Symptomatic mature teratoma of the lumbar spine: A case report

Background: Teratomas are a unique family of tumors derived from two or more of the three embryonic layers: endoderm, mesoderm, and ectoderm. Mature teratomas are comprised the most well-differentiated tissue types and may contain skin, hair, teeth, smooth muscle, respiratory tissues, etc. Infrequently, mature teratomas may be found within the central nervous system and, in exceedingly rare cases, may be occur within the spinal cord itself (i.e., intramedullary/intradural). Case Description: A 78-year-old female presented with a subacute progressive lower extremity paraparesis. The MR revealed a cystic 81 × 30 × 25 mm intradural/intramedullary spinal mass involving the distal conus with exophytic extension into the L1-L4 spinal canal. Following surgical intervention consisting of a L1-L4 laminectomy, the lesion was largely removed. Pathology of the mass confirmed a large mature teratoma containing a multilobulated cyst that intraoperatively compressed the conus and cauda equina. Immediately postoperatively, the patient significantly improved neurologically. However, on postoperative day 2, she acutely developed a change in mental status with the left gaze preference and hemiparesis. CT brain in the acute setting showed no evidence of causative pathology and subsequent MR brain was unremarkable. The patient’s neurologic deficits progressively improved leading to eventual discharge. Conclusion: Intrathecal intramedullary/extramedullary mature teratomas of the conus that results in subacute cauda equina syndromes are rare. The differential diagnosis for such lesions exophytic to the conus must include mature teratomas which, though rare, may be readily resected resulting in generally favorable outcomes.

Cerebral hemodynamic effects of early blood pressure lowering after TIA and stroke in patients with carotid stenosis

Background: Effects of early blood pressure (BP) lowering on cerebral perfusion in patients with moderate/severe occlusive carotid disease after transient ischemic attack (TIA) and non-disabling stroke are uncertain. Aims: We aimed to evaluate the changes in transcranial Doppler (TCD) indices in patients undergoing blood pressure lowering soon after TIA/non-disabling stroke. Methods: Consecutive eligible patients (1 November 2011 to 30 October 2018) attending a rapid-access clinic with TIA/non-disabling stroke underwent telemetric home blood pressure monitoring (HBPM) for 1 month and middle cerebral artery velocities measurements ipsilateral to carotid stenosis on TCD ultrasound in the acute setting and at 1 month. Hypertensive patients (HBPM ⩾ 135/85) underwent intensive BP-lowering guided by HBPM unless they had bilateral severe occlusive disease (⩾ 70%). Changes in BP and TCD parameters were compared in patients with extracranial moderate/severe carotid stenosis (between 50% and occlusion) versus those with no or mild (< 50%) stenosis. Results: Of 764 patients with repeated TCD measures, 42 had moderate/severe extracranial carotid stenosis without bilateral severe occlusive disease. HBPM was reduced from baseline to 1 month in hypertensive patients both with versus without moderate/severe carotid stenosis (−12.44/15.99 vs −13.2/12.2 mmHg, respectively, p-difference = 0.82), and changes in TCD velocities (4.69/14.94 vs 2.69/13.86 cm/s, respectively, p-difference = 0.52 for peak systolic velocity and 0.33/7.06 vs 1.75/6.84 cm/s, p-difference = 0.34 for end-diastolic velocity) were also similar, with no evidence of greater hemodynamic compromise in patients with stenosis/occlusion. Conclusion: There was no evidence of worsening of TCD hemodynamic indices in patients with moderate/severe occlusive carotid disease treated with BP-lowering soon after TIA/non-disabling stroke, suggesting that antihypertensive treatment in this group of patients is safe in the acute setting of TIA clinics.

Point-of-Care Ultrasound for Identification of Ruptured Infrarenal Abdominal Aortic Aneurysm

Ruptured abdominal aortic aneurysms are associated with high mortality rates and require prompt diagnosis with subsequent intervention. CT scan is considered the gold-standard for diagnosis, however, in the acute setting ultrasound may be a reasonable diagnostic test for certain patients. We report a case that demonstrates the utility of bedside ultrasound of rAAA for a patient in extremis. Also, we provide a brief review of literature for the diagnosis of rAAA with ultrasound.

Nonspecific abdominal pain: Do I have to allocate a specific diagnosis for every patient?

Acute abdominal pain is one of the most common chief complaints in the acute setting all over the world. The definitive diagnoses of these patients vary depending on age, gender, geographical and sociodemographic characteristics etc. Apart from these, aging of the population, obesity, advanced diagnostic imaging modalities and changes in nutritional habits also have an impact on the rates of specific diagnoses. On the other hand, nonspecific abdominal pain constitutes almost half of all visits due to acute abdominal pain in the acute care setting. This phenomenon is the main differential diagnostic problem in the management of these patients because missing a life-threatening condition can cause enormous medicolegal problems for the caregivers. Certain diagnostic scoring systems have also been developed to facilitate recognition and management of these conditions. This article aims to review the entity and underline the challenges it can bring to the scene.

