To define patterns of infarction on computed tomography that are characteristic of embolism, as opposed to hemodynamically or microangiopathically induced brain lesions, a consecutive series of 60 patients with acute brain embolism were studied. Strokes were embolic in origin; that is, hemodynamic and in situ thrombotic stroke mechanisms had been excluded. Embolically active, cardiac disease was proved in 42 and was clinically evident in 13 patients. Five patients had suffered a stroke due to catheter-related embolism. Computed tomography revealed pial artery territorial infarction in 55 patients (92%). In 5, the infarction had the size or location (or both) characteristic of lacunes, although shape and lack of multiplicity raised questions about this interpretation. No patient showed a low-flow type of infarction pattern. These findings strongly support the view that (1) except for in situ thrombosis, pial artery territorial infarctions are indicative of an embolic mechanism, and (2) that the mechanism underlying lacunes is hardly, if ever, embolic.
SUMMARY Percutaneous transluminal coronary angioplasty (PTCA) was performed in 21 patients with acute myocardial infarction (AMI) treated by intracoronary infusion of streptokinase within 8 hours after the onset of symptoms. Streptolysis therapy began a mean of 3.6 1.2 hours (±+ SD) after the onset of symptoms. The vessel was occluded in 14 patients and highly stenosed in seven. After the infusion of 67,300 + 63,200 IU of streptokinase over 26.1 21.5 minutes, patency of the occluded vessels was reached.PTCA as performed 20-60 minutes after the end of streptokinase treatment in 19 patients and 24 and 31 hours after treatment in two patients. The dilation was successful in 17 patients (81%). The degree of vessel obstruction was reduced from 90.2 + 7.3% to 58.6 19.5% (area method) and from 71.4 + 12.4% to 39.2 + 19.7% (diameter method). The improvement was 31.5 18.4% and 32.2 ± 19.3%, respectively. No reocclusion was induced by PTCA. Twenty patients were discharged. One died during hospitalization; at autopsy, the treated vessel was still patent. During the follow-up period, two reinfarctions and one asymptomatic reocclusion occurred.The clinical findings during the hospital course and the follow-up period were compared with those of a control group of 18 patients with AMI and comparable coronary stenoses who were treated only with streptokinase infusion. Four of these patients had a reinfarction during the hospital course, and three died during the follow-up period.PTCA can be performed safely and successfully immediately after intracoronary infusion of streptokinase in patients with AMI. By reducing the subtotal stenosis, this treatment contributes to the reperfusion of the ischemic myocardium, diminishes the risk of a reocclusion and seems to improve the prognosis.
Complete closure of the pericardium after cardiac operation would have the advantage of avoiding injury of the heart and great vessels should repeat sternotomy prove to be necessary. In such situations, various pericardial closure techniques have been described. Synthetic materials produced severe scarring, while xenografts appeared to be satisfactory, although fibrous reactions and aseptic cystic formations have been reported recently. Between 1985 and 1986 we closed the pericardium with GORE-TEX-Surgical Membrane in a selected series of 72 patients aging 1 month to 76 years, median 24 years. Overall hospital mortality was 3/72 cases. In no instance was there a relationship between death occurrence and pericardial closure through Surgical Membrane. There were 5 cases each of low cardiac output and rethoracotomy because of bleeding. No cardiac tamponade occurred. Two patients had to be reoperated three and four weeks after primary repair. Surgical Membrane was explanted. Electron microscopy examination showed no cellular ingrowth in the low porosity membrane. No immunocompetent cellular compounds were present on either side of the graft. Follow-up interval averaged 13 months. No complication related to pericardial closure has occurred until now. The Surgical Membrane has the advantages of easy availability, of lack of reactions both between its surface and the underlying epicardium and with the rest of the pericardium. We believe its routine use should be encouraged mainly in patients with high probability of reoperation.
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