Dit is een artikel van 1972. Dat betekent dat gerechtsdeskundigen al meer dan 40 jaar weten dat de autogordel de bloedtoevoer naar de hersenen kan afsnijden in geval van whiplash. Toch worden hersenletsels niet (of zeer zelden) erkend en doen ze alsof hun neus bloedt.
This official textbook of the European Association of Echocardiography (EAE) serves the educational requirements of cardiologists and all clinical medical professionals, underpinning the structural training in the field in accordance with EAE aims and goals, and reflecting the EAE Core Syllabus. Published in partnership with the European Society of Cardiology, and written by a team of expert authors from across Europe, it is a valuable resource to support not only those with an interest in echocardiography but specifically those seeking the information needed for accreditation and training through the EAE.
This article provides a review of the history and current status of constrictive pericarditis. It begins with a brief overview of the history of constrictive pericarditis dating back to the 17th century. It then discusses the various etiologies of constrictive pericarditis including infections, connective tissue diseases, neoplastic diseases, and iatrogenic causes. The clinical presentation and physical exam findings are described. Various diagnostic tools are discussed including echocardiography, nuclear ventriculography, and angiocardiography. The article concludes with a discussion of differentiating constrictive pericarditis from restrictive cardiomyopathy and the timing of pericardial resection for treatment
Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...asclepiuspdfs
Ventricular tachycardia (VT) is a rhythmic emergency due to the poor hemodynamic tolerance, the possibility of transformation into ventricular fibrillation, and the occurrence of sudden death. It is a late complication after thoracic trauma due to ventricular remodeling and scar tissue fibrosis, the main arrhythmogenic substrate. The case we report is that of an 80-year-old patient admitted to our unit for lipothymic discomfort that has been evolving for several months. In this antecedent, we find a violent thoracic traumatism 23 years ago by accident of the public way. On admission, it has a stable hemodynamics; the surface electrocardiogram inscribes a sinus rhythm with diffuse negative T waves and reassuring biology. A few hours after his hospitalization, the discomfort will reappear with unsupported TV. Coronary angiography eliminates an ischemic cause with non-significant atheroma of the bisector. Echocardiography demonstrates a particular aspect of hypertrophy of the left ventricular apex with normal contractile function. Cardiac magnetic resonance imaging shows myocardial fibrosis in this area of hypertrophy and the cardiac computed tomography with three-dimensional reconstruction allows to visualize partial apical inferior disinsertion with an interventricular septum with a thin wall on the right ventricular slope calcified in places with an inlet opening closing in systole. The mechanism of TV in our patient is related to myocardial fibrosis and ventricular remodeling secondary to myocardial contusion 23 years ago. In this context, an implantable automatic defibrillator has been set up with half-yearly monitoring.
Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...asclepiuspdfs
Our aim is to present a rare cause of tricuspid valve infective endocarditis (IE) in grown-up age due to cerebrospinal fluid shunt-associated infection. A 32-year-old woman, with a history of hydrocephalus that was treated with ventriculoperitoneal (VP) shunt at the age of 4, was admitted to a hospital due to fever. The VP shunt was replaced several times due to dysfunction and replaced with ventriculoatrial (VA) shunt 3 months before admission. Transesophageal echocardiogram revealed two separate VA catheters in the right atrium, with two floating echo formations, one attached to the tip of one catheter and the other to the anterior leaflet of tricuspid valve. Blood cultures grew methicillin-susceptible Staphylococcus aureus. Computed tomography scan showed bilateral pneumonia. The patient was treated with antibiotics followed by partial extraction of the VA shunt. After 8 weeks, the patient was discharged, without signs of infection. Two months later, she was readmitted due to fever, echocardiographic signs of catheter infection, and septic pulmonary embolization. Complete extraction of VA catheter was done and treatment was continued with antibiotics with complete recovery. Early diagnosis and optimal management that combines both conventional and surgical approaches is crucial for reducing the high embolic risk, risk of complications, and mortality risk.
A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...asclepiuspdfs
Hypertrophic obstructive cardiomyopathy is mostly associated with mitral insufficiency rather than mitral stenosis. This association is very rare and no cases have been reported in Africa. Our case was about 22-month-old female child that was referred with a 1-year history of tachypnea and III to IV class of dyspnea. Transthoracic echocardiography showed serious mitral stenosis and a mean gradient of 27 mmHg. The interventricular septum was hypertrophic with a width of 8.5 mm with small aortic annulus, leading subaortic stenosis with a mean gradient of 73 mmHg. There was also a severe pulmonary hypertension at 79 mmHg. It was expected to doing a standard septal myectomy and mitral valve replacement.
This document describes a case study of a patient with Brugada syndrome who experienced progression of his heart condition. The patient initially presented with ventricular fibrillation and was found to have a low-voltage area in his right ventricle. One year later, he experienced recurrent ventricular fibrillation. Mapping of his heart found the low-voltage area had increased in size. Biopsies of the area found myocardial inflammation and necrosis. Radiofrequency ablation successfully terminated arrhythmias but also induced polymorphic ventricular tachycardia on occasion. The case suggests structural abnormalities in Brugada syndrome can progress and lead to arrhythmia recurrence.
This case report describes a 19-year-old male who presented with chest pain and was found to have ST elevations on EKG suggestive of a heart attack. He received thrombolytics which normalized his EKG. Further testing showed normal coronary arteries and features of myocarditis on cardiac MRI. This is a unique case because the patient's EKG normalized immediately after thrombolytics, unlike typical cases of myocarditis, yet he was ultimately diagnosed with myocarditis rather than a heart attack. The report discusses the challenges in distinguishing myocarditis from heart attack given similarities in presentation and discusses the rare occurrence of EKG normalization after thrombolytics in myocarditis cases.
The document describes a study of 27 patients in Iraq who underwent surgical treatment for left ventricular aneurysms between 2001-2011. Left ventricular aneurysms are complications that can arise after a myocardial infarction. The patients were mostly middle-aged males and had multiple blocked coronary arteries. Surgical techniques used to repair the aneurysms included linear repair and the Dor procedure. Post-operative complications were common, with the highest rate being bleeding. The overall hospital mortality rate for the surgeries was 18.5%.
This official textbook of the European Association of Echocardiography (EAE) serves the educational requirements of cardiologists and all clinical medical professionals, underpinning the structural training in the field in accordance with EAE aims and goals, and reflecting the EAE Core Syllabus. Published in partnership with the European Society of Cardiology, and written by a team of expert authors from across Europe, it is a valuable resource to support not only those with an interest in echocardiography but specifically those seeking the information needed for accreditation and training through the EAE.
This article provides a review of the history and current status of constrictive pericarditis. It begins with a brief overview of the history of constrictive pericarditis dating back to the 17th century. It then discusses the various etiologies of constrictive pericarditis including infections, connective tissue diseases, neoplastic diseases, and iatrogenic causes. The clinical presentation and physical exam findings are described. Various diagnostic tools are discussed including echocardiography, nuclear ventriculography, and angiocardiography. The article concludes with a discussion of differentiating constrictive pericarditis from restrictive cardiomyopathy and the timing of pericardial resection for treatment
Ventricular Tachycardia in Chronic Myocardial Contusion Interest of Multimoda...asclepiuspdfs
Ventricular tachycardia (VT) is a rhythmic emergency due to the poor hemodynamic tolerance, the possibility of transformation into ventricular fibrillation, and the occurrence of sudden death. It is a late complication after thoracic trauma due to ventricular remodeling and scar tissue fibrosis, the main arrhythmogenic substrate. The case we report is that of an 80-year-old patient admitted to our unit for lipothymic discomfort that has been evolving for several months. In this antecedent, we find a violent thoracic traumatism 23 years ago by accident of the public way. On admission, it has a stable hemodynamics; the surface electrocardiogram inscribes a sinus rhythm with diffuse negative T waves and reassuring biology. A few hours after his hospitalization, the discomfort will reappear with unsupported TV. Coronary angiography eliminates an ischemic cause with non-significant atheroma of the bisector. Echocardiography demonstrates a particular aspect of hypertrophy of the left ventricular apex with normal contractile function. Cardiac magnetic resonance imaging shows myocardial fibrosis in this area of hypertrophy and the cardiac computed tomography with three-dimensional reconstruction allows to visualize partial apical inferior disinsertion with an interventricular septum with a thin wall on the right ventricular slope calcified in places with an inlet opening closing in systole. The mechanism of TV in our patient is related to myocardial fibrosis and ventricular remodeling secondary to myocardial contusion 23 years ago. In this context, an implantable automatic defibrillator has been set up with half-yearly monitoring.
