Hossein Kalantari

Correlation of optic nerve sheath diameter measurements by computed tomography and magnetic resonance imaging

BACKGROUND Traditionally, intracranial pressure is measured by direct ventriculostomy, which is invasive. Noninvasive measures such as bedside ultrasound and magnetic resonance imaging have been advocated and utilized recently to assess the intracranial pressure. The role of this study is to determine the degree of agreement between measurements of the optic nerve sheath diameter by computed tomography (CT) and magnetic resonance imaging (MRI). MATERIALS AND METHODS Retrospective chart review of 100 consecutive patients who had both MRI and CT scan of the head from January 1, 2011, until March 31, 2013, at our center was performed. A discrepancy of 0.2 mm between the 2 measurements was set as acceptable difference. The measurements of optic nerve sheath diameter (ONSD) were compared for agreement between the 2 modalities using the method by Bland and Altman. RESULTS A total of 100 patients with both MRI and CT scan of the head were selected. Of these 100 patients, 24 were male and 76 were female. The average age was 63 years. No ONSD abnormality was detected in any of the patients. The discrepancy in measurements of the ONSD between CT and MRI in transverse plane was less than the predetermined cut-off value of 0.2 mm. Within-subject variance was estimated at 0.0058 for both CT and MRI. CONCLUSION Comparable results without significant discrepancy as predetermined by the study groups were obtained from CT scan. Measurement of ONSD by CT scan can be used to indirectly asses the intracranial pressure in addition to clinical assessment and other signs of increased intracranial pressure on CT scan.

Diplopia from Subacute Bilateral Subdural Hematoma after Spinal Anesthesia

Subdural hematoma (SDH) is a rare, but life-threatening complication of spinal anesthesia. Subdural hematoma resulting from this procedure could present with vague symptoms such as chronic headache and could easily be missed. Chronic headache is one of the symptoms of chronic SDH in postpartum women. Diplopia as the presenting complaint in SDH secondary to peripartum spinal anesthesia has not, to our knowledge, been previously reported. Here, we report a case of diplopia secondary to postpartum subacute bilateral SDHs with transtentorial herniation after spinal anesthesia in a healthy primagravid 25-year-old woman. SDH can expand gradually and the initial symptoms might be subtle as in our case, despite critically high intracranial pressure.

The role of bedside ultrasound in pretherapeutic and posttherapeutic lumbar puncture in patient with idiopathic intracranial hypertension

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is often a debilitating condition characterized by headaches, blurry vision, nausea, and vomiting. Lumbar puncture (LP) is an essential component of the diagnostic and therapeutic approach; however, the procedure itself can cause postlumbar puncture headache. In addition to the clinical presentation, the use of bedside ultrasound to measure the optic nerve sheath diameter may aid in differentiating the 2 conditions.We hereby report a case of a 33-year old woman with known IIH who presented with recurrent headache after the initial therapeutic LP.

Persistent Hiccups as a Rare Presenting Symptom of Pulmonary Embolism

Pulmonary embolism (PE) is a life-threatening condition that may present as dyspnea, chest pain, cough or hemoptysis, but often occurs without symptoms. It is not typically associated with hiccups. Hiccups are generally self-limiting benign contractions of the diaphragm that may be associated with medications or food but may also be symptomatic of serious disease when persistent. We report 3 cases of PE presenting as persistent hiccups.

Lead aVL on electrocardiogram: emerging as important lead in early diagnosis of myocardial infarction?

Although a diagnosis of acute myocardial infarction (AMI) that mandates emergency reperfusion therapy requires ST-segment elevation greater than 1 mm in at least 2 contiguous leads, some of the early electrocardiogram (ECG) changes of AMI can be subtle. Any ST-segment depression or T-wave inversion in lead aVL may be implicated in left anterior descending artery lesion or early reciprocal changes of inferior wall myocardial infarction, particularly when the clinical context suggests ischemia. Early recognition of reciprocal changes and serial ECG help initiate early appropriate intervention. Heightened awareness of ST segment and T-wave changes in lead aVL is of paramount importance to quickly identifying life-threatening condition.

Isolated T Wave Inversion in Lead aVL: An ECG Survey and a Case Report

Background. Computerized electrocardiogram (ECG) analysis has been of tremendous help for noncardiologists, but can we rely on it? The importance of ST depression and T wave inversions in lead aVL has not been emphasized and not well recognized across all specialties. Objective. This studys goal was to analyze if there is a discrepancy of interpretation by physicians from different specialties and a computer-generated ECG reading in regard to a TWI in lead aVL. Methods. In this multidisciplinary prospective study, a single ECG with isolated TWI in lead aVL that was interpreted by the computer as normal was given to all participants to interpret in writing. The readings by all physicians were compared by level of education and by specialty to one another and to the computer interpretation. Results. A total of 191 physicians participated in the study. Of the 191 physicians 48 (25.1%) identified and 143 (74.9%) did not identify the isolated TWI in lead aVL. Conclusion. Our study demonstrated that 74.9% did not recognize the abnormality. New and subtle ECG findings should be emphasized in their training so as not to miss significant findings that could cause morbidity and mortality.

