A multicenter study of transient global amnesia for the better detection of magnetic resonance imaging abnormalities.

BACKGROUND AND PURPOSE: The detection rate of diffusion-weighted (DWI) hyperintense lesions varies widely in patients with transient global amnesia (TGA). The aim was to examine the association of hyperintense lesions on DWI magnetic resonance imaging (MRI) with patient characteristics, precipitating factors, clinical presentation and MRI settings in patients with TGA. METHODS: In this multicenter retrospective observational study, using the standardized diagnosis entry system of electronic health records of four tertiary medical centers in the Kansai district of Japan, TGA patients (n = 261) who underwent brain MRI within 28 days of onset were examined. When the onset time was unavailable, the discovery time was used. RESULTS: Diffusion-weighted hyperintense lesions were observed in 79 patients (30%). There were no significant differences in age, sex, vascular risk factors, precipitating factors or clinical presentation between patients with and without DWI lesions. The detection rate increased linearly 24 h after onset and then reached a plateau of 60%-80% by 84 h. After 84 h, the detection rate decreased rapidly. In a multivariate logistic regression model, MRI examination 24-84 h after onset (odds ratio 7.00, 95% confidence interval 3.50-13.99) and a thin-slice (≤3 mm) DWI sequence (odds ratio 7.59, 95% confidence interval 3.05-18.88) were independent predictors of DWI lesions. CONCLUSIONS: This study suggests that DWI hyperintense lesions in TGA are not associated with patient characteristics and clinical presentation. Brain MRI examination 24-84 h after onset and thin-slice DWI sequences enhance the detection of DWI lesions in TGA patients.

Cancer is an independent predictor of poor outcomes in patients following intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Patients with cancer have been reported to have poorer outcomes following intracerebral hemorrhage (ICH) than those without cancer, but the findings were not consistent between studies. The aim of this study was to test the hypothesis that cancer is associated with poor outcomes following ICH. METHODS: In all, 3137 consecutive patients admitted to the stroke unit of Osaka University Hospital were reviewed. Patients diagnosed with ICH were extracted and divided into two groups according to the presence of cancer. ICH characteristics were compared between the groups. The outcomes were measured using the 30-day and 90-day modified Rankin Scale (mRS). RESULTS: Amongst the 399 ICH patients (37.1% women; median age 66 years), the frequency of cancer was 15.3%. Of these, 70.5% of patients had distant metastatic cancers. Compared to controls, cancer patients were comparable in the Glasgow Coma Scale, hematoma volume and the frequency of infratentorial location and intraventricular hemorrhage extension, but had poorer outcomes following ICH. Ordinal logistic regression analysis revealed that cancer was independently associated with poor outcomes following ICH (odds ratio 5.14; 95% confidence interval 2.63-10.06). Adjustment was made for the covariates age, sex, time from onset to admission, prior use of antithrombotic agents, pre-stroke mRS, Glasgow Coma Scale, hematoma volume, infratentorial location and intraventricular hemorrhage extension. When the analysis was performed using data from individuals with localized cancer, the effect remained significant after assessment with 90-day mRS but not after that with 30-day mRS. CONCLUSIONS: The results suggest that cancer, especially distant metastatic cancer, is an independent predictor of poorer outcomes following ICH.

Presence of platelet-associated anti-glycoprotein (GP)VI autoantibodies and restoration of GPVI expression in patients with GPVI deficiency.

BACKGROUND: Glycoprotein (GP)VI deficiency is a rare platelet disorder with a mild bleeding tendency. However, its pathophysiology remains unclear. OBJECTIVES: We characterized a novel GPVI-deficient patient with immune thrombocytopenic purpura and searched for the presence of anti-GPVI autoantibodies in this and another patient with GPVI deficiency. METHODS AND RESULTS: A 12-year-old Japanese girl (case 1) with moderate thrombocytopenia and mild bleeding showed selectively impaired collagen-induced platelet aggregation. Flow cytometric analysis indicated that the patient had a defect in the expression of GPVI-FcRgamma. An eluate of her platelet-associated IgG contained anti-alpha(IIb)beta3 autoantibodies. Moreover, using GPVI-FcRgamma-transfected cells, we unexpectedly identified anti-GPVI antibodies against the soluble ectodomain of GPVI in the eluate, despite the patient's GPVI deficiency. In contrast, anti-GPVI antibodies were not detectable in her plasma. In another case of GPVI deficiency (case 2) without detectable plasma anti-GPVI antibodies, we again detected platelet-associated anti-GPVI antibodies. In a 2-year follow-up of case 1, the platelet count increased to within the normal range and the bleeding tendency improved. Interestingly, GPVI was again expressed on her platelets, in association with a decrease in the relative amount of anti-GPVI antibodies. CONCLUSIONS: This is the first demonstration of platelet-associated anti-GPVI antibodies in GPVI-deficient subjects, in one case with spontaneous restoration of GPVI expression. These results strongly suggest an autoimmune mechanism in GPVI deficiency.