Infective Endocarditis as a Complication of Ventriculoatrial Shunting for Hyd...asclepiuspdfs
Our aim is to present a rare cause of tricuspid valve infective endocarditis (IE) in grown-up age due to cerebrospinal fluid shunt-associated infection. A 32-year-old woman, with a history of hydrocephalus that was treated with ventriculoperitoneal (VP) shunt at the age of 4, was admitted to a hospital due to fever. The VP shunt was replaced several times due to dysfunction and replaced with ventriculoatrial (VA) shunt 3 months before admission. Transesophageal echocardiogram revealed two separate VA catheters in the right atrium, with two floating echo formations, one attached to the tip of one catheter and the other to the anterior leaflet of tricuspid valve. Blood cultures grew methicillin-susceptible Staphylococcus aureus. Computed tomography scan showed bilateral pneumonia. The patient was treated with antibiotics followed by partial extraction of the VA shunt. After 8 weeks, the patient was discharged, without signs of infection. Two months later, she was readmitted due to fever, echocardiographic signs of catheter infection, and septic pulmonary embolization. Complete extraction of VA catheter was done and treatment was continued with antibiotics with complete recovery. Early diagnosis and optimal management that combines both conventional and surgical approaches is crucial for reducing the high embolic risk, risk of complications, and mortality risk.
A Rare Case of Hypertrophic Cardiomyopathy Associated with Congenital Mitral ...asclepiuspdfs
Hypertrophic obstructive cardiomyopathy is mostly associated with mitral insufficiency rather than mitral stenosis. This association is very rare and no cases have been reported in Africa. Our case was about 22-month-old female child that was referred with a 1-year history of tachypnea and III to IV class of dyspnea. Transthoracic echocardiography showed serious mitral stenosis and a mean gradient of 27 mmHg. The interventricular septum was hypertrophic with a width of 8.5 mm with small aortic annulus, leading subaortic stenosis with a mean gradient of 73 mmHg. There was also a severe pulmonary hypertension at 79 mmHg. It was expected to doing a standard septal myectomy and mitral valve replacement.
This document describes a case study of a patient with Brugada syndrome who experienced progression of his heart condition. The patient initially presented with ventricular fibrillation and was found to have a low-voltage area in his right ventricle. One year later, he experienced recurrent ventricular fibrillation. Mapping of his heart found the low-voltage area had increased in size. Biopsies of the area found myocardial inflammation and necrosis. Radiofrequency ablation successfully terminated arrhythmias but also induced polymorphic ventricular tachycardia on occasion. The case suggests structural abnormalities in Brugada syndrome can progress and lead to arrhythmia recurrence.
This case report describes a 19-year-old male who presented with chest pain and was found to have ST elevations on EKG suggestive of a heart attack. He received thrombolytics which normalized his EKG. Further testing showed normal coronary arteries and features of myocarditis on cardiac MRI. This is a unique case because the patient's EKG normalized immediately after thrombolytics, unlike typical cases of myocarditis, yet he was ultimately diagnosed with myocarditis rather than a heart attack. The report discusses the challenges in distinguishing myocarditis from heart attack given similarities in presentation and discusses the rare occurrence of EKG normalization after thrombolytics in myocarditis cases.
The document describes a study of 27 patients in Iraq who underwent surgical treatment for left ventricular aneurysms between 2001-2011. Left ventricular aneurysms are complications that can arise after a myocardial infarction. The patients were mostly middle-aged males and had multiple blocked coronary arteries. Surgical techniques used to repair the aneurysms included linear repair and the Dor procedure. Post-operative complications were common, with the highest rate being bleeding. The overall hospital mortality rate for the surgeries was 18.5%.
Isolated venous thrombosis of the posterior fossa is a rare form of intracranial vein thrombosis that can cause localized cerebellar infarction or hemorrhage. The authors studied 9 cases of isolated posterior fossa vein thrombosis identified among 230 patients with intracranial vein thrombosis. Presentations included intracranial hypertension and cerebellar syndromes. Risk factors included puerperium, contraceptive use, and genetic factors. Diagnosis was challenging but was made using CT, MRI, or histopathology. Outcomes ranged from full recovery to death or disability.
Definition of LVA Centerline analysis of RWMA on LV angio in 30º RAO shows hypocontractile segments moving more than 2 standard deviations out of normal range.
Acs0616 Repair Of Femoral And Popliteal Artery Aneurysmsmedbookonline
Femoral and popliteal artery aneurysms are the most common type of peripheral aneurysms. While rarely rupturing, they can cause limb-threatening complications like embolization and thrombosis if left untreated. The optimal treatment is elective repair and reconstruction, rather than emergency repair after complications occur. Factors like symptoms, aneurysm size, and extent of disease help determine the appropriate treatment approach. Preoperative evaluation involves imaging to characterize the aneurysm and assess inflow and outflow vessels. The goals of surgical repair are to eliminate embolic risk, prevent rupture, relieve mass effect if present, restore distal limb perfusion, and achieve durable reconstruction.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
Presentation at the Fourth International Conference of Advanced Cardiac Sciences, 2012, by Carlos Monteiro.
An overview about the new pathophysiological and therapeutic concepts of the myogenic theory of myocardial infarction, developed by Quintiliano H. de Mesquita in 1972, by reviewing the following topics:
Coronary thrombosis: cause or consequence of myocardial infarction?; Introduction and fundamentals; Mechanism and sequence of events; Stress and acute myocardial syndromes; The benefits of cardiotonic drugs in patients with stable heart disease, unstable angina and acute myocardial infarction; The role of the cardiotonic completing the effects of coronary collateral circulation; The cardiotonic sympatholytic properties; Endogenous cardiotonic steroids; etc..
ARVD (Arrythmogenic right ventricular cardiomyopathy) - updated task force cr...Imran Ahmed
This document discusses arrythmogenic right ventricular cardiomyopathy (ARVC). It begins by explaining the genetics of ARVC, noting that mutations can be either dominant or recessive. It then describes the natural history, clinical presentation, diagnosis, and criteria used to diagnose ARVC based on the revised Task Force Criteria. This includes major and minor criteria in categories such as imaging, electrocardiography findings, biopsy results, and family history. The document concludes by discussing management strategies for ARVC including ICD therapy, antiarrhythmic drugs, ablation, heart failure treatment, and transplantation.
This document summarizes the history of treatment for penetrating cardiac injuries. It discusses how cardiac injuries were initially considered fatal throughout ancient times but that views gradually changed as more successful repairs were performed from the late 19th century onward. The clinical presentation of cardiac injuries can vary widely from stability to sudden collapse, depending on factors like the type of injury and whether a pericardial tamponade is present.
This document summarizes a study examining left ventricular remodeling after myocardial infarction. The study found:
1) In 30 patients who underwent cardiac catheterization at admission and 2 weeks post-myocardial infarction, left ventricular volumes (end-diastolic and end-systolic) increased significantly from admission to 2 weeks, while pressures (left ventricular end-diastolic and pulmonary capillary wedge) decreased.
2) The increase in left ventricular end-diastolic volume correlated with the percentage of the ventricle that was akinetic or dyskinetic on admission angiograms.
3) Serial angiograms found increases in endocardial perimeter lengths of both infarcted (akinetic/dyskinetic)
Cabg is superior to pci in heart failure patients with multivessel disease co...drucsamal
PCI is a good alternative to CABG for revascularization in patients with heart failure and viable myocardium. Revascularization of viable myocardium may improve left ventricular function and remodeling, as well as quality of life and survival. While CABG is technically straightforward and evidence-based, PCI has less risk for patients with heart failure despite being technically challenging. More research is still needed comparing PCI to CABG and medical therapy alone for chronic heart failure. Treatment must be individualized based on patient characteristics and local clinical expertise.
