Spontaneous Renal Artery Dissection with Bilateral Renal Infarction Successfully Treated with Rivaroxaban.

Spontaneous renal artery dissection (SRAD) causing bilateral renal infarction is a rare condition. It may present with nonspecific symptoms, resulting in delayed diagnosis. We report a case of SRAD in an adult male who presented with flank pain and fever. The patient was initially worked up for possible pyelonephritis, which came back negative. Later, a diagnosis of SRAD with bilateral renal infarction was made on contrast-enhanced computed tomography (CT) abdomen followed by CT angiogram. The patient was treated with rivaroxaban and antihypertensive therapy. He was followed up for 12 months after the initial presentation and repeat imaging showed no new infarcts and a stable renal function.

[Clinical analysis of syndrome-relative biological indices in acute lacuna encephalon infarction patients of upper hyperactivity of Gan Yang syndrome].

OBJECTIVE: To analyze and summarize changes of syndrome-related biological indices in acute lacuna encephalon infarction patients of upper hyperactivity of Gan yang syndrome (UHGYS), thus providing objective evidence for syndrome typing and disease identification. METHODS: Recruited were 50 patients at Department of Encephalopathy, Xiyuan Hospital, China Academy of Chinese Medical Sciences, who were in line with diagnostic criteria of UHGYS as the experimental group in this study. Another 40 healthy volunteers were recruited as the control group from May 2010 to July 2012. Blood routines (including WBC, RBC, Hb, NEUT%, and LY%), hepatic and renal functions tests (including ALT, AST, TBIL, TP, ALB, Cr, and BUN) were performed by automatic whole blood analyzer and colorimetric technique. The levels of fasting blood glucose, HbAlc, blood lipids (including TC, TG, HDL-C, LDL-C, and VLDL-C), and coagulation functions (including AT-III, PT, PTA, INR, TT, APTT, and FBG, reaction time), renin, angiotensin II, hs-CRP, and Hcy were also measured. The thyroid functions (including FT3, FT4, T3, T4, and TSH) were detected by electrochemiluminescence immunoassay. The levels of tumor necrosis factor alpha (TNF-alpha), IL-6 and IL-1 in serum were measured by ELISA and radioimmunoassay respectively. RESULTS: Compared with the control group, RBC, LY%, ALT, TP, ALB, HDL-C, AT-III activities, contents of PTA and FT4 obviously decreased, TBIL, BUN, Glu, HbAlc, TSH, hs-CRP, renin, Ang II, TNF-alpha, IL-1 and IL-6 significantly increased in the experimental group (P < 0.05, P < 0.01). CONCLUSION: The pathological process of acute lacuna encephalon infarction patients of UHGYS was closely correlated with thyroid functions, the renin-angiotensin-aldosterone system, the extrinsic and intrinsic coagulation systems, as well as inflammation reaction.

Carotid cavernous fistula with bilateral thalamic infarct.

Carotid cavernous fistula (CCF) is an abnormal communication between cavernous sinus and carotid arterial system. Diagnosis depends on clinical manifestations and MRI findings and angiography. Clinical presentation of CCFs is characterized with chemosis, orbital bruit and pulsatile proptosis. Cranial nerve dysfunction and orbital pain might accompany these symptoms. Although spontaneous remission might occur, sometimes CCF might develop life threatening complications. Here in this case we presented a patient with CCF who afterwards developed bilateral thalamic infarct. Cerebral ischemia in CCF is a rare complication and CCF together with bilateral thalamic infarct has not been reported before.

Seventh cervical rib associated with subclavian artery occlusion and multiple infarcts: case report.

