Background:Cavernous malformations (CMs) are the second most common intracranial vascular lesions. They typically present after hemorrhage or as incidental findings. Several risk factors have been identified for hemorrhage, however, electrocution as a cause has not been described. We performed a literature review of electrocution associated with CM hemorrhage and of the mechanisms of pathological injury in the central nervous system (CNS) secondary to electrocution. We found no cases of hemorrhage of CMs associated with electrocution.Case Description:A 19-year-old male electrician was accidentally electrocuted with 277 V of alternating current (AC) at a job site. He suffered no trauma or physical injuries and reported no immediate abnormal findings. He then experienced progressive nausea, emesis, and lethargy until he presented to the emergency department (ED) where it was discovered that he had a left thalamic/midbrain hemorrhage with hydrocephalus. His hydrocephalus was treated and he began to improve. Subsequent magnetic resonance imaging (MRI) of his head demonstrated characteristic features of a CM.Conclusions:There are several proposed mechanisms in the literature by which electrocution may cause CNS damage. It is conceivable that given the pathology of CMs and the proposed mechanisms of electrical injury, these lesions may have an increased risk of hemorrhage as result of electrocution and we are reporting the first case of such an association.
W hile carotid endarterectomy (CEA) is a wellestablished treatment for patients with carotid stenosis, 2,11,21 it is associated with a small but not insignificant rate (3.9%-6.5%) of perioperative stroke/transient ischemic attack (TIA). 9,16 This can necessitate urgent postoperative neuroimaging of the brain and supplying vasculature. Imaging findings associated with ischemic/hemorrhagic stroke 3,5,18,26 and hyperperfusion syndrome 12 after CEA are well reported, as are arterial changes (days to weeks) 8,19 and restenosis (months to years) 6,7,10,17 after CEA. However, there are few studies examining the carotid artery within the early 24-hour period following CEA (during which more than 75% of perioperative strokes occur), 9 and, to our knowledge, all have relied upon duplex ultrasound. obJect Carotid endarterectomy (CEA) carries a small but not insignificant risk of stroke/transient ischemic attack (TIA), most frequently observed within 24 hours of surgery, which can lead to the need for urgent vascular imaging in the immediate postoperative period. However, distinguishing expected versus pathological postoperative changes may not be straightforward on imaging studies of the carotid artery early after CEA. The authors aimed to describe routine versus pathological anatomical findings on CTA performed within 24 hours of CEA, and to evaluate associations between these CTA findings and postoperative stroke/TIA. methods The authors reviewed 113 consecutive adult patients who underwent postoperative CTA within 24 hours of CEA at a single academic institution. Presence and location of arterial "flaps," luminal "step-off," intraluminal thrombus and hematoma were documented from postoperative CTA scans. Medical records were reviewed to determine the incidence of new postoperative neurological findings. results Postoperative CTA findings included common carotid artery (CCA) step-off (63.7%), one or more intraarterial flaps (27.4%), hematoma at the surgical site (15.9%), and new intraluminal thrombus (7.1%). Flaps were seen in the external carotid artery (ECA), internal carotid artery (ICA), and CCA in 18.6%, 9.7%, and 6.2% of patients, respectively. New postoperative neurological findings were present in 7.1% of patients undergoing CTA. Flaