Cupping (Hijama) Treatment: Benign or Sinister?

Cupping treatment is on the rise in the Western world as an alternative medicine modality.We present a hitherto unreported complication of bilateral subdural hemorrhage associated with this therapy, highlighting the need for vigilance in patients presenting with headache because they may get misdiagnosed unless history for such therapies is explored.

Outcome and complications of chronically implanted subdural electrodes for the treatment of medically resistant epilepsy.

BACKGROUND: Surgery for medically resistant epilepsy is safe and effective. However, when noninvasive techniques are insufficient, then consideration is given to invasive electrocorticography (EcoG). OBJECTIVE: The aim of the study was to analyze results and complications of subdural electrodes placement in the treatment of intractable epilepsy. METHODS: Ninety-one consecutive patients who underwent placement of subdural electrodes (1999-2010) were considered for this study. All patients underwent a standardized pre-operative evaluation. Invasive subdural electrode placement was considered when there were inadequate ictal recordings, there was discordance between EEG and neuroimaging or the epileptogenic zone was localized near eloquent cortex. RESULTS: Resective epilepsy surgery was performed in 70/91 patients (76.9%). Twenty-four out of seventy (34.3%) who underwent surgical resection were seizure-free (CL-I) at last follow-up. A statistical evaluation revealed a very strong trend for patients with positive lesional pre-operative MRI to have improved outcomes compared to normal brain MRI population (p=.028). There were 10 surgical related complications (11%), but no mortality or permanent morbidity. Statistical analysis demonstrated that placement of a subdural grid in any combination was statistically significant (p=.01) for surgical complications. CONCLUSIONS: Invasive monitoring is a useful and necessary technique for the surgical treatment of intractable epilepsy. Careful surveillance is required during the monitoring period especially when the patient has undergone large subdural grid placement. A good working hypothesis can minimize complications and achieve better outcomes.

An evidence-based approach to managing the anticoagulated patient in the emergency department.

You start another busy shift with a double row of charts waiting to be seen. Your first patient is an elderly man who fell 1 hour prior to presentation. He did not lose consciousness, but he was dazed for a few minutes. He complains of a mild headache but denies any neck pain. He takes warfarin for valvular heart disease. He looks good and has no focal neurological complaints. His mental status is normal, he has a negative head CT scan, and his INR is 3.9. His family wants to take him home, which would help relieve some of the congestion in the ED, but you wonder what would be best. To observe and repeat imaging? Reverse his anticoagulation? Change his dosing regimen of warfarin? In the next room, you quickly evaluate a 51-year-old obese woman with nonspecific back and abdominal pain that started 24 hours before and has slowly progressed to become intolerable. She denies fever, chills, nausea, or vomiting. She is on the last day of a 5-day course of ciprofloxacin for a UTI. She takes warfarin for a pulmonary embolus that occurred 2 months prior. Her hematocrit is mildly decreased, and her white blood count is normal; however, the INR is 6.8. You wonder if her abdominal pain is related to the UTI, or if it could be somehow related to the prolonged INR. In fact, you wonder why her INR is so prolonged...

Acquired hemophilia first manifesting as life-threatening intracranial hemorrhage: case report.

A 74-year-old man presented with life-threatening intracranial hemorrhage and prolonged activated partial thromboplastin time (APTT). The massive subdural hematoma was removed, but multiple intracranial hemorrhages occurred despite the administration of factor VIII and factor IX concentrates. Subdural hematoma, intracerebral hemorrhage in the left temporal lobe, and thalamic hemorrhage subsequently occurred with further prolongation of APTT. He died of enlargement of the thalamic hemorrhage. Acquired hemophilia was diagnosed caused by factor VIII inhibitor. Acquired hemophilia may cause life-threatening hemorrhage, and should be considered in patients with intracranial hemorrhages associated with unexplained prolongation of APTT.

Subdural hematoma after a fall in an elderly patient taking high-dose omega-3 fatty acids with warfarin and aspirin: case report and review of the literature.

The elderly population is at an increased risk for major bleeding, possibly due to increased sensitivity to anticoagulation, multiple comorbidities, and polypharmacy. Elderly patients receiving antiplatelet and anticoagulant therapy have an additional risk for bleeding. Omega-3 fatty acids, also known as fish oil, have been used for hyperlipidemia, coronary heart disease, hypertension, and other conditions. Some studies have demonstrated that consumption of fish oil concentrate, n-3 polyunsaturated fatty acid (n-3 PUFA), results in cardiovascular benefits that include reductions in mortality, sudden death, nonfatal myocardial infarction, and thrombotic stoke, as well as improvement in graft patency. The mechanism of action of n-3 PUFA is not completely understood, but a dual antiplatelet and anticoagulant effect has been proposed. Few data exist on whether or not fish oil can be used safely with other antiplatelet or anticoagulant drugs. We report the case of a patient who after a minor fall developed a subdural hematoma requiring craniotomy that likely was precipitated by concomitant use of high-dose omega-3 fatty acids 6 g/day with both aspirin and warfarin. These findings are important because of the wide availability of omega-3 fatty acids and the propensity for use of complementary and alternative medicine in patients with cardiovascular disease who are already taking antiplatelet and/or anticoagulant agents. Judicious use of these combinations is advised, and pharmacists can play an important role in educating patients and other health care providers about the bleeding risks associated with combination therapy.

