Progressive hematoma in anterior neck after endovascular treatment of middle cerebral artery aneurysm / Hematoma progressivo na região anterior do pescoço após tratamento endovascular de aneurisma da artéria cerebral média

Abstract Background: Cervical hematomas can lead to airway compromise, a life threatening condition, regardless of the cause. The following case is the first presentation of cervical hematoma as a complication of endovascular treatment of middle cerebral artery aneurysm. Case report: A 49 year-old woman was scheduled for stent placement under general anesthesia for middle cerebral artery aneurysm. Few days before intervention, acetyl salicylic acid and clopidogrel treatment was started. Following standard monitoring and anesthesia induction, the patient's trachea was intubated with a 7.5 mm endotracheal tube and the procedure was completed without any complications. Three hours later, dyspnea developed and physical examination revealed progressive swelling and stiffness in the neck. Endotracheal intubation was performed with a 6 mm diameter uncuffed tube with the aid of sedation. The vocal cords were completely closed due to compression. There was no leak around the endotracheal tube. The rapidly performed computerized tomography scans showed an enormous hematoma around the neck and extravasation of contrast medium through superior thyroid artery. After coil embolization of superior thyroid artery, she was taken to the intensive care unit as intubated and sedated. Surgical exploration of the hematoma was not recommended by the surgeons, because she was on clopidogrel. After two days, the patient's trachea was extubated safely ensuring that the swelling was sufficiently ceased and leak detected around the endotracheal tube. Conclusions: Securing the airway rapidly by endotracheal intubation is the most crucial point in the management of cervical hematomas. Diagnostic and therapeutic procedures should be performed only afterwards.

Resumo Justificativa: Hematomas cervicais podem levar ao comprometimento das vias aéreas, uma condição de risco para a vida, independentemente da causa. O presente caso é a primeira apresentação de hematoma cervical como uma complicação do tratamento endovascular de aneurisma da artéria cerebral média. Relato de caso: Uma mulher de 49 anos foi agendada para a colocação do stent sob anestesia geral para aneurisma da artéria cerebral média. Poucos dias antes da intervenção, um tratamento com ácido acetilsalicílico e clopidogrel foi iniciado. Após a indução da anestesia e o monitoramento padrão, a traqueia da paciente foi intubada com um tubo endotraqueal de 7,5 mm e o procedimento foi concluído sem quaisquer complicações. Três horas mais tarde, a paciente desenvolveu dispneia e o exame físico revelou edema progressivo e rigidez do pescoço. A intubação endotraqueal foi feita com um tubo de calibre 6 mm sem balonete com o auxílio de sedação. As pregas vocais estavam completamente fechadas devido à compressão. Não houve vazamento ao redor do tubo endotraqueal. Tomografias computadorizadas feitas rapidamente mostraram um enorme hematoma no pescoço e extravasamento do meio de contraste através da artéria tireoidiana superior (ATS). Após embolização com molas da ATS, a paciente foi levada para a unidade de terapia intensiva intubada e sedada. A exploração cirúrgica do hematoma não foi recomendada pelos cirurgiões porque a paciente tomava clopidogrel. Depois de dois dias, a traqueia da paciente foi extubada com segurança. Isso garantiu que o edema havia cessado o suficiente e o vazamento detectado ao redor do tubo endotraqueal também. Conclusões: Proteger as vias aéreas rapidamente por meio de intubação endotraqueal é a conduta mais crucial no manejo de hematomas cervicais. Os procedimentos diagnósticos e terapêuticos devem ser feitos somente após essa conduta.

[Progressive hematoma in anterior neck after endovascular treatment of middle cerebral artery aneurysm]. / Hematoma progressivo na região anterior do pescoço após tratamento endovascular de aneurisma da artéria cerebral média.

BACKGROUND: Cervical hematomas can lead to airway compromise, a life threatening condition, regardless of the cause. The following case is the first presentation of cervical hematoma as a complication of endovascular treatment of middle cerebral artery aneurysm. CASE REPORT: A 49 year-old woman was scheduled for stent placement under general anesthesia for middle cerebral artery aneurysm. Few days before intervention, acetyl salicylic acid and clopidogrel treatment was started. Following standard monitoring and anesthesia induction, the patient's trachea was intubated with a 7.5mm endotracheal tube and the procedure was completed without any complications. Three hours later, dyspnea developed and physical examination revealed progressive swelling and stiffness in the neck. Endotracheal intubation was performed with a 6mm diameter uncuffed tube with the aid of sedation. The vocal cords were completely closed due to compression. There was no leak around the endotracheal tube. The rapidly performed computerized tomography scans showed an enormous hematoma around the neck and extravasation of contrast medium through superior thyroid artery. After coil embolization of superior thyroid artery, she was taken to the intensive care unit as intubated and sedated. Surgical exploration of the hematoma was not recommended by the surgeons, because she was on clopidogrel. After two days, the patient's trachea was extubated safely ensuring that the swelling was sufficiently ceased and leak detected around the endotracheal tube. CONCLUSIONS: Securing the airway rapidly by endotracheal intubation is the most crucial point in the management of cervical hematomas. Diagnostic and therapeutic procedures should be performed only afterwards.

