Wijeyaratne and co-authors report on a case with fatal pulmonary
embolism of polyvinyl alcohol particles following therapeutic embolisation
of a peripherial arteriovenous malformation(1).
The citation that there is one other report of acute 'pulmonary
hypertension' following transcatheter embolisation is not total correct.
It was a circulatory arrest ( pulmonary embolism grade IV) which requir...
Wijeyaratne and co-authors report on a case with fatal pulmonary
embolism of polyvinyl alcohol particles following therapeutic embolisation
of a peripherial arteriovenous malformation(1).
The citation that there is one other report of acute 'pulmonary
hypertension' following transcatheter embolisation is not total correct.
It was a circulatory arrest ( pulmonary embolism grade IV) which required
mechanical resuscitation for about 50 minutes and veno-arterial
extracorporeal membrane oxygenation support was preformed until
hemodynamic stability was regained (2).
(1) Wijeyaratne SM, Ubayasiri RA, Weerasinghe C. Fatal pulmonary
embolism of polyvinyl alcohol particels following therapeutic embolisation
of a peripheral arteriovenous malformation. BMJ Case Reports 2009;
doi:10.1136/bcr.02.2009.1635
(2) Haller I, Kofler A, Lederer W, Chemelli A, Wiedermann FJ. Acute
pulmonary artery embolism during transcatheter embolization: successful
resuscitation with veno-arterial extracorporeal membrane oxygenation.
Anesth Analg. 2008 Sep;107(3):945-7
In the middle age, Asian Caucasian males frequently present with the
complaints of (1) penile retraction into pelvis leaving glans penis at
pubic arch, (2) feeling of mass or heaviness in pelvic urethra, (3)
discomfort requiring the patient to repeatedly pick the glans under
garments to pullout the penis to get relieved. Examinations in such cases
show evidence of prostate enlargement (80% cases) with o...
In the middle age, Asian Caucasian males frequently present with the
complaints of (1) penile retraction into pelvis leaving glans penis at
pubic arch, (2) feeling of mass or heaviness in pelvic urethra, (3)
discomfort requiring the patient to repeatedly pick the glans under
garments to pullout the penis to get relieved. Examinations in such cases
show evidence of prostate enlargement (80% cases) with or without
prostatitis and some cases presenting additional anal inflammatory
problem. In the case report where psychiatric patients present with Koro-
like symptoms, prostate findings need be described even if unequivocal.
Thanks to the author and his colleagues. Two notes only:
1. Figure 2 is a sagittal, not a coronal MRI view.
2. The addition of "T2-weighted" to the phrases of both figures would
be helpful; the surrounding CSF signal is hyper-intense. Many doctors
don't know how to interpret the brain MRI images and we should deliver the
information as complete as possible.
Thanks to the author and his colleagues. Two notes only:
1. Figure 2 is a sagittal, not a coronal MRI view.
2. The addition of "T2-weighted" to the phrases of both figures would
be helpful; the surrounding CSF signal is hyper-intense. Many doctors
don't know how to interpret the brain MRI images and we should deliver the
information as complete as possible.
As a former iv drug user of some 20 years I can certainly confirm the
existence of needle fixation and its considerable prevelence amongst iv
drug users.
Commonly this expresses itself in withdrawing and injecting blood
after the injection of drugs, known as "flushing". It is more readily seen
in longer term iv users or for those who finding a vein involves a lot of
stabbing about and then a release from the pain...
As a former iv drug user of some 20 years I can certainly confirm the
existence of needle fixation and its considerable prevelence amongst iv
drug users.
Commonly this expresses itself in withdrawing and injecting blood
after the injection of drugs, known as "flushing". It is more readily seen
in longer term iv users or for those who finding a vein involves a lot of
stabbing about and then a release from the pain of this through the effect
of the drugs.
As far as I am aware there are no harm reduction initiatives
available to raise awareness about or reduce the effects of needle
fixation in terms of its impact on the health of the veins.
More importantly there seems no recognition of a extra layer of
conditioning involved in the re-enforcement of addiction.
I really congratulate the hard work which was done to report this
case as we all know that we have some in patients presenting in our
psychiatric inpatients/community with incontinence .we always seek the
medical help to roll out any underlying cause for the incontinence.
However if we study the pathogeneses of incontinence and the depression it
purely eradicate our doubt ,that with severity of illness the more 5HT2A
in...
I really congratulate the hard work which was done to report this
case as we all know that we have some in patients presenting in our
psychiatric inpatients/community with incontinence .we always seek the
medical help to roll out any underlying cause for the incontinence.