Use of the vacuum extractor by midwives--what has changed in the last decade?

This article provides an update on use of vacuum extraction by certified nurse-midwives (CNMs) and certified midwives (CMs). Research findings from the last decade relevant to the training and use of vacuum extractors are reviewed along with professional guidelines and legal implications.

Maternal total parenteral nutrition and fetal subdural hematoma.

BACKGROUND: Fetal subdural hematoma is rare, and no case resulting from vitamin K deficiency secondary to maternal total parenteral nutrition has been reported. CASE: A 28-year-old woman was managed with total parenteral nutrition from 28 weeks' gestation because of continuous vomiting due to esophageal hiatal hernia. A sinusoidal pattern by cardiotocogram was observed at 31 weeks' gestation. Serial sonograms showed a fetal subdural hematoma, and cesarean delivery was performed. Although the maternal hepaplastin test result was normal and the maternal PIVKA-II concentration was only slightly elevated, the neonate was severely anemic and had severe vitamin K deficiency. CONCLUSION: Severe fetal vitamin K deficiency can develop even when the maternal deficiency is mild. When maternal total parenteral nutrition is necessary, supplemental vitamin K should be administered.

Artificial elevation of brain tissue glycerol by administration of a glycerol-containing agent. Case report.

In recent years the development of secondary brain damage and derangement of neurochemical parameters after severe head injury has been monitored using microdialysis. Provided the blood-brain barrier is intact, glycerol is regarded as a potential marker for membrane phospholipid degradation. The authors report a case in which marked elevation of interstitial glycerol was induced after exogenous administration of a glycerol-containing agent. A 25-year-old man was injured in a motorcycle accident and was admitted to the authors' institution with a unilateral dilated and fixed pupil and a Glasgow Coma Scale score of 3. Computerized tomography scans revealed a large subdural hematoma on the left side, subsequent midline shift, and generalized edema. Emergency craniotomy was performed for evacuation of the hematoma. The patient was prepared for multisensory monitoring and a microdialysis catheter was inserted into his left frontal lobe. After a routine enema containing 85% glycerol had been administered, the authors measured a marked increase in glycerol in the dialysate. This occurred while the patient was in as stable a condition as could be expected given the circumstances. The increase in interstitial glycerol in the injured tissue was most likely due to an impaired blood-brain barrier. Thus, the interstitial glycerol concentration had been corrupted by exogenous glycerol, and the marker properties of glycerol in this case became questionable. Consequently, administration of glycerol, which is frequently found in various infusions and emulsions, can promote secondary brain damage by adversely shifting osmotic gradients.

Complications of deep brain stimulation surgery.

Although technological advances have reduced device-related complications, DBS surgery still carries a significant risk of transient and permanent complications. We report our experience in 86 patients and 149 DBS implants. Patients with Parkinson's disease, essential tremor and dystonia were treated. There were 8 perioperative, 8 postoperative, 9 hardware-related complications and 4 stimulation-induced side effects. Only 5 patients (6%) sustained some persistent neurological sequelae, however, 26 of the 86 patients undergoing 149 DBS implants in this series experienced some untoward event with the procedure. Although there were no fatalities or permanent severe disabilities encountered, it is important to extend the informed consent to include all potential complications.

[Clinical study on Zhuyu Xiaozhong mixture combined with stereotaxic drainage in treating hypertensive cerebral hemorrhage].

OBJECTIVE: To explore the effective method of integrated traditional Chinese and western medicine (TCM-WM) therapy in treating hypertensive cerebral hemorrhage (HCH). METHODS: Sixty-one HCH patients were randomly divided into two groups: the treated group (group A, 31 cases) and the control group (group B, 30 cases), the former group was treated with stereotaxic drainage and orally taken Zhuyu Xiaozhong mixture (ZYXZM), and the latter group with stereotaxic drainage alone. RESULTS: The total effective rate of group A was 83.9%, significantly higher than that of group B (60.0%, P < 0.05). In comparing the two groups, the neurological function recovery, the quality of life and the hematoma absorption in group A were significantly better than those of group B (P < 0.05). CONCLUSION: ZYXZM combined with stereotaxic drainage is effective in treating HCH. It could promote the neurological function recovery and improve the quality of life as well.

The fate of the cerebrospinal fluid after neuroendoscopic third ventriculostomy.