Transcatheter aortic valve implantation in patients with a mitral prosthesis; single center experience and review of literature.

OBJECTIVES: Following the encouraging results of several registries and trials, transcatheter aortic valve implantation (TAVI) has been recognized as a valid option in patients with severe aortic stenosis deemed at high or prohibitive risk for surgical treatment. Good procedural success and good clinical outcomes have been showed and very limited data exist on TAVI in the setting of a preexisting mitral prosthesis regarding the technique, potential complications, and outcomes. METHODS: Here, we report six cases of transfemoral TAVI with a self-expanding bioprosthesis (CoreValve; Medtronic, Inc) in patients who had previously undergone mitral valve replacement. Preprocedural, intraprocedural ve postprocedural outcome and data were analyzed and a brief literature review is also presented. RESULTS AND CONCLUSION: Our experiences show that transfemoral CoreValve implantation can be performed successfully in patients with mechanical and bioprosthetic mitral valves.

Subcutaneous defibrillator implantation in pediatric patients.

OBJECTIVE: Although sudden cardiac death is rare in children, an intracardiac defibrillator system is indicated in children with various types of cardiomyopathy, primary electrical diseases, and after surgical repair of congenital heart defects. The use of transvenous defibrillator lead systems is limited in pediatric patients because of a small body size and/or limited vascular access. Subcutaneous array leads combined with an abdominally placed generator can enable implantation. METHOD: This is a retrospective study of 13 patients who underwent subcutaneous defibrillator implantation between September 2010 and March 2015. The subcutaneous system was preferred because patients were not amenable to transvenous lead placement. RESULTS: The median patient age was 4.1 years, and the median patient weight was 12.1 kg. Diagnoses of patients were long-QT syndrome in 6, aborted cardiac arrest with left ventricular non-compaction in 3, hypertrophic cardiomyopathy with sustained ventricular tachycardia in 3, and arrythmogenic right ventricular cardiomyopathy in 1. Revision of the subcutaneous lead was required in 5 patients 2-26 months after the implantation. Appropriate shocks were observed in three patients. Inappropriate shock and lead fractures were observed in one patient during the follow-up period. The failure of therapy was observed in one patient. There were no perioperative complications and no early or late deaths. CONCLUSION: Subcutaneous defibrillator systems are safe and effective in pediatric patients when the transvenous method is risky and contraindicated. Because the high growth rate in this population leads to lead failures, a close follow-up of this population is essential.

Comparison of propofol and midazolam on patients undergoing spinal surgery with intraoperative wake-up test: randomized clinical trial / Comparação de propofol e midazolam em pacientes submetidos à cirurgia de coluna vertebral com teste de despertar no intraoperatório: estudo clínico randomizado

BACKGROUND AND OBJECTIVES: Instrumentation in correction operations for spinal deformities carries a 0.5-5% risk of injuring the spinal cord. The wake-up test is used for early detection of these injuries. In this study we compared the effects of propofol and midazolam during wake-up test in scoliosis surgery. METHODS: Thirty patients were randomly assigned as group P and group M. Anesthesia was induced with propofol 2.5 mg kg-1 for group P or midazolam 0.5 mg kg-1 for group M with remifentanil 0.5 µg kg-1 and cisatracurium 0.15 mg kg-1 for both groups. At the maintenance of anesthesia O2/air and infusions of remifentanil and cisatracurium were used. In group P, propofol 6-10 mg kg-1 h-1 and in group M, midazolam 0.5 mg mg kg-1 were preferred. Approximately 15 min before the wake-up test, all drugs were discontinued. At the wake-up test, anesthesiologist asked the patients to open their eyes and squeeze his/her hand at every 30 s until the patients responded. Then patients were told to wiggle their toes. Hemodynamic parameters, time of eye-opening, appropriate movement upon verbal command were evaluated. BIS frequency throughout the operation was recorded. RESULTS: The eye opening time was 9 ± 2.15 min in group P and 7 ± 3.15 min in group M. Motor movement time was 12 ± 2.55 min in group P and 21.25 ± 3.93 min in group M. CONCLUSION: Propofol provided better wake-up conditions and conducted a better neurologic assessment within the same BIS values than midazolam.

