this rapidly evolving setting, especially in case of reversible adverse event.

A novel minimally invasive surgery combined with early exercise therapy promoting tendon regeneration in the treatment of spontaneous Achilles tendon rupture.

OBJECTIVE: Acute closed spontaneous Achilles tendon rupture often occurs in elderly individuals and is usually accompanied with many complications. Conventional surgical approaches to remove the tendon lesions and enthesophytes are highly traumatic and cause complications. In this study, a previously established minimally invasive surgical approach was modified and combined with a Kazakh exercise therapy to reduce trauma, improve wound healing, and promote tendon regeneration in the management of acute closed spontaneous Achilles tendon rupture. METHODS: Fifty-two patients with acute closed spontaneous Achilles tendon rupture were randomly classified into 2 groups. Group A included 23 patients that were treated with the novel approach. Group B included 29 patients that were treated with a continuous medial oblique surgical approach. Follow-up examinations were performed at post-operative weeks 12 and 24, and year 2. Outcomes were assessed by Achilles tendon rupture score (ATRS), a heel-rise endurance test, and ultrasonographic and multislice spiral computerized tomography. RESULTS: Mean ATRS in Group A was 68.6 and 86.0 at post-operative week 12 and 24, respectively, significantly higher than that in Group B (55.9 and 72.0, respectively). Recovery of patients in Group A was significantly better compared to Group B (p < 0.01), allowing them to participate in early rehabilitating kinesiotherapy. Patients in Group A rarely experienced complications after surgery, such as infection and Achilles tendon exposure, while in Group B, the wound healing was slower, the inside flaps were prone to necrosis and infection, and Achilles tendon exposure occurred in 10% of patients. CONCLUSIONS: The novel minimally invasive surgery is more advantageous in the treatment of acute closed spontaneous Achilles tendon rupture over previous approaches by promoting wound healing and tendon regeneration.

Model-based cap thickness and peak cap stress prediction for carotid MRI.

A rupture-prone carotid plaque can potentially be identified by calculating the peak cap stress (PCS). For these calculations, plaque geometry from MRI is often used. Unfortunately, MRI is hampered by a low resolution, leading to an overestimation of cap thickness and an underestimation of PCS. We developed a model to reconstruct the cap based on plaque geometry to better predict cap thickness and PCS. We used histological stained plaques from 34 patients. These plaques were segmented and served as the ground truth. Sections of these plaques contained 93 necrotic cores with a cap thickness <0.62mm which were used to generate a geometry-based model. The histological data was used to simulate in vivo MRI images, which were manually delineated by three experienced MRI readers. Caps below the MRI resolution (n=31) were (digitally removed and) reconstructed according to the geometry-based model. Cap thickness and PCS were determined for the ground truth, readers, and reconstructed geometries. Cap thickness was 0.07mm for the ground truth, 0.23mm for the readers, and 0.12mm for the reconstructed geometries. The model predicts cap thickness significantly better than the readers. PCS was 464kPa for the ground truth, 262kPa for the readers and 384kPa for the reconstructed geometries. The model did not predict the PCS significantly better than the readers. The geometry-based model provided a significant improvement for cap thickness estimation and can potentially help in rupture-risk prediction, solely based on cap thickness. Estimation of PCS estimation did not improve, probably due to the complex shape of the plaques.

Spontaneous Hemothorax, A Rare Face of Vertebral Osteochondroma.

BACKGROUND: Osteochondroma is the most common benign tumor of the bone. It is usually asymptomatic, but complications may result from mechanical injury to adjacent anatomic structures, such as the diaphragm and lung, when located intrathoracically. CASE REPORT: We report the unusual occurrence of a large hemothorax and lacerated right diaphragm in a 41-year-old woman caused by vertebral osteochondroma affecting the eleventh thoracic vertebra. Thoracoscopic exploration with resection of the osteochondroma and repair of the diaphragm was performed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous hemothorax is a potential life-threatening condition when the initial diagnosis is postponed and hemodynamic instability and hypovolemic shock occurs. Osteochondroma as a cause of spontaneous hemothorax is uncommon but may require urgent surgical intervention with video-assisted thoracoscopic surgery of thoracotomy to control the hemorrhage and prevent recurrence.