A Review on Some Important Notes about the Surgical Anatomy of the Internal Jugular Vein - Juniper Publishers

 Anatomy Physiology & Biochemistry - Juniper Publishers

Abstract

Internal Jugular Vein is an important anatomical structure in the head and neck region. As a paired jugular vein, it originates from sigmoid and inferior petrosal sinuses. At the skull base level, it begins at the jugular foramen posterior compartment. Then it goes down to the neck. It collects blood from some parts of the face and neck and also the brain.

Considering the importance of having knowledge about the anatomy of the internal jugular vein specifically for the surgeons and other clinicians who are dealing with the patients with head and neck and vascular pathologies, this brief review tries to point to some important anatomical aspects related to the internal jugular vein as well as some important clinical points.

Keywords: Jugular Vein; Internal; Anatomy; Surgery; Clinical Relevance

Body

Internal jugular vein as a paired jugular vein, originates from sigmoid and inferior petrosal sinuses and is usually known as the largest neck vein. At the level of the skull base, it begins at the jugular foramen posterior compartment and since it is somehow dilated at its original part, it would be named as superior bulb at this level. Internal jugular vein runs downward in an almost vertical direction in the carotid sheath.

Internal jugular vein has some relations with the internal carotid artery at different levels. At the C2 level, internal jugular vein would be in the posterior part of the internal carotid artery. Then it turns towards the lateral direction while still being in the posterior part of the artery which at the level of C3, internal jugular vein would be in a posterolateral part of the internal carotid artery. At the level of C4, the internal jugular vein would be located at the lateral part of the internal carotid artery. It is important to notice that the tenth cranial nerve lies between the internal jugular vein and the internal carotid artery. After leaving the carotid sheath, deep cervical lymph nodes surround the internal jugular vein. In a downward direction, the internal jugular vein lies on the lateral mass of the first cervical vertebra, prevertebral fascia, middle scalene muscle, anterior scalene muscle and the cervical pleura dome.

In case of dividing the internal jugular vein into three anatomical parts meaning upper, middle, and lower thirds, it will be crossed and overlaid by different anatomical structures. The eleventh cranial nerve’s spinal root would cross the internal jugu lar vein at its origin. The middle third of the internal jugular vein would be crossed by the inferior root of the ansa cervicalis. The lower third of the internal jugular vein would be covered by the omohyoid muscle tendon and the sternocleidomastoid muscle. Usually, the right internal jugular vein is larger than the left one because its blood drainage is done from the superior sagittal sinus which in contrast with the left one meaning the inferior sagittal sinus, is larger in its size [1-4].

From the clinical point of view and at the bedside, the internal jugular vein can be found while it runs from the posterior part of the jaw angle to the posterior part of the sternoclavicular joint. Central venous catheterization with or without the ultrasound guidance, would preferably be done through the internal jugular vein. Estimation of the jugular venous and right atrium pressures and also estimation of the patients hemodynamic status, can be done at the bedside by observing the internal jugular vein. In Trauma settings, the internal jugular vein is susceptible to various damages given its superficial course in the neck. So, any blunt or penetrating trauma can cause injury to the internal jugular vein which result in the occurrence of hemorrhage and increased risk for the occurrence of air embolism. Thrombosis of the internal jugular vein and Lemierre syndrome which is known as a thrombosis of the internal jugular vein due to infection of the pharynx, are another pathologies which can affect the internal jugular vein.

Surgery of the internal jugular vein requires paying enough attention to its and surrounding anatomical structures. Surgical repairing of the internal jugular vein should be considered first and during this, it should be tried by the surgeon to limit the amount of narrowing the vessel as much as possible. Ligation may be necessary in the cases which the amount of damage to the vessel is high.

In any of these cases, care should be taken to avoid causing injury to the surrounding anatomical structures like internal carotid artery and the tenth cranial nerve. In case the carotid sheath is affected by the injury, the surrounding anatomical structures should be evaluated for possible injury and necessary surgical repair as well [2,5,6].

Conclusion

Internal jugular vein is an important anatomical structure which having detailed knowledge about its anatomy is of great importance specifically for the surgeons and other clinicians whom are dealing with the patients with head and neck and vascular pathologies, to approach its relevant pathologies and damages with more precision and with lowest surgical complications at the bedside.

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Periodontal and Restorative Treatment Approach to Gingival Recession Associated with Non-Carious Cervical Lesion: Report of Three Cases - Juniper Publishers

 Dentistry & Oral Health - Juniper Publishers

Abstract

Gingival recession (GR) is a common problem in the world population that can induce aesthetic complaints and dentin hypersensitivity. It is often complicated by dental substance wear at the gingival third of the tooth due to reasons other than dental caries. This condition is described as a non-carious cervical lesion (NCCL). If a NCCL is present in a site with gingival recession, the muco-gingival condition is defined as a combined defect (CD). Thus, a multidisciplinary approach should be considered for the treatment of this condition which includes muco-gingival surgery and the reconstruction of the cemento-enamel junction. Zucchelli et al. proposed a treatment strategy based on the position of the Maximum root coverage (MRC) and the NCCL location and extent. The aim of this article is to review the treatment protocols regarding a CD and present the different steps of the management of three clinical cases.

Keywords: Case report; Gingival recession; Cemento enamel junction; Tooth abrasion; Surgery

Abbreviations: GR: Gingival recession; NCCL: Non-carious cervical lesion; CD: Combined defect; MRC: Maximum root coverage; CEJ: Cemento-enamel junction

Introduction

According to the Glossary of Periodontal Terms [1], gingival recession [GR] is defined as the location of the gingival margin apical to the cemento-enamel junction (CEJ). It is associated with attachment loss due to the migration of the whole periodontal attachment apparatus [gingiva, periodontal ligament, and alveolar bone]. These defects are greatly prevalent worldwide, affecting from 40% to 100% individuals [2,3]. This common problem leads to root exposure, therefore favoring root caries, non-carious cervical lesions, dentin hypersensitivity, poor plaque control and compromising aesthetics. Moreover, if left untreated, GR has a high risk of progression over time. Due to these issues, many patients seek gingival recession treatment [2]. GR defects have multifactorial causes; Trauma from improper toothbrushing and low plaque control have been proposed as the main triggers of this disease in the presence of various predisposing factors including a thin periodontal biotype, the absence of attached gingiva, tooth malposition and iatrogenic factors such as uncontrolled orthodontic movement and defective restorations [4]. After examining 1010 GR defects, Pini-Prato reported that only 46% of the considered root surfaces were intact, with an identifiable CEJ and absence of cervical wear. Consequently, it has been reported that cervical abrasion was observed in about 50% of the examined teeth with gingival recessions [5].

Based on this finding, the new classification of the muco-gingival conditions of the 2017 World Workshop proposed a treatment-oriented classification including gingival recession severity, gingival phenotype and the presence of associated cervical lesion. In a first step, the interdental clinical attachment level is determined with reference to a new classification system (Cairo 2011) [6], then, the gingival phenotype which includes gingival thickness and keratinized tissue width is examined. Following this, the condition of the tooth surface in the area of the gingival recession is evaluated. Since NCCLs are common findings in patients with gingival recession defects, a classification of these defects has been introduced [5]. A tooth with an identifiable CEJ belongs to class A, while one with no identifiable CEJ belongs to class B. Each class is subdivided depending on the presence (+) or absence (-) of a cervical step over 0.5 mm, yielding four classes (A+, A-, B+, B-).

