Pregnancy-Induced Hypertension, But Not Gestational Diabetes Mellitus, Is a Risk Factor for Venous Thromboembolism in Pregnancy

BACKGROUND AND OBJECTIVES: The aim of this study was to identify the association of pregnancy-induced hypertension (PIH) or gestational diabetes mellitus (GDM) with the development of venous thromboembolism (VTE). SUBJECTS AND METHODS: This was a retrospective study of 57,009 pregnancies during 2002-2008 at Cheil General Hospital, Kwandong University. The diagnosis of VTE {deep vein thrombosis or pulmonary embolism (PE)} was based on clot visualization via ultrasound or computed tomography. RESULTS: In total, 27 cases (PE, 20 cases) were detected. The incidence of VTE was 0.47 per 1,000 pregnancies. To determine risk factors associated with pregnancy-induced VTE, univariate analysis using a chi-square test was performed. Cesarean (C)-section, multiple pregnancy, PIH, placenta previa, and assisted reproduction technique (ART) were statistically significant compared to the controls (all, p=0.000). However, age, premature rupture of membrane, and GDM were not statistically related to VTE. Logistic regression analysis was used to calculate the odds ratios for the risk factors. Placenta previa showed a 12.6-fold higher risk, while PIH had a 9.8-fold higher risk for the occurrence of VTE. C-section and ART procedures increased the risk of VTE by 4.2 times compared to that of the controls. CONCLUSION: Placenta previa and PIH were significant risk factors for VTE, whereas the known traditional risk factors of increased age and GDM were not found to be associated with VTE.

Spinal Epidural Hematoma after Pain Control Procedure

Spinal epidural hematoma is a rare complication associated with pain control procedures such as facet block, acupuncture, epidural injection, etc. Although it is an uncommon cause of acute myelopathy, and it may require surgical evacuation. We report four patients with epidural hematoma developed after pain control procedures. Two procedures were facet joint blocks and the others were epidural blocks. Pain was the predominant initial symptom in these patients while two patients presented with post-procedural neurological deficits. Surgical evacuation of the hematoma was performed in two patients while in remaining two patients, surgery was initially recommended but not performed since symptoms were progressively improved. Three patients showed near complete recovery except for one patient who recovered with residual deficits. Although, spinal epidural hematoma is a rare condition, it can lead to serious complications like spinal cord compression. Therefore, it is important to be cautious while performing spinal pain control procedure to avoid such complications. Surgical treatment is an effective option to resolve the spinal epidural hematoma.

Role of B-type natriuretic peptide in the recurrence of atrial fibrillation after electrical cardioversion / 대한내과학회지

BACKGROUND/AIMS: No studies have conclusively determined whether the B-type natriuretic peptide (BNP) level measured before electrical cardioversion for atrial fibrillation (AF) is associated with the maintenance of sinus rhythm after the procedure. Therefore, we investigated whether the plasma BNP can predict AF recurrence in the short-term. METHODS: We prospectively recruited 20 consecutive patients with persistent AF, without symptomatic congestive heart failure. The plasma BNP was measured before and after electrical cardioversion. RESULTS: In all patients, AF was converted to normal sinus rhythm (NSR) after the procedure. NSR was maintained in 70.0% of the patients at 1 week and in 52.6% of the patients at 4 weeks. Of the patients with NSR at 1 week, five patients had relapsed by 4 weeks (4-week relapse group, 4WRG). The log BNP levels after cardioversion decreased significantly in all patients, except for the failed group at 1 week and the 4WRG. Multivariate analysis revealed that the maintenance of sinus rhythm was associated with body mass index at 1 week, and left atrial diameter (LAD) and left ventricular mass index (LVMI) at 4 weeks. 4WRG had a significantly higher baseline BNP. The baseline BNP was associated with the LVMI (R2=0.241, p=0.028) and tissue Doppler imaging (TDI) E' (R2=0.432, p=0.002). CONCLUSION: A higher plasma BNP at baseline in AF patients may help to predict the failure to maintain sinus rhythm 4 weeks after electrical cardioversion, but not the early recurrence at 1 week.