1) Takotsubo syndrome is a cardiac condition triggered by stressful events where the left ventricle temporarily takes on a distinctive "Takotsubo" shape.
2) It is thought to be caused by very high levels of stress hormones like adrenaline activating negative inotropic pathways in the heart through beta-2 adrenergic receptors, particularly in the left ventricular apex.
3) This leads to left ventricular dysfunction and heart failure symptoms, but the heart typically recovers its normal function within weeks as the stress response subsides. However, the full pathophysiology and long term effects are still being uncovered.
Revascularization in heart faliure seminarAnkit Jain
This document discusses revascularization in patients with heart failure due to coronary artery disease and residual left ventricular dysfunction. It provides details on myocardial hibernation and stunning - two states of sustained contractile dysfunction despite viable myocardium. Revascularization can lead to improved survival and reverse remodeling in such patients if a sufficient amount of viable myocardium is present. Techniques to assess myocardial viability include stress echocardiography, nuclear imaging with SPECT or PET, and cardiac magnetic resonance. Revascularization is recommended for patients who have viability in at least 25% of the left ventricular segments.
A 61-year-old man presented with chest pain and was found to have ST-segment elevation in multiple leads on his electrocardiogram (ECG), indicating a heart attack. Additional ECG views showed involvement of the right ventricle. Coronary angiography revealed a 100% blockage of the right coronary artery near the branch supplying the right ventricle. The blockage was opened with a percutaneous coronary intervention, restoring blood flow. The man's condition improved with treatment, and follow-up testing showed his left ventricle function was normal but there was mild dysfunction of the right ventricle.
- A study examined ruptured coronary plaques in patients with acute coronary syndrome using intravascular ultrasound (IVUS) and found ruptured plaques not just at the culprit lesion but also in other vessels.
- Both culprit lesions and additional ruptured plaques showed positive arterial remodeling, where the vessel expands to accommodate plaque growth.
- Positive remodeling is associated with plaque vulnerability and unstable coronary syndromes, while negative remodeling is more common in stable lesions and involves vessel constriction around plaque.
- The direction of remodeling may represent different inflammatory stages of plaque development, with positive remodeling indicating early active lesions and negative remodeling indicating more stabilized advanced lesions.
This document discusses Paget-Schroetter syndrome, also known as effort thrombosis, which is thrombosis (blood clot) of the axillary and subclavian veins caused by repetitive arm motions. It affects young, active individuals and causes swelling and pain in the arm. Treatment options discussed include anticoagulation alone versus thrombolysis or decompression of the thoracic outlet through surgery. Follow up of surgical patients found low complication rates, satisfactory long-term outcomes with patent veins, and good post-operative quality of life scores.
Coronary heart disease is a major cause of mortality worldwide. Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a non-surgical procedure used to treat blockages within the coronary arteries of the heart. During PCI, a catheter is inserted into an artery and guided to the site of blockage where a balloon is inflated to open the artery. Often a stent is placed to keep the artery open. PCI has become a common revascularization treatment for acute coronary syndromes and stable angina. While generally safe, complications from PCI occur in less than 2% of patients and include adverse reactions, acute myocardial infarction, bleeding, and death in less than 0.08% of patients.
Cardiology lecture toIternal Medicine 21/10/2013hospital
This document provides an outline and content for a cardiology lecture for internal medicine board exam preparation. It includes multiple choice questions (MCQs), a picture quiz, and explanatory notes on topics like myocardial infarction, heart failure, atrial fibrillation, and hypertension. The lecture was given by Dr. Ihab Suliman on October 20, 2013 and covered diagnostic tests, treatments, medications, and pathophysiology related to cardiology.
A rara associação de drenagem anômala total de veias pulmonares e cor triatri...gisa_legal
This document describes a rare case of a patient with both total anomalous pulmonary venous connection (TAPVC) and cor triatriatum. A pre-operative cineangiocardiogram ruptured the membrane dividing the left atrium in cor triatriatum, improving hemodynamics. Successful corrective surgery was then performed, involving resection of the cor triatriatum membrane and anastomosis of the left atrium to the pulmonary veins. At a six month follow up, the patient was doing well with mild residual effects.
The document summarizes arrhythmogenic right ventricular dysplasia (ARVD), a condition where the right ventricle of the heart is replaced by fat and fibrous tissue. It affects mostly young males and can cause sudden cardiac death. Genetic factors are involved in many cases. The condition starts with fatty infiltration of the right ventricle and progresses to include fibrosis, thinning of the ventricular wall, and later involvement of the left ventricle. Diagnosis involves criteria related to structural changes, electrocardiogram abnormalities, arrhythmias, and family history.
Broken Heart Syndrome: Cardiovascular Manifestations of Traumatic Brain InjuryAmit Agrawal
This document summarizes cardiovascular complications that can occur following traumatic brain injury (TBI). Up to 15.7% of patients with severe TBI can develop left ventricular dysfunction and wall motion abnormalities due to increased sympathetic activity and catecholamine release after brain injury. This can cause hypotension, hypertension, arrhythmias, and myocardial injury. ECG changes, echocardiogram abnormalities, and elevated biomarkers of cardiac injury have been documented following TBI. While the exact mechanisms are not fully understood, autonomic dysfunction and systemic inflammation following TBI can directly or indirectly impact cardiovascular function. Treatment involves optimizing hemodynamics and treating the underlying brain injury, as the cardiac abnormalities are often transient.
IMAGES OF A COMPLEX CASE OF MULTIPLE ANEURYSMAL DISEASE IN A 58 YEAR OLD MAN
IMMAGINI DI UN CASO COMPLESSO DI MALATTIA POLINEURISMATICA
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
This letter summarizes potential complications that can arise from closed-chest cardiac resuscitation based on the authors' experience. It includes a table listing various cardiac, gastrointestinal, skeletal, respiratory, vascular, embolic, and miscellaneous complications that have been reported in literature, such as myocardial rupture, liver laceration, rib fracture, hemothorax, aortic rupture, fat embolism, and neuropsychiatric issues. The authors constructed this table to inform healthcare providers of possible ill effects of resuscitation to allow for more informed care during and after the procedure.
Isolated venous thrombosis of the posterior fossa is a rare form of intracranial vein thrombosis that can cause localized cerebellar infarction or hemorrhage. The authors studied 9 cases of isolated posterior fossa vein thrombosis identified among 230 patients with intracranial vein thrombosis. Presentations included intracranial hypertension and cerebellar syndromes. Risk factors included puerperium, contraceptive use, and genetic factors. Diagnosis was challenging but was made using CT, MRI, or histopathology. Outcomes ranged from full recovery to death or disability.
Definition of LVA Centerline analysis of RWMA on LV angio in 30º RAO shows hypocontractile segments moving more than 2 standard deviations out of normal range.
Acs0616 Repair Of Femoral And Popliteal Artery Aneurysmsmedbookonline
Femoral and popliteal artery aneurysms are the most common type of peripheral aneurysms. While rarely rupturing, they can cause limb-threatening complications like embolization and thrombosis if left untreated. The optimal treatment is elective repair and reconstruction, rather than emergency repair after complications occur. Factors like symptoms, aneurysm size, and extent of disease help determine the appropriate treatment approach. Preoperative evaluation involves imaging to characterize the aneurysm and assess inflow and outflow vessels. The goals of surgical repair are to eliminate embolic risk, prevent rupture, relieve mass effect if present, restore distal limb perfusion, and achieve durable reconstruction.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
Presentation at the Fourth International Conference of Advanced Cardiac Sciences, 2012, by Carlos Monteiro.
An overview about the new pathophysiological and therapeutic concepts of the myogenic theory of myocardial infarction, developed by Quintiliano H. de Mesquita in 1972, by reviewing the following topics:
Coronary thrombosis: cause or consequence of myocardial infarction?; Introduction and fundamentals; Mechanism and sequence of events; Stress and acute myocardial syndromes; The benefits of cardiotonic drugs in patients with stable heart disease, unstable angina and acute myocardial infarction; The role of the cardiotonic completing the effects of coronary collateral circulation; The cardiotonic sympatholytic properties; Endogenous cardiotonic steroids; etc..