Tooth position, aberrant frenum, and the number of the adjacent recessions are also features contributing to the description of the site. It is assumed that GR and NCCL may share the same etiologic factors. Although an abrasion, due to mechanical forces, plays an important role in the development of NCCLs, it is not the unique cause, other factors such as corrosion, and possibly abfraction may be involved. Frequently, as a misdiagnosis, restorative procedures are adopted as the only treatment of these cervical lesions leading to marginal bleeding, attachment loss and the increase of the gingival recession. A decision-making process to facilitate the treatment of GR associated with NCCLs was proposed based on the topography of the NCCL and its relationship with the maximum root Coverage [MRC] achievable by mucogingival procedures. The aim of this report is to discuss, through three clinical cases, the different steps of restorative and/or surgical phases for treating GR associated with NCCL based on Zucchelli’s decision making process for treating NCCLs associated with gingival recessions.

First Case

A 56-year-old female patient, in good general medical condition, nonsmoker, complained of root exposure on her frontal maxillary teeth and a cervical abrasion of the upper canines, causing plaque retention and increased sensitivity (Figure 1). The patient expressed her desire to regain the previous position of her gingiva. At clinical examination, multiple adjacent buccal recessions were found on the four maxillary incisors and canines. The profile visual inspection of the left and right canine confirmed the presence of a NCCL concomitant to the GR (Figure 2). The patient was asked about her tooth-brushing and dietary habits. She revealed that she brushes her teeth horizontally with excessive force. After the exclusion of a traumatic occlusion and data analysis, the main contributing factors were thin gingival biotype and improper tooth-brushing. Full mouth radiographs, periodontal charting and photographic documentation were carried out.

With the use of a periodontal probe, a thorough clinical examination of the hard tissues showed:

A deep crown radicular defect on the right canine and a less deep crown radicular defect on the left canine: Class B+ defects; A complete disappearance of the CEJ was observed on both teeth with the presence of a step >0,5mm. A mild rotation was observed on both lateral incisors.

Regarding the soft tissues: GR RT2 on the incisors and the upper canines and a sufficient band of keratinized tissue was present apically to the gingival margins.

Afterwards, the patient was informed about the treatment plan which was the following:

i. Initial therapy includes first etiologic factors management: the modified bass brushing technique was demonstrated to the patient, a soft toothbrush and a nonabrasive tooth-paste were prescribed.

Second; a session of scaling and professional tooth cleaning was performed with the use of a polishing paste.

ii. A reevaluation session was then scheduled to assess the supragingival plaque control and the tooth brushing technique.

The patient was compliant with the instructions and well prepared for the treatment of the cervical and recession defect. The restorative and surgical procedures were performed during the same session by two clinicians of the Departments of Conservative Dentistry and Periodontology. The key step in the combined approach is the determination of the MRC line. It is the line that represents the limit for apical preparation of the conservative restoration [7]. In fact, the MRC is considered to be the clinical CEJ both in the upper canines where the anatomical CEJ disappeared and also in the incisors where the conditions for a complete root coverage are not present: malposition of the lateral incisors, interdental attachment loss. Therefore, prior to the restoration, this curved line was calculated for each affected tooth and marked by means of a dental pen. On the left and right canine, the MRC was located in the deepest portion of the NCCL (Zucchelli’s Type 3 defect) separating the defect into a coronal area treated by a resin restoration and an apical area treated by coronally advanced flap for multiple gingival recession and a CTG placed on the right and left maxillary canines to avoid the collapse of the flap on the cervical lesion (Figure 3).

Restorative Procedures

Following local anesthesia, a gingival cord was inserted to isolate the restoration field on the canines. The area located coronally to the MRC was prepared with diamond burs removing the superficial dentin. Mild enameloplasty was also done to reduce the depth of the defect (Figure 4). The aims of this crown odontoplasty were to obtain an emergence profile compatible with periodontal health, preventing plaque accumulation and pseudo pocketing and to increase the retention of the resin by creating a beveled surface. After Adhesive procedures, the conservative therapy is then performed by applying fluid resin to the level of the MRC and a thorough finishing and polishing made sure of a smooth surface condition (Figure 5).

Surgical Procedures

As illustrated above, the NCCL defects on the canines are combined with multiple adjacent recessions. The surgical technique was the coronally advanced envelope flap (Zucchelli) underneath which a CTG was applied specifically on both canines. Under local anesthesia, the incision design consisted in paramarginal incisions to create surgical papillae followed by intrasulcular incisions, a distal and mesial vertical releasing incisions. The flap was raised with the split-full-split technique and a deep and superficial incisions were performed in order to release the muscle insertions and to coronally advance the flap (Figure 6). A deepithelization of the anatomical papillae was made by using surgical scissors and a CTG was harvested from the palate and applied on the canine’s defects, the flap was advanced and sutured 1mm coronal to the MRC with sling sutures (Figure 7 & Figure 8).

Results

The GM was coronally advanced to the level of the MRC on the incisors, as for the canines, the advanced tissues and the CTG were filling the NCCL defect and merged with the cervical restoration. Follow up results are illustrated in the figures (Figure 9 & Figure 10).

Second Case

A 40-year-old patient in good general medical condition, nonsmoker, consulted after complaining from hypersensitivity related to defective resin restorations on the left maxillary premolars. After clinical examination, old cervical resin restorations were partially covering a NCCL located on the 24 and 25, RT1 GR was also concomitant to the defects. A wide band of keratinized tissue was present apically to the recessions (Figure 11). After one session of initial therapy, a combined approach was decided since the cervical abrasions involved the root and crown area resulting in the disappearance of the CEJ (B+ defects). In fact, restorative therapy alone will result in a long crown and an apical position of the GM which is esthetically unfavorable. The MRC was calculated (type 3 defect) and the restoration of the coronal part of the defect was performed by means of fluid resin (Figure 12) After the finishing and polishing of the restoration, the root coverage procedure was achieved. The surgical technique consisted of a coronally advanced flap after marginal incision and deepithelization of the anatomical papillae (Figure 13).

Results

There was a decrease in hypersensitivity with acceptable esthetic results. The GM was coronally advanced demonstrating the complete coverage and the successful restoration of the defects (Figure 14 & Figure 15).

Third case

A female patient, nonsmoker and in a good general condition complained from poor smile aesthetics related to root exposures on her frontal maxillary teeth accentuated on her left and right canines (Figure 16). The clinical examination revealed RT2 recessions and non-carious cervical lesion on the left canine confined to the root of the tooth (Figure 17). The treatment approach was periodontal only, as the lesion was exclusively radicular. Zucchelli’s envelope flap was performed, and a connective tissue graft was placed at the level of 21, 22 and 23 (Figure 18-20).

Results

Discussion

Treatment of combined defects are challenging since, in these cases, the surgical root coverage does not achieve complete defect coverage resulting in persistence of dentin hypersensitivity and plaque retention, and the restorative treatment, when performed alone, yields to unesthetic long tooth. The combined restorative and periodontal approach were a subject of numerous studies. In fact, Santamaria et al proved in their two Randomized clinical trials, that reconstructing the whole damaged cervical area with a filling material such as modified glass ionomer and performing a CAF or CAF + CTG is a feasible and efficacious approach since the restorative material did not interfere with the root coverage outcome, and the coronal part of the defect that could not be managed with a CAF alone, is then restored. This induced the complete resolution of hypersensitivity [8-10]. These findings were confirmed in a recently published systematic review and meta-analysis by Gennai et al. [11]; indeed, the restoration of NCCL provides better outcomes for the reduction of Dentin hypersensitivity, which can be explained by obturation of the dentinal tubules by the material alone [complete restoration] or by the material and the root coverage (partial restoration + CTG).

Although histologic studies showed that the soft tissues can adhere to the subgingival resin composite or modified glass ionomer [12], Zucchelli argued that it was not biologically acceptable to restore a part of the root that was once covered with soft tissues [13]. Moreover, alteration of the complete restoration overtime due to discoloration, bacterial infiltration or material wear, complicates the reintervention. Gennai et al. [11] mentioned that the advantage of the partial restoration approach is the decreased risk of restoration detachment and/ or marginal deterioration and the ease of replacing or removing the restoration, as only a minimum portion is covered by the gingival tissue. In consideration of this, the classification of NCCLs, bringing forward an algorithm-based treatment, was proposed by Pini-Prato et al. [5] followed by Zucchelli’s NCCL types exposed in his case series [7].

In this latter, the rationale was that only the part of the CD that will not be covered by the soft tissues will be restored. Therefore, prior to the restoration, it is essential to relocate the lost CEJ or determine the MRC line in order to identify the apical limit of the partial restoration. Although deemed to be subjective and difficult in teeth without intact CEJ [11], The MRC line is an effective method in predicting the final position of the coronally advanced tissues and avoiding mistaking the abrasion line for the CEJ [14]. It is calculated by first measuring the ideal papilla height, from the contact point to the proximal CEJ of the tooth. This coronal reference point is easily detected when the interdental papilla is elevated with the use of a probe. Once this measurement is taken, this distance is reported starting from the actual tip of each papilla. The MRC is then predetermined by connecting with a scalloped line the projection of this distance on the recession margin [12].

Based upon the topographic relationship between the MRC and the NCCL, 5 treatment alternatives to 5 NCCL types were introduced:

If the lesion concerns the root surface only [NCCL types I and II], the adequate treatment is the periodontal surgical approach. Whereas NCCLs occurring coronally to the CEJ [NCCL type V] can only be restored properly with a resin composite filling. Crownradicular NCCLs associated with gingival recession [NCCL types III and IV] are the most complicated and challenging [7]. In fact, in a deep crown radicular NCCL areas, a coronally advanced flap alone could not predict root coverage to the level of the MRC since the presence of the root concavity left after the restoration. These concavities may lead to the flap shrinkage and collapse. Therefore, this type of lesion requires the addition of a CTG underneath the advanced flap. Moreover, one other reason for applying CTG is to augment gingival thickness, therefore ensuring the long-term stability of the coverage procedure [13].

Conclusion

Gingival recessions associated with NCCLs can be successfully treated. Before any restorative/surgical procedure, it is necessary to remove or control all the possible etiological factors associated with GR and NCCLs. The predetermination of the MRC can be used for the selection of the treatment approach of a CD. For the restorative procedure, resin composites may be recommended because of their esthetic properties. In cases where a surgical approach is indicated, CAF and bilaminar procedures combined or not with a CTG are considered the most predictable treatment options for single and multiple recession defects. This report of three cases supports the effectiveness of the combined approach in managing, non-carious cervical lesions associated with gingival recession with regards to tissues biology, surpassing the limitations of each treatment conducted alone and ensuring a long-term stability result.

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Tumor-Related Epilepsy and Post-Surgical Outcomes: Tertiary Hospital Experience in Saudi Arabia - Juniper Publishers

 Neurology & Neurosurgery - Juniper Publishers

Abstract

Objectives: Recent studies reported that tumor histopathology plays a significant role in predicting freedom from seizures after epilepsy surgery; however, no consensus among researchers regarding this issue exists. This study retrospectively examined different types of tumor-related epilepsy and post-epilepsy surgical outcomes and the relationship between various tumor Histopathology and these outcomes.

Methods: In this hospital-based retrospective study, patients with brain tumors and drug-resistant epilepsy, which is defined as the failure of two tolerated and appropriately chosen antiepileptic drugs (whether as monotherapies or in combination) to achieve and alleviate sustained seizure freedom, were recruited. These patients underwent a thorough pre-surgical evaluation in an Epilepsy Monitoring Unit (EMU) before deciding to undergo surgical intervention according to an epilepsy case management conference.

Results: One-hundred patients (including 45 children) with brain tumors were included in this study (male: female = 3:2). Most of the patients (93) had G/GNT. No significant differences in outcome were observed among sex, age, or histopathological categories. However, during the first year after epilepsy surgery, most of the low-grade G/GNT cases showed favorable outcomes based on ILAE classes 1 and 2 (61.3% and 9.7%, respectively), whereas high-grade gliomas and meningothelial tumors showed outcomes of ILAE class 1 (40% and 100%, respectively).

Conclusion: Post-epilepsy surgical outcomes of different brain tumors have been achieved with favorable outcomes in children and adults with low-grade gliomas and meningiomas. Thus, pre-surgical evaluation in EMU is highly recommended to enhance better post-epilepsy surgical outcomes.

Keywords: Epilepsy; Brain tumor; Histopathology; Surgery; Saudi Arabia; ILAE

Introduction

Approximately 30%–50% of patients with brain tumors have epilepsy as an initial presentation [1]. However, 6%–45% of patients with brain tumors develop seizures later in life [2,3]. Although the exact mechanism of seizure development in patients with brain tumors is not clearly understood, recent studies have identified that some changes in the peritumoral regions affect the release of neurotransmitters that lead to seizure development [4]. Many studies have reported a relationship between tumor type and seizure frequency. For example, low-grade gliomas and glioneuronal tumors (G/GNT) are associated with a high rate of seizure incidence (85%–92%) [5-7]. In contrast, glioblastomas, which are high-grade tumors, are associated with a low rate of seizure incidence (20%–50%) [8,9]. The incidence rates of seizures in meningiomas, especially in atypical and malignant subtypes, remain understudied [10]. Despite the abundance of knowledge regarding surgical management of resistant forms of epilepsy, including those associated with brain tumors, especially of the low-grade type, prospective studies regarding the medical treatment of epilepsy in this type of patient are scarce [11]. Reportedly, resection of the epileptogenic zone due to the development of brain tumors lead to freedom from or significant control of seizures in 70-90% of patients [12,13]. Furthermore, tumor type, seizure severity, early surgical intervention, frequency during the pre-operative stage, histopathology of the tumors, and the extension of surgical resection to include peritumoral tissues are reportedly the factors that increase the likelihood of freedom from seizures post-operatively [14]. Two of the best predictors of freedom from post-operative seizures include a duration of less than one year since the onset of epilepsy and gross total surgical resection [15,16]. Tumor histopathology plays a significant role in predicting freedom from seizures after epilepsy surgery; however, there is no consensus among researchers regarding this issue [17,18]. This study retrospectively investigated different types of tumor-related epilepsy and their outcomes in the first year after epilepsy surgery.

Materials and Methods

Study design

A hospital-based retrospective study was conducted using secondary data from the epilepsy registry at King Faisal Specialist Hospital and Research Center (KFSH&RC) between 1998 and 2017.

Study population

The included patients underwent surgery for drug-resistant epilepsy. The patients were admitted to the Epilepsy Monitoring Unit (EMU) for long-term monitoring; they underwent presurgical evaluations such as surface electroencephalography (EEG), 3-tesla magnetic resonance imaging (MRI) of the brain, and fluoro-deoxy-glucose positron emission tomography (PET) brain scans. Additionally, a qualified neuropsychologist was present during the evaluation of the enrolled patients with epilepsy. In some patients, intracranial subdural recordings, intracarotid amobarbital procedure (Wada test) and electrocorticography (ECoG), and motor, sensory, and language mapping were performed.

