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Clinical application of continent anal plug in bedridden patients with intractable diarrhea

PURPOSE: Some patients bedridden from various causes such as stroke or spinal cord injury experience poor control of bowel movement. This causes fecal leakage and diarrhea, increases the risk of perianal excoriation and bed sores, and is a burden on caregivers. To evaluate the efficacy of fecal evacuation and the prevention and treatment of skin complications in intractable diarrhea patients using a new device. METHODS: A continent anal plug (US Patent No. 5 569 216) comprises an inner balloon surrounded by an outer balloon, both of which are mounted on a silicone tube containing a pair of air passages and an enema fluid inlet. The tube is secured in place in the rectum by the inflatable outer balloon and is designed to drain fecal matter through a thin collapsible hose situated in the anal canal. Thirty-two patients (21 male; median age 61 (range, 28–76) years) were evaluated after fully informed consent. Median duration was 12 (range, 3–37) days. RESULTS: The continent anal plug evacuated efficiently in those patients with loose or watery stools who only required irrigation once daily or not at all. Skin excoriations improved in three to seven days. Minimal leakage was seen around the anus. There was no anorectal mucosal injury noted over 37 days. CONCLUSIONS: The continent anal plug is an efficient method of treating patients with loss of bowel control and incontinence because it enables controlled fecal evacuation and helps reduce skin complications without causing anorectal mucosal injury.

Subarachnoid Hemorrhage with Negative Baseline Digital Subtraction Angiography: Is Repeat Digital Subtraction Angiography Necessary?

Introduction Patients with negative initial digital subtraction angiography (DSA) are at significant risk for re-bleeding, which can lead to severe disability and death. The purpose of this study was to evaluate the necessity of repeat DSA in subgroups of patients with subarachnoid hemorrhage (SAH) with negative initial DSA. Methods A total of 904 spontaneous SAH patients were admitted to our department between May 2005 and May 2012. Twenty eight patients were selected for inclusion in this study because repeated DSA performed due to the etiology of the SAH could not be demonstrated on the initial DSA. According to the SAH pattern on initial computed tomography scans, patients were divided into perimesencephalic nonaneurysmal SAH (PN-SAH) and non PN-SAH (NPN-SAH) groups. Repeat DSA was performed in all patients, and two of these patients underwent a third DSA. Results Of the 904 patients, 28 patients (3.1%) had no vascular abnormality on initial DSA. Sixteen PN-SAH patients underwent a repeat DSA; however, no aneurysms were found. In contrast, 12 patients with NPN-SAH underwent repeat DSA, with detection of two cerebral aneurysms. Overall, the false-negative rate of the initial DSA was 7.1% (2/28 patients). No significant differences in false-negative results on initial DSA were observed between the PN-SAH and NPN-SAH groups. Conclusion In the line with the results of the current study, we should be highly suspicious of patients with a nonaneurysmal SAH, especially those with a NPN-SAH pattern. In order to reduce the morbidity and mortality resulting from a misdiagnosis, repeat DSA is necessary, and exclusion of an aneurysm is important.

Cardiac troponin I elevation in patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVE Cardiac dysfunction after aneurysmal subarachnoid hemorrhage (SAH) is associated with elevation of serum cardiac troponin I (cTnI) levels. Elevation of cTnI predicts cardiopulmonary and neurological complications, and poor outcome. METHODS We retrospectively reviewed the medical and radiologic records of 114 (male : 30, female : 84) patients who developed aneurysmal SAH between January 2006 and June 2007 and had no history of previous cardiac problems. We evaluated their electrocardiography and cTnI level, which had been measured at admission. A cTnI level above 0.5 microg/L was defined as an indicator of cardiac injury following SAH. We examined various clinical factors for their association with cTnI elevation and analyzed data using chi-square test, t-test and logistic regression test with SPSS version 12.0. The results were considered significant at p < 0.05. RESULTS THE FOLLOWING PARAMETERS SHOWS A CORRELATION WITH CTNI ELEVATION : higher Hunt-Hess (H-H) grade (p = 0.000), poor Glasgow Outcome Scale (GOS) score (p = 0.000), profound pulmonary complication (p = 0.043), higher heart rate during initial three days following SAH (p = 0.029), ruptured aneurysm on communicating segment of internal carotid artery (p = 0.025), incidence of vasospasm (p = 0.421), and duration of hyperdynamic therapy for vasospasm (p = 0.292). A significant determinants for outcome were cTnI elevation (p = 0.046) and H-H grade (p = 0.000) in a multivariate study. CONCLUSION A cTnI is a good indicator for cardiopulmonary and neurologic complications and outcome following SAH. Consideration of variable clinical factors that related with cTnI elevation may be useful tactics for treatment of SAH and concomitant complications.

Chronic subdural hematoma after spontaneous intracranial hypotension : a case treated with epidural blood patch on c1-2.

Spontaneous cerebrospinal fluid (CSF) leak is a recognized cause of spontaneous intracranial hypotension (SIH). Subdural hematoma (SDH) is a serious but rare complication of SIH. An autologous epidural blood patch at the CSF-leak site can effectively relieve SIH. We report a case of bilateral SDH with SIH caused by a CSF leak originating at the C1-2 level. A 55-year-old male complained of orthostatic headache without neurological signs. His symptoms did not respond to conservative treatments including bed rest, hydration and analgesics. Magnetic resonance imaging showed a subdural hematoma in the bilateral fronto-parietal region, and computed tomography (CT) myelography showed a CSF leak originating at the C1-2 level. The patient underwent successful treatment with a CT-guided epidural blood patch at the CSF-leak site after trephination for bilateral SDH.