Isolated relapse of acute lymphoblastic leukemia in the breast of a young female.

A 20-year-old female developed a relapse of B-precursor acute lymphoblastic leukemia (ALL) as a mass in her left breast after 6 years of maintained continuous complete remission. No leukemic lesions were identified in other sites such as the bone marrow or cerebrospinal fluid. The relapsed leukemic cells in the breast revealed the same immunophenotypes (CD10(+), CD19(+), CD20(+), HLA-DR(+), CD34(+)) as those of the onset ALL cells in the bone marrow. A literature survey found 10 other cases of ALL relapse in the breast without bone marrow involvement, mostly consisting of adolescent girls. Including the present report, a total of 11 cases were analyzed; the onset ages of ALL were a median of 16.5 (range 5-50) years old and the ages of relapse in the breast a median of 20 (range 12-51) years old. Data suggest that, although rare, the breast could become one of the extramedullary relapse sites of ALL developed in adolescent girls.

A metastatic haemangiopericytoma of the floor of the mouth.

A case of metastatic haemangiopericytoma in the floor of the mouth is described. Haemangiopericytoma is a relatively rare slow-growing vascular tumour with variable malignant potential. This tumour has been identified in almost every region of the body, but its occurrence in the oral cavity has been rarely reported. The rate of regional and distant metastasis of the tumour is low. This case, presented 12 years after initial surgery suggested the need for careful long-term follow-ups of patients with haemangiopericytoma.

Three-dimensional helical computed tomographic angiography in neonates and infants with complex congenital heart disease.

BACKGROUND: For the clinical management of patients with complex congenital heart disease (CHD), accurate evaluation of their morphologic conditions is critical. Three-dimensional (3D) helical computed tomography (CT) angiography has been used to assess the vascular system in adult patients; the indication for complex CHD, especially in the neonatal period, has not yet been defined. Therefore the purposes of our study were to determine the quality and limitations of current 3D helical CT angiography for neonates and infants with complex CHD and to assess the clinical utility of this technique. METHODS AND RESULTS: 3D helical CT angiography was performed in 17 patients with various types of complex CHD. Their median age was 41 days (range 3 days to 9 months), and mean body weight was 3.6 kg (range 2.2 to 8.5 kg). All 3D images were produced with the 3D reconstruction algorithm of shaded-surface display. Oral sedation was required in only 4 infants during the procedure. 3D helical CT angiography clearly demonstrated the shape and spatial relation of great arteries, proximal branch pulmonary arteries, anomalous pulmonary venous connections, the patent ductus arteriosus, and a shunt. The 3D information of extracardiac morphologic characteristics and 3D anatomic relation of each extracardiac structure were easily recognized by this imaging process. However, intracardiac structure could not be visualized because of blurred and/or unclear edges of the ventricular wall caused by respiratory movement. CONCLUSIONS: 3D helical CT angiography represents an important additional diagnostic tool and may become an alternative method to angiography or other noninvasive techniques used in the evaluation of extracardiac anomalies in neonates and infants with complex CHD.

Coronary artery bypass grafting without cardiopulmonary bypass for high-risk patients.