Detailed information about the patients was collected. This information included demographic characteristics (age, gender, handedness, age at onset of the disease) and history and clinical data (type of seizure and frequency, seizure observed at EMU, MRI findings, PET scan, ictal EEG (IEEG) location and type, subdural EEG recording, and inter-ictal EEG [IIEEG] location and type). Moreover, final diagnosis, surgical procedures, and pathology were recorded as the primary outcome. All tumor cases enrolled in this study were reviewed and graded independently by a neuropathologist according to the World Health Organization (WHO) classification [19]. Epilepsy data were discussed in an epilepsy surgery conference with epileptologists, epilepsy surgeons, neuroradiologists, and neuropsychologists to determine the status and surgical candidacy of the patient.

According to the International League Against Epilepsy (ILAE) commission report (1997–2001), six outcomes of interest were proposed [20]. However, the categories 4, 5, and 6 are difficult to measure and implement in daily practice, particularly when parameters related to the quality of life are included. Hence, we suggested simplifying the ILAE classification of epilepsy surgical outcomes with only four categories rather than six to facilitate its application for a new modification that shares the ILAE classification for classes 1, 2, and 3, while classes 4, 5, and 6 would be merged into only one class, called class 4. Thus, the definitions of the classes were divided into four groups:

1. class 1, patients who were completely seizure-free with no auras;

2. class 2, patients with auras but no seizures;

3. class 3, patients experiencing one to three seizure days per year ±auras; and

4. class 4, ranging from four or more seizure days per year to those experiencing ≥ 50% reduction of baseline seizure days ±auras to ≥ 100% increase in baseline seizure days; ±auras. Furthermore, outcomes of classes 1 and 2 were considered favorable, while those of classes 3 and 4 were considered unfavorable. These four outcomes were investigated during the first post-surgical year.

Data analysis

Statistical analysis through cross-tabulation of the tumor groups, pathologies, and progressive outcomes was performed using SAS software (ver. 9.4). Due to the small sample size, some subgroups, pathologies, and outcomes were collapsed. Proportional statistics, and chi-square and Fisher’s exact test were used to explain the findings within a 95% confidence interval (CI). A P-value of < 0.05 was considered statistically significant.

Results

Among the 100 patients with brain tumors related epilepsy included in this study, 59 (59%) were males, and 41 (41%) were females. The incidence of brain tumor-related epilepsy (BTRE) in our center was lower among children than adults (45% versus 55%). However, the differences among sex, age, and the histopathology categories were not statistically significant (P = 0.111 and 0.878, respectively) as depicted in Table 1.

According to histopathological findings, the cases of brain tumors were grouped into three main categories (Table 2). Most of the tumors (93%) were low-grade gliomas or glioneuronal tumors (G/GNT) followed by high-grade gliomas (5%); only two meningioma cases (2%) were detected. Among the three main categories of brain tumors, low-grade G/GNT consisted of 11 entities. Under this category, 40 tumors were gangliogliomas, and 29 tumors were Dysembryoplastic neuroepithelial tumors (DNET). Among the five high-grade gliomas, three were astrocytic tumors. Interestingly, only two meningiomas were found. Table 2 details the pathological categories.

In this study, the primary postoperative outcome was evaluated using the modified ILAE classification described in the methodology section. During the first post-surgical year, most patients with low-grade G/GNT experienced favorable outcomes (classes 1 and 2, 61.3% and 9.7%, respectively) as shown in Table 3. In contrast, approximately 40% of the patients with high-grade gliomas showed favorable outcomes (ILAE class 1). Both meningioma cases (100%) showed outcomes of ILAE class 1. Among the 100 patients with brain tumors, 71 (71%) patients, including 66 patients with low-grade G/GNT, three patients with high-grade gliomas, and two patients with meningiomas, experienced favorable outcomes during the one-year post-surgical period (Table 4). Moreover, the incidence of favorable outcome was higher in adult patients than in children (52.2% versus 47.8%) and in male versus female patients (41% versus 30%). However, these differences in outcome dependent on histopathological type, age, and sex were not statistically significant (P = 0.864, 0.559, and 0.159, respectively).

Discussion

From the epilepsy registry at KFSH&RC, 100 patients who underwent surgery for tumor-related epilepsy were included in this study. Varying associations between different brain tumor types and epilepsy have been reported. Most studies show gangliogliomas to be the most common tumor type associated with epilepsy, followed by DNET, oligodendrogliomas, and astrocytomas [21-24]. These findings support our results, that is, most of our patients had low-grade G/GNT (93.0%), most of which were gangliogliomas (40%) followed by DNET (29%). Furthermore, Babini et al. reported that gangliogliomas (66.7% versus 40%) [25] were the most frequent tumors among their patients; however, their sample size was smaller (30 cases) than in our study. Contrary to our findings, Kahlenberg et al. reported that mixed oligo-astrocytomas were the most prevalent tumors followed by astrocytomas grade II and oligodendrogliomas of grade II [25]. The incidence of high-grade gliomas was lower (5%) in our study than in a study by Michelucci et al. in Italy (77.0%), a finding attributed to a significantly high prevalence of high-grade gliomas in that area [15].

Seizures have a great impact on patient and caregiver quality of life. Seizures affect all aspects of a patient’s life, such as employment, social life, driving, and entertainment. Epilepsy surgery as described in many recent studies, is considered to relieve tumor-related epilepsy and achieve favorable outcomes [15,26,27]. However, in some cases, epilepsy persist even after resecting the primary focus [25]. All of our patients underwent well-planned epilepsy surgery, which is defined as the resection of the tumor and peritumoral tissues [23]. Consequently, our patients showed varying degrees of improvement during the first post-surgical year depending on the type of brain tumor (low-grade G/GNT versus high-grade gliomas); however, the differences were not statistically significant (P = 0.864). For example, patients with low-grade tumors, which were the most common type of tumor in our study (93 cases), showed a favorable outcome during the first post-epilepsy surgery year with approximately 71% freedom from seizure (classes 1 and 2). Michelucci et al. reported findings that were similar to our study, that is, better outcomes was observed in patients with low-grade gliomas (76%) [15]. In contrast, Kahlenberg et al. showed that about half of their patients (30 out of 54; 55.6%) with brain tumor-related epilepsy showed good post-surgical outcomes (seizure-free periods > 12 months) [25]. These proportions were lower than those observed in our study (55.6% versus 71%).

In our opinion, the ILAE classification of epilepsy surgical outcomes should be simplified using only four categories rather than six to facilitate ILAE application. Hence, whenever patients have four or more seizures (outcomes 4, 5, and 6), they should be classified into one category (category 4). The currently used ILAE Commission on Neurosurgery in 2001[28] still has some elements that make the use of categories 4, 5, and 6 difficult to measure and implement in daily practice, particularly when including parameters related to quality of life. This new modified classification can help the researchers in their ongoing studies.

Furthermore, few patients in our study had high-grade gliomas (five) or meningiomas (two). These patients showed a favorable outcome during the first post-surgical year (60% and 100%, respectively). Michelucci et al. reported similar results in which 58% of their patients with high-grade glioma became seizure free after tumor removal [15].

Pediatric and adult groups showed no significant differences regarding seizure outcomes during the first post-surgical year (P = 0.559); thus, we cannot claim that surgery is more beneficial in pediatric patients. These findings were similar to those of other studies [23].

