Staphylococcal thoracic aortitis complicated by aortic dissection

BACKGROUND:

The diagnosis of aortitis is often delayed as symptoms are largely non-specific. We report a case of Staphylococcal thoracic aortitis in a 73-year-old Chinese woman complicated by aortic dissection.

METHODS:

The patient presented with pyrexia of unknown origin, and a contrast enhanced computed tomography aortogram revealed a large thrombus at the anterior aspect of the ascending aorta with two large ulcerations as a result of a chronic type A aortic dissection. A hemiarch replacement with a 28 mm Gleweave Vascutek graft was performed with resuspension of aortic valve commisures. Aortic thrombus cultures were positive for coagulase negative Staphylococcus aureaus, and histology showed chronic dissection of the aorta.

RESULTS:

The patient was treated with intravenous cefazolin for a 6-week duration and made good progress.

CONCLUSIONS:

This case highlights Staphylococcal infective aortitis complicated by dissection presenting as fever of unknown origin. Timely diagnosis is essential as progression to catastrophic rupture may occur.KEY WORDS: Aneurysm, Aortic diseases, Endovascular stent, Infected/microbiology, Staphalococcus aureus     

Successful emergency endovascular treatment of juxtarenal and infrarental mycotic aortic aneurysms in patients with small diameter aortae using Cook? Zenith ESLE Stentgrafts

BACKGROUND:

Endovascular repair of mycotic aneurysm is an alternative to open repair if the patho-anatomy is suitable. The aortic size above and below the mycotic aneurysm may be small.

METHODS:

A retrospective review was made of prospectively collected departmental computerised database.

RESULTS:

Three oriental patients with juxta- and infra-renal mycotic aortic aneurysms with a small aortic diameter of 17 mm to 18 mm underwent successful emergency endovascular treatment using Cook^® Zenith ESLE stentgrafts. These are ancillary devices aimed at iliac extensions usually.

CONCLUSION:

This is to our knowledge the first case series of Cook^® Zenith ESLE iliac component endografts for the treatment of aortic mycotic aneurysms with small aortae, and short- and mid-term results are encouraging.KEY WORDS: Endovascular, Mycotic, Small aorta, Oversizing, Cook^®, Zenith ESLE Stentgrafts     

Dilation of the ascending aorta in Turner syndrome - a prospective cardiovascular magnetic resonance study

Background

The risk of aortic dissection is 100-fold increased in Turner syndrome (TS). Unfortunately, risk stratification is inadequate due to a lack of insight into the natural course of the syndrome-associated aortopathy. Therefore, this study aimed to prospectively assess aortic dimensions in TS.

Methods

Eighty adult TS patients were examined twice with a mean follow-up of 2.4 ± 0.4 years, and 67 healthy age and gender-matched controls were examined once. Aortic dimensions were measured at nine predefined positions using 3D, non-contrast and free-breathing cardiovascular magnetic resonance. Transthoracic echocardiography and 24-hour ambulatory blood pressure were also performed.

Results

At baseline, aortic diameters (body surface area indexed) were larger at all positions in TS. Aortic dilation was more prevalent at all positions excluding the distal transverse aortic arch. Aortic diameter increased in the aortic sinus, at the sinotubular junction and in the mid-ascending aorta with growth rates of 0.1 - 0.4 mm/year. Aortic diameters at all other positions were unchanged. The bicuspid aortic valve conferred higher aortic sinus growth rates (p < 0.05). No other predictors of aortic growth were identified.

Conclusion

A general aortopathy is present in TS with enlargement of the ascending aorta, which is accelerated in the presence of a bicuspid aortic valve.     

Aortic dissection presenting with acute pulmonary edema

Background

Acute aortic dissection is a cardiovascular emergency with high mortality that necessitates prompt diagnosis and immediate treatment. Though asymmetric extremity pulses/blood pressures and mediastinal widening on chest roentgenogram are often clues to diagnosis, aortic regurgitation (AR) of variable degrees could be the only sign on initial assessment. Mostly resulting from dilated aortic ring with valvular insufficiency, the AR could be caused by different pathogenic mechanisms. Herein we report a case of Stanford type A aortic dissection presenting with acute pulmonary edema. Physical examination detected severe AR murmur and bedside echocardiogram confirmed prolapsed dissecting intima flap with interference of aortic valve closure as a specific mechanism.

Acute temporal lobe infarction in a young patient associated with marijuana abuse: An unusual cause of stroke

BACKGROUND:

Cardiovascular or cerebrovascular events associated with drug abuse have been frequently reported, particularly in young patients. The drugs include generally cocaine, heroin, and amphetamines. Although marijuana is among the widely used narcotics in the world, stroke associated with the marijuana use is infrequently reported.

