Cuerpo extraño en mediastino: resolución multidisciplinaria de un caso crítico / Foreign body in mediastinum: multidisciplinary resolution of a critical case

La ingesta de cuerpos extraños es una situación frecuente y cotidiana. La mayoría de las veces cursa con resolución espontánea, pero cuando el cuerpo extraño resulta ser un elemento punzante, suele producir perforación esofágica con el consiguiente riesgo de mediastinitis y/o sangrado. Se presenta un caso crítico derivado de diferentes centros asistenciales donde se logra mediante un manejo y tratamiento multidisciplinario, un resultado favorable

The intake of foreign bodies is a frequent and daily situation. Most of the time he has spontaneous resolution, but when the foreign body turns out to be a sharp element, it usually causes esophageal drilling with the consequent risk of mediastinitis and/or bleeding. A critical case derived from different care centers is presented where multidisciplinary management and treatment, achieves a favorable result

A propósito del neumomediastino espontáneo / About spontaneous pneumomediastinum

La definición de la mayoría de los neumomediastinos espontáneos publicados en la actualidad no son coherentes con lo expresado, y en la clasificación, todo lo que no sea traumático es “espontáneo”. Esto crea confusión sobre la terminología y provoca dificultades conceptuales por el caos que genera, por lo tanto, son inapropiados y carecen de especificidad.Expresamos nuestra opinión partiendo de la concordancia entre la definición y lo manifestado en los casos publicados, y proponemos una clasificación que sea precisa y útil para la enseñanza.(AU)

The definition of most of the spontaneous pneumomediastinum published today is not consistent with what has been expressed, and in the classification, everything that is not traumatic is “spontaneous”. This creates confusion about terminology and causes conceptual difficulties due to the chaos it generates, therefore, they are inappropriate and lack specificity.We express our opinion based on the concordance between the definition and what has been stated in the published cases and we propose a classification that is precise and useful for teaching.(AU)

The Frequency of Mediastinal Injury in Acute Posterior Sternoclavicular Dislocations: A Multicenter Study.

BACKGROUND: Acute posterior sternoclavicular dislocations (APSCD) are rare injuries that historically have prompted concern for injury to the great vessels and other mediastinal structures from initial trauma or subsequent treatment, resulting in the recommendation that a thoracic or vascular surgeon be present or available during operative treatment. The objectives of the study were to characterize the demographic, clinical, and radiographic characteristics of a large series of APSCDs in skeletally immature patients and to describe the rate and nature of any vascular or mediastinal complications that occurred during treatment. METHODS: Following Institutional Review Board approval, records of consecutive patients under 25 years of age treated for APSCD were collected from each of 6 participating centers. Only acute injuries (sustained fewer than 10 days before presentation) were included. Patient demographics, injury mechanism, associated mediastinal injuries, and need for thoracic/vascular surgery were recorded. Mediastinal structures injured or compressed by mass effect were specifically characterized by review of preoperative computed tomography imaging. RESULTS: Review identified 125 patients with a mean age of 14.7 years; 88% were male. APSCD most commonly resulted from a sporting injury (74%) followed by falls from standing height (10%) and high-energy motor vehicle trauma (10%). The most common finding on cross-sectional imaging was compression without laceration of the ipsilateral brachiocephalic vein (50%). Eleven patients had successful closed reduction, and 114 (90%) had open reduction and internal fixation, with 25 failed or unstable closed reductions preceding open treatment. There were no vascular or mediastinal injuries during reduction or fixation that required intervention. CONCLUSIONS: In this multicenter series of 125 APSCDs no injuries to the great vessels/mediastinal structures requiring intervention were identified. Although more than half of patients had evidence of extrinsic vascular compression at the time of injury, careful open reduction of acute injuries can be safely performed. Although vascular injuries following APSCD seem to be quite rare, vascular complications can be catastrophic. Treating providers should consider these data and their own institutional resources to maximize patient safety during the treatment of APSCD. LEVEL OF EVIDENCE: Level III-therapeutic case control study.

The Importance of the Mediastinal Triangle in Traumatic Lesions of the Aorta.