ARVD (Arrythmogenic right ventricular cardiomyopathy) - updated task force cr...Imran Ahmed
This document discusses arrythmogenic right ventricular cardiomyopathy (ARVC). It begins by explaining the genetics of ARVC, noting that mutations can be either dominant or recessive. It then describes the natural history, clinical presentation, diagnosis, and criteria used to diagnose ARVC based on the revised Task Force Criteria. This includes major and minor criteria in categories such as imaging, electrocardiography findings, biopsy results, and family history. The document concludes by discussing management strategies for ARVC including ICD therapy, antiarrhythmic drugs, ablation, heart failure treatment, and transplantation.
This document summarizes the history of treatment for penetrating cardiac injuries. It discusses how cardiac injuries were initially considered fatal throughout ancient times but that views gradually changed as more successful repairs were performed from the late 19th century onward. The clinical presentation of cardiac injuries can vary widely from stability to sudden collapse, depending on factors like the type of injury and whether a pericardial tamponade is present.
This document summarizes a study examining left ventricular remodeling after myocardial infarction. The study found:
1) In 30 patients who underwent cardiac catheterization at admission and 2 weeks post-myocardial infarction, left ventricular volumes (end-diastolic and end-systolic) increased significantly from admission to 2 weeks, while pressures (left ventricular end-diastolic and pulmonary capillary wedge) decreased.
2) The increase in left ventricular end-diastolic volume correlated with the percentage of the ventricle that was akinetic or dyskinetic on admission angiograms.
3) Serial angiograms found increases in endocardial perimeter lengths of both infarcted (akinetic/dyskinetic)
Cabg is superior to pci in heart failure patients with multivessel disease co...drucsamal
PCI is a good alternative to CABG for revascularization in patients with heart failure and viable myocardium. Revascularization of viable myocardium may improve left ventricular function and remodeling, as well as quality of life and survival. While CABG is technically straightforward and evidence-based, PCI has less risk for patients with heart failure despite being technically challenging. More research is still needed comparing PCI to CABG and medical therapy alone for chronic heart failure. Treatment must be individualized based on patient characteristics and local clinical expertise.
1) Takotsubo syndrome is a cardiac condition triggered by stressful events where the left ventricle temporarily takes on a distinctive "Takotsubo" shape.
2) It is thought to be caused by very high levels of stress hormones like adrenaline activating negative inotropic pathways in the heart through beta-2 adrenergic receptors, particularly in the left ventricular apex.
3) This leads to left ventricular dysfunction and heart failure symptoms, but the heart typically recovers its normal function within weeks as the stress response subsides. However, the full pathophysiology and long term effects are still being uncovered.
Revascularization in heart faliure seminarAnkit Jain
This document discusses revascularization in patients with heart failure due to coronary artery disease and residual left ventricular dysfunction. It provides details on myocardial hibernation and stunning - two states of sustained contractile dysfunction despite viable myocardium. Revascularization can lead to improved survival and reverse remodeling in such patients if a sufficient amount of viable myocardium is present. Techniques to assess myocardial viability include stress echocardiography, nuclear imaging with SPECT or PET, and cardiac magnetic resonance. Revascularization is recommended for patients who have viability in at least 25% of the left ventricular segments.
A 61-year-old man presented with chest pain and was found to have ST-segment elevation in multiple leads on his electrocardiogram (ECG), indicating a heart attack. Additional ECG views showed involvement of the right ventricle. Coronary angiography revealed a 100% blockage of the right coronary artery near the branch supplying the right ventricle. The blockage was opened with a percutaneous coronary intervention, restoring blood flow. The man's condition improved with treatment, and follow-up testing showed his left ventricle function was normal but there was mild dysfunction of the right ventricle.
- A study examined ruptured coronary plaques in patients with acute coronary syndrome using intravascular ultrasound (IVUS) and found ruptured plaques not just at the culprit lesion but also in other vessels.
- Both culprit lesions and additional ruptured plaques showed positive arterial remodeling, where the vessel expands to accommodate plaque growth.
- Positive remodeling is associated with plaque vulnerability and unstable coronary syndromes, while negative remodeling is more common in stable lesions and involves vessel constriction around plaque.
- The direction of remodeling may represent different inflammatory stages of plaque development, with positive remodeling indicating early active lesions and negative remodeling indicating more stabilized advanced lesions.
This document discusses Paget-Schroetter syndrome, also known as effort thrombosis, which is thrombosis (blood clot) of the axillary and subclavian veins caused by repetitive arm motions. It affects young, active individuals and causes swelling and pain in the arm. Treatment options discussed include anticoagulation alone versus thrombolysis or decompression of the thoracic outlet through surgery. Follow up of surgical patients found low complication rates, satisfactory long-term outcomes with patent veins, and good post-operative quality of life scores.
Coronary heart disease is a major cause of mortality worldwide. Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a non-surgical procedure used to treat blockages within the coronary arteries of the heart. During PCI, a catheter is inserted into an artery and guided to the site of blockage where a balloon is inflated to open the artery. Often a stent is placed to keep the artery open. PCI has become a common revascularization treatment for acute coronary syndromes and stable angina. While generally safe, complications from PCI occur in less than 2% of patients and include adverse reactions, acute myocardial infarction, bleeding, and death in less than 0.08% of patients.
Cardiology lecture toIternal Medicine 21/10/2013hospital
This document provides an outline and content for a cardiology lecture for internal medicine board exam preparation. It includes multiple choice questions (MCQs), a picture quiz, and explanatory notes on topics like myocardial infarction, heart failure, atrial fibrillation, and hypertension. The lecture was given by Dr. Ihab Suliman on October 20, 2013 and covered diagnostic tests, treatments, medications, and pathophysiology related to cardiology.
A rara associação de drenagem anômala total de veias pulmonares e cor triatri...gisa_legal
This document describes a rare case of a patient with both total anomalous pulmonary venous connection (TAPVC) and cor triatriatum. A pre-operative cineangiocardiogram ruptured the membrane dividing the left atrium in cor triatriatum, improving hemodynamics. Successful corrective surgery was then performed, involving resection of the cor triatriatum membrane and anastomosis of the left atrium to the pulmonary veins. At a six month follow up, the patient was doing well with mild residual effects.
The document summarizes arrhythmogenic right ventricular dysplasia (ARVD), a condition where the right ventricle of the heart is replaced by fat and fibrous tissue. It affects mostly young males and can cause sudden cardiac death. Genetic factors are involved in many cases. The condition starts with fatty infiltration of the right ventricle and progresses to include fibrosis, thinning of the ventricular wall, and later involvement of the left ventricle. Diagnosis involves criteria related to structural changes, electrocardiogram abnormalities, arrhythmias, and family history.
Broken Heart Syndrome: Cardiovascular Manifestations of Traumatic Brain InjuryAmit Agrawal
This document summarizes cardiovascular complications that can occur following traumatic brain injury (TBI). Up to 15.7% of patients with severe TBI can develop left ventricular dysfunction and wall motion abnormalities due to increased sympathetic activity and catecholamine release after brain injury. This can cause hypotension, hypertension, arrhythmias, and myocardial injury. ECG changes, echocardiogram abnormalities, and elevated biomarkers of cardiac injury have been documented following TBI. While the exact mechanisms are not fully understood, autonomic dysfunction and systemic inflammation following TBI can directly or indirectly impact cardiovascular function. Treatment involves optimizing hemodynamics and treating the underlying brain injury, as the cardiac abnormalities are often transient.
IMAGES OF A COMPLEX CASE OF MULTIPLE ANEURYSMAL DISEASE IN A 58 YEAR OLD MAN
IMMAGINI DI UN CASO COMPLESSO DI MALATTIA POLINEURISMATICA
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
This letter summarizes potential complications that can arise from closed-chest cardiac resuscitation based on the authors' experience. It includes a table listing various cardiac, gastrointestinal, skeletal, respiratory, vascular, embolic, and miscellaneous complications that have been reported in literature, such as myocardial rupture, liver laceration, rib fracture, hemothorax, aortic rupture, fat embolism, and neuropsychiatric issues. The authors constructed this table to inform healthcare providers of possible ill effects of resuscitation to allow for more informed care during and after the procedure.