METHODS:

Stroke caused by the use of marijuana was investigated in a 23-year-old man and the importance of inquiry of drug abuse in case of stroke was emphasized.

RESULTS:

The patient was treated for 7 days in a follow-up, but he was not recovered. The patient was discharged in his existing condition and was directed for physiotherapy and rehabilitation.

CONCLUSION:

Ischemic stroke is associated with drug abuse and/or substance use, mainly cannabinoids and amphetamines, particularly in young patients.KEYWORDS: Marijuana abuse, Stroke, Emergency medicine     

Normal values of aortic dimensions,distensibility, and pulse wave velocity in children and young adults: a cross-sectional study

Background

Aortic enlargement and impaired bioelasticity are of interest in several cardiac and non-cardiac diseases as they can lead to cardiovascular complications. Cardiovascular magnetic resonance (CMR) is increasingly accepted as a noninvasive tool in cardiovascular evaluation. Assessment of aortic anatomy and bioelasticity, namely aortic distensibility and pulse wave velocity (PWV), by CMR is accurate and reproducible and could help to identify anatomical and bioelastic abnormalities of the aorta. However, normal CMR values for healthy children and young adults are lacking.

Methods

Seventy-one heart-healthy subjects (age 16.4 ± 7.6 years, range 2.3 - 28.3 years) were examined using a 3.0 Tesla CMR scanner. Aortic cross-sectional areas and aortic distensibility were measured at four positions of the ascending and descending thoracic aorta. PWV was assessed from aortic blood flow velocity measurements in a aortic segment between the ascending aorta and the proximal descending aorta. The Lambda-Mu-Sigma (LMS) method was used to obtain percentile curves for aortic cross-sectional areas, aortic distensibility and PWV according to age.

Results

Aortic areas, PWV and aortic distensibility (aortic cross-sectional areas: r = 0.8 to 0.9, p < 0.001; PWV: r = 0.25 to 0.32, p = 0.047 to 0.009; aortic distensibility r = -0.43 to -0.62, p < 0.001) correlated with height, weight, body surface area, and age. There were no significant sex differences.

Conclusions

This study provides percentile curves for cross-sectional areas, distensibility and pulse wave velocity of the thoracic aorta in children and young adolescents between their 3^rd and 29^th year of life. These data may serve as a reference for the detection of pathological changes of the aorta in cardiovascular disease.     

MR angiography can guide ED management of suspected acute aortic dissection

Background

Aortic dissection is typically evaluated with computed tomography angiography (CTA). However, the feasibility of using magnetic resonance angiography (MRA) in the ED is unclear. This study examined the indications and outcomes of MRA in suspected aortic dissection evaluation in the ED.

Hemodynamic predictors of aortic dilatation in bicuspid aortic valve by velocity-encoded cardiovascular magnetic resonance

Background

Congenital Bicuspid Aortic Valve (BAV) is a significant risk factor for serious complications including valve dysfunction, aortic dilatation, dissection, and sudden death. Clinical tools for identification and monitoring of BAV patients at high risk for development of aortic dilatation, an early complication, are not available.

Methods

This paper reports an investigation in 18 pediatric BAV patients and 10 normal controls of links between abnormal blood flow patterns in the ascending aorta and aortic dilatation using velocity-encoded cardiovascular magnetic resonance. Blood flow patterns were quantitatively expressed in the angle between systolic left ventricular outflow and the aortic root channel axis, and also correlated with known biochemical markers of vessel wall disease.

Results

The data confirm larger ascending aortas in BAV patients than in controls, and show more angled LV outflow in BAV (17.54 ± 0.87 degrees) than controls (10.01 ± 1.29) (p = 0.01). Significant correlation of systolic LV outflow jet angles with dilatation was found at different levels of the aorta in BAV patients STJ: r = 0.386 (N = 18, p = 0.048), AAO: r = 0.536 (N = 18, p = 0.022), and stronger correlation was found with patients and controls combined into one population: SOV: r = 0.405 (N = 28, p = 0.033), STJ: r = 0.562 (N = 28, p = 0.002), and AAO r = 0.645 (N = 28, p < 0.001). Dilatation and the flow jet angle were also found to correlate with plasma levels of matrix metallo-proteinase 2.

Conclusions

The results of this study provide new insights into the pathophysiological processes underlying aortic dilatation in BAV patients. These results show a possible path towards the development of clinical risk stratification protocols in order to reduce morbidity and mortality for this common congenital heart defect.     

Free tubercular perforation of the ileum

BACKGROUND:

Peritonitis secondary to small bowel perforation is a common surgical emergency seen across the globe.