Background: Trauma-induced aortic injuries continue to be an important factor in morbimortality in patients with blunt trauma. Objectives: To determine the characteristics of aortic lesions in patients with closed thoracic trauma and associated thoracic injuries. Methods: Multicenter cohort study conducted during the years 1994 to 2014 in the radiology service in the University Hospital Complex of A Coruña. Patients >15 years with closed thoracic trauma were included. Sociodemographic and clinical variables were studied in order to determine the lesion cause, location, and degree. Results: We analyzed 232 patients with a mean age of 46.9 ± 18.7 years, consisting of 81.4% males. The most frequent location was at the level of the isthmus (55.2%). The most frequent causes of injury were traffic accidents followed by falls. Patients with aortic injury had more esophageal, airway, and cardiopericardial lesions. More than 85% of the patients had lung parenchyma and/or chest wall injury, which was more prevalent among those who did not have an aortic lesion. Conclusions: Patients with trauma due to traffic accidents or being run over presented three times more risk of aortic injury than from other causes. Those with an aortic lesion also had a higher frequency of cardiopericardial, airway, and esophageal lesions.

Tip Migration Post-Contrast Pressure Injection Through Pressure-Injectable Peripherally Inserted Central Catheters Causing Vascular Injury: A Report of 3 Cases.

Pressure-injectable peripherally inserted central catheters are now widely used for contrast pressure injections for CT scans. While they are generally regarded as safe, they are not free from complication. In this case review, we present three cases of PICC tips migrating post-CT contrast pressure injection including into the pleural cavity and subsequent complications, to raise awareness of this complication not previously encountered in our institution. Level of Evidence Level 4, Case Series.

Neurofibromatosis sin neurofibromas con tumor mediastinal como forma de debut / Neurofibromatosis without neurofibromas. Case report with a mediastinal tumor as the first sign of the disease

Se presenta paciente con historia familiar de neurofibromatosis (NF) tipo I, con síntomas y signos sugestivos de esta enfermedad que refiere dolor torácico paravertebral izquierdo al cual mediante estudios de imagen se le diagnostica lesión tumoral en mediastino posterior. Es de notar la presencia de manchas cutáneas características de la neurofibromatosis, localizadas solo en un dermatoma del cuerpo sin neurofibromas en ninguna otra localización. Se intervino quirúrgicamente el enfermo, se resecó una gran masa mediastinal que se confirmó histológicamente ser un neurofibroma. La evolución posquirúrgica fue satisfactoria. Se discuten las singularidades de este enfermo sobre la base de criterios diagnósticos de neurofibromatosis tipo I, pero sin neurofibromas periféricos hasta ese momento. La posibilidad de una neurofibromatosis segmentaria tampoco se descarta. Se hace énfasis en la necesidad de resección de cualquier lesión tumoral en el contexto de este síndrome genético por la frecuencia de lesiones malignas asociadas a la neurofibromatosis y a la progresión hacia la malignidad de lesiones primariamente benignas(AU)

A patient with a family history of Neurofibromatosis type I was presented. The patient referred symptoms and signs suggestive of that disease and complaint of left paravertebral chest pain. Imaging investigations were done and a posterior mediastinal tumor was diagnosed. It is important to highlight the presence of characteristics spot of neurofibromatosis localized only in one dermatome without neurofibromas in any other part of the body. The patient underwent a surgical intervention and a left thoracotomy was done, a large posterior mediastinal tumor was found and totally resected. The histology confirmed a neurofibroma. The postoperative evolution was satisfactory. The singularities of this patient were discussed, especially diagnosis criteria for neurofibromatosis type I, and the lack of peripheral neurofibromas until that moment. The possibility for a segmental neurofibromatosis also was considered. We pointed out about the necessity to remove any neoplastic lesion in the background of this genetic syndrome due to the high frequency of malignancies associated with neurofibromatosis, and also related with the malignant degeneration these tumors can develop(AU)

Neurofibromatosis sin neurofibromas con tumor mediastinal como forma de debut / Neurofibromatosis without neurofibromas. Case report with a mediastinal tumor as the first sign of the disease

