Masanao Tabuse

Histamine H2-Blocker and Proton Pump Inhibitor Use and the Risk of Pneumonia in Acute Stroke: A Retrospective Analysis on Susceptible Patients

Background Although histamine H2-blockers (H2B) and proton pump inhibitors (PPI) are used commonly to prevent gastrointestinal bleeding in acute stroke, they are implicated in the increased risk of pneumonia in other disease populations. In acute stroke, the presence of distinctive risk factors of pneumonia, including dysphagia and impaired consciousness, makes inclusive analysis vulnerable to confounding. Our aim was to assess whether acid-suppressive drugs increase pneumonia in acute stroke in a population controlled for confounding. Methods We analyzed acute stroke patients admitted to a tertiary care hospital. To minimize confounding, we only included subjects who could not feed orally during 14 days of hospitalization. Exposure was defined as H2B or PPI, given in days; the outcome was development of pneumonia within this period. The incidence was calculated from the total number of pneumonias divided by the sum of person-days at risk. We additionally performed multivariate Poisson regression and propensity score analyses, although the restriction largely eliminated the need for multivariate adjustment. Results A total of 132 pneumonias occurred in 3582 person-days. The incidence was 3.69%/person-day (95% confidence interval (CI); 3.03–4.37%/day). All subjects had dysphagia. Stroke severity and consciousness disturbances were well-balanced between the groups exposed to H2B, PPI, or none. The relative risk (RR) compared with the unexposed was 1.22 in H2B (95%CI; 0.83–1.81) and 2.07 in PPI (95% CI; 1.13–3.62). The RR of PPI compared with H2B was 1.69 (95%CI; 0.95–2.89). In multivariate regression analysis, the RRs of H2B and PPI were 1.24 (95% CI; 0.85–1.81) and 2.00 (95% CI; 1.12–3.57), respectively; in propensity score analyses they were 1.17 (95% CI; 0.89–1.54) and 2.13 (95% CI; 1.60–2.84). Conclusions The results of this study suggested that prophylactic acid-suppressive therapy with PPI may have to be avoided in acute stroke patients susceptible to pneumonia.

Late-Onset Massive Epistaxis due to a Ruptured Traumatic Internal Carotid Artery Aneurysm: A Case Report

A traumatic internal carotid artery (ICA) aneurysm is rare and difficult to treat. Trapping of ICA is commonly performed owing to the difficulty of directly approaching ICA aneurysms. Recently, coiling the aneurysm itself was recommended if possible. However, it is controversial which of methods are best to completely treat aneurysm. We present the case of a 74-year-old man, who had experienced a head injury 8 years previously, with recurrent severe epistaxis. An ICA aneurysm was detected on computed tomography. The trapping and bypass was planned. However, sudden epistaxis occurred, we performed trapping to stop the bleeding and save his life. After the operation, no right ICA or aneurysm was detected. However, severe epistaxis recurred two months after the operation. In the second operation, a ligation of the common -/- external carotid artery and a severance of an ICA portion between the ophthalmic artery and the aneurysm were insufficient to stop the bleeding. This case indicates ICA trapping, even if a trapping portion is below an ophthalmic artery, is insufficient to treat an ICA aneurysm. ICA aneurysms should be suspected when a patient present with recurrent -/- massive epistaxis, who has a head injury history, even if it is far past.

Spontaneous Intraventricular Pneumocephalus.

Backgroud: Pneumocephalus without a known underlying cause is defined as spontaneous pneumocephalus. Few patients of intraventricular pneumocephalus have been reported. Patient Presentation: An 84-year-old man presented with dysarthria and incontinence. Computed tomography revealed an intraventricular pneumocephalus, thinning in the petrous bone, fluid in the air cells, and cleft in temporal lobe. A right subtemporal extradural approach was taken to detect bone-/-dural defects, and a reconstruction was performed using a musculo-pericranial flap. Conclusion: This is the first patient of an isolated intraventricular spontaneous pneumocephalus without any other site air involved. Surgical approaches to repair such bone and dura defects should be considered an appropriate option.

Delayed Acute Subdural Hematoma Associated With Percutaneous Coronary Intervention.

Background:Delayed acute subdural hematoma (DASH) is a subdural hematoma which is detected later. An initial computed tomography (CT) does not reveal any intracranial hemorrhage at all. Few patients of DASH after mild traumatic brain injury associated with percutaneous coronary intervention (PCI) have been published. Patient Presentation:A 63-year-old woman presented with cardiac pulmonary arrest due to acute myocardial infarction and lethal arrhythmia. She had hit her head on the road. The initial CT did not reveal any hemorrhage in the intra-cranium. She fully recovered after PCI. However, 1 hour after PCI, she lost consciousness and immediate CT showed acute subdural hematoma and subarachnoid hemorrhage. The period from losing consciousness to brain herniation presenting as anisocoria was very short—only 30 minutes in our patient. Although emergent evacuation of hematoma and external decompression were performed, the patient died 1 day after the operation. Conclusion:The authors encountered a patient of DASH after PCI that resulted in death. Clinicians should be aware that subdural hemorrhage can occur after PCI if no hemorrhage is noted in the initial head CT, and the operation should be performed as soon as possible when the consciousness level decreases.