1/31. Video-assisted crossover iliofemoral obturator bypass grafting: a minimally invasive approach to extra-anatomic lower limb revascularization.Graft infection continues to be one of the most feared complications in vascular surgery. It can lead to disruption of anastomoses with life-threatening bleeding, thrombosis of the bypass graft, and systemic septic manifestations. One method to ensure adequate limb perfusion after removal of an infected aortofemoral graft is extra-anatomical bypass grafting. We used a minimally invasive, video-assisted approach to implant a crossover iliofemoral obturator bypass graft in a patient with infection of the left limb of an aortofemoral bifurcated graft. This appears to be the first case report describing the use of this technique.- - - - - - - - - - ranking = 1keywords = fear (Clic here for more details about this article) |
2/31. Late abdominal aortic aneurysm rupture after AneuRx repair: a report of three cases.rupture due to device failure and/or endoleak is the most feared complication of endoluminal grafting for exclusion of abdominal aortic aneurysm. We present three previously unreported cases of abdominal aortic aneurysm rupture 23 months after AneuRx "repair" and describe the mechanisms of failure and discuss instructive technical aspects of their management.- - - - - - - - - - ranking = 1keywords = fear (Clic here for more details about this article) |
3/31. Mesial temporal lobe epilepsy versus amygdalar epilepsy: late seizure recurrence after initially successful amygdalotomy and regained seizure control following hippocampectomy.We summarise the concept of mesial temporal lobe epilepsy and the pros and cons in order to define amygdala epilepsy. We present a patient with stereotactically proven right amygdalar seizure onset, associated with fear and vegetative autonomic signs and symptoms as the most prominent clinical ictal features. Following a right stereotactic amygdalotomy, the patient experienced an 11-year seizure-free period. Similar, but not identical, semeiology of complex partial seizures then recurred. A right-sided selective hippocampectomy and excision of the previously lesioned amygdala was performed. Except for 2 complex partial seizures associated with withdrawal of antiepileptic drugs, the patient remained seizure-free 9.5 years. This case underscores the important role of the amygdala in generating the semiology, and raises several questions concerning the existence of "amygdalar epilepsy". The 11-year seizure-free period following the stereotactic destruction of the amygdala is a strong argument for this notion. The late seizure recurrence requiring a second operation might, however, be seen as an argument for the important role of the hippocampal formation in the syndrome of mesial temporal lobe epilepsy even when the amygdala has been identified as the seizure onset zone. The role of stereotactic amygdalotomy is briefly reviewed.- - - - - - - - - - ranking = 1keywords = fear (Clic here for more details about this article) |
4/31. Intractable epilepsy after a functional hemispherectomy: important lessons from an unusual case. Case report.Residual seizures after functional hemispherectomy occur in approximately 20% of patients with catastrophic epilepsy. These episodes are traditionally attributed to incomplete disconnection, persistent epileptogenic activity in the ipsilateral insular cortex, or bilateral independent epileptogenic activity. The authors report on the case of an 8-year-old boy with an intractable seizure disorder who had classic frontal adversive seizures related to extensive unilateral left hemispheric cortical dysplasia. The initial intervention consisted of extensive removal of the epileptic frontal and precentral dysplastic tissue and multiple subpial transections of the dysplastic motor strip, guided by intraoperative electrocorticography, Subsequently, functional hemispherectomy including insular cortex resection was performed for persistent attacks. After a seizure-free period of 6 months, a new pattern ensued, consisting of an aura of fear, dystonic posturing of the right arm, and unusual postictal hyperphagia coupled with an interictal diencephalic-like syndrome. electroencephalography and ictal/interictal single-photon emission computerized tomography were used to localize the residual epileptic discharges to deep ipsilateral structures. Results of magnetic resonance imaging indicated a complete disconnection except for a strip of residual frontobasal tissue. Therefore, a volumetric resection of the epileptogenic frontal basal tissue up to the anterior commissure was completed. The child has remained free of seizures during 21 months of follow-up review. Standard hemispherectomy methods provide extensive disconnection, despite the presence of residual frontal basal cortex. However, rarely, and especially if it is dysplastic, this tissue can represent a focus for refractory seizures. This is an important consideration in determining the source of ongoing seizures posthemispherectomy in patients with extensive cortical dysplasia. It remains important to assess them fully before considering their disease refractory to surgical treatment.- - - - - - - - - - ranking = 1keywords = fear (Clic here for more details about this article) |