CorrespondenceAnterior chamber depth measurement using ultrasound to assess elevated intraocular pressure

The rise in recreational drug abuse and corresponding increases in the production of newer and more potent synthetic drugs are alarming [1]. Our institution has experienced periodic increases in emergency department (ED) visits from synthetic drug use at music festivals [2,3]. However more recently, daily visits have increased significantly due to synthetic cannabinoid (SC) abuse. The Substance Abuse and Mental Health Services Administration reported 11 406 SC ED visits in 2010 increasing to 28 531 in 2012 [4]. Presenting symptoms include agitation, altered mental status, seizures, vomiting, delusions, and hallucinations. Manypatients require sedation and continuous cardiac andpulse oximetry monitoring, leading to increased length of stay in the ED and ED crowding. A study by Pines [5] recently reported that ED crowding contributed to a 5% higher chance of death, 1% longer hospital stay, and 1% higher costs per admission. In 2012, the White House reported that the use of SC contributed to 11.3% of the illicit drug use by 12th graders [6]. Their relatively low cost and ease of availability made them increasingly popular [2]. Sold as K2, Spice or Fake weed, they compromise a variety of herbal mixtures that are intentionally adulterated with SC compounds in order to produce marijuana-like effects [7,8]. Clearly labeledas “not forhumanconsumption” and marketed as incense, the packaging specifically indicates that they do not contain tetrahydrocannabinol (THC)-like compounds such as JWH018, HU-210, or CP-47. The first severe toxic effects of SCs were reported in 2010 in Iowa when an 18 year old male committed suicide after smoking K2, leading to efforts to categorized SC as class I controlled substances in 2012 [9]. Despite these legislative efforts, the distribution of SCs is difficult to control as continuous minimal alterations of the chemical structure enable them to be legally marketed as aromatic products and incense [3]. Castaneto et al [10] reported symptoms such as suicidal ideations and thought disorder that required inpatient psychiatric admission from SC use in young healthy men. Their pronounced central inhibition of γ-amino butyric acid as compared with tetrahydrocannabinol (THC) is thought to lower seizure threshold [2]. Currently, there is no specific antidote to reverse the toxic effects of SCs. The concomitant use of other substances such as phencyclidine, cocaine, and alcohol further complicates the clinical picture. These substances can produce anxiety, tremors, hypertension, tachycardia, and tachydysrhythmia [11]. Chest pain is a common complaint, and a case of myocardial infarction and death has been reported [12]. Synthetic cannabinoids increase psychomotor activity and dystonia, leading to an increased risk of rhabdomyolysis and renal failure [13]. It remains vitally important for ED physicians to recognize symptoms of SC intoxication in order to prevent life-threatening events. Surveillance of SC use is of utmost public health importance in order to assess prevalence of abuse and adverse outcomes. Information about the type of SC used and the corresponding symptoms, as well as the demographics of SC users, may help assess risks of adverse outcomes associated with specific products and initiate community outreach and education to prevent their increased use.

The Role of Acetyl Cysteine in Cocaethylene (Non-Acetaminophen) Acute Liver Failure

Background Acute liver failure can result from acetaminophen overdose, viral infection, toxins, and other disease conditions. Liver transplant is available in limited fashion and the criteria are strict as to who should get an available liver. N- Acetyl Cysteine (NAC) has been used in non-acetaminophen induced liver failure with success. Here we report a case of acute liver failure from cocaethylene that was reversed with NAC along with other medical therapy. Case Presentation A 50-year-old female patient presented to the Emergency Department (ED) with a two-day history of coffee ground vomiting and hematemesis. She reported occasional substance abuse and heavy alcoholism. She reported shortness of breath and chest pain from the recurrent forceful vomiting. The rest of the review of systems was unremarkable except a fall from intoxication. Physical examination revealed anicteric conjunctiva and nontender abdomen and her vital signs were within normal limits. Initial blood work revealed acute liver and renal failure. The patient was started with general medical management and liver transplant service rejected the case due to active substance abuse. She underwent brief hemodialysis and was started on NAC. Over the course of her hospital stay her liver function and kidney function improved significantly and patient was discharged to home. Conclusion In cases where liver transplant is not an option for various reasons including active substance abuse, a trial of N-Acetyl Cysteine may be beneficial and should be considered in the Emergency Department.

Acute stent thrombosis: Should preventative measures start in the emergency department?

ABSTRACT Stent thrombosis is a potentially life threatening condition caused by several factors or a combination factors, such as resistance to platelet agents and type of anticoagulation used as well as stent types. We report a case of acute thrombosis and discuss potential areas of intervention with literature review.

Real time optic nerve sheath diameter measurement during lumbar puncture

&NA; Measurement of optic nerve sheath diameter (ONSD) using point of care ultrasound has been used to indirectly assess the intracranial pressure (ICP) particularly in conditions where it is raised. Direct pressure measurements using probes reaching the ventricle system correlated with ONSD using ultrasound. Attempts were made to measure the ONSD pre and post lumbar puncture (LP) after draining cerebrospinal fluid (CSF) as well as post ventricular shunt placement. We report ONSD measurement and demonstrate dynamic changes during LP in a patient with known idiopathic intracranial hypertension (IIH).