Between January 1991 and June 1993, coronary artery bypass grafting was performed without either cardiopulmonary bypass or cardiac arrest in 23 patients. Most patients had several surgical risk factors, including age > or = 70 years, poor left ventricular function, left main coronary artery stenosis, chronic renal failure, and aortic aneurysm. Distal anastomoses were made under temporary interruption of coronary flow. A total of 37 distal anastomoses to the left anterior descending coronary artery and/or right coronary artery (mean 1.6 per patient) were made, 24 of which were internal thoracic arteries. The coronary occlusion time ranged from 7-14 min (mean 9.8 min). Combined cardiac or vascular operations were carried out in six patients (abdominal aortic aneurysm repair, thoracic aortic aneurysm repair, carotid endarterectomy, and coronary endarterectomy). There was one hospital death. Postoperative angiography was performed in 22 patients and showed a patency rate of 89%. In summary, coronary artery bypass grafting without cardiopulmonary bypass may improve the postoperative outcome of high-risk patients.

[Usefulness of open lung biopsy for corrective surgery on incomplete atrioventricular septal defect associated with severe pulmonary hypertension and right to left shunting].

In congenital heart defects, it is sometimes difficult to decide the operative indication in patients, who has severe pulmonary hypertension (PH) and right to left shunting, from clinical symptoms and cardiac catheterization. We here report a case of incomplete atrioventricular septal defect. The patient is 9 months old with the Down's syndrome. The cardiac catheterization showed severe PH and right to left shunting. Preoperative mean pulmonary artery pressure was 75 mmHg, pulmonary systemic pressure to systemic pressure ratio (PP/PS) was 1.17, pulmonary systemic flow to systemic flow ratio (QP/QS) was 0.79, pulmonary systemic resistance to systemic resistance ratio (RP/RS) was 1.54 and pulmonary vascular resistance (PVR) was 9.6 woodunits.m2. These data suggested that the irreversible pulmonary vascular disease was present. However the PVR decreased from 9.6 to 3.6 woodunits.m2 after inspiration of 100% oxygen. We therefore performed open lung biopsy for further evaluation of the pulmonary vascular bed. The pathological findings obtained at lung biopsy indicated that there was no irreversible pulmonary vascular disease. This case was diagnosed suitable for a corrective surgery. Total repair was performed and the subsequent clinical course was satisfactory. We thus suggest that the open lung biopsy is useful to decide the surgical indication when it is difficult to determine an operative indication from hemodynamic measurement alone.

Extended endocardial repair of postinfarction ventricular septal rupture: new operative technique--modification of the Komeda-David operation.

Between January 1992 and November 1992, four consecutive patients (ages 53 to 81 years) underwent early surgical repair of postinfarction ventricular septal ruptures using a new simple operative technique. The principles of the technique are longitudinal incision of the infarcted left anterior ventricular wall, placement of a saccular patch of single equine pericardium that covers the infarcted left ventricular wall, and large buttressed suture closure of the left ventriculotomy. The infarcted septum and infarcted left ventricular wall are completely separated from the left ventricular cavity. In this procedure, the infarcted myocardium is not resected, and left and right ventricular muscles are preserved. This technique is simple and safe for use in the acute phase of myocardial infarction, and it preserves ventricular function after surgery.

Sequential internal mammary artery grafts: clinical and angiographic assessment.

Between January 1988 and August 1992, the internal mammary artery was used as a sequential graft to the left anterior descending artery and/or diagonal branch in 34 patients. One patient died in hospital. After surgery all survivors were free from angina for a follow-up of up to 4 years. Recatheterization was performed in 33 patients within 1 year of surgery. Postoperative angiography showed that 65 anastomoses (98%) were patent, but three patent grafts (5%) between the proximal and distal sequential anastomoses showed 'string sign'. It is important to prevent 'string sign' in sequential grafting. It is considered that sequential internal mammary artery grafting should be limited to coronary arteries with severe stenosis that divides anastomosed coronary arteries into two.

Anomalous origin of the left coronary artery from the pulmonary artery. New operative technique.

We report a new operative technique for repair of anomalous origin of the left coronary artery from the pulmonary artery. The principles of the proposed technique are left main coronary angioplasty using a transected main pulmonary artery, side-to-side anastomosis of the aorta and newly created left coronary artery, and direct anastomosis of the transected pulmonary artery. No prosthetic material is used in this procedure. Our experience in two adults (a 35-year-old man and a 68-year-old woman) indicated that this technique permits two coronary system repair for any anatomic variation of the left coronary artery without the use of prosthetic material. This is more advantageous in infants.

[Clinical experience with continuous warm blood cardioplegia].

