Bryan J. Duke

Traumatic bilateral jugular vein thrombosis: case report and review of the literature.

OBJECTIVE AND IMPORTANCE Thrombosis of the internal jugular vein (IJV) with associated elevated intracranial pressure (ICP) is a rare complication of central venous catheterization but has not been reported as a result of blunt trauma. CLINICAL PRESENTATION An 18-year-old male patient was observed to be obtunded after an assault. The initial examination was remarkable for somnolence, bruising of the anterior neck, and diffuse, edematous swelling of the face and scalp. The results of computed tomography of the brain were normal. An angiogram obtained on the 2nd hospital day to rule out carotid injury revealed bilateral IJV thromboses to the cranial base. An ICP monitor was placed with an opening pressure of 33 mm Hg. The central venous pressure was measured to be 9 mm Hg. A catheter was passed through the left IJV thrombus and into the sigmoid sinus, where the pressure was 17 mm Hg. INTERVENTION An intravascular stent was deployed in the left IJV. ICP rapidly normalized. A regimen of coumadin was administered to the patient for 6 weeks, at which time the stent remained patent. CONCLUSION We conclude that traumatic jugular vein thrombosis can be associated with significant elevation in ICP and that treatment with an endovascular stent can affect the rapid correction of intracranial hypertension in patients who are candidates for anticoagulation.

Outcome after urgent surgery for grade IV subarachnoid hemorrhage

BACKGROUND Outcome after subarachnoid hemorrhage (SAH) in patients presenting with poor clinical grade has historically been dismal. As a result, many poor-grade patients have been excluded from early, aggressive surgery. We present a consecutive series of 27 patients with acute (less than 24 h since clinical onset) Grade IV SAH treated with early surgery. METHODS All patients were treated with immediate ventricular drainage, rigid hemodynamic control, early angiography and surgery within 24 h of presentation. Patients were followed for a minimum of 6 months and their outcomes categorized using a four-tiered scale: 1) independent and working, 2) impaired but independent, 3) severely impaired and dependent, and 4) dead. RESULTS Seven patients died within 48 h of admission. The remaining 20 patients survived to discharge. At the time of discharge eight of these patients were considered to be impaired but independent and twelve were considered severely impaired and dependent. At follow-up, seven patients were independent and working, six were impaired but independent, five were severely impaired and dependent, and two severely impaired patients had subsequently died. CONCLUSIONS We conclude that urgent surgery for poor-grade SAH can produce quality survival for a higher percentage of patients than is historically reported with delayed surgery.

Balamuthia mandrillaris meningoencephalitis presenting with acute hydrocephalus

The leptomyxid amoeba Balamuthia mandrillaris, previously believed to be a harmless soil-inhabiting organism, is now known to be a rare but consistently lethal cause of meningoencephalitis in humans. We report a case of amebic meningoencephalitis caused by B. mandrillaris which presented as a febrile illness with acute hydrocephalus.

Transcranial Migration of Microf ixation Plates and Screws

A case of transcranial, transdural migration of microplates and screws with damage to the subjacent cortex in an infant with craniosynostosis is described. The authors believe that plates and screws should be reserved for exceptional cases in which bony approximations are unstable or difficult to align by other means.

Induced Hypervolemia and Inotropic Support for Acute Cerebral Arterial Insufficiency: An Underused Therapy

BACKGROUND Hypervolemia and induced systemic hypertension are generally considered the standard approach to the treatment of vasospasm. Despite evidence in favor of its efficacy, this therapy is used rarely in acute cerebrovascular occlusion. We present a case supporting this treatment paradigm. CASE DESCRIPTION A patient developed aphasia and hemiplegia 8 h after carotid endarterectomy caused by embolic occlusion of the middle cerebral artery. Hyperdynamic/hypervolemic therapy was instituted. Serial angiograms filmed over the next 8 h demonstrated reperfusion of the hemisphere, through collateral flow. The patients symptoms resolved. CONCLUSIONS We believe this case demonstrates the effectiveness of hypervolemia and inotropic support in the treatment of acute embolic stroke by inducing dilatation of the leptomeningeal collateral circulation.

Posterior circulation cerebral infarcts associated with repair of thoracic aortic disruption using partial left heart bypass.

BACKGROUND Partial left heart bypass is widely used in the repair of traumatic aortic disruptions. We recently encountered two patients with posterior circulation infarctions after repair of traumatic aortic disruptions using heparin-less partial left heart bypass. METHODS/RESULTS Both patients underwent interposition graft repair of thoracic aortic transections at the level of the isthmus. The first patient developed a left posterior inferior cerebellar artery infarct after a clamp time of 44 minutes. Swelling of this infarct necessitated ventriculostomy placement. The second patient developed a pontine infarct postoperatively after a cross-clamp time of 56 minutes and suffered a persistent left upper extremity paresis. CONCLUSIONS Partial left heart bypass may have predisposed these two patients to clamp-related embolic events via the left vertebral artery. This experience warrants further surveillance to detect these infarcts which can require neurosurgical intervention. Additionally, the events suggest reconsideration of systemic anticoagulation during aortic cross-clamp times exceeding 30 minutes.

Blunt Carotid Injury in Children

Blunt carotid injury (BCI) is a rare entity which can have devastating neurologic consequences. Little has been reported on the mechanism of injury, presentation or management of these injuries in children. We present a series of 5 children with BCI. One patient died at presentation while the remainder developed delayed infarctions. Three surviving patients developed intracranial hypertension and required intracranial pressure (ICP) monitoring. Surgical resection of infarcted tissue was required to control ICP in 2 patients. All four surviving patients are impaired but ambulatory. We propose an aggressive management strategy for BCI aimed at early detection of deficit, early angiography, anticoagulation if appropriate, and active management of ischemia including hemodynamic treatment, ICP monitoring, and active use of medical and surgical means to monitor and control intracranial hypertension.

PERCUTANEOUS ENDOLUMINAL STENT PLACEMENT FOR TRAUMATIC OCCLUSION OF THE INTERNAL JUGULAR VEIN

O SCVIR, 1997 THE causes of internal jugular vein thrombosis are myriad. Specific etiologies previously reported include intravenous drug abuse, indwelling venous catheters, adjacent neoplasms, hypercoagulability, soft-tissue infections, and spontaneous or idiopathic thrombosis (1-4). We report a case of traumatic occlusion of the internal jugular veins that was successfully treated with percutaneous endoluminal stent placement.