Se presenta paciente con historia familiar de neurofibromatosis (NF) tipo I, con síntomas y signos sugestivos de esta enfermedad que refiere dolor torácico paravertebral izquierdo al cual mediante estudios de imagen se le diagnostica lesión tumoral en mediastino posterior. Es de notar la presencia de manchas cutáneas características de la neurofibromatosis, localizadas solo en un dermatoma del cuerpo sin neurofibromas en ninguna otra localización. Se intervino quirúrgicamente el enfermo, se resecó una gran masa mediastinal que se confirmó histológicamente ser un neurofibroma. La evolución posquirúrgica fue satisfactoria. Se discuten las singularidades de este enfermo sobre la base de criterios diagnósticos de neurofibromatosis tipo I, pero sin neurofibromas periféricos hasta ese momento. La posibilidad de una neurofibromatosis segmentaria tampoco se descarta. Se hace énfasis en la necesidad de resección de cualquier lesión tumoral en el contexto de este síndrome genético por la frecuencia de lesiones malignas asociadas a la neurofibromatosis y a la progresión hacia la malignidad de lesiones primariamente benignas(AU)

A patient with a family history of Neurofibromatosis type I was presented. The patient referred symptoms and signs suggestive of that disease and complaint of left paravertebral chest pain. Imaging investigations were done and a posterior mediastinal tumor was diagnosed. It is important to highlight the presence of characteristics spot of neurofibromatosis localized only in one dermatome without neurofibromas in any other part of the body. The patient underwent a surgical intervention and a left thoracotomy was done, a large posterior mediastinal tumor was found and totally resected. The histology confirmed a neurofibroma. The postoperative evolution was satisfactory. The singularities of this patient were discussed, especially diagnosis criteria for neurofibromatosis type I, and the lack of peripheral neurofibromas until that moment. The possibility for a segmental neurofibromatosis also was considered. We pointed out about the necessity to remove any neoplastic lesion in the background of this genetic syndrome due to the high frequency of malignancies associated with neurofibromatosis, and also related with the malignant degeneration these tumors can develop(AU)

Mediastinal injury is the strongest predictor of mortality in mounted blast amongst UK deployed forces.

BACKGROUND: Blast injury has been the most common cause of morbidity and mortality encountered by UK forces during recent conflicts. Injuries sustained by blast are categorised by the injuring component of the explosion and depend upon physical surroundings. Previous work has established that head injuries and intra cavity haemorrhage are the major causes of death following exposure to under body (mounted) blast but has yet to explore the precise nature of these torso injuries nor the effect of particular injuries upon survival. This study examines the patterns of torso injury within the mounted blast environment in order to understand the effect of these injuries upon survivability. METHODS: This retrospective study examined the UK Joint Theatre Trauma Registry to determine precise injury patterns of mounted blast casualties within a 13year period of UK military deployments. Survival rates of individual injuries were compared and a multivariable logistic regression model was developed in order to assess the effect that each injury had upon likelihood of death. RESULTS: 426 mounted casualties were reviewed of whom 129 did not survive. Median NISS and ISS for non-survivors was found to be 75. Torso injuries were significantly more common amongst non-survivors than survivors and high case fatality rates were associated with all haemorrhagic torso injuries. Multivariable analysis shows that mediastinal injuries have the largest odds ratio for mortality (20.4) followed by lung laceration and head injury. CONCLUSIONS: Non-compressible torso haemorrhage is associated with mortality amongst mounted blast. Of this group, mediastinal injury is the strongest predictor of death and could be considered as a surrogate marker of lethality. Future work to link blast loading characteristics with specific injury patterns will inform the design of mitigating strategies in order to improve survivability of underbody blast.

Intracardiac foreign body resulting from a transmediastinal gunshot mimics an extracardiac foreign body: An image presentation.