This paper describes the case of a 9-year-old girl with a posterior thalamic/pineal region lesion and secondary obstructive hydrocephalus. The hydrocephalus was treated by neuroendoscopic third ventriculostomy (NTV), and she underwent simultaneous transendoscopic biopsy. The tumour biopsy was haemorrhagic, but the bleeding settled with constant irrigation. The patient remained neurologically unchanged, but subsequent imaging revealed an asymptomatic thoracolumbar spinal subdural haematoma thought to be due to blood flowing out through the NTV into the subdural space. This demonstrates the subdural location of the cerebrospinal fluid after NTV.

Traumatismo encefalocraneano en niños / Encephalocranial trauma in children

Se siguió la evolución de 150 niños, de un mes a 15 años de edad, ingresados en una temporada de 18 meses a la unidad de tratamiento intensivos pediátrica de una clínica privada de Santiag, Chile, por traumatismo encéfalo craneano, con el propósito de describir las características del trauma, las complicaciones intracraneanas más frecuentes y la importancia del examen clínico y la tomografía axial computarizada del cráneo en el diagnóstico. Ciento seis pacientes (70,6 por ciento) eran escolares, 34 lactantes (22,6 por ciento) y los restantes preescolares. Sesenta por ciento (n:90 casos) de los accidentes ocurrió en el hogar y 23 por ciento (n:35) en la vía pública (accidentes de tránsito). 26 pacientes (17,3 por ciento) sufrieron complicaciones demostradas con tomografía axial: 11 (7,3 por ciento) hemorragias quirúrgicas, 9 (6 por ciento) lesiones hemorrágicas no quirúrgicas y 6 (4 por ciento) edema cerebral. 36 niños (24 por ciento) tenían fractura de cráneo: 16 (44,4 por ciento) sufrieron complicaciones. Entre los pacientes sin fractura (n:114) en sólo 10 (8,7 por ciento) ocurrieron complicaciones. Todos los niños que ingresaron con calificación de Glasgow inferior a 7 (n:7) presentaron complicaiones detectadas por tomografía axial, requirieron de respiradores y, en 6, vigilancia instrumental de la presión intracraneana (PIC). En 111 pacientes la calificación de Glasgow al ingreso era normal (Glasgow 15), sin embargo, 12 de ellos (10,8 por ciento) sufrieron complicaciones posteriormente, las que fueron detectadas por tomografía axial de cráneo de rutina. Dos pacientes quedaron con secuelas definitivas, uno con alteraciones motoras y visuales y otro con higroma subdural crónico, que requirió válvula ventrículoperitoneal. Ningún paciente falleció

Acute subdural hemorrhage complicating embolization of a cerebral arteriovenous malformation.

We present a case of a young adult in whom acute subdural hemorrhage developed immediately after embolization of a cerebral arteriovenous malformation with glue. Inadvertent venous outlet obstruction with glue was implicated in the production of the hemorrhage. Possible mechanisms of spread of blood to the subdural space are discussed. Awareness of the possibility of iatrogenic subdural hemorrhage is necessary before undertaking embolization procedures.

A case of subdural hematoma and temporal bone fracture as complications of chiropractic manipulation.

We present a case of subdural hematoma and temporal bone fracture as a complication of chiropractic manipulation. Subdural hematoma in the elderly may follow insignificant, often forgotten, trauma and may develop slowly and progress. Our patient presented with a complaint of headache three days after forceful chiropractic manipulation, but denied any history of trauma. Computed tomography confirmed the presence of a subdural hematoma and a temporal bone fracture and the patient underwent successful surgical treatment. Our experience identifies a previously unreported mechanism of injury in patients with subdural hematoma presenting to the emergency department with a complaint of headache.

Incidence and causes of intracranial hemorrhage in infancy: a prospective surveillance study after vitamin K prophylaxis.

In order to evaluate the effect of vitamin K prophylaxis on the incidence of intracranial hemorrhage (ICH) in infants aged from 1 week to 12 months, a prospective surveillance study, from 1974 to 1988, was performed on the well-defined population of Nagasaki Prefecture, Japan. The incidence of ICH in infancy markedly decreased, from 34.3/100,000 to 10.1/100,000 live births, with the oral administration of vitamin K2 at both birth and 1 week, or with additional supplementation at 1 month of age. The diminished incidence was attributed to the decreased occurrence of acute ICH due to late hemorrhagic disease (LHD), a late onset form of vitamin K deficiency, and chronic subdural hematoma. On comparing the possible etiological factors, and clinical and laboratory findings between these 2 groups, it became apparent that chronic subdural hematoma shared some etiological factors (such as breast-feeding, liver dysfunction and no supplementation of vitamin K) with LHD. Furthermore, chronic subdural hematoma developed in some patients who had previously had acute ICH due to LHD. These findings suggest that coagulopathy due to vitamin K deficiency, including LHD, is causally related in the majority of, if not all, cases of chronic subdural hematoma without any history of trauma or central nervous system infections.