JUSTIFICATIVA E OBJETIVOS: A instrumentação em cirurgias de correção de deformidades da coluna vertebral tem risco de 0,5 a 5% de lesionar a medula espinhal. O teste de despertar é usado para a detecção precoce dessas lesões. Neste estudo comparamos os efeitos de propofol e midazolam durante o teste de despertar em cirurgia de escoliose. MÉTODOS: Trinta pacientes foram designados de forma aleatória para os grupos P e M. A anestesia foi induzida com propofol (2,5 mg kg-1) no grupo P ou midazolam (0,5 mg kg-1) no grupo M, com remifentanil (0,5 µg kg-1) e cisatracúrio (0,15 mg kg-1) em ambos os grupos. A manutenção da anestesia foi feita com O2/ar e infusões de remifentanil e cisatracúrio. Nos grupos P e M, respectivamente, doses de propofol (6-10 mg kg-1 h-1) e de midazolam (0,5 mg mg kg-1) foram preferidas. Aproximadamente 15 min antes do teste de despertar, todos os medicamentos foram interrompidos. No teste de despertar, o anestesiologista pedia ao paciente que abrisse os olhos e apertasse sua mão a cada 30 s até que o paciente respondesse. Depois, o paciente era solicitado a mexer os dedos dos pés. Os parâmetros hemodinâmicos, o tempo de abertura dos olhos e o movimento apropriado sob comando verbal foram avaliados. A frequência do BIS foi registrada durante toda a cirurgia. RESULTADOS: O tempo de abertura dos olhos foi de 9 ± 2,15 min no grupo P e de 7 ± 3,15 min no grupo M. O tempo de movimento motor foi de 12 ± 2,55 min no grupo P e de 21,25 ± 3,93 min no grupo M. CONCLUSÃO: Propofol proporcionou melhores condições de despertar e possibilitou uma melhor avaliação neurológica dentro dos mesmos valores do BIS que midazolam.

Comparison of propofol and midazolam on patients undergoing spinal surgery with intraoperative wake-up test: randomized clinical trial.

BACKGROUND AND OBJECTIVES: Instrumentation in correction operations for spinal deformities carries a 0.5-5% risk of injuring the spinal cord. The wake-up test is used for early detection of these injuries. In this study we compared the effects of propofol and midazolam during wake-up test in scoliosis surgery. METHODS: Thirty patients were randomly assigned as group P and group M. Anesthesia was induced with propofol 2.5 mg kg(-1) for group P or midazolam 0.5 mg kg(-1) for group M with remifentanil 0.5 µg kg(-1) and cisatracurium 0.15 mg kg(-1) for both groups. At the maintenance of anesthesia O2/air and infusions of remifentanil and cisatracurium were used. In group P, propofol 6-10 mg kg(-1)h(-1) and in group M, midazolam 0.5 mg mg kg(-1) were preferred. Approximately 15 min before the wake-up test, all drugs were discontinued. At the wake-up test, anesthesiologist asked the patients to open their eyes and squeeze his/her hand at every 30s until the patients responded. Then patients were told to wiggle their toes. Hemodynamic parameters, time of eye-opening, appropriate movement upon verbal command were evaluated. BIS frequency throughout the operation was recorded. RESULTS: The eye opening time was 9 ± 2.15 min in group P and 7 ± 3.15 min in group M. Motor movement time was 12 ± 2.55 min in group P and 21.25 ± 3.93 min in group M. CONCLUSION: Propofol provided better wake-up conditions and conducted a better neurologic assessment within the same BIS values than midazolam.

[Comparison of propofol and midazolam on patients undergoing spinal surgery with intraoperative wake-up test: randomized clinical trial]. / Comparação de propofol e midazolam em pacientes submetidos à cirurgia de coluna vertebral com teste de despertar no intraoperatório: estudo clínico randomizado.

BACKGROUND AND OBJECTIVES: Instrumentation in correction operations for spinal deformities carries a 0.5-5% risk of injuring the spinal cord. The wake-up test is used for early detection of these injuries. In this study we compared the effects of propofol and midazolam during wake-up test in scoliosis surgery. METHODS: Thirty patients were randomly assigned as group P and group M. Anesthesia was induced with propofol 2.5mgkg(-1) for group P or midazolam 0.5mgkg(-1) for group M with remifentanil 0.5µgkg(-1) and cisatracurium 0.15mgkg(-1) for both groups. At the maintenance of anesthesia O2/air and infusions of remifentanil and cisatracurium were used. In group P, propofol 6-10mgkg(-1)h(-1) and in group M, midazolam 0.5mgmgkg(-1) were preferred. Approximately 15min before the wake-up test, all drugs were discontinued. At the wake-up test, anesthesiologist asked the patients to open their eyes and squeeze his/her hand at every 30s until the patients responded. Then patients were told to wiggle their toes. Hemodynamic parameters, time of eye-opening, appropriate movement upon verbal command were evaluated. BIS frequency throughout the operation was recorded. RESULTS: The eye opening time was 9±2.15min in group P and 7±3.15min in group M. Motor movement time was 12±2.55min in group P and 21.25±3.93min in group M. CONCLUSION: Propofol provided better wake-up conditions and conducted a better neurologic assessment within the same BIS values than midazolam.