METHODS:

A young male patient presented with ileal perforation that was repaired primarily. He recovered uneventfully after the operation.

RESULTS:

Histopathology of the margins of the perforation revealed tuberculosis. A search for evidence of a primary focus of tuberculosis was unsuccessful. The patient was started on anti- tubercular therapy and he was followed up with good results.

CONCLUSION:

This present case underscores the importance of biopsy specimens taken from the margins of patients with ileal perforation to avoid the misdiagnosis of such condition.KEY WORDS: Peritonitis, Perforation, Ileum, Tuberculosis     

Acute Type A Aortic Dissection in a 37-Week Pregnant Patient: An Unusual Clinical Presentation

Background

Aortic dissection in pregnancy is relatively rare, but it is often fatal. The estimated incidence of aortic dissection in the general population is 2.9 per 100,000 person-years. Early recognition and treatment of aortic dissections are crucial for survival. Whereas the majority of patients who present with aortic dissection are older than 50 years of age and have a history of hypertension, younger patients with connective tissue disease, bicuspid aortic valves, or a family history of aortic dissection are also at increased risk for developing this condition.

Cardiac arrest: a case-based review

BACKGROUND:

Coffee is commonly consumed among young people in China. However, consumers are rarely aware of physically adverse effects as a result of excessive consumption of caffeine.

DATA SOURCES:

A literature search using multiple databases was performed for articles published with concentration on meta-analyses, systematic reviews, and randomized controlled trials.

RESULTS:

Excess coffee consumption is also a risk of primary cardiac arrest especially in young people. Treatment modalities include activated charcoals, beta-blockers, vasopressin and hemodialysis when necessary.

CONCLUSION:

Coffee consumers should be advised not to routinely take more than moderate coffee.KEY WORDS: Cardiac arrest, Coffee, Young people     

Impaired aortic distensibility and elevated central blood pressure in Turner Syndrome: a cardiovascular magnetic resonance study

Background

Women with Turner Syndrome have an increased risk for aortic dissection. Arterial stiffening is a risk factor for aortic dilatation and dissection. Here we investigate if arterial stiffening can be observed in Turner Syndrome patients and is an initial step in the development of aortic dilatation and subsequent dissection.

Methods

Fifty-seven women with Turner Syndrome (48 years [29–66]) and thirty-six age- and sex-matched controls (49 years [26–68]) were included. Distensibility, blood pressure, carotid-femoral pulse wave velocity (PWV), the augmentation index (Aix) and central blood pressure were determined using cardiovascular magnetic resonance, a 24-h blood pressure measurement and applanation tonometry. Aortic distensibility was determined at three locations: ascending aorta, transverse aortic arch, and descending aorta.

Results

Mean aortic distensibility in the descending aorta was significantly lower in Turner Syndrome compared to healthy controls (P =?0.02), however, this was due to a much lower distensibility among Turner Syndrome with coarctation, while Turner Syndrome without coarctation had similar distensibility as controls. Both the mean heart rate adjusted Aix (31.4% vs. 24.4%; P?=?0.02) and central diastolic blood pressure (78.8 mmHg vs. 73.7 mmHg; P?=?0.02) were higher in Turner Syndrome compared to controls, and these indices correlated significantly with ambulatory night-time diastolic blood pressure. The presence of aortic coarctation (r = ??0.44, P =?0.005) and a higher central systolic blood pressure (r = ??0.34, P =?0.03), age and presence of diabetes were inversely correlated with aortic distensibility in TS.

Conclusion

Aortic wall function in the descending aorta is impaired in Turner Syndrome with lower distensibility among those with coarctation of the aorta, and among all Turner Syndrome higher Aix, and elevated central diastolic blood pressure when compared to sex- and age-matched controls.

Trial registration

The study was registered at ClinicalTrials.gov (#NCT01678274) on September 3, 2012.

     

Increasing the feasibility of minimally invasive procedures in type A aortic dissections: a framework for segmentation and quantification

Purpose

Our goal is to provide precise measurements of the aortic dimensions in case of dissection pathologies. Quantification of surface lengths and aortic radii/diameters together with the visualization of the dissection membrane represents crucial prerequisites for enabling minimally invasive treatment of type A dissections, which always also imply the ascending aorta.

Methods

We seek a measure invariant to luminance and contrast for aortic outer wall segmentation. Therefore, we propose a 2D graph-based approach using phase congruency combined with additional features. Phase congruency is extended to 3D by designing a novel conic directional filter and adding a lowpass component to the 3D Log-Gabor filterbank for extracting the fine dissection membrane, which separates the true lumen from the false one within the aorta.