However if we study the pathogeneses of incontinence and the depression it
purely eradicate our doubt ,that with severity of illness the more 5HT2A
involvement. The regulation of bladder function is influenced by central
serotonergic modulation. Several genetic polymorphisms related to
serotonin control have been described in the literature. T102C
polymorphism of the serotonin receptor 2A gene (5-HT2A) has been shown to
be associated with certain diseases such as non-fatal acute myocardial
infarction, essential hypertension, and alcoholism. In the Brazil study,
they examined the association between 5-HT2A gene polymorphism and urinary
incontinence in the elderly. A case-control study was performed in elderly
community dwellers which studies gene-environmental interactions in aging
and age-related diseases. Clinical, physical, biochemical, and molecular
analyses were performed on volunteers. 5-HT2A genotyping was determined .
there was an independent significant association between the TT genotype
(35.7%) and urinary incontinence (OR = 2.06, 95%CI = 1.16-3.65).
Additionally, urinary incontinence was associated with functional
dependence and systolic hypertension. The results suggest a possible
genetic influence on urinary incontinence involving the serotonergic
pathway. I believe with your case result and with other literatures
further investigations including urodynamic evaluation need to be
performed to better explain these findings.
Dr Osama Hammer
Sussex partnership trust MBBCH.,MSC.,MRCPsych
We are thankful to Lonergan and his colleagues for reporting this very interesting case of stroke that has been linked to sunitinib therapy. I have a few notes:
1. The very first thing is the age of the patient? How old is he?
2. The author did mention that the patient had several risk factors for ischaemic stroke, but he linked this stroke mainly to sunitinib. What evidence points...
We are thankful to Lonergan and his colleagues for reporting this very interesting case of stroke that has been linked to sunitinib therapy. I have a few notes:
1. The very first thing is the age of the patient? How old is he?
2. The author did mention that the patient had several risk factors for ischaemic stroke, but he linked this stroke mainly to sunitinib. What evidence points to sunitinib as the potential culprit? Does the negative work-up for an embolic source suffice? Tumor cells may embolize as well.
3. The MRI image suggests a right hemispheric infarction in the territory of the right middle cerebral artery; most likely, the main stem is occluded rather than the posterior inferior branch. Occlusion of either of these is usually embolic, and the work-up was directed properly to this. The given image is the T2 FLAIR, not the T2. The peri-ventricular white matter hyper-intense lesions seen in this image (which were not suppressible on the T2 FLAIR) are compatible with small vessel disease. These lesions are strong indicators of the presence of long-standing hypertension.
Kunitz and Foulkes and their co-workers at the National Institute of Neurologic Disease and Stroke (NINDS) Stroke Data Bank were the first to use the term cryptogenic stroke [1,2]; this was in the mid 80s. Several years later, the TOAST investigators modified this term to "stroke of
undetermined origin" and further categorized it [3].
The TOAST defines this "stroke of undetermined origin" as brain infarction that is not attributable to a source of definite cardio-embolism, large artery atherosclerosis, or small artery disease despite extensive vascular, cardiac, and serologic evaluation. This form of ischaemic stroke forms about 30-40% of all ischaemic strokes [4-6].
It is well known that malignancy is a hypercoagulable state; this, together with the "old" age of the patient, hypertension, and smoking would put the patient at risk of developing a vascular incidence/event. The common is
common!
Depending simply on the negative imaging studies for an embolic source to mark sunitinib as the likely cause behind this stroke might be reasonable in a young patient with no atherosclerosis/vascular risk factors.
References:
1. Kunitz SC, Gross CR, Heyman A, et al. The pilot Stroke Data Bank: definition, design, and data. Stroke 1984; 15:740.
2. Foulkes MA, Wolf PA, Price TR, et al. The Stroke Data Bank: design, methods, and baseline characteristics. Stroke 1988; 19:547.
3. Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. Stroke 1993; 24:35.
4. Sacco RL, Ellenberg JH, Mohr JP, et al. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol 1989; 25:382.
5. Petty GW, Brown RD, Whisnant JP, et al. Ischemic stroke subtypes: A population-based study of incidence and risk factors. Stroke 1999; 30:2513.
6. Kolominsky-Rabas PL, Weber M, Gefeller O, et al. Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study. Stroke 2001; 32:2735.
Thanks to von Heinemann et al for reporting this brainstem stroke as a reminder of a grave complication of brainstem lesions, and that is cardiac arrest.
The writer of this case report has mentioned lateral medullary syndrome of Wallenberg after providing us with abbreviated neurological findings, and he has linked his observation with this type of brainstem stroke. The given brain imaging fi...
Thanks to von Heinemann et al for reporting this brainstem stroke as a reminder of a grave complication of brainstem lesions, and that is cardiac arrest.