A comparative analysis of the outcome of surgical clipping and endovascular treatment in the ruptured posterior circulation aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: Posterior circulation aneurysms are difficult lesions to treat surgically because they have a potential for high morbidity and mortality. We have used both surgical clipping and endovascular coiling techniques to treat posterior circulation aneurysms and report the comparative results of these two treatment modalities. METHOD: Of 999 patients with intracranial aneurysms admitted between January 1996 and May 2005, 77 (7.7%) had aneurysms of the posterior circulation. Forty-three cases of posterior circulation aneurysms (43/77 [55.8%]) who were treated with clipping or coiling were included in this study. These aneurysms were located in the following sites: 20 cases (46.5%) in the basilar bifurcation artery (BBA), 9 cases (20.9%) in the superior cerebellar artery (SCA), 7 cases (16.7%) in the vertebral artery (VA), 4 cases (9.5%) in the distal posterior inferior cerebellar artery (PICA), and 4 cases (9.5%) in the posterior cerebral artery (PCA). Fourteen (31%) aneurysms were treated with surgical clipping and 29 (69%) aneurysms were treated with endovascular coiling. The treatment outcomes from outpatient follow-up 12 months after treatment were analyzed according to Glasgow outcome scale (GOS). RESULT: Overall, 10 patients who were treated with surgical clipping and 22 (74.4%) patients who were treated with endovascular therapy had good outcomes (GOS, 4~5). The mortality of surgical treatment and endovascular coiling was approximately 7.1% (1/14) and 6.9% (2/29), respectively. The postoperative complications included two transient cranial nerve deficits in the patients who underwent surgical treatment, whereas the patients who underwent endovascular treatment had more serious complications (two intra-operative aneurysm ruptures and three embolic infarctions). CONCLUSION: Patients treated with endovascular coiling had more severe intra-procedure rebleeding than patients treated with surgical clipping; however, there was no statistical significant difference in overall outcome between the two treatment groups. Both surgical and endovascular approaches to posterior circulation aneurysms can achieve good outcomes, and appropriate choice depends on the judgment of the surgeon and neurointerventionist based on angiographic findings. More cautious judgment according to patient factors and angiographic findings can improve the final results.

Thromboembolism during pregnancy or postpartum / 대한내과학회지

BACKGROUND/AIMS: Venous thromboembolism (VTE) during pregnancy or postpartum is a major cause of maternal complications and death; however, the risk is uncertain. In this study, we sought to estimate the incidence of VTE during pregnancy and to identify risk factors for pregnancy-related VTE. METHODS: We retrospectively evaluated the incidence, risk factors, treatment, and prognosis for VTE based on 40,989 deliveries at Cheil General Hospital, Kwandong University College of Medicine, over a five-year period from February 2003 to January 2008. The risk factors were analyzed by chi-square-analysis and forward stepwise logistic regression, and are presented as crude and adjusted odds ratios (ORs) with a 95% confidence interval (CI). RESULTS: The incidence of VTE was 0.042% (17 patients, mean age 32.4+/-2.5 years), with deep venous thrombosis (DVT) in 0.01% of the patients (4 patients, mean age 31.5+/-2.9 years), and pulmonary embolism (PE) in 0.032% of the patients (13 patients, mean age 32.6+/-2.5 years). The postnatal incidence of VTE was higher than the antenatal incidence (2 vs. 15). The main manifestations at the time of diagnosis, in order of frequency, were: dyspnea in 8 patients (62%), chest pain in 4 patients (31%), cough in 2 patients (15%), and syncope in 1 patient (8%). The risk factors for VTE were Cesarean section (OR=7.4; 95% CI: 2.1-25.7, p=0.002) and preeclampsia (OR=12.0; 95% CI: 4.2-34.2, p<0.000). All cases showed clinical improvement spontaneously, or with anticoagulation and surgical thrombectomy, and caused no fetal or maternal mortality. CONCLUSIONS: The incidence of VTE during pregnancy was 0.042%; the independent risk factors were Cesarean section and preeclampsia.

Pituitary Apoplexy Presenting as Isolated Oculomotor Nerve Palsy

The most common cause of isolated oculomotor nerve palsy is ischemia of the peripheral nerve caused by a disease, such as diabetes mellitus. Another common cause of isolated oculomotor nerve palsy is compression by an intracranial aneurysm, usually an posterior communicating artery aneurysm. However, it is extremely rare in the pituitary tumor. We report an unusual case of pituitary adenoma presenting with isolated oculomotor nerve palsy in the setting of pituitary apoplexy. We suggest that pituitary apoplexy should be included in the differential diagnosis of a patient with isolated oculomotor nerve palsy and early surgery should be considered for preservation of oculomotor nerve function.