Simultaneous Multi-Vessel Very Late Stent Thrombosis in Acute ST-Segment Elevation Myocardial Infarction

Simultaneous multi-vessel very later stent thrombosis (VLST) is a very rare complication of percutaneous coronary intervention (PCI). We present a case of simultaneous multi-vessel VLST as the cause of acute ST-segment elevation myocardial infarction (STEMI). PCI of the culprit vessel was performed at acute presentation. Resolution of in-stent thrombosis in non-culprit vessels was noted on coronary angiography 2 days later. Our case suggests that PCI for culprit lesion in acute setting may be a reasonable option for simultaneous multi-vessel VLST.

Transient Myocardial Ischemia in a Case Post Intra-Muscular Adrenaline

Background: Anaphylaxis is a medical emergency and requires immediate medical attention. Kounis syndrome is myocardial infarction or injury occurring in the setting of anaphylaxis and can also be due to the effects of epinephrine. Adrenaline is a common drug in the management of anaphylaxis but the electrocardiographic consequences of its administration post an attack are seldomly seen. Vasospasm is generally the cause for myocardial injury in an acute setting following the administration of epinephrine. Case Presentation: A 21-year- old female developed sudden onset breathlessness and giddiness post vaccination with the oxford –AstraZeneca COVID -19 vaccine. She was administered 0.5 ml adrenaline (1:1000) intramuscularly on the lateral aspect of the left thigh, following which she complained of chest tightness and palpitations. This was accompanied by hypotension and global ST segment depression on her Electrocardiogram. The second electrocardiogram, done after 30 minutes showed a relative resolution in ST segment depressions with sinus rhythm in the one done at 16:00 hours. Creatine Kinase- MB and Troponin I were within normal limits and the patient experienced symptomatic improvement with normalization of blood pressure post fluid challenge. Conclusion: This case report highlights the case of a young female with no comorbidities who developed transient myocardial ischemia after administration of intramuscular adrenalin in therapeutic dose in view of an anaphylactic reaction. The probable action is alpha mediated coronary vasospasm. The potential adverse effects in an acute setting are hence outlined in this case report without discouraging its use given the potential benefits outweigh the risks.

Potential of heart fatty-acid binding protein, neurofilament light, interleukin-10 and S100 calcium-binding protein B in the acute diagnostics and severity assessment of traumatic brain injury

BackgroundThere is substantial interest in blood biomarkers as fast and objective diagnostic tools for traumatic brain injury (TBI) in the acute setting.MethodsAdult patients (≥18) with TBI of any severity and indications for CT scanning and orthopaedic injury controls were prospectively recruited during 2011–2013 at Turku University Hospital, Finland. The severity of TBI was classified with GCS: GCS 13–15 was classified as mild (mTBI); GCS 9–12 as moderate (moTBI) and GCS 3–8 as severe (sTBI). Serum samples were collected within 24 hours of admission and biomarker levels analysed with high-performance kits. The ability of biomarkers to distinguish between severity of TBI and CT-positive and CT-negative patients was assessed.ResultsAmong 189 patients recruited, neurofilament light (NF-L) was obtained from 175 patients with TBI and 40 controls. S100 calcium-binding protein B (S100B), heart fatty-acid binding protein (H-FABP) and interleukin-10 (IL-10) were analysed for 184 patients with TBI and 39 controls. There were statistically significant differences between levels of all biomarkers between the severity classes, but none of the biomarkers distinguished patients with moTBI from patients with sTBI. Patients with mTBI discharged from the ED had lower levels of IL-10 (0.26, IQR=0.21, 0.39 pg/mL), H-FABP (4.15, IQR=2.72, 5.83 ng/mL) and NF-L (8.6, IQR=6.35, 15.98 pg/mL) compared with those admitted to the neurosurgical ward, IL-10 (0.55, IQR=0.31, 1.42 pg/mL), H-FABP (6.022, IQR=4.19, 20.72 ng/mL) and NF-L (13.95, IQR=8.33, 19.93 pg/mL). We observed higher levels of H-FABP and NF-L in older patients with mTBI. None of the biomarkers or their combinations was able to distinguish CT-positive (n=36) or CT-negative (n=58) patients with mTBI from controls.ConclusionsS100B, H-FABP, NF-L and IL-10 levels in patients with mTBI were significantly lower than in patients with moTBI and sTBI but alone or in combination, were unable to distinguish patients with mTBI from orthopaedic controls. This suggests these biomarkers cannot be used alone to diagnose mTBI in trauma patients in the acute setting.

Post-traumatic amnesia

Post-traumatic amnesia is the transient state of altered brain function that may follow a traumatic brain injury. At a practical level, an individual has emerged from post-traumatic amnesia when he or she is fully orientated and with return of continuous memory. However, the clinical manifestations are often more complex, with numerous cognitive domains commonly affected, as well as behaviour. In the acute setting, post-traumatic amnesia may easily go unrecognised; this is problematic as it has important implications for both immediate management and for longer-term prognosis. We therefore recommend its careful clinical assessment and prospective evaluation using validated tools. Patients in post-traumatic amnesia who have behavioural disturbance can be particularly challenging to manage. Behavioural and environmental measures form the mainstay of its treatment while avoiding pharmacological interventions where possible, as they may worsen agitation. Patients need assessing regularly to determine their need for further rehabilitation and to facilitate safe discharge planning.