Two cases of an extremely rare accessory coronary artery are reported. In both cases, the accessory artery arose from the left coronary cusp and traveled parallel to the left main coronary artery and left anterior descending artery. While one case showed an ostial lesion, the accessory arteries did not seem to be clinically significant. The authors propose naming this previously unreported anomaly the "Khan-Malek anomaly" due to its discovery.
This document discusses loops, kinks, and anomalies of vertebral arteries. It provides a historical overview of the development of vertebral artery surgery from the 1950s onward. Key pioneers and their contributions are highlighted. The etiology and pathophysiology of various vertebral artery anomalies are described, including loops, kinks, compressions, and variations in branching patterns. A case example is presented to illustrate how angiography findings can evolve over time for anomalies involving vertebral artery strangulation. In summary, the document reviews the history and current understanding of anomalies affecting the vertebral arteries and their surgical management.
The Right Aortic Arch with Mirror Image Branching of Brachiocephalic Arteries...Povilas Pauliukas
This document describes a rare case of a 35-year-old female who presented with dizziness, vertigo, left arm claudication, and syncopal episodes since childhood due to an anomalous right aortic arch with mirror-image branching of the brachiocephalic arteries and aplasia of the left brachiocephalic trunk. Angiography revealed a complex vascular pathology where blood flow to the left cerebral hemisphere occurred through a long route from the right vertebral artery to the left vertebral artery and left carotid arteries. The patient underwent surgery where a PTFE graft was implanted from the ascending aorta to the left carotid and subclavian arteries in place of the missing left brachiocephalic
The document describes a case involving a chest x-ray and pulmonary angiogram findings in a 57-year-old female patient who presented with chest pain two weeks following a hemorrhagic stroke. The pulmonary angiogram shows multiple filling defects in the left main pulmonary artery and its branches, consistent with pulmonary embolism. While anticoagulation is usually the standard therapy for pulmonary embolism, it is contraindicated in this patient due to her recent stroke. Therefore, the best management option is placement of an inferior vena cava filter to prevent further pulmonary emboli while existing clots dissolve, as anticoagulation cannot be used due to her recent hemorrhagic stroke.
The CT images show a high-attenuation collection displacing the heart to the right, indicating hemopericardium or blood in the pericardial sac. Figure 3B further shows a brightly enhancing structure near a surgical clip on the distal posterior descending coronary artery, consistent with a pseudoaneurysm causing the hemorrhage. The findings are most consistent with hemopericardium developing several days after coronary bypass surgery.
A brief History of Coronary Artery Bypass Grafting (CABG)Abhijit Joshi
this presentation traces the early reports of angina, when it was thought to be a disease of the breast, goes on to describe the stepping stones leading to myocardial revascularisation.
Akinetic mutism after subarachnoid haemorrhageGuus Schoonman
This document describes three cases of patients who developed akinetic mutism after suffering subarachnoid haemorrhages from ruptured cerebral aneurysms. Akinetic mutism is characterized by a lack of verbal and motor output despite preserved alertness. In the cases presented, MRI imaging showed bilateral ischemia of the medial frontal lobes in all three patients. The cingulate cortex, which was affected in these cases, plays an important role in motor function, vocalization, and emotions. While prognosis is variable, two of the three patients showed significant improvement in functioning over time despite initial severe symptoms of akinetic mutism.
Some personal surgical cases of intracranial aneurysmys and tumorsJuvela Seppo
A man aged 50 years presented with subarachnoid hemorrhage from a complex left internal carotid artery aneurysm that was clipped during surgery. He recovered without deficits. A woman aged 29 years presented with recurrent aneurysms that were coiled and clipped over several years with good recovery each time. A woman aged 44 years presented with an anterior communicating artery aneurysm that was coiled twice after rupturing but required clipping after regrowth; she recovered well.
A man aged 50 years presented with subarachnoid hemorrhage from a complex left internal carotid artery aneurysm that was clipped during surgery. He recovered without deficits. A woman aged 29 years previously had an aneurysm clipped that later recurred, requiring another clipping. A woman aged 44 years had two bleedings from an anterior communicating artery aneurysm that was ultimately clipped after two coiling attempts.
A beautiful paper published by Eugene Braunwald
European Heart Journal, Volume 42, Issue 24, 21 June 2021, Pages 2327–2328, https://doi.org/10.1093/eurheartj/ehab264
This case report describes an 82-year-old male who developed intracardiac shunts following a redo aortic valve replacement surgery. Doppler echocardiography detected shunts from the left ventricle outflow tract across the membranous septum into the right atrium, right ventricle, and left atrium. The anatomical basis for this complication is the proximity and relationship of the thin membranous septum to the aortic root, tricuspid valve, and ventricular chambers. Aggressive debridement during valve surgery can cause injury and necrosis of the membranous septum, leading to fistula formation over time. While the shunts were initially small and asymptomatic, they could enlarge
Cardiac transplantation is considered for patients with end-stage heart failure who have failed optimal medical management including medications, cardiac resynchronization therapy, and implantable cardioverter defibrillators. The document discusses the history of cardiac transplantation and ventricular assist devices. It provides details on patient selection criteria for coronary artery bypass grafting and surgical valve replacements as treatments prior to consideration of transplantation or ventricular assist devices. Key trials evaluating these surgical treatments are summarized.
BACKGROUND: Penetrating carotid artery injuries (PCAI) in civil time are infrequent, yet they present significant diagnostic and therapeutic challenges and can be associated with significant morbidity and mortality. Proper resuscitation and urgent exploration is necessary for actively bleeding patients.
OBJECTIVE: The aim of this paper is to present our humble experience in management of such injuries with literature review.
PATIENTS AND METHODS: Herein, we present 5 cases of penetrating carotid artery injuries managed in Sulaimania and Basrah from January 1996 to 30th of November 2009.
RESULTS: All patients were young males. Three injuries were located in zone III and 2 in zone II. Four patients presented hours to days after the injury while the fifth presented after few months. Angiography was done in 2 patients with a false aneurysm of internal carotid artery (ICA). All 3 patients with ICA injuries were managed by ligation due to profuse bleeding and poor access. The 2 patients with common carotid artery (CCA) injuries in zone II had an end to end repair. All 5 patients have survived without significant neurological deficits.
CONCLUSIONS: Penetrating carotid artery injuries in zone II usually do not require preoperative angiography unlike those in zone I and III. Repair is always desired. It is a straightforward operation for zone II injuries but really challenging for zone III due to poor access. Certain zone III injuries may be just observed or treated by endovascular stenting when facilities permit. Ligation of ICA carries a high risk of stroke; however, young people with well developed circle of Willis may tolerate it well.
Key Words: carotid artery, penetrating injury, zone I, II and III, neurological deficit.
Publication Date: 2013
Publication Name: The Iraqi Postgraduate Medical Journal
SPONTANEOUS CORONARY ARTERY DISSECTION IN A PRE- MENOPAUSAL WOMAN OCCURRING J...Apollo Hospitals
SCAD is a rare presentation of acute coronary syndrome(ACS) and clinically indistinguishable from
plaque rupture. It predominantly affects young women with
no traditional cardiovascular risk factors, especially during
the post-partum and pre-menopausal period [1-3]. The
aetiology of SCAD is multifactorial and complex. Optimal
treatment strategy for SCAD is not clearely defined.
COMPUTATIONAL ASSESSMENT OF INTRA-CRANIAL ANEURYSMguest629cef
1) The document describes a study analyzing the relationship between intracranial aneurysm height to neck ratio and wall shear stress using computational fluid dynamics models.
2) Five models were developed with increasing height to neck ratios to simulate how changes in aneurysm geometry affect fluid dynamics and wall shear stress.
3) The simulations indicated that wall shear stress increases correspondingly with increasing height to neck ratios, suggesting an association with increased rupture risk.