The writer of this case report has mentioned lateral medullary syndrome of Wallenberg after providing us with abbreviated neurological findings, and he has linked his observation with this type of brainstem stroke. The given brain imaging findings are compatible with Wallenberg’s
syndrome of a wedge-shaped infracted area in the dorso-lateral medulla; however, the patient demonstrates many symptoms and signs that strongly question the “classical” Wallenberg syndrome:
1. One of the features that strongly stand against Wallenberg is the presence of limb weakness.
The motor system (pyramids) is typically spared with lateral medullary lesions because the corresponding anatomic structure is located in the medial medulla. Therefore, hemiplegia in this patient would reflect
anterior/medial medullary damage (as part of Dejerine’s anterior bulbar syndrome). However, “ipsilateral” hemiplegia is a very rare, yet well document feature of lateral medullary lesions. This ipsilateral hemiparesis is thought to result from the involvement of the lower most
caudal end of the medulla just below the pyramidal decussation (1). This ipsilateral spastic hemiplegia that has been linked to Wallenberg syndrome is also known as the submedullary syndrome of Opalski (2). “Clumsiness” of
the ipsilateral upper limb may also result from extension of the injury into the subolivary area (3); a very rare but a well-characterized feature of Wallenberg syndrome.
2. Lateral lesions located in the “rostral” medulla are associated with more severe dysphagia, hoarseness and the presence of facial paresis. Some patients with Wallenberg syndrome display ipsilateral facial palsy presumably due to the involvement of an aberrant corticobulbar tract, or
extension of the infarct to the pons with compromise of the facial nerve nucleus or fascicles; emotional-facial paresis related to involvement of looping medullary corticofacial projections in the upper medulla (4, 5).
Therefore, the presence of “facial paresis” in this patient would be an atypical sign.
3. The classical ipsilateral facial hypalgesia and thermoanesthesia and the contralateral trunk and extremity hypalgesia and thermoanesthesia are not seen in this patient; rather, the patient displays a constellation
of sensory deficits that are not reflecting the classical Wallenberg’s syndrome. However, Matsumoto described several patients with a continuous hemisensory defect of the face, arm, and trunk (unilateral pattern), with the lower border demarcated at a sensory level. These patients were thought to have mediolateral medullary and pontine lesions contralateral to the side of the sensory defect, which affected the medial cervical and thoracic afferents of the lateral spinothalamic tract (i.e., spared the lateral sacral and lumbar afferents) and the ventral trigeminothalamic tract (accounting for contralateral facial sensory loss), but spared the spinal nucleus and tract of the trigeminal nerve (6).
It is true that “classic” or “typical” brainstem stroke syndromes are rarely encountered in clinical practice; most patients present with a constellation of signs and symptoms, which either overlap with many “adjacent” syndromes or form an incomplete syndrome, however.
This patient’s overall clinical picture points to an ischemic damage to the lower brainstem, but it does not fit the “classical” Wallenberg syndrome; this case report does mention rare features of this syndrome that are not the reason behind writing this care report (7).
Does this patient have total unilateral medullary syndrome (8, 9) on clinical basis? I would suggest linking these recurrent cardiac arrest events with “medullary” infarction, and not specifically to Wallenberg syndrome, as the damaged lower brainstem per se might result in a variety of autonomic dysfunctions (10); profound bradycardia may be seen with subsequent cardiac arrest(11).
Osama SM Amin
References
1. Dhamon SK, Ikbal J, Collins GH. Ipsilateral hemiplegia and the Wallenberg syndrome. Arch Neurol 1984;41:179-180.
3. Brochier T, Ceccaldi M, Milandre L, et al. Dorsolateral infarction of the lower medulla: clinical MRI study. Neurology 1999;52:190-193.
4 . Kim JS, Lee JH, Suh DC, et al. Spectrum of lateral medullary syndrome. Correlation between clinical findings and magnetic resonance imaging in 33 subjects. Stroke 1994;25:1405-1410.
5. Cerrato P, Imperiale D, Berguy M, et al. Emotional facial paresis in a patient with a lateral medullary infarction. Neurology 2003;60:723-724.
6. Matsumoto S, Okuda B, Imai T, et al. A sensory level on the trunk in lower lateral brainstem lesions. Neurology 1988;38:1515.
7. Brazis PW, Masdeu JC, Biller J. Localization in clinical
neurology, 5th edition. Philadelphia: Lippincott Williams & Wilkins; 2007.
We are pleased to go through the interesting articles published by BMJ Case Reports. Having gone through this article ,the lesson is very good, but the fig 1A looks that of an adolscent--just look on the upper arm and elbow. Also thyroid hormone replacement alone leading to regression of such a big mass, does not explain why tumors from other pitutary cell types do not regress without other intevent...