Our study has three main limitations:

1. the sample size was small and included only five patients with high-grade gliomas and two patients with meningothelial tumors (two cases); this made comparison with low-grade G/GNT insufficient although our sample size (100 cases) is comparable to that of other studies;

2. this series of tumor-related epilepsy does not represent the population with epilepsy in Saudi Arabia because not all patients with tumor-related epilepsy are eligible to be admitted to our institution, and thus, they are treated; and

3. the possibility of bias occurring during data collection in a retrospective study. Despite the above-mentioned limitations, we hope that our study provides valuable information on one of the most debatable topics in epilepsy surgery in the country and throughout the Middle East.

Conclusion

In this study, the most common tumor-related epilepsy was low-grade G/GNT. Outcomes of post epilepsy surgery of different brain tumors have been achieved with a favorable outcome in both children and adults. Thus, thorough pre-surgical evaluation of patients with brain tumor-related epilepsy in EMU is highly recommended to enhance better post-epilepsy surgical outcomes. Further prospective, multicenter studies are needed with a larger number of patients to allow the findings to be more generalizable in Saudi Arabia.

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Transcatheter Aortic Valve Implantation - Tavi - Juniper Publishers

 Current Trends in Clinical & Medical Imaging - Juniper Publishers

Definition

The valves used for TAVI consists of biological heart valve mounted within a metal stent, this metal stent can be made from Ni–Ti super-elastic alloy, resulting in a self-expandable device, or from elasto-plastic metals (stainless steel). In both cases, the stent expansion pushes the native aortic valve leaflets against the aortic root. Degree and pattern of calcification of aortic valve may affect the expansion of the stent and patient’s outcome. Stroke may potentially be associated to the breakdown of calcium deposits [1]. Edward-Sapien valves are made from bovine pericardium in a trileaflet configuration mounted on a stent 14 mm in length and 23 or 26 mm in diameter and is delivered via 24-26 F catheter (internal diameter) [2,3]. Edward-Sapien valve 23 mm has a height of 14 mm, height of skirt 10.1 and 7.74 mm and used for annulus 18-22mm. Edward-Sapien valve 26 mm has a height of 16 mm, height of skirt 11.4 and 8.67 mm and used for annulus 21-25mm.

The Sapien-X has cobalt-chromium alloy which needs a smaller delivery system. The Edward-Sapien XT has the sizes of 20,23,26 and 29 mm and is used for annulus (16-19), (18-22), (21-25) and (24-27) mm respectively. Cor-valve is made of porcine mono-layer pericardium in a trileaflet configuration mounted on a self-expandable nitinol frame with inflow 26-29 and 31 mm and can be used for annulus between 20-29 mm. It can be used with 18 F delivery system. CorValve 23 mm has a height of 53 mm, height of skirt 12 mm and is used for annulus 20-23mm. Sinus of valsalva should be equal or more than 27mm and sinotubular junction≤40 mm. Corvalve 26 mm has a height of 55 mm, height of skirt 12 mm and is used for annulus 23-27mm. Sinus of valsalva should be equal or more than 28mm and sinotubular junction≤43mm.

CorValve 31 mm is used for annulus 26-29mm. Sinus of valsalva should be equal or more than 28mm and sinotubular junction≤43 mm. Medtronic Valve are supra-valvular valves and ADVANCE trial showed survival rate 95.5% at 30 days and 87.2 % at 6 months, MACE about 8.3% in 30 days and stroke 2.9% and success implantation 97.8% [4].

Keywords: TAVI, Migration, Paravalvular Leakage, Surgery, Anatomy, Transcatheter Aortic-valve Replacement

History

Previous trials have shown that among high-risk patients with aortic stenosis, survival rates are similar with transcatheter aortic-valve replacement (TAVR) and surgical aortic-valve replacement. PATNER I trial showed that in 25 patients with severe AS and STS 8.9 and Euroscore 25%, TAVI was successfully performed for all 25 patinets, mortality was 0 at 30 days and mean age was 85 years and mean AVA achieved to 1.6±0.27 form 0.59 ±0.15 cm2 [5]. In PARTNER II Trial, intermediate risk (STS=4) patients with symptomatic severe AS were entered in the study and were followed for 2 years, the endpoints were death or disabling stroke. The patients underwent TAVI or surgical AVR. The event rate was similar for TAVI and SAVR, at 2 years, endpoints was 19.3% for TAVI and 21.1% for SAVR, P=0.25. In the transfemoral-access cohort, TAVI resulted in a lower rate of death or disabling stroke than surgery (P=0.05), whereas in the transthoracic-access cohort, outcomes were similar in the two groups of TAVI and SAVR.

TAVI resulted in larger aortic-valve areas than did surgery and also resulted in lower rates of acute kidney injury, severe bleeding, and new-onset atrial fibrillation; surgery resulted in fewer major vascular complications and less paravalvular aortic regurgitation. In PARTNER II trial, the balloon-expandable SAPIEN XT heart-valve system was used .The major differences of the SAPIEN XT system, as compared with the first-generation SAPIEN valve system, are a thinner strut cobalt–chromium frame, a partially closed resting geometry of the bovine pericardial leaflets, the addition of a valve size that is 29 mm in diameter, and a reduced-profile delivery catheter.

A total of 18 patients (0.9%; 10 patients in the TAVI group and 8 in the surgery group) died during the procedure or within 3 days. A second transcatheter valve was placed within the first valve in 22 additional patients (2.2%) because of moderate or severe aortic regurgitation. In the TAVI group at 30 days, mild paravalvular aortic regurgitation was observed in 22.5% of patients, and moderate or severe paravalvular aortic regurgitation in 3.7%. Patients in the TAVI group who had moderate or severe paravalvular aortic regurgitation at 30 days had higher mortality during 2 years of follow-up than did patients who had no or trace regurgitation.

Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients

In PARTNER IB study, the patients with severe AS and no option for surgery, and candidate for medical therapy or TAVI were followed for one year. There was significant reduction in death and stroke in TAVI patients. The results of two-year follow up also showed reduction of mortality in TAVI vs medical therapy. According to this study, TAVI is the procedure of choice for patients with severe AS who are not candidate for surgery and have life expectancy for at least one year.

Indications and Contraindications

In extremely high-risk patients, TAVI is superior to surgery (class I). In high risk patients(I) and moderate (IIa)risk patients TAVI is non-inferior or even superior to surgery (with transfemoral approach). In two large studies on moderate risk patients, the mean age of patients was more than 80 years and STS were more than 4. In low risk patients and patients younger than 75 years, the surgery is the method of choice [6]. History of CABG, sequel of chest radiation or scliosis, and porcelain aorta favour for TAVI, whereas, short coronary ostia, annulus out of range , septal hypertrophy more than 18mm, aneurysme of aorta, bicuspid AV or severe calcification of AV and pattern of calcification (arch form with commissure to commissure),LV apical clot ,aortic root morphology unfavorable for TAVI, severe mitral or tricuspid disease or need for CABG fovor for surgery. For symptomatic severe AS with prohibitive surgical risk and survival more than 1 year, TAVI is class I indication. For symptomatic severe AS with high surgical risk and survival more than 1 year, TAVI and surgical AVR are class I indication. For symptomatic severe AS with intermediate surgical risk, surgical AVR is class I and TAVI is class IIa indication [7].

In Low Risk Patients with Severe Symptomatic AS, Surgical AVR Is Classi

In the PARTNER II (Placement of Aortic Transcatheter Valve II) RCT , which enrolled symptomatic patients with severe AS at intermediate risk (STS score ≥4%), there was no difference between TAVR and surgical AVR for the primary endpoint of all-cause death or disabling stroke at 2 years (HR: 0.89; 95% CI: 0.73 to 1.09; p=0.25). All-cause death occurred in 16.7% of those randomized to TAVR, compared with 18.0% of those treated with surgical AVR. Disabling stroke occurred in 6.2% of patients treated with TAVR and 6.3% of patients treated with surgical AVR. MSCT is the preferred technique for assessing the aortic root and size and shape of aortic annulus, the distance of coronary ostia from aortic annulus and shape of calcification. TEE 3D is an alternative tool for evaluating anatomy but is operator and image-quality dependent. Paravalvular leakage, need for pacemaker and vascular complications was more with TAVI and acute kidney injury, bleeding and AF was more with surgery, risk of stroke equal.

TAVI for Pure AI

David Roy A et al reported 43 cases of severe native valve aortic regurgitation underwent TAVI, men ST score was 10%,TAVI was successful in 42 patients, Implantation of a TAVI was performed in 42 patients (97.7%), and 8 patients (18.6%) required a second valve during the index procedure for residual aortic regurgitation. In all patients requiring second valves, valvular calcification was absent (p = 0.014). Post-procedure aortic regurgitation grade I or lower was present in 34 patients (79.1%). At 30 days, the major stroke incidence was 4.7%, and the all-cause mortality rate was 9.3%. At 12 months, the allcause mortality rate was 21.4% (6 of 28 patients) [8].

Complications

i. Migration

ii. Paravalvular Leakage

iii. CVA

iv. Death

Paravalvular Leakage

Redilation (5%) and second valve (4%) are used for paravalvular leak after TAVI. 52% of patients have no AI, 25% trivial and 23% mild AI and 2% have moderate AI. AI was paravalvular in 32%, transvalvular in 13% and both in 3% of patients. Male sex, NYHA IV and no previous aortic valve replacement are predictors of AI after TAVI. Transapical Aortic Valve Implantation [9]. Moderate to severe paravalvular leakage has been reported in up to 24% of patients.

Paravalvular Leakage was Graded as

Trivial:only pinpoint regurgitation jet in short-axis view of aortic valve,

Mild:Less than 10% of arc length/ circumference of AV,

Moderate:Between 10-30% arc length/ circumference of AV,

Severe: More than 30% of arc length/ circumference of AV.

In Partner trial, 12% had moderate to severe AI and 66% had no, trace or mild AI. With cor-valve paravalvular leak (9-21%) was slightly higher than Edward-Sapien valves. In FRANCE 2 registry, it has been confirmed that moderate to severe paravalvular leak at discharge was higher with self-expandable (19.8%) vs Balloon-expandable (12.8%). One of the major concerns about paravalvular leak is about its progression over time. While Webb et al reported that paravalvular leak is stable at one year follow up, Ussia et al repotted regression of paravalvular leak over time (3 year follow up) and no patient has changed from mild to moderate or severe PVL. Data from PATNER trial showed that at 2 year follow up, in 22.4% of patients, paravalvular leak is worsened more than 1 grade, in 46% remained unchanged and 31% it has been improved at least one grade. For Balloonexpandable valves, PVL should be assessed below the skirt of the valve. For central jet, it should be assessed at coaptation point of the leaflets.

Paravalvular leak occurs in 4% of patients post-surgical AVR.

Predictors of Paravalvular Leak Post TAVI

i. Malpositioning of valve,

ii. Undersizing of valve,

iii. Extent and pattern of calcification and eccentricity.

A smaller aortic valve area was associated with more paravalvular leak and smaller aortic valve area is due to larger calcification. In Cor-valve lower depth of implantation and larger LVOT aortic angle is associated with more paravalvular leakage. In one study by Cor valve implantation, larger annulus size, low implantation and peripheral vascular disease were the factors predicting equal or more than moderate paravalvular leak after TAVI,40.5% patients showed ≥ 2+ AI after TAVI which the majority respond to post dilation (2011). Eccentricity Index was reported as a predictor for paravalvular leak, Eccentricity index is calculated by dividing Min D/Max D of aortic annulus and EI>0.25 is reported as a predictor for PVL after TAVI in some reports whereas other cannot find a relationship between EI and PVL. Amount of calcification in the landing zone is reports as a predictor of PVL in some reports but in German Registry of TAVI, it has not been found. In a study by Luigi et al, Agaston score was the only predictor of paravalvular leak after TAVI and the aortic annulus eccentricity index was not a predictor of PVL. Maximal annulus diameter and cover index as predictors of more than mild PVL in univariate analysis but did not remain in the multivariate analysis [10].

Predictors of Early and Late Stroke After TAVI Are Categorized in Two Groups

i. Patient related: female gender, peripheral vascular disease, kidney disease, new onset atrial fibrillation, history of previous stroke and fall, angina, no previous CABG and low body mass index.

ii. Procedure related: annulus size, pure AS, time of procedure, rapid atrial pacing and Balloon predilation, valve repositioning and post dilation.

In a recent meta-analysis, in multivariate analysis, prior stroke and renal impairment were found as the only independent predictors for stroke complicating TAVI [11,12].

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Forensic Evidence of a Surgical Fetus- A Rare Case Report - Juniper Publishers

Forensic Sciences & Criminal Investigation -                            Juniper Publishers 

Abstract

Rape is the fasted growing crime in the country compared to other crime against women. It is also seen minor girl age between (7-12year) is found rape-victim and sometimes reported pregnant being raped. In such cases, pregnancy is terminated by doctors using different methods to save the life of minor innocent girl, protect from Human Rights and social stigma. In one case, a girl child, age about 12 year, was staying with single parent family. She used to visit and play with her friend being the neighbour. Taking advantage of age, the girl was lured and repeatedly raped by her friend’s uncle, an elderly man age about 57 year. One day, the victim girl complained abdominal pain and the doctor confirmed her pregnant but then she was about 20 weeks. The mother took up the matter to legal court to save her daughter being unable to access to medical termination of pregnancy (MTP). Considering the girls age/health, medical board was held under judge’s order and decided to end the pregnancy. The unborn fetus of the victim girl was removed and received in forensic science laboratory for DNA evidence to link the accused and establish the crime. The minor girl was saved to carry the pregnancy further. The details have been discussed in this rarest of the rare case.

Keywords: Minor girl; Illegal sex; Fetus, Surgery; DNA evidence

Introduction

In the life cycle of women, they are subjected to different violence in the society. The crime against women includes mostly sexual assault, foeticide, infanticide, dowry death, bride burning forced prostitution/sterilization etc. [1-3]. But rape/sexual assault is one of the most common crime reported against women of different age groups even kids and aged women are not spared. The sex with minor girl is an evil scenario in the society and reported for various reasons [4] According to National Crime Records Bureau (NCRB), MHA, Govt. of India, 2013 Annual Report, 24,923 rape cases were reported across India in 2012, out of which 24,470 committed by someone known to the victim [5] The statistical figure of rape cases is available but pregnant being raped is not much as such statistics under such crime head is not found in literature. The following are the reasons for increase of sexual offence cases in the country [6,7].

a) Man dominated society

b) Improper respect for women

c) Girls are not properly educated to react

d) Use of mobile blue film

e) No exemplary punishment and trials get unusually delay

f) Want of quality investigation

g) Media and dress code

h) Sadistic lifestyle

i) All want girl friend

j) Use of internet-based child sexual exploitation networking (Dark net market).

There is law to permit termination of pregnancy when there is threat to life or abnormal fetus. In this case, the victim was minor and under order of Hon’ble court unborn fetus was surgically removed by a team of doctors to terminate the pregnancy.