Results

The result of the outer wall segmentation is compared with manually annotated axial slices belonging to 11 CTA datasets. Quantitative assessment of our novel 2D/3D membrane extraction algorithms has been obtained for 10 datasets and reveals subvoxel accuracy in all cases. Aortic inner and outer surface lengths, determined within 2 cadaveric CT datasets, are validated against manual measurements performed by a vascular surgeon on excised aortas of the body donors.

Conclusions

This contribution proposes a complete pipeline for segmentation and quantification of aortic dissections. Validation against ground truth of the 3D contour lengths quantification represents a significant step toward custom-designed stent-grafts.

     

Emergency Bedside Ultrasound Diagnosis of Superior Mesenteric Artery Dissection Complicating Acute Aortic Dissection

Background

A timely diagnosis of aortic dissection is associated with lower mortality. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, there is limited literature regarding the use of bedside ultrasound to identify superior mesenteric artery dissection, a known high-risk feature of aortic dissection.

Objective

Our aim was to present a case of superior mesenteric artery dissection identified by bedside ultrasound and review the utility of bedside ultrasound in the diagnosis of aortic emergencies.

Case Report

We report a case of superior mesenteric artery dissection found on emergent bedside ultrasound in a 46-year-old male complaining of abdominal pain with a history of cocaine abuse and prior aortic dissection. Bedside ultrasound in the emergency department revealed an intimal flap in the descending aorta with extension into the superior mesenteric artery prompting early surgical consultation before computed tomography because of concern for acute mesenteric ischemia.

Conclusion

Superior mesenteric artery dissection is a high-risk feature of aortic dissection and can be identified with emergent bedside ultrasound.     

Acute Aortic Regurgitation with Myocardial Infarction: An Important Clue for Aortic Dissection

Background

Aortic dissection is an important cause of acute chest pain that should be rapidly diagnosed, as mortality increases with each hour this condition is left untreated. The diagnosis can be challenging, especially if concomitant myocardial infarction is present. Echocardiography is an important tool for the differential diagnosis.

Objectives

To stress the importance of recognizing aortic regurgitation for the differentiation of myocardial infarction and aortic dissection.

Case Report

An 80-year-old woman was admitted to our hospital with chest pain that was diagnosed as inferior and lateral wall myocardial infarction based on electrocardiographic findings. The diagnosis was reevaluated when aortic regurgitation was detected on echocardiography. Closer inspection of the ascending aorta revealed a dissection flap as the cause of aortic regurgitation.

Conclusion

Detection of aortic regurgitation in a patient with myocardial infarction and normal valves should prompt the search for a possible aortic dissection, whether or not the dissection flap can be visualized.     

Emergency Cesarean Section Due to Acute Aortic Dissection Type A (Debakey I) without Marfan Syndrome: A Case Report and Review of the Literature

Background

Acute aortic dissection during pregnancy is an uncommon but important emergency due to its lethal risk to both mother and child. The dissection usually involves the ascending aorta or the aortic arch. Although additional affection of the descending aorta up to bifurcation is possible, further increasing the risk of organ malperfusion, full-length aortic dissection (DeBakey I) is known to be very rare. Dissection during pregnancy has been reported predominantly in combination with Marfan syndrome. Acute aortic dissection Stanford type A (AADA) DeBakey I during pregnancy without signs of Marfan syndrome as a warning signal is very uncommon in the current literature.

Objectives

The etiology, diagnosis, differential diagnosis, and management of this rare disease are discussed in relation to the current literature.

Case Report

We report the case of an athletic 34-year-old woman in the third trimester of pregnancy, without history of previous diseases, who presented to our Emergency Department after collapsing. In the resuscitation department, an emergency cesarean section was performed due to the start of circulation failure in the mother. Computed tomography scan revealed a severe aortic dissection starting from 1 cm distal the aortic valve over the full length up to the iliac arteries, involving the brachiocephalic and carotid arteries up to the level of the larynx. Emergency replacement of the ascending aorta and the aortic arch was performed. Both the mother and baby survived and were doing well 1 year postoperatively.

Conclusion

This alarming result of AADA (DeBakey I) in late pregnancy without obvious warnings such as Marfan syndrome illustrates the importance of performing early imaging in similar cases.     

Early diagnosis of bowel obstruction and strangulation by computed tomography in emergency department

BACKGROUND:

Closed loop bowel obstruction is a specific type of mechanical obstruction with a high risk of strangulation and bowel infarction, especially in the small bowel. It is associated with a high mortality rate. Hence, it is important for emergency physicians to identify the presence of strangulation, while making the diagnosis of closed loop small bowel obstruction.