We are pleased to go through the interesting articles published by BMJ Case Reports. Having gone through this article ,the lesson is very good, but the fig 1A looks that of an adolscent--just look on the upper arm and elbow. Also thyroid hormone replacement alone leading to regression of such a big mass, does not explain why tumors from other pitutary cell types do not regress without other inteventions.
I read with interest your case report of bilateral meniscal tears in
a 17 year old rower. Admittedly meniscal tears are not as common as
Chondromalacia patellae, Iliotibial Band syndrome or Patella tendonitis,
however they have been reported in a survey of knee injuries in rowers
(Hosea TM et al. Rowing injuries. Postgraduate Advances in Sports
Medicine 1989;3:1–16)
I read with interest your case report of bilateral meniscal tears in
a 17 year old rower. Admittedly meniscal tears are not as common as
Chondromalacia patellae, Iliotibial Band syndrome or Patella tendonitis,
however they have been reported in a survey of knee injuries in rowers
(Hosea TM et al. Rowing injuries. Postgraduate Advances in Sports
Medicine 1989;3:1–16)
The act of rowing combines deep knee flexion with considerable
rotation of the tibio-femoral joint predisposing to meniscal sheer forces.
In my opinion the act of rowing can not be classified as atruamatic.
Dear Sir,
Wijeyaratne and co-authors report on a case with fatal pulmonary embolism of polyvinyl alcohol particles following therapeutic embolisation of a peripherial arteriovenous malformation(1).
The citation that there is one other report of acute 'pulmonary hypertension' following transcatheter embolisation is not total correct. It was a circulatory arrest ( pulmonary embolism grade IV) which requir...
Editor Sir:
In the middle age, Asian Caucasian males frequently present with the complaints of (1) penile retraction into pelvis leaving glans penis at pubic arch, (2) feeling of mass or heaviness in pelvic urethra, (3) discomfort requiring the patient to repeatedly pick the glans under garments to pullout the penis to get relieved. Examinations in such cases show evidence of prostate enlargement (80% cases) with o...Hi Dr Wu and Dr Mueller,
Thanks for your excellent case report. I have a patient of proven refractory reflux pain even after fundoplication .
Do you think coeliac plexus or other blocks may help in such situations? What other such interventions may help to relieve his reflux pain?
What happened to your patient's pain after 11 weeks?
Would be grateful for your response to these queri...
Thanks to the author and his colleagues. Two notes only:
1. Figure 2 is a sagittal, not a coronal MRI view.
2. The addition of "T2-weighted" to the phrases of both figures would be helpful; the surrounding CSF signal is hyper-intense. Many doctors don't know how to interpret the brain MRI images and we should deliver the information as complete as possible.
Conflict of Interest:
...As a former iv drug user of some 20 years I can certainly confirm the existence of needle fixation and its considerable prevelence amongst iv drug users.
Commonly this expresses itself in withdrawing and injecting blood after the injection of drugs, known as "flushing". It is more readily seen in longer term iv users or for those who finding a vein involves a lot of stabbing about and then a release from the pain...
I really congratulate the hard work which was done to report this case as we all know that we have some in patients presenting in our psychiatric inpatients/community with incontinence .we always seek the medical help to roll out any underlying cause for the incontinence. However if we study the pathogeneses of incontinence and the depression it purely eradicate our doubt ,that with severity of illness the more 5HT2A in...
Dear Editor
We are thankful to Lonergan and his colleagues for reporting this very interesting case of stroke that has been linked to sunitinib therapy. I have a few notes:
1. The very first thing is the age of the patient? How old is he?
2. The author did mention that the patient had several risk factors for ischaemic stroke, but he linked this stroke mainly to sunitinib. What evidence points...
Dear Editor
Thanks to von Heinemann et al for reporting this brainstem stroke as a reminder of a grave complication of brainstem lesions, and that is cardiac arrest.
The writer of this case report has mentioned lateral medullary syndrome of Wallenberg after providing us with abbreviated neurological findings, and he has linked his observation with this type of brainstem stroke. The given brain imaging fi...
Dear Editor
We are pleased to go through the interesting articles published by BMJ Case Reports. Having gone through this article ,the lesson is very good, but the fig 1A looks that of an adolscent--just look on the upper arm and elbow. Also thyroid hormone replacement alone leading to regression of such a big mass, does not explain why tumors from other pitutary cell types do not regress without other intevent...
Dear Editor
I read with interest your case report of bilateral meniscal tears in a 17 year old rower. Admittedly meniscal tears are not as common as Chondromalacia patellae, Iliotibial Band syndrome or Patella tendonitis, however they have been reported in a survey of knee injuries in rowers (Hosea TM et al. Rowing injuries. Postgraduate Advances in Sports Medicine 1989;3:1–16)
The act of rowing comb...
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