Case Report

A girl child age about 12-year was staying with single parent and used to visit her friend’s house being neighbor. Taking advantage of frequent visit, her friend’s uncle an elderly man age about 57 year lured the girl and developed physical relation. Subsequently, the girl got pregnant. One day having severe abdominal pain the girl child (victim) told her mother and on medical checkup, she was confirmed to be pregnant. Thereafter, the child revealed the hidden truth to her mother about sexual abuse by the uncle of her friend. She (victim) was then twenty weeks of pregnancy and risky on her age/health to continue. Hence took help of Hon’ble court for termination of pregnancy to save the life of minor girl child and lodged a FIR in the local police station for justice. The case was registered u/s 376(2)(1)(a)/506 Indian Penal Code (IPC) and sec 6 of Protection of Children from sexual offences (POCSO) Act.

Materials and Methods

In this critical case, as per order of the Hon’ble Court the fetus of the victim girl was removed by surgical method by a team of gynecological experts. Subsequently biological fluid (blood) from the offender and the victim girl was collected as per blood sample authentication form. The illegal surgical fetus after removal was also received for DNA evidence.

Medical examination and result

Potency test of the offender

A. General Physical Examination: Height 157cm, weight 51kg, pulse 78bpm, beard and moustache adult type, axillary and pubic hair adult type.

B. Local Examination: Penis length 8cm and circumference 9cm in flaccid condition, both the testes descended into the scrotal sac, scrotal skin is healthy; no genital, extra-genital injury was noted.

C. Based on the above findings the medico-legal expert opined that there was nothing to suggest that the offender is not capable of performing sexual intercourse

Surgical method used to remove unborn fetus

It was a case of late mid-trimester abortion. As per protocol, medical termination was attempted first by using prostaglandins and oxytocin. But as it failed it was decided to do surgical induction by transabdominal anterior hysterotomy under general anesthesia. In this procedure, after opening the abdomen low transverse incision was made on lower segment of the uterus. Abortus and placenta were removed completely; uterine wall was sutured in layers. Complete hemostasis was secured followed by closure of abdomen. Postoperative period was monitored meticulously by intravenous fluid, antibiotics, sedation and oxytocin.

Forensic DNA Evidence

Samples received from three different sources were properly preserved in the laboratory. The DNA Typing from three sources was made by using Genetic Analyzer AB 3130, Life Technologies Holding Pvt. Ltd., USA, following standard procedure available in literature [8]. The DNA profiling of all the three different exhibits are shown in (Table 1). The allelic distribution of fetus, victim and offender shown conclusively confirms that the victim and the offender are the biological parents of the fetus (Figure 1-3).

Conclusion

In this case the minor innocent girl was easily lured by the elderly man and repeatedly raped to satisfy his sex desire. But the offender could not think of the consequence as a result the girl got pregnant being raped. Moreover, the innocent girl could not understand what is being done on her and going to happen. She was also not taught to protest from such inhuman activity by her parents. As a child, she (victim) totally surrendered without any resistance to the offender and became the rape-victim of the devil. The fear of threatening in the mind of the girl being killed by the offender also kept her silent. As such, she was not at fault, abuser to blame. The criminal profile of the accused in this case, appears to be psychopath and mentally perverted and could not understand the barbaric act with a girl 12-year age almost like a daughter. The offender also did not care about stringent punishment prescribed under Protection of Children from Sexual Offences (POCSO) Act, leading to life imprisonment and even death. The offender is to be further examined by the psychiatric professional to know such unusual aggressive behavior. This is humiliating event in women’s life. The incident reminds a quote:

“Surgery during life is painful and benefit individual.

Surgery after death is not painful but benefits mankind”

The forensic result showing DNA evidence supported by the statement of the victim girl and medical report and circumstantial evidence could conclusively identified the offender & establish the crime.

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Is Spontaneous Resolution of Traumatic Tension Pneumothorax Possible? A Case Report and Brief Review of Literature - Juniper Publishers

Journal of Surgery- Juniper Publishers

Abstract

Tension pneumothorax is an infrequently encountered clinical condition in the emergency departments. It is a potential life-threatening condition which can result in cardiopulmonary deterioration and ultimately cardiac arrest if not promptly diagnosed and managed. It has various etiologies with blunt chest injuries being one of common causes. We report a rare case of a large traumatic tension pneumothorax following a blunt injury which resolved without specific intervention. The diagnosis was initially missed in the emergency department and was identified on a retrospective radiology report after 2 days. A repeat CXR has surprisingly shown that the tension pneumothorax resolved into “simple” pneumothorax without specific intervention. Interestingly, the patient remained stable all through his hospital stay for 7 days.

Conclusion: A spontaneous resolution of a large traumatic tension pneumothorax in a previously healthy and hemodynamically stable patient can occur. Nevertheless, the exact mechanism of this observation still remains poorly understood.

Learning points

a. The possibility of the tension pneumothorax should be considered in blunt chest trauma patients even when the typical clinical features are not present.

b. A radiologically-diagnosed tension pneumothorax should be promptly managed.

c. An alert system should be activated if critical radiological findings are detected and an effective response has to be followed by the trauma management team

Keywords: Tension pneumothorax; Misdiagnosis; Critical radiological finding; Spontaneous resolution

Abbrevations: ATLS: Advanced Trauma Life Support; CXR: Chest X-Rays; ED: Emergency Department, GCS: Glasgow Coma Scale

background

Tension pneumothorax is an infrequently encountered clinical occurrence with a variable incidence worldwide [1,2]. It merits special attention as it is a potentially life-threatening condition due to the progressive hemodynamic instability and cardiopulmonary deterioration. A high index of clinical suspicion is therefore required for a prompt diagnosis [1,2]. The recommendations regarding the management of pneumothoraxes depend on size, underlying etiology, and clinical stability of the patient [1]. The Advanced Trauma Life Support (ATLS) guidelines recommend insertion of a chest drain in a patient with a traumatic pneumothorax to prevent developing a tension pneumothorax [3]. We report an unusual case of a large traumatic tension pneumothorax in which the tension pneumothorax resolved spontaneously without specific intervention. The patient was stable all through his hospital stay; his oxygen saturation remained above 94% when breathing room air. To the best of our knowledge this is only the second reported case in the English medical literature in which spontaneous resolution of a large traumatic tension pneumothorax occurred [1].

Case Presentation

A previously healthy 23-year-old non-English speaking male was brought to our Emergency Department (ED) four hours earlier following an assault by a group of people. He stated that he had been hit repeatedly by heavy objects on different parts of his body. He complained of severe pain in both arms and right leg. There was no history of loss of consciousness, headache or vomiting. He denied chest pain or shortness of breath. His past medical and surgical history was insignificant. He was alert but in severe pain.

His vital signs on arrival were heart rate 102 beats per minute, blood pressure 131/87 mmHg, respiratory rate 22 breaths per minute and an oxygen saturation of 94% when breathing on room air. His GCS was 15. Multiple superficial abrasions were noted on his forehead and scalp, anterior aspect of the both forearms and the right lower leg. Tenderness was elicited over the right lower leg. Examination of the chest, abdomen and back was reported as normal by the ED resident. Right leg X-ray showed a right distal tibial fracture without deformity. His CXR revealed a large tension left-sided tension pneumothorax (Figure 1).