5/31. role of bedside microdialysis in the diagnosis of cerebral vasospasm following aneurysmal subarachnoid hemorrhage.OBJECT: ischemia due to vasospasm is a feared complication in patients following aneurysmal subarachnoid hemorrhage (SAH). Cerebral online microdialysis monitoring may detect the metabolic changes in the extracellular fluid associated with ischemia. The aims of the present study were to correlate clinical course, microdialysis-recorded data, transcranial Doppler (TCD) ultrasonography findings, and angiographic findings in patients with SAH. methods: In 60 patients a microdialysis catheter was inserted into the brain parenchyma that is most likely to be affected by vasospasm directly after aneurysm clipping. Hourly analyses of glucose, pyruvate, lactate, and glutamate levels were performed using a bedside device. blood-flow velocities were obtained using serial TCD measurements. cerebral angiography was routinely performed on Day 7 after aneurysm clipping or earlier in cases of clinical deterioration (30 patients). In all patients the results of microdialysis monitoring, TCD ultrasonography, and angiography were correlated. The mean duration of monitoring was 7.3 /-2.5 days. In patients with acute ischemic neurological deficits (18 patients) immediate microdialysis-recorded alterations were observed if the probe was placed close to the malperfused region. In 13 of 15 patients with symptomatic vasospasm (delayed ischemic neurological deficit [DIND]), the microdialysis-recorded values revealed secondary deterioration. In terms of confirming DIND, microdialysis had the highest specificity (0.89, 95% confidence interval [CI] 0.78-1) compared with TCD ultrasonography (0.63, 95% CI 0.46-0.8) and angiography (0.53, 95% CI 0.35-0.7). For microdialysis, the positive likelihood ratio was 7.8, whereas this was significantly lower for TCD ultrasonography (1.7) and angiography (2.1). CONCLUSIONS: Although angiography also demonstrates vessel narrowing in asymptomatic patients, online microdialysis reveals characteristic metabolic changes that occur during vasospasm. Thus, online microdialysis may be used to confirm the diagnosis of vasospasm.- - - - - - - - - - ranking = 1keywords = fear (Clic here for more details about this article) |
6/31. Omental transplantation for epilepsy.Residual seizures after functional hemispherectomy occur in approximately 20% of patients with catastrophic epilepsy. These episodes are traditionally attributed to incomplete disconnection, persistent epileptogenic activity in the ipsilateral insular cortex, or bilateral independent epileptogenic activity. The authors report on the case of an 8-year-old boy with an intractable seizure disorder who had classic frontal adversive seizures related to extensive unilateral left hemispheric cortical dysplasia. The initial intervention consisted of extensive removal of the epileptic frontal and precentral dysplastic tissue and multiple subpial transections of the dysplastic motor strip, guided by intraoperative electrocorticography. Subsequently, functional hemispherectomy including insular cortex resection was performed for persistent attacks. After a seizure-free period of 6 months, a new pattern ensued, consisting of an aura of fear, dystonic posturing of the right arm, and unusual postictal hyperphagia coupled with an interictal diencephalic-like syndrome. electroencephalography and ictal/interictal single-photon emission computerized tomography were used to localize the residual epileptic discharges to deep ipsilateral structures. Results of magnetic resonance imaging indicated a complete disconnection except for a strip of residual frontobasal tissue. Therefore, a volumetric resection of the epileptogenic frontal basal tissue up to the anterior commissure was completed. The child has remained free of seizures during 21 months of follow-up review. Standard hemispherectomy methods provide extensive disconnection, despite the presence of residual frontal basal cortex. However, rarely, and especially if it is dysplastic, this tissue can represent a focus for refractory seizures. This is an important consideration in determining the source of ongoing seizures posthemispherectomy in patients with extensive cortical dysplasia. It remains important to assess them fully before considering their disease refractory to surgical treatment.- - - - - - - - - - ranking = 1keywords = fear (Clic here for more details about this article) |