METHODS:

We reported three patients with strangulated closed loop small bowel obstruction associated with severe abdominal pain, who had been treated at the emergency department. Urgent computerized tomography was performed in the patients.

RESULTS:

Two patients were discharged with stable conditions, and one patient died after hemodialysis.

CONCLUSION:

Urgent computerized tomography of the abdomen serves as an important diagnostic tool in view of its ability to detect the site, level and cause of obstruction along with the distinctive CT appearance of closed loop small bowel obstruction and signs of ischemia. Early definitive diagnosis will guide subsequent management and improve outcomes.KEY WORDS: Closed loop small bowel obstruction, Computed tomography, Ischemia, Strangulation     

Thromboelastometry Based Early Goal-Directed Coagulation Management Reduces Blood Transfusion Requirements,Adverse Events,and Costs in Acute Type A Aortic Dissection: A Pilot Study

Background

In aortic surgery bleeding complications can be fatal. Therefore, rotational thromboelastometry(ROTEM™)-based coagulation management was introduced.

Methods

After 5 cases of acute type A aortic dissection and aortic arch replacement had been treated based on ROTEM findings (ROTEM group; RG), 5 cases without ROTEM were matched as control group (CG). CG treatment was based on conventional tests and clinical findings. Blood component and coagulation factor requirements, ventilation time, duration of stay at intensive care unit (ICU), hospitalization, and thrombotic or bleeding incidents as well as transfusion-associated costs were compared.

Results

Administration of blood products and coagulation factor concentrates, ventilation time, ICU length of stay, and hospitalization tended to be lower in RG. Postoperative plasma transfusion (p = 0.038), recognized incidents (p = 0.048), and resulting costs on coagulation treatment (p = 0.049) were significantly reduced.

Conclusion

Our data suggest that ROTEM-based coagulation management can reduce transfusion requirements and corresponding costs in patients with aortic arch replacement. These data has to be confirmed by prospective randomized trials.     

Feasibility of asymmetric stretch assessment in the ascending aortic wall with DENSE cardiovascular magnetic resonance

Background

Vessel diameter is the principal imaging parameter assessed clinically for aortic disease, but adverse events can occur at normal diameters. Aortic stiffness has been studied as an additional imaging-based risk factor, and has been shown to be an independent predictor of cardiovascular morbidity and all-cause mortality. Reports suggest that some aortic pathology is asymmetric around the vessel circumference, a feature which would not be identified with current imaging approaches. We propose that this asymmetry may be revealed using Displacement Encoding with Stimulated Echoes (DENSE). The objective of this study is to investigate the feasibility of assessing asymmetric stretch in healthy and diseased ascending aortas using DENSE.

Methods

Aortic wall displacement was assessed with DENSE cardiovascular magnetic resonance (CMR) in 5 volunteers and 15 consecutive patients. Analysis was performed in a cross-sectional plane through the ascending aorta at the pulmonary artery. Displacement data was used to determine the wall stretch between the expanded and resting states of the aorta, in four quadrants around the aortic circumference.

Results

Analysis of variance (ANOVA) did not only show significant differences in stretch between groups of volunteers (p < 0.001), but also significant differences in stretch along the circumference of the aorta (p < 0.001), indicating an asymmetric stretch pattern. Furthermore, there is a significant difference in the asymmetry between volunteers and different groups of patients (p < 0.01).

Conclusions

Evaluation of asymmetric stretch is feasible in the ascending aorta with DENSE CMR. Clear differences in stretch are seen between patients and volunteers, with asymmetric patterns demonstrated around the aortic circumference.     

A man with a fracture from minor trauma

BACKGROUND:

We commonly encounter fractures secondary to trauma on and off in our daily practice. While it is not uncommon to see fractures due to underlying pathology, we need to be on the alert when patients present atypically because the treatment for pathological fractures is far different from that for simple fractures.

METHODS:

We presented a case of left clavicle fracture secondary to minor trauma, in which the initial X-ray shows suspicious lesion around the fracture site and further investigation reveals multiple myeloma. The patient received treatment at the clinical oncology department upon diagnosis. Since he was relatively young and fit, he was started on the induction therapy of VTD, which was followed by high dose melphalan and autologous stem cell transplant.

RESULTS:

He is currently free from symptoms and on maintenance thalidomide.

CONCLUSIONS:

Though multiple myeloma is not commonly encountered in emergency practice, earlier identification of relatively subtle symptoms can allow early treatment. Missing this diagnosis will delay treatment and produce severe outcome to the patient. We should be on the alert for such important condition.KEY WORDS: Spontaneous fracture, Multiple myeloma, Neoplasm metastasis