However, this critical finding was missed by the ED resident and the patient was admitted for neuro-observation and pain management. He remained clinically stable with normal neuroobservations. A retrospective radiology report received 2 days later depicted those findings which were consistent with a leftsided tension pneumothorax. On receipt this radiological report a repeat CXR was taken which revealed a left-sided pneumothorax with no midline mediastinal shift or tension features Figure 2, thus a spontaneous decompression of the previously noted tension pneumothorax occurred without specific intervention, a finding that was both a clinical as well as a radiological surprise.

The patient remained vitally stable all through his hospital stay and his oxygen saturation was constantly maintained above 94% when breathing room air. He never complained of shortness of breath or chest pain. Following this repeat CXR, size 32F chest drainage was inserted by the surgical team after informed consent for the “simple” large left-sided pneumothorax. A follow-up CXR showed a satisfactory position of the chest drain. He was reviewed at a Fracture Clinic on Day 5 for further management of the right tibial fracture. The chest drain remained in-situ for 4 days and was removed on Day 6 and the final CXR was relevant for a very small (<5%) pneumothorax. He was discharged home on Day 7 in a stable condition. The patient didn’t attend scheduled follow-up visits.

Results

The importance of the prompt clinical diagnosis of tension pneumothorax has been well-emphasized. The clinical features suggesting a tension pneumothorax are chest pain and respiratory distress (90%), tachycardia and ipsilateral decreased air entry (50-70%), low oxygen saturation, hypotension and contra-lateral tracheal deviation in less than 25% [2]. Nevertheless, these typical features are not always present [1,2]. Moreover, these features are poorly correlated with the diagnosis, and perhaps many cases were missed before doing chest radiographs [4]. In fact, there is increasing appreciation that tension pneumothoraces are generally diagnosed radiologically rather than clinically [4]. We have only identified one case of spontaneous resolution of a large traumatic tension pneumothorax in the reviewed English literature [5].

The reported patient was a clinically stable 33-year-old female who presented to ED following a fall. Her CXR showed a large right-sided tension pneumothorax and rib fractures, however, the diagnosis was missed by the ED resident and she was sent home. The diagnosis was made on a retrospective basis after reviewing her CXR and all attempts to contact her had failed. However, she returned to the hospital after 50 days with intractable vomiting due to methadone withdrawal and an admission CXR showed a complete resolution of the previously noted tension pneumothorax [5]. This reported case bears two similarities to ours as the diagnosis was initially missed by the ED doctor and the patient remained clinically stable through the course of the disease. However, we re-evaluated the patient after 2 days and this explains the resolution of tension pneumothorax with persistence of pneumothorax, as the presumed re-absorption rate is 1.25% per day on room air [6], and hence a complete lung re-expansion will not be expected after 2 days only.

This case demonstrates that tension pneumothorax can be a radiological diagnosis in clinically stable patients, nevertheless it should be managed promptly to prevent grave consequences that would rapidly occur. An alert system should be activated if critical radiological findings are detected and an effective response must be followed by trauma management team.  

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Live Taenia Worms in the Appendix: A Case Report-JuniperPublishers

Journal of Surgery-Juniper Publishers

Abstract

Taenia saginata is a zoonotic cestode causing taeniasis. Taeniasis refers to the intestinal infection with the adult stage of this tapeworm. An association between teaniasis and acute appendicitis is uncommon. We present the case of a 60 year old female who presented with abdominal pain for one day. She was diagnosed with having appendicitis and an appendectomy was performed. Live worms were retrieved intraoperatively from the distended, inflamed appendix. pathology of the appendix showed Taenia saginata eggs in the lumen. Histological analysis showed acute inflammation consistent with acute appendicitis caused by T saginata.

Keywords: Taenia saginata; Appendicitis; Taeniasis

Introduction

Taenia saginata, more commonly known as beef tapeworm, is a zoonotic cestode that causes taeniasis. Taeina saginata requires a cow as an intermediate host but humans are the only definitive hosts for the adult stage of the parasite. Adult tapeworms infest the human small intestine where they attach to the mucosa to absorb food from the host. Adult worms can reach a length of 4 to 6 meters and survive for as long as 25 years in the definitive host [1-6]. Taeniasis occurs worldwide and is relatively more common in developing countries where raw or undercooked meat with cysticercus bovis (larval stage) is consumed as part of traditional food cultures [6-10]. Once the cysticercus bovis, the larval stage, is ingested, the larval worm excysts in the small intestine and develops into an adult within two months, then the scolex attaches itself to the intestinal mucosa to initiate infection.

Most people with a light infection are asymptomatic or have minor complications lasting years. With fairly heavy infections, people may have allergic reactions, constipation, diarrhea, dizziness, and nausea, and weight loss, irritation of the intestine and stomach ache [11,12]. The most common symptom is the presence of proglottids being passed in the feces [11,12]. Rarely, the worm can cause intestinal obstruction [11,12], colonic anastomotic leakage [13] and individual proglottids may migrate into the appendix causes acute appendicitis by blocking the appendiceal lumen [10-14]. Few cases of T. saginata infestation of the appendix have been reported [15]. We report here a case of acute appendicitis caused by T. saginata.

Case Report

A 60 year old female presented to our emergency department with a one day history of abdominal pain lower abdomen. On examination she had diffuse tenderness in lower abdomen without any other symtoms or fever. Pain was constant in nature associated with decreased appetite sine a few days. With an Alvadaro score of 3/10, patient did not fit into a particular diagnosis, we did a CT scan of abdomen, which revealed features suggestive of perforated appendicitis (Figure 1). The patient was diagnosed with having appendicitis and she underwent an explorative appendectomy. Intraoperatively the appendix was found to be moderately inflamed, distended near tip, no perforation, with no free fluid in peritoneal cavity. After ligating the appendix we opened the tip of the appendix, two live, small (approx 2-3 cm) tape worms came out (Figure 2).

We looked for other viscera in abdomen and peklvis which was found to be grossly normal. In postoperative period patient was dewormed and discharged on 2nd postoperative day. Pathology of the appendix showed inflam-mation. Histopatology of the appendix showed a free T saginata eggs and fecal matter in the appendixs. There was diffuse inflammation covering the appendix and eosinophils (consistent with parasite infection) and neutrophils in the appendiceal wall. These findings are consistent with acute suppurative appendicitis and parasite infestation.

Discussion

Acute appendicitis is a common abdominal emergency worm induced appendicitis is a known entity, however its rare [1] ; a small percentage of cases may be due to intestinal worms [2] . The pathogenisis of parasite induced appendicitis is poorly understood [2,3]. One study found 1.5% of acute appendicitis cases were caused by parasites [4]. Some parasites, especially worms, can accidentally enter the appendix. It is unclear why Enterobius vermicularis and Schistosoma haematobium enter the appendix [5]. Enterobius vermicularis is the most common nematode located predominantly in the cecum, appendix and colon and is the most common parasite associated with acute appendicitis [6-9].

Taeniasis is an uncommon cause of appendicitis and few cases have been described in the literature [9-12]. T. saginata is one of the most common helminthes located predominantly in the human intestinal tract causing important medical and social problems, especially in developing countries [11]. Adult worms live in the proximal part of the small intestine without causing any serious symptoms [13,12]. However, in heavy worm infections, proglottids of the parasite may migrate to the pancreas, liver and less commonly into the appendix [13,12].

The most common symptoms with teaniasis are abdominal discomfort, epigastric pain, vomiting and diarrhea [13,12]. T. saginata associated acute appendicitis may occur as a result of the worm proglottids (ova) entering the appendix [14,15]. However, some cases are reported in the literature where the parasite may be present in the lumen of the appendix [16]. Further studies are necessary to determine the role of parasites in the pathogenesis of acute appendicitis.

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