A cervical rib, or supernumerary (extra) rib arising from the 7th cervical vertebra, is a congenital abnormality that occurs in less than 1% of the population. Clinically, it can cause obscure nervous or vascular symptoms and be difficult to diagnose. In this rare case, a 37-year-old woman developed a subclavian artery occlusion after undergoing a chiropractic manipulation for neck, shoulder, and arm pain. The occlusion led to multiple cerebellar infarcts, frontal subarachnoid hemorrhage, myocardial infarction, and right-hand vascular compromise. The patient was subsequently diagnosed with a 7th cervical rib, which likely caused compression of the subclavian artery after a hyperextension injury sustained during the chiropractic procedure. The departments of vascular surgery, neurosurgery, cardiology, and neurology collaborated to review all elements of the patient's diagnosis and care. After the patient was stabilized, she spent 6 weeks in acute inpatient rehabilitation; upon discharge, her symptoms were greatly improved but still present. Three months later, the patient underwent a subclavian-artery-to-axillary-artery bypass with resection of the left cervical rib. She tolerated surgery well with no complications. As a result of the devastating insults sustained secondary to the presence of the 7th cervical rib and her subclavian artery occlusion, this patient faced months of recovery. Treatment involved a structured interdisciplinary plan of care.

[Torsion and infarction of an accessory liver lobe]. / Lob hepatic accesoriu torsionat si infarctat.

Anatomical abnormalities of the liver are extremely rare. We report a case of a 32 year old female who has admitted with acute epigastric pain and vomiting. Physical exam revealed a mobile mass in right middle abdominal quadrant. Ultrasound and contrast--enhanced CT demonstrated a heterogeneous vascular left mass. Small bowel enema shows left jejunal loops displacement. Surgical findings: twisted, congested swelling, attached by a long pedicle to the liver's third segment. Histological examination showed recent hepatic infarction.

[Bilateral cerebellar infarction caused by intracranial dissection of the vertebral artery after long periods of "Shiatsu"].

For five years, a 56-year-old woman had undergone "Shiatsu" (a technique that uses fingers and the palm of the hand to apply pressure to particular sections of the body's surface to correct neck stiffness and body imbalances in order to maintain and promote health). She suddenly developed neck pain, dizziness, dysphagia, and speech and gait disturbances during treatment. A neurological examination detected bradylalia and truncal and mild bilateral limb ataxia of the cerebellar type. Diffusion-weighted brain MRI showed multiple hyperintense signal lesions at the bilateral cerebellar hemisphere in the posterior inferior cerebellar artery territory. Three-dimensional computed tomographic angiography (3D-CTA) revealed irregular stenosis of the intracranial right vertebral artery (string sign). Dissection of the intracranial portion of the vertebral artery owing to trauma is rare. Physicians need to be aware of patients who have acute dissecting infarction after long periods of repeated trivial pressure such as "Shiatsu". 3D-CTA is a very useful diagnostic procedure for arterial dissection.

Muscle infarction involving muscles of abdominal and thoracic walls in diabetes.

AIMS: This paper presents two cases of muscle infarction involving four major muscles of the anterior abdominal wall (case 1) and pectoralis major (case 2) in individuals with diabetes. METHODS: Erythrocyte sedimentation rate (ESR) and creatine kinase (CK) were measured and Doppler ultrasound, an open muscle biopsy (case 1) and magnetic resonance imaging (MRI) (case 2) were performed. RESULT: The diagnosis of muscle infarction was made by histological findings and MRI images with hyper-intensive signals on a gadolinium-enhanced T2-weighted sequence, respectively. Both patients were treated with bed rest, immobilization of the involved extremities, analgesia and intensive insulin therapy. In addition, anticoagulant drugs such as low molecular weight heparin sodium and cilostazol, and some traditional Chinese medicines such as ligustrazine and salvia miltiorrhiza were administered. The symptoms of both patients resolved gradually after 3 weeks. However, muscle infarction reoccurred in case 1 on the opposite side of the abdomen and recovered after 40 days. CONCLUSIONS: This is the first report of muscle infarction involving the muscles of anterior abdominal walls and pectoralis major in diabetes. MRI is the best non-invasive technique and T2-weighted imaging is the most valuable method for the diagnosis. In addition to supportive therapy, administration of anticoagulant agents and some Chinese traditional medicine may be useful in symptom relief.

[Susac syndrome as a cause of sensorineural hearing loss]. / Síndrome de Susac como causa de hipoacusia neurosensorial.