A transmediastinal gunshot wound (TMGW) is one of the most severe traumatic injuries, with a high mortality rate. Prompt diagnosis and emergency surgical intervention with or without cardiopulmonary bypass are usually required to save lives. We report a particular case of TMGW in which the computed tomography imaging findings indicated an extracardiac foreign body. However, intraoperative findings revealed an intracardiac foreign body, and urgent cardiopulmonary bypass was performed to remove the foreign body. We suggest that cardiopulmonary bypass should be on standby during an exploratory sternotomy for TMGW, when the trajectory of the bullet hints at a cardiac-penetrating injury according to imaging studies and the location of the bullet remains unaffected by the patient's postural changes.

Clinical Significance of Spontaneous Pneumomediastinum.

BACKGROUND: Spontaneous pneumomediastinum (SPM) is classified as free air in the mediastinum in the absence of any precipitating cause. It is relatively uncommon, and the clinical significance and risk associated with SPM is not well understood and has not been widely documented in the literature. Our goals were to determine the outcomes of patients who presented with SPM and to determine predictors of severe pathology associated with SPM. METHODS: From 2004 through 2013, a retrospective review was conducted of patients who presented with SPM to our institution. Patient demographics, comorbidities, laboratory tests, and esophageal perforation were recorded. RESULTS: In all, 249 patients were discovered to have SPM on chest radiograph or computed tomography scan. Mean age was 38.7 years (range, 17 to 81). Sixty-one percent of patients (151 of 249) were male. Ten percent of all patients (24 of 249) were ultimately discovered to have esophageal perforation, determined by upper endoscopy, upper gastrointestinal series, or intraoperatively during emergent surgery. Age (p < 0.01), pleural effusion (p < 0.01), and elevated white blood cell count (p < 0.01) were the only significant risk factors for esophageal perforation on multivariate analysis. CONCLUSIONS: Spontaneous pneumomediastinum is usually associated with a benign clinical course. Risk factors for esophageal perforation in these patients include age, elevated white blood cell count, and a pleural effusion. In the absence of abnormal laboratory values or associated radiologic findings, the majority of patients with SPM may be safely observed without the need for further diagnostic testing.

Knife in the superior mediastinum: Amazing escape.

This text describe through images, how a knife is retrieved from the superior mediastinum.

Late pacemaker lead tip perforation documented by chest CT.

Late cardiac perforation by a right ventricular (RV) pacemaker lead may be a challenge to diagnose. Echocardiography often will not adequately demonstrate lead tip migration, but chest computed tomography (CT) readily identifies the lead and tip location. A patient presented one month after dual-chamber pacemaker implantation with fever, sepsis and failure of RV pacer lead capture. Echocardiography demonstrated vegetations on the RV lead and a pericardial effusion, but the lead tip location could not be identified. CT identified the tip as having migrated through the pericardium into the anterior mediastinum. These complimentary echo and CT findings helped make a diagnosis and direct patient therapy.

[Minimally invasive treatment for traumatic chylopericardium. Paediatric case report]. / Tratamiento por mínima invasión del quilopericardio traumático. Reporte de un caso pediátrico.

BACKGROUND: Chylopericardium is a rare occurrence in children. The most common causes are associated with cardiac surgery, malformations of the lymphatic system, idiopathic reasons, among others. OBJECTIVE: The case is presented of a patient with traumatic chylopericardium, the diagnostic methodology, and in particular, its successful resolution by surgical means. CLINICAL CASE: Male patient of 6 years old, previous accident of fall from patient's height. Chest x-ray showed evidence of cardiomegaly. An echocardiogram with pericardial effusion was performed. Pericardial puncture was performed with drainage of milky material, confirming chylous liquid. Treatment included pericardial catheterisation, total parenteral nutrition, octreotide, and diet with medium chain triglycerides, with persistent increased pericardial fluid. Lymphatic abnormalities were ruled out by MRI. He underwent surgical treatment due to failure of prior treatment. A thoracoscopic approach was adopted with a favourable outcome. CONCLUSIONS: Chylopericardium occurs in children in most cases after cardiovascular surgery. The case presented here was classified as idiopathic. Patients with this condition may present with severe symptoms, such as tamponade, or can be asymptomatic as in the case presented. If medical treatment fails, it should be resolved by surgery; the best choice is minimally invasive treatment with its well-known advantages.