Fusiform Aneurysm on the Basilar Artery Trunk Treated with Intra-Aneurysmal Embolization with Parent Vessel Occlusion after Complete Preoperative Occlusion Test

Fusiform aneurysms on the basilar artery (BA) trunk are rare. The microsurgical management of these aneurysms is difficult because of their deep location, dense collection of vital cranial nerves, and perforating arteries to the brain stem. Endovascular treatment is relatively easier and safer compared with microsurgical treatment. Selective occlusion of the aneurysmal sac with preservation of the parent artery is the endovascular treatment of choice. But, some cases, particularly giant or fusiform aneurysms, are unsuitable for selective sac occlusion. Therefore, endovascular coiling of the aneurysm with parent vessel occlusion is an alternative treatment option. In this situation, it is important to determine whether a patient can tolerate parent vessel occlusion without developing neurological deficits. We report a rare case of fusiform aneurysms in the BA trunk. An 18-year-old female suffered a headache for 2 weeks. Computed tomography and magnetic resonance image revealed a fusiform aneurysm of the lower basilar artery trunk. Digital subtraction angiography revealed a 7.1×11.0 mm-sized fusiform aneurysm located between vertebrovasilar junction and the anterior inferior cerebellar arteries. We had good clinical result using endovascular coiling of unruptured fusiform aneurysm on the lower BA trunk with parent vessel occlusion after confirming the tolerance of the patient by balloon test occlusion with induced hypotension and accompanied by neurophysiologic monitoring, transcranial Doppler and single photon emission computed tomography. In this study, we discuss the importance of preoperative meticulous studies for avoidance of delayed neurological deficit in the patient with fusiform aneurysm on lower basilar trunk.

E-020 The Effectiveness and Safety of Dexmedetomidine during Coil Embolisation for Intracranial Aneurysm

Introduction/Purpose The general goals of anaesthetic management during endovascular procedure involve haemodynamic control to minimise the risk of aneurysm re-rupture, to protect the brain against ischaemic injury and to keep the patient motionless to optimise the quality of the images used to perform the endovascular procedure: hence, general anaesthesia with endotracheal intubation is often preferred for these procedures at most centres. But general anaesthesia is not available in all hospital and in all situations. At the authors’ institution, coil embolisation of the intracranial aneurysm is performed under monitored anaesthesia using dexmedetomidine. To determine the feasibility and safety of this approach, the author has reviewed our clinical experience. Methods Retrospectively analysis of prospectively collected data at single neurovascular institution was performed during July 2012 to November 2012. We performed more than 50cases using this method. In these cases, we analysed 12cases, their procedure time is more than 1hour for statistical significance. To measure the haemodynamic and respiratory impact of the drug to the patients, vital signs of the patients were checked every 10 minutes throughout the procedures. Systolic blood pressure (sBP), diastolic blood pressure (dBP), mean arterial blood pressure (mABP), heart rate (HR), respiratory rate (RR) and peripheral oxygen saturation (SpO2) were recorded at each time point as follow; preoperative baseline, at anaesthesia start, after every 10 minute until the end of procedures. Depth of sedation was measured by Ramsay sedation scale and frequency of the repeated roadmap caused by the patient head movement during the endovascular procedure. Results All procedures were completed without procedure related complications. Obliteration of the intracranial aneurysm was performed in all cases. With dexmedetomidine induced monitored anaesthesia, vital signs (sBP, dBP, and mABP, HH, RR and SpO2) of the patients were not changed during the procedure. Haemodynamic and respiratory parameters did not showed any statistical significance (P value > 0.05). Adequate sedation for endovascular procedure was achieved. Mean Ramsay sedation scale was 3.67 ± 1.61 (2 to 6). Repeated roadmap due to patient’s factor was occurred in only one case. The drug dose for adequate sedation for endovascular procedure was 0.65 ± 0.12 mcg/kg/hr without loading doses. Conclusion Embolisation of the intracranial aneurysms with dexmedetomidine anaesthesia appeared to be safe and feasible. Differently with other drugs, there was no systemic side effects such as hypotensio, bradycardia and respiratory depressions. In you need endovascular surgery for intracranial aneurysm; general anaesthesia is the first choice to be selected. But local anaesthesia with dexmedetomidine should be considered as alternative, when it is not suitable . Disclosures C. Chang: None. Y. Jung: None. B. Choi: None.

Nonsurgical Management of Parasagittal Epidural Hematoma Report of 4 Cases

Nonsurgical management of four cases of the parasagittal epidural hematoma were experienced. Patients were mildly symptomatic or minimal neurological disturbances on admission. Patients were treated conservatively because of stable neurologic sign. All patients had who diastatic fracture and/or suture have become a complete neurological recovery with satisfactory absorption of EDH over a period of 5 to 12 weeks.

Astrocytoma in the Bilateral Thalamus: A Case Report

Astrocytoma in the thalamus is not so frequent in incidence (1%). Moreover, bilateral thalamic tumor is rare. Certain tumors of the thalamus are considered resectable but most of thalamic tumors are thought to be untouchable. Bilateral thalamic astrocytoma with hydrocephalus was diagnosed by stereotactic biopsy and ventriculo-peritoneal shunt operation was done with result of improvement. We report a case of astrocytoma in the bilateral thalamus with literature review.