A Ruptured Blood Blister-Like Aneurysm that Experienced Regrowth with Coil Compaction Twice in a Month : Case Report

Unlike other aneurysms, blood blister-like aneurysms(BBA) occur at non-branching sites, are commonly located at the dorsal wall of the supraclinoid internal carotid artery (ICA), and are suspected to arise from dissecting aneurysms. They are typically diagnosed after a bleed because of their small size and unusual site. Therefore, lesions exist after brain computed tomography or magnetic resonance imaging, but they are often not found. In the case of BBA, which have a high risk of recurrence, the treatment is difficult, and selecting the treatment method is also challenging. This paper describes the treatment of a BBA with internal trapping of the ICA that eventually recurred despite performing coil embolization twice.

Association between Neurologic Outcomes and Changes of Muscle Mass Measured by Brain Computed Tomography in Neurocritically Ill Patients

This study aimed to investigate whether skeletal muscle mass estimated via brain computed tomography (CT) could predict neurological outcomes in neurocritically ill patients. This is a retrospective, single-center study. Adult patients admitted to the neurosurgical intensive care unit (ICU) from January 2010 to September 2019 were eligible. Cross-sectional areas of paravertebral muscles at the first cervical vertebra level (C1-CSA) and temporalis muscle thickness (TMT) on brain CT were measured to evaluate skeletal muscle mass. The primary outcome was the Glasgow Outcome Scale score at 3 months. Among 189 patients, 81 (42.9%) patients had favorable neurologic outcomes. Initial and follow-up TMT values were higher in patients with favorable neurologic outcomes compared to those with poor outcomes (p = 0.003 and p = 0.001, respectively). The initial C1-CSA/body surface area was greater in patients with poor neurological outcomes than in those with favorable outcomes (p = 0.029). In multivariable analysis, changes of C1-CSA and TMT were significantly associated with poor neurological outcomes. The risk of poor neurologic outcome was especially proportional to changes of C1-CSA and TMT. The follow-up skeletal muscle mass measured via brain CT at the first week from ICU admission may help predict poor neurological outcomes in neurocritically ill patients.

Repeat percutaneous tracheostomy in a COVID-19 patient

A 73-year-old man with history of hypertension and chronic obstructive pulmonary disease was admitted to the emergency department with acute respiratory failure from COVID-19. After 10 days of mechanical ventilation (MV) the patient underwent a successful trial of extubation. However, 3 days later his neurological status deteriorated and required re-intubation. A brain computed tomography (CT) scan showed right cerebellar hemorrhage. Considering extent and location of the hemorrhage we decided to perform a percutaneous tracheostomy on the 18th day. The patient was then successfully weaned from MV (day 47th), and finally decannulated (day 50th). On day 62nd, the patient experienced an episode of septic shock, requiring oro-tracheal re-intubation, for we decided to perform a repeat percutaneous tracheostomy. All the procedure steps were uneventful. The patient was subsequently transferred to another ICU, and then successfully discharged to the Respiratory Ward. Keywords: coronavirus; airways; dilational tracheostomy

Endoscopic Third Ventriculostomy for an Idiopathic Disproportionately Large Communicating Fourth Ventricle: A Case Report

A disproportionately large communicating fourth ventricle (DLCFV) is a rare condition. A 34-year-old man experienced severe headaches, nausea, vomiting, and gait disturbance. Initial brain computed tomography (CT) showed markedly dilated ventricles with prepontine cistern shrinkage. Following extraventricular drain (EVD) insertion, approximately 400 mL/d of cerebrospinal fluid (CSF) was removed over 8 days. During this time, no significant changes in ventricle size were observed on CT images or the facial pain scale (FPS). We then performed an endoscopic third ventriculostomy and changed the drainage catheter. Immediately after surgery, the patient’s symptoms were relieved, and the drainage volume gradually decreased. EVD was successfully removed on the eighth postoperative day. Our experiences suggest that neurosurgeons should consider the importance of a third ventriculostomy for the diagnosis and treatment of DLCFV.

Efficacy of a four-tier infection response system in the emergency department during the coronavirus disease-2019 outbreak

Introduction The coronavirus disease (COVID-19) pandemic has delayed the management of other serious medical conditions. This study presents an efficient method to prevent the degradation of the quality of diagnosis and treatment of other critical diseases during the pandemic. Methods We performed a retrospective observational study. The primary outcome was ED length of stay (ED LOS). The secondary outcomes were the door-to-balloon time in patients with suspected ST-segment elevation myocardial infarction and door-to-brain computed tomography time for patients with suspected stroke. The outcome measures were compared between patients who were treated in the red and orange zones designated as the changeable isolation unit and those who were treated in the non-isolation care unit. To control confounding factors, we performed propensity score matching, following which, outcomes were analyzed for non-inferiority. Results The mean ED LOS for hospitalized patients in the isolation and non-isolation care units were 406.5 min (standard deviation [SD], 237.9) and 360.2 min (SD, 226.4), respectively. The mean difference between the groups indicated non-inferiority of the isolation care unit (p = 0.037) but not in the patients discharged from the ED (p>0.999). The mean difference in the ED LOS for patients admitted to the ICU between the isolation and non-isolation care units was -22.0 min (p = 0.009). The mean difference in the door-to-brain computed tomography time between patients with suspected stroke in the isolation and non-isolation care units was 7.4 min for those with confirmed stroke (p = 0.013), and -20.1 min for those who were discharged (p = 0.012). The mean difference in the door-to-balloon time between patients who underwent coronary angiography in the isolation and non-isolation care units was -2.1 min (p<0.001). Conclusions Appropriate and efficient handling of a properly planned ED plays a key role in improving the quality of medical care for other critical diseases during the COVID-19 outbreak.