7/31. Gastric surgery and restraint from food as triggering factors of eating disorders in morbid obesity.Obese patients may share some clinical features with anorexia nervosa patients because they risk developing an eating disorder when they diet. methods and Results Some common etiological, psychological, and social factors have been proposed for both disorders. We present two cases of patients suffering from morbid obesity who, after weight loss, presented an intense fear of regaining weight and developed anorexic-like symptoms. In the first case, the symptoms appeared after gastric reduction surgery. In the second case, a strict diet was the triggering factor. DISCUSSION: This paper stresses the need for psychiatric evaluation of all patients with morbid obesity who seek treatment in clinical settings, in order to identify the factors that may lead to psychiatric complications.- - - - - - - - - - ranking = 1keywords = fear (Clic here for more details about this article) |
8/31. Saturday night fever: finding and controlling the source of sepsis in critical illness.fever is a daily concern in the intensive care unit. Although about half of all febrile cases are due to non-infectious causes, fear of sepsis frequently leads to diagnostic tests and escalation of therapy, including broadening antibiotic therapy. Using a case to illustrate this dilemma, we discuss the commonest non-infectious and infectious causes of fever, and suggests approaches to their management. Any unexplained fever in intensive care unit patients warrants investigation, which includes complete clinical assessment and blood cultures. When the source of fever is not immediately apparent, non-infectious and infectious causes should be considered. If stable, non-neutropenic patients should be monitored before further tests or empiric antibiotics are started. In an era of rapid emergence and spread of antimicrobial-resistant pathogens and intense scrutiny of resources, optimal diagnosis and management of patients with suspected infection entails much more than the escalation of antimicrobial therapy.- - - - - - - - - - ranking = 1keywords = fear (Clic here for more details about this article) |
9/31. The management of glaucoma in nanophthalmos.patients with nanophthalmos are prone to develop a chronic painless type of glaucoma in middle age, probably due to the natural increase in the size of the lens which is already relatively too large for the small eye. Although the underlying mechanism is obscure, a slowly progressive "creeping" chronic angle-closure is postulated, but gonioscopic evaluation is difficult due to the shallow anterior chamber, with grade I and slit angles. Response to medical treatment is poor and miotics may even make the condition worse by producing relative pupillary block and by relaxing the lens zonule. Ordinary glaucoma surgery is to be avoided in nanophthalmos because of the fear of postoperative ciliary-block malignant glaucoma. Periopheral iridectomy performed in five eyes at an advanced stage of the chronic angle-closure did not facilitate glaucoma control in three eyes, and in two eyes in which the operation was combined with posterior sclerotomy, the eyes became blind from vitreous hemorrhage. Lenx extraction in five eyes controlled the glaucoma but was followed by choroidal effusion and nonrhegmatogenous retinal detachements in two eyes and blindness in another eye when combined with a posterior sclerotomy. No firm therapeutic recommendations can be made on the basis of the author's experience in the six reported cases. Conventional medical therapy seems ineffectual even when begun early in the glaucoma. Conventional glaucoma surgery must be performed early, before permanent damage to the outflow mechanism occurs but removal of the lens must be anticipated. The surgeon must also remain aware of the high incidence of serious posterior-segment complications which inexplicably follow glaucoma or lens surgery in nanophthalmos, as described by Brockhurst.- - - - - - - - - - ranking = 1keywords = fear (Clic here for more details about this article) |
10/31. Dissociation of affective modulation of recollective and perceptual experience following amygdala damage.It has been suggested that similar neural mechanisms may underlie the affective modulation of both recollective and perceptual experience. A case is reported of a patient who has bilateral amygdala damage and marked impairment in the perception of emotion, particularly fear. The patient DR and 10 healthy control subjects (matched for school leaving age, intelligence quotient, and non-emotional memory performance) were shown a series of slides accompanied by an emotionally arousing narrative. One week later DR and the controls were given a surprise memory test for this material. In addition, they completed a verbal memory test using emotionally arousing stimuli. Both DR and the healthy control subjects showed a normative pattern of enhanced memory for emotional material. On the basis of these results and the previously demonstrated impairment of perception of emotion in this patient, it is concluded that different neural mechanisms may underlie affective modulation of recollective and perceptual experience.- - - - - - - - - - ranking = 1keywords = fear (Clic here for more details about this article) |
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