Computational Fluid Dynamic Evaluation of Intra-Cranial AneurymsChapman Arter
This document describes a study analyzing the relationship between intracranial aneurysm height to neck ratio and wall shear stress using computational fluid dynamics models. The study aims to relate increases in height to neck ratio with increases in wall shear stress and changes in fluid flow patterns. Five models were created with increasing height to neck ratios to simulate how geometry affects vascular fluid dynamics and wall shear stresses. The results indicate that wall shear stress increases correspondingly with increases in height to neck ratio.
2D CFD simulation of intracranial aneurysmwalshb88
This document discusses a computational fluid dynamics (CFD) analysis of intracranial aneurysms. It presents details about two patients, one with a large anterior communicating artery aneurysm and one with an incidental finding. It provides background on intracranial aneurysms, including their prevalence, risk factors for rupture, and typical locations. It also discusses cerebral hemodynamics, the circle of Willis, and prior research using CFD models and imaging to study wall shear stresses and flows within aneurysms.
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Hier vindt u de integrale conclusies die door Santens ingediend werden bij de Kortrijkse rechtbank. De volledige stukkenbundel wordt op latere datum gepubliceerd.
Ze bevatten veel informatie over enerzijds de bedrogstrategieën die toegepast worden door verzekeringsmaatschappijen en gerechtsdeskundigen, anderzijds over de zgn. 'onzichtbare' letsels zoals TBI/NAH/whiplash/CVS/uitputting van de bijnieren, ook over de 'dode letter wetten' die verondersteld zijn slachtoffers van een ongeval te beschermen tegen corruptie, literatuur over qEEG, de vergoedingen die een slachtoffer verondersteld is te ontvangen, en meer.
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Autogordel verantwoordelijk voor hersenletsel
1. Stroke Associated with Elongation and Kinking of
the Carotid Artery:
Long-Term Follow-Up
JULIAN K. QUATTLEBAUM, JR., M.D., JOHN S. WADE, M.D.
C. MAURICE WHIDDON, M.D.
CAROTID ELONGATION and tortuosity was recognized by
otolaryngologists decades ago because of the haz-
ards posed by the carotid artery bulging into the pharynx
during the course of tonsillectomy.89,15,18,26,27 However,
it remained for Riser et al.23 in 1951 to recognize the
association between carotid kinking and cerebrovascular
insufficiency and to obtain relief of "crises of vertigo" in
their patient using a piece of the sheath of the sterno-
cleidomastoid muscle to fix the vessel and make it "de-
scribe a turn with a large radius." They postulated that
changing head position might lead to ischemia. The first
internal carotid resection was reported by Hsu and
Kisten14 to have been done for fear the buckled segment
would rupture. Unfortunately, thrombosis of the anas-
tomotic suture line led to a fatal outcome. In December
1958, we discussed before this Association a paper by
Bahnson et al.1 We reported three cases of transient
hemiparesis associated with elongation and kinking of
the internal carotid artery treated by carotid resection
which were subsequently published in detail.22 A fourth
case of carotid tortuosity, which at that time was asymp-
tomatic and under observation, was also presented. Since
all four of these patients were followed until death, we
felt it would be of interest to present their ultimate course
with an analysis of the remainder of our series of 138
patients with carotid elongation and kinking treated
surgically.
Case Reports
Case 1. A 69-year-old hypertensive woman noted numbness
and weakness of the entire right side of the body on April 29,
From the Department of Surgery, Candler
General Hospital, Savannah, Georgia
1958. Carotid arteriogram (Fig. 1) showed overt kinking of the left
internal carotid artery. This was confirmed at operation under
general anesthesia on May 12, 1958 (Fig. 2) by which time
neurologic changes had cleared. A 2 cm. segment of the left
common carotid artery was resected which relieved the kinking
(Fig. 3) as confirmed by a postoperative arteriogram (Fig. 4).
Following recovery she remained in Savannah for several years
and then moved to Nashville, Tennessee, where she continued to
remain asymptomatic though hypertensive till 1968. She began
to have "fainting spells" which were believed to be due to harden-
ing of the arteries. On April 25, 1970, 2 months of frequent
episodic dizziness and confusion culminated in the development
of left hemiplegia. She recovered slightly in the hospital and was
transferred 17 days later to an extended care facility where she
died July 30, 1970 at the age of 83 years. Arteriograms were not
done in the hospital and autopsy was not performed.
Case 2. On September 4, 1958, a 75-year-old normotensive
man was admitted with a history of several years of intermittent
dizzy spells. A transient ischemic episode 2 months previously had
involved the right side and then complete right hemiparesis with
aphasia had occurred that day which had begun to clear by the
time of admission to the hospital some 4 hours later. Spinal tap
revealed clear fluid. Carotid arteriograms showed corkscrew-type
elongation of the right internal carotid just below the skull, while
on the left there was elongation with a transverse band of radio-
lucency across the vessel about 2 cm. above the bifurcation (Fig.
5). This proved to be due to a kink in the artery (Fig. 6) and
resection of the bifurcation, which contained a non-obstructing
plaque, was carried out under local anesthesia. End-to-end anas-
tomosis of the common to the internal carotid was made. Post-
operatively the residual neurologic changes gradually cleared over
a period of several weeks. He remained asymptomatic until Jan-
uary 28, 1963. On this date he was involved in an automobile
accident in which he received a severe blow to the right side of
his head. In the presence of unconsciousness and paralysis of the
left side, bilateral carotid arteriograms showed no change of the
left carotid circulation from that seen on the previous postopera-
572
Presented at the Annual Meeting of the Southern Surgical Asso-
ciation, December 4-6, 1972, Boca Raton, Florida.
2. ELONGATED CAROTID ARTERY
tive study. On the right there was found a large subdural hema-
toma which was evacuated surgically by Dr. Charles Usher, Jr.
Initial response was good, but on February 21 it was necessary
to plicate the inferior vena cava because of multiple pulmonary
emboli. Thereafter the neurologic state gradually improved, but he
died April 29, 1963 while still in the hospital of congestive heart
failure secondary to infaretion of the left ventricle and complicated
by pneumonia in all lobes of both lungs. Autopsy also showed
focal necroses in both frontal lobes of the brain with cerebral
edema.
Case 3. A 68-year-old man was admitted October 11, 1958
with paralysis of the right upper extremity with associated aphasia
which had occurred 4 days previously. Partial clearing had oc-
curred. Spinal tap yielded clear fluid, and carotid arteriograms
showed marked elongation of both internal carotid arteries without
overt kinking (Fig. 7). The left carotid bifurcation, which con-
tained a small non-obstructing plaque, was resected under local
anesthesia. Anastomosis was performed from the common to the
internal carotid artery. Over a period of several weeks there was
complete resolution of the neurologic deficit. He remained wvell
until 1960 when transurethral resection of the prostate was com-
plicated by postoperative retinal hemorrhage in the right eye.
Chronic atrial fibrillation then developed, but he remained active
until December 19, 1963, when he developed hemiparesis in-
volving the left side. No definitive evaluation was carried out, and
he died January 1, 1964.
Case 4. The case of an asthmatic man, who was 67 vears old
. _ ~~~~~~~~~i._. i.1.......
FIG. 1. Case 1. Left carotid arteriogram shows overt kink of
internal carotid artery.
FIC. 2. Case 1. Internal carotid kink as seen at operation.
at the time of arteriogram in June 1957 (Fig. 8), was reported to
this Association as an asymptomatic case of internal carotid tor-
tuosity. He was seeni on several occasions for other conditions but
he remaiined neurologically asymptomatic until October of 1960
wheni he was adlmitted to the hospital in mild congestive heart
failure which was controlled with diuiretics. On the night of Oc-
tober 19, he had anl episode of unconsciousness with associated
eyanosis and bronchospasm which passed without neur-ologic
residual. The following night a similar episode began with a con-
vulsive seizure. He wvas left with spastic changes which were
bilaterl at first but remained longer in the right upper extremity.
On carotid arteriogram the following dav, there was marked
elongation and tortuosity of the left internal carotid artery similar
to that demonstrated initially on the right side. At exploration
FIG. 3. Case 1. After resection of segment of common carotid
(seen at side of anastomosis) the kink is eliminated.