We applied the Continuous Warm Blood Cardioplegia (CWBC) as an approach to improve myocardial preservation. From March to June in 1992, we used the CWBC in six patients and the conventional cold crystalloid cardioplegia (CCCP) in seven patients. All of them underwent isolated coronary artery bypass grafting. There was no marked difference between the CWBC and CCCP in post operative serum level of creatine kinase (MB type), cardiac output and dose of dopamine during they weaned from cardiopulmonary bypass. All patients treated with CWBC spontaneously restored the normal sinus rhythm shortly after removal of the aortic crossclamp, which was distinct from the fact that the CCCP group showed no such recovery. This result suggest that CWBC kept high-energy phosphate level without disturbing production of ATP in myocardium. Furthermore, reperfusion injury was also likely to be prevented by CWBC.

[Coronary artery bypass surgery in patients with poor left ventricular function].

As the indications for coronary artery bypass grafting (CABG) among patients with poor left ventricular function remain incompletely defined, We undertook the study to assess the results of CABG surgery for a group of such patients. We retrospectively reviewed the clinical features and outcome for 7 patients with poor left ventricular function defined as an ejection fraction below 0.3 who underwent CABG. The mean age of the patients was 63 years (range, 38 to 78 years), and 4 were 70 years of age or older. All patients had history of previous myocardial infarction, and all had left main trunk stenosis or left main equivalent stenosis. The patients underwent CABG with three to six distal anastomoses (mean, 4.3/patient), the internal thoracic artery could be used in all patients, for one or two distal anastomoses (mean, 1.6/patient). Combined coronary endarterectomy was performed in 2 patients. With the exception of one 78-year-old patient with renal failure who died during the early postoperative period, all patients showed marked postoperative improvement in cardiac function. Cardiac catheterization and exercise stress test studies revealed significant improvement in left ventricular function and exercise tolerance in these six patients. These results suggest that excellent results can be obtained with CABG surgery in patients with poor left ventricular function when the viability of the myocardium in the bypassed area has been confirmed.

[Coronary artery bypass grafting surgery without cardiopulmonary bypass].

Improved technique in coronary artery surgery has allowed coronary artery bypass graftings (CABG) to be placed on beating heart. The effects of extracorporeal circulation and cardiac arrest are eliminated. From Jan. 1991 to June, 1992, we performed CABG surgery without cardiopulmonary bypass and cardiac arrest in 15 patients; the age ranged from 47 to 82 years with the mean of 65. Patients who had LAD and/or RCA stenosis were candidate of this procedure in early series. However in recent series, we extended the candidate to three-vessel or LMT stenosis cases who were considered ineligible for standard CABG because of renal failure or poor left ventricular function. Distal anastomoses were performed with interruption of coronary flow. From one to two distal anastomosis to the LAD and/or RCA (mean 1.4/patient) were performed. The ITA was used in all 15 patients. Combined cardiac or vascular operation was performed in 5 patients (AAA repair, TAA repair, carotid endarterectomy or coronary endarterectomy). There were no deaths and no perioperative myocardial infarction. Postoperative angiography were performed in 12 patients with a patency rate of 89%.

[A case report of simultaneous procedure of Cabrol's operation and aortic arch replacement: method to reduce the duration of ischemic cardiac arrest].

A 57-year-old female underwent simultaneous Cabrol's operation and aortic arch replacement for aortic dissection. She was admitted with complaint of back pain. Aortography demonstrated acute dissecting aneurysm of the ascending, arch and descending aorta (DeBakey type I) as well as aortic valve regurgitation (Seller's II degree). The operation was undertaken using cardiopulmonary bypass (CPB) under hypothermia with selective cerebral perfusion. A new method to reduce the duration of ischemic cardiac arrest was applied. Initially a low-porosity woven Dacron tube graft (8 mm) was anastomosed to coronary arteries. Blood of CPB was perfused to this graft. This coronary perfusion contributed to shorten ischemic cardiac arrest time and cardiac function was favorable. This method to reduce the duration of ischemic cardiac arrest brought about good result.

Modified application of intra-aortic balloon pump after repair of thoracic dissecting aneurysm.

We describe a patient who could not be weaned from cardiopulmonary bypass without mechanical circulatory assistance because of severe cardiac failure after surgical repair of a dissecting aneurysm of the descending aorta. Placement of an intra-aortic balloon in a conduit attached to the proximal aorta enabled the patient to recover from perioperative cardiac failure after all other measures had failed.