Susac's syndrome is an extremely rare clinical manifestation characterized by the triad of fluctuating sensorineural hearing loss, sudden visual loss and encephalopathy. Probably underdiagnosed, it affects young women who start the clinical history with headache, visual and hearing disturbances, with neurological findings in MRI. With unknown aetiology, pathogenesis is based on arteriolar microinfarcts in retina, cochlea, and grey and white matter in the brain. Treatment is, as stated in the bibliography and our experience, intravenous high doses of steroids followed by oral steroids together with hyperbaric oxygen to minimize ischaemic lesions. Aspirin associate to nimodipine has been useful to date in the treatment of our patient. We present a case and review the existing literature.

Nonocclusive mesenteric infarction in continuous ambulatory peritoneal dialysis.

Nonocclusive mesenteric infarction has recently been diagnosed with increasing frequency in dialysis patients. Although most reports have concerned patients on hemodialysis, the condition has also been reported to occur in patients on continuous ambulatory peritoneal dialysis. This report describes such a case developing in a woman whose end-stage renal failure was due to adult polycystic kidney disease. Associated predisposing factors were the presence of orthostatic hypoxemia, postural hypotension and extensive atheromatous changes of the abdominal aorta. In keeping with the known difficulty of establishing the diagnosis of mesenteric ischemia, the diagnosis in our patient was also delayed. She was initially thought to suffer from an episode of peritonitis and/or colonic perforation secondary to the performance of a cleansing enema. Only upon showing pneumatosis coli of the right colon on abdominal computerized tomography was the correct diagnosis made. Laparotomy revealed extensive necrosis of the ascending and transverse colon. A total colectomy and ileorectal anastomosis were performed. The patient died on the 17th day following surgery. This case serves to illustrate that mesenteric infarction should be considered in predisposed patients on continuous ambulatory peritoneal dialysis. The presence of peritonitis may mask the underlying pathology and waylay the unwary physician.

Left tuberothalamic artery territory infarction: neuropsychological and MRI features.

We examined a 29-year-old woman who had language disturbances and memory impairment after a left thalamic infarction. MRI showed injury that was limited to the tuberothalamic artery territory. Beside reduced voice volume and verbal memory trouble, she presented with aspontaneity, loss of psychic self-activation and affective drive. Considering thalamic lesions, this loss of psychic self-activation or 'athymhormie' was found in a left thalamic infarct and could not be considered as an exclusive characteristic of bithalamic infarctions. The disappearance of the neurobehavioral disturbances within 15 days after the onset of the troubles was associated with the decreasing of the mass lesion found by MRI.

Transient global amnesia and thalamic infarction.

We describe the clinical and neuroradiologic features of a patient with two episodes of transient amnesia who later developed persistent amnesia and an acute infarction in the left thalamus. The neurobehavioral manifestations were strikingly similar in all three episodes. Cranial computed tomography was normal following the first two episodes. Thalamic ischemia could explain some cases of transient global amnesia.

Locked-in syndrome following cervical manipulation.

A case of locked-in syndrome following cervical manipulation in a 36-year-old woman is described. The patient had always been healthy but was born with polydactyly on one hand and had 2 mentally retarded children with progressive leucoencephalopathia. Because of pain in the neck the patient was treated with cervical manipulation, during which she became ill and developed a locked-in syndrome, where she was awake but mutistic and totally paralyzed. Following intensive training the patient became able to perform rocking movements with the head, which were used to activate an electronic system for communication. MR scanning 3 months after admission exhibited a sharply demarcated triangular area stretching through most of the pons, which was compatible with a recent infarction.

The complementary uses of nuclear medicine and ultrasound in the kidney.

Together, sonography and renal isotope techniques can provide greater information than either technique alone. These studies can replace excretory urography in the diagnosis of hydronephrosis and renal infarction. Arteriography is no longer necessary for the diagnosis of a pseudotumor, which has a specific isotope and a helpful sonographic appearance. The diagnosis of a renal abscess opposed to pyelonephritis can be made in a more definite fashion than is possible with other imaging techniques. We believe that the sonogram and isotope studies are particularly helpful in trauma because there is a more realistic assessment of the absence of renal function with isotopes than with the excretory urogram. One may detect hematoma within and around the kidney by ultrasonography.