Vol. 177 * No. S
3. QUATTLEBAUM, WADE AND WHIDDON Ann. Surg. * May 1973
FiG. 4. Case 1. Postop-
erative arteriogram con-
firm elimination of kink.
FIG. 6. Case 2. At operation, vessel is found to be kinked at point
of arteriographic lucency.
under local anesthesia, approximately 5 cm. excess length was
estimated to be present in the kinked and looped internal carotid
artery. The proximal internal carotid artery was resected and the
end of the vessel above was anastomosed into the side of the
common carotid 2 cm. below the bifurcation after the fashion of
Lorimer.17 Postoperatively he had no further seizures but de-
veloped increasingly severe bronchospasm with cyanosis and
tachypnea, then coma, followed by death on October 23. Autopsy
showed massive bilateral pneumonia.
FIG. 5. Case 2. Arrow
points to band-like lu-
cency seen across artery.
Analysis of these cases plus the remainder of our series,
a total of 138 patients upon whom 149 operations were
performed, has been carried out. The youngest patient
was 45 years of age; the oldest 93. One hundred and one
of the patients were between 56 and 75 years of age.
There were 66 men and 72 women. One hundred and
twenty-six were Caucasian and 12 were Negro. Blood
pressure on initial examination was greater than 160
systolic or 90 diastolic or both in 60 per cent of the
FIG. 7. Case 3. A, Right and B, Left, carotid arteriograms showing
bilateral marked elongation.
574
-.
4OW'
4. ELONGATED CAROTID ARTERY 575
patients. Arteriographic evaluation of the internal carotid
arteries showed that elongation was bilateral in 102
patients. It was unilateral in 20 patients and was not
determined in eight. In 56 instances, an arteriosclerotic
plaque was associated with elongation, and in three the
plaque was stenosed and was the primary cause of symp-
toms. There was no significant plaque associated in 90
instances. The indication for operation (Table 1) was
transient ischemic attack in 56 operations, stroke in 47
operations, vertigo in 21, blackout in 19, progressive
mental deterioration in four and asymptomatic pulsating
retropharyngeal mass in one. The term transient ischemic
attack as used here includes an attack in which there is
a focal neurologic deficit due to selective ischemia of one
portion of the brain. Vertigo and blackout represent
transient ischemic attacks in which the ischemia is dif-
fuse and which differ in the degree of severity of the
ischemia. They are classified separately for purposes of
analysis. In two of the patients with stroke the condition
involved first the one side and then the other. Of the
patients who had vertigo, two had opposite arteries op-
erated upon for one of the other indications.
As for the procedure which was carried out (Table 2),
the common carotid artery was resected in seven in-
stances, in three of which endarterectomy of the bifurca-
tion was carried out concomitantly. The carotid bifurca-
tion was resected with end-to-end anastomosis of the
internal to the common carotid artery in 106 instances.
Three of these required supplemental endarterectomy of
the proximal internal carotid. In 34 instances, transplanta-
tion of the artery under a sternomastoid muscle flap was
carried out, and in two a plastic procedure to the artery
was done. The right side was operated on in 62 patients
and the left in 65. Both sides were operated on in 11
patients. In each instance evaluation of the availability of
*v.AK@_~~~~'W.
FIG. 8. Case 4. Right carotid arteniogram shows elongation of
internal carotid which presented as aneurysmoid pulsation in neck.
TABLE 1. Indtcation For Surgery
T. I.A. 56
Stroke 47
Vertigo 21
Blackout 19
Progressive Mental Deterioration 5
Pulsating Retropharyngeal Mass 1
collateral flow by compression of the common carotid
artery on the side to be operated for a period of 2 minutes
was carried out. The occurrence of air hunger, aphasia,
vertigo or more severe neurologic deficit was considered
a positive test and occurred on 49 occasions, of which
five were negative on the opposite side. The test was
negative 95 times and, of course, five of these were
positive on the opposite side. Two patients changed from
positive preoperatively to negative on the table, and one
changed from negative preoperatively to positive on the
table. Anesthesia used (Table 3) was general with
hypothermia in 16 operations, general with hypothermia
plus shunt one time, general with shunt alone one time
and general anesthesia without any measure to provide
collateral flow was carried out five times. A total of 23
operations were performed under general anesthesia. The
procedures under hypothermia and/or with shunt were
employed early in the series in patients in whom the
carotid compression test was positive. Local anesthesia
was employed in 126 operations, and since August of
1966 all except four operations have been done under
local anesthesia, carrying out transplantation in those
who were positive to compression.
In the assessment of results a grade of excellent, good,
fair or poor was assigned. Excellent signifies complete
recovery from any neurologic deficit and remaining
asymptomatic since. Good indicates a case in which the
course of the disease has been unequivocally altered but
in which minor symptoms may persist, such as occasional
slight vertigo in a patient who was experiencing black-
outs, or failure to recover totally from the neurologic
deficit of a stroke. A grade of fair was assigned when the
patient was better than preoperatively, but continued to
have symptoms which were troublesome. Poor was used
to denote patients who died in the hospital or who failed
to improve. They have been analyzed individually as to
the cause of failure. A single grade was assigned to pa-
tients who had both sides operated on for the same
indication. If the two sides were operated upon for sep-
TABLE 2. Operative Procedure
Resection Common Carotid 7
Resection Carotid Bifurcation 106
Carotid Transplant 34
Arterioplasty 2
Vol. 177 * No. 5
5. QUATTLEBAUM, WADE AND WHIDDON
TABLE 3. Anesthesia*
General Alone 5
General plus Hypothermia 16
General plus Hypothermia with
Shunt 1
Local with Shunt 1
Local 126
* Since 1966, local anesthesia has been used in all but four cases.
arate indications, a separate grade was given for each.
Except for hospital deaths (Table 4), patients who were
available for follow-up for less than 1 year were excluded
from final assessment. The basis of evaluation included
personal interview and examination, evaluation by the
family physician, or questionnaire answered by the pa-
tient or his family, or combinations of these. Follow-up
assessment was carried out in 107 patients. Analysis of
the series as a whole shows our results to be excellent in
28 per cent, good in 44 per cent, fair in 10 per cent and
poor in 18 per cent. When viewed with respect to indica-
tion for operation (Table 5), it becomes apparent that
the best results were obtained in those operated for
transient ischemic attacks (TIA), where the grade was
excellent or good in 82 per cent of the cases. Worst re-
sults, conversely, were found in those operated upon for
progressive mental deterioration, although the one good
result obtained in this group was significant, occurring
in a condition generally considered to be hopeless.
Discussion
In the 14-year period since our original presentation, a
number of authors have reported the clinical relationship
of carotid elongation to cerebrovascular insufficiency.2'4,5,
7,10-13,17,1921,25,28,29 In addition Brice3 and Derrick6 have
investigated the relationship between kinking and re-
duction of flow in arteries.
Concerning its etiology, carotid elongation in children
has given credence to the theory of its congenital origin
due to failure of embryonic absorption of the third aortic
arch as postulated by Kelley.16 However, the failure to
develop symptoms of cerebrovascular insufficiency in any
TABLE 4. Cause of Death
In Hospital Late
Original Stroke 2 4
Contralateral Stroke 3
Other CVA 1 3
Cardiac 3 5
Cancer 3
Pulm. Embolism 1
Suicide 1
Pneumonia 1
Unknown 7
Total 6 28
Tia (38) E
G
F
p
Stroke (38) E
G
F
p
Vertigo (16) E
Blackout (12)
TABLE 5. Results*
17
45%
14
37%
2
5%
5
13%
8
21%
16
47%
6
16%
8
- 21%
2
12%
8
G 50%
2
F - 12%
4
P - 26%
3
E 25%
8
G
F
P 0
PMD (5) E 0
Tota
67% E
1 G
-8% F
p
il Series
28%
44%
10%
18%
G - 20%
F - 20%
3
P 60%
* Includes follow-up study from 1-14 years. Except for hospital
deaths short-term results are not included.
of our patients before the age of 45, many of whom still
had no atherosclerotic narrowing of the collateral vessels,
would tend to suggest an acquired condition. Addition-
ally, the familiar progressive elongation of the aorta and
other arteries, and the demonstration by Henley et al.12
of degenerative changes in the walls of the involved
carotid arteries in adults, tend to support the latter
theory. As we have developed experience with this entity
over the years, it has become apparent that in many
instances it is selective elongation of the artery to a
greater extent than that of its adventitia that leads to the
tendency to buckle and kink. This in itself explains the
rarity of obstructive symptoms in children in whom a
congenital elongation should involve the muscularis and
adventitia equally.