[Arterial switch operation for transposition of the great arteries without use of prosthetic material].

For transposition of the great arteries (TGA), arterial switch operation (ASO) is theoretically preferable to atrial switch operation, since the left ventricle is established as the systemic ventricle and sinus node function is maintained. However, ASO is a delicate operation requiring the transfer of the coronary arteries. Use of prosthetic material for reconstruction of the neo-pulmonary artery causes postoperative supra-valvular pulmonary arterial stenosis. Five neonates and young infants with TGA underwent ASO without the use of prosthetic material by the technique reported by Pacifico et al. Three patients with simple TGA ranged in age from 10 to 27 days, and in weight from 2.9 to 3.9 kg. Two patients with TGA and ventricular septal defect ranged in age from 41 to 63 days, and in weight from 2.8 to 4.2 kg. There were no deaths, either early or late, and all patients are well 7 to 21 months after surgery. Catheterization and Doppler echocardiographic studies performed in all patients showed that pressure gradient between the right ventricle and pulmonary artery decreased significantly during mean follow-up period of 14 months. These results suggest excellent growth of the pulmonary artery after surgery.

[Intra-graft balloon pumping--a clinical case report].

A 29-year-old female underwent tube graft replacement of distal aortic arch and descending aorta for dissecting aneurysm. After 42 minutes of aortic cross-clamping the patient was initially weaned satisfactorily from cardiopulmonary bypass (CPB). However, cardiac arrhythmia and cardiac arrest necessitated reestablishment of CPB. Electro-cardiography showed inferior myocardial infarction. To wean CPB intraaortic balloon pumping (IABP) was mandatory. But because of dissecting aortic aneurysm IABP in conventional method was contra-indicated. Intra graft balloon pumping (IGBP) was initiated while the patient was on full CPB. A low-porosity woven Dacron tube graft (22 mm) was anastomosed end-to-side to ascending aorta. A balloon was inserted into the tube graft to establish IGBP. This IGBP provided effective circulatory assist. The patient was weaned from CPB 1 hours after reestablishment of IGBP. Postoperative course was stable. The patient was returned to the operating room for removal of the balloon 3 days postoperatively. We reported the case for whom IGBP was effective. IGBP was effective circulatory support for the patient when conventional use of IABP was contra-indicated.

[Routine use of the internal mammary artery for aorto-coronary bypass surgery].

Internal mammary artery (IMA) grafts have excellent long-term patency rate and result in improved late survival. Conventional use of IMA was only for selected cases. Elder or acute myocardial infarction case had been excluded from IMA use. During past 30 months we extended the indication of the IMA use for all the ACB case. The present study was undertaken to assess the possibility of routine use of the a IMA for aorto-coronary bypass (ACB). From Nov. 1987 through May 1990, we performed consecutive 110 ACB with the protocol "routine use of the IMA for all the ACB surgery". The 78 men and 32 women (29%) had a mean age of 64 years old (range 38 to 80 years old). Thirty-five patients (32%) were 70 years of age or older. Eighty-four patients had stable angina, nineteen patients had unstable angina, seven patients had acute myocardial infarction. IMA was used in 106 patients (96%). An average of 3.6 coronary arteries per patient were bypassed, and 1.6 distal anastomosis per patient were made with IMA. Combined cardiac surgery was performed in 8 cases (ventricular septal rupture repair: 2 cases, coronary endarterectomy: 4 cases, left ventricular aneurysm resection: 1 case, mitral commissurotomy: 1 case). Post operative complication due to IMA use were infrequent and operative mortality was 6.3%. In summary, routine use of the IMA for ACB surgery was possible method as if in high risked cases (elder or poor left ventricular function). We believe this method result in improved late result. We concluded routine use of the IMA for ACB was possible and usefull method.

[A successful surgical case of ruptured thoracoabdominal aneurysm].

A successful surgical case of ruptured thoracoabdominal aortic aneurysm was reported. The patient was a 77-year-old male. He entered our hospital and was diagnosed ruptured Crawford type 3 thoracoabdominal aortic aneurysm by chest X-ray, CT scan and aortography. Operative procedure was tube graft insertion into thoracoabdominal aorta with celiac artery reconstruction. Postoperative course was excellent and discharged on 55th postoperative day.