Since the outset we have been convinced that the
development of symptoms depends upon the fortuitous
positioning of the head in such a way that the vessels
are kinked rather than merely elongated. While we have
576 Ann. Surg. -
May 1973
6. Vol. 177 * No. 5 ELONGATED CAROTID ARTERY 577
seen three patients with complete obstruction due to
kinking and many with lesser degrees of overt kinking on
arteriograms, we also look for elongation which might
logically be expected to produce kinking though such is
not present at the time of the arteriogram. Roberts et al.24
demonstrated that the neutral position of the head is the
one most favorable to full cerebral blood flow. It is in this
position that most angiograms are made. Roberts also
demonstrated in a group of cadavers of all age groups
that flow ceased in at least one of the four vessels sup-
plying the brain at some point throughout the range of
"normal" positions in every subject studied. The older the
patient, the more readily was flow occluded. Kinking
must be considered as a dynamic affair with symptoms
dependent not only on the degree but on the time in-
terval involved. In our series, the patient frequently
awakened with neurologic deficit. Presumably it is easier
for the vessel to remain in an unfavorable position for
extended periods during sleep.
We have placed great reliance upon the carotid com-
pression test preoperatively to estimate the relative safety
of temporary occlusion of carotid flow. We feel that it is
always best to resect the carotid bifurcation if it contains
a plaque, however small. In 94 resections in which the
compression test was negative, the only permanent neu-
rologic deficit occurred before the vessel was to be oc-
cluded, presumably due to middle cerebral thrombosis.
The test should be repeated on the table before com-
mitting oneself to resection because in one instance in
this series the test changed from negative preoperatively
to positive on the table. If the test is positive, then pro-
cedures requiring occlusion of the vessel should be
avoided if possible, for in 18 resections under such cir-
cumstances significant increase in neurologic deficit oc-
curred twice despite general anesthesia with hypo-
thermia.
Analysis of our poor results (Table 6) suggests that in
a significant number of patients, kinking of the carotid
arteries was not responsible for the clinical symptoms.
Death in the hospital of three patients from myocardial
infarction, occurring after uneventful operation under
local anesthxiia, emphasizes the need for careful evalua-
tion of the cardiac status. Obviously Stokes-Adams at-
tacks can lead to many of the symptoms included as
indications for operation. Hypertension per se did not
seem to mediate against a good result, but hypertensive
encephalopathy must be considered as a cause of vertigo
or TIA, and cerebral hemorrhage must eliminated as
a cause of stroke. Diffuse intracerebral atherosclerosis as
the primary cause of symptoms is especially difficult to
eliminate, since it is so difficult to demonstrate angio-
graphically and is present coincidentally with some fre-
quency. We have learned to defer operation in the patient
with a severe neurologic deficit until it becomes apparent
TABLE 6. Analysis of Poor Results
Tia (5) Unimproved 2
Operative Complication (SBE) 1
Hospital Death 2
(a) Myocardial Infarct
(b) Pneumonia
Stroke (8) Failure to Recover from Stroke (2 Died in
Hospital) 5
Hemorrhage into Infarct 1
Recurrent Stroke (Kink Not Relieved by Trans-
plant) 1
Hospital Death (Myocardial Infarct) 1
Vertigo (4) Unimproved 2
Hospital Death 2
(a) Myocardial Infarct
(b) Cerebral Hemorrhage
PMD (3) Unimproved 2
Hemiparesis on Table 1
that significant improvement will occur, for carotid
surgery is prophylactic and not therapeutic.
Summary and Conclusion
Our experience with 149 operations performed on 138
patients with carotid elongation and kinking associated
with symptoms of cerebrovascular insufficiency has been
reported. The condition is felt to represent an acquired
degenerative process which permits relatively greater
elongation of the muscular wall of the artery than its
adventitia. Symptoms depend upon the fortuitous posi-
tioning of the head to cause kinking and upon the time
it remains so. The condition is bilateral in the great
majority of patients. Hypertension, heart disease and
cerebral atherosclerosis are frequently present as well and
must be eliminated as primary causes for symptoms. Cere-
bral vascular insufficiency due to carotid elongation must
remain a diagnosis by exclusion, but when such has been
accomplished the very high percentage of good results
should lead to a firm recommendation of an operative
procedure which can be done in almost every instance
under local anesthesia with virtually no risk and minimal
morbidity. We prefer resection of the carotid bifurcation
with end-to-end anastomosis in patients who tolerate
compression of the common carotid artery for 2 minutes
without symptoms. For those who cannot, transplantation
of the carotid under a sternomastoid muscle flap has been
a satisfactory alternative in most instances.
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DISCUSSION
DR. ALTON OCHSNER, JR. (Metairie): I think this is such a
significant paper that many surgeons in this audience will be look-
ing now for these carotid elongations and kinks. I would like to
point out, however, ,.that our neurologist confreres, with rare
exceptions, think they have no significance at all. Of course, I do
not agree with them;*I agree with Dr. Quattlebaum that they are
significant.
In the last 4 years we have had 40 cases not associated with
any significant stenosis in the carotid artery. A third of these are
my own cases; the others are cases of two young men that I
assisted, one of whom, Dr. Ricardo Del Real, is now practicing
here in Boca Raton.
From this experience, I think, particularly because there may be
those who will be interested in looking into this subject further in
terms of diagnosis and treatment, I would like to make a few
cogent remarks.
First, the only way this can be diagnosed is by angiography,
and one does not look for murmurs, because there should not be
any murmurs. Angiograms must be performed on people with
symptoms of cerebrovascular insufficiency without murmurs.
[Slide] This is a continuous condition, I think, with beginning
elongation and folding back upon itself, and eventually complete
looping or kinking. It is in these early stages that the symptoms
are most likely to be seen. This complete looping is seen as an
incidental finding sometimes, and may lead the neurologists to
believe that none of this is important. This is, of course, one of
the few diseases that I know of in which in the late stages the
symptoms are less.
[Slide] In taking angiograms, one must recognize that this con-
dition is sometimes seen only in one plane, and it is usually the
AP projection. This is a lateral projection of the carotid artery,
and if that is all you had, you would miss this condition. How-
ever, there is a kink, or an uncoiling which can lead to kinking,
when the X-ray is taken in the AP position.
[Slide] This is just another example of the same thing. In the
lateral position there is no evidence of kinking. In the AP po-
sition there is a kink.
[Slide] This is just one patient with X-rays in AP, with the
head turned to one side and the head turned to the other side.
The kinking is seen in the AP position when the head is turned
to one side, but not when the head is turned to the other side.
So taking the X-ray in two planes may be necessary to com-
pletely rule in or rule out this condition.
The amount of kinking or coiling can be lessened or greatened
by the position of the head, and sometimes if you want to take
real effort, [slide] you can actually demonstrate the occlusion.
This is an AP view of an uncoiled, potentially kinkable internal
carotid artery, with the head extended.
[Slide] This is the same patient with the head flexed, and the
blood flow is cut off there.
Regarding comments about treatment, we would have to take
issue with the authors about the use of local anesthesia. We think
that general anesthesia is important in the management of this
condition, because if the kinking is to be completely overcome,
the internal carotid artery must be dissected up to the base of
the skull. Sometimes the kink will not be found except at the
very base of the skull. In order to do this, you have to have re-
traction on the base of the skull, and I think it is too much of a
hardship on both the patient and the surgeon to do it under local
anesthesia.
Do not pull on the carotid! I think part of the etiology of this
condition is the lack of elastic tissue, and I can assure you that
traction on the carotid will put it apart. I have done this in two
instances. We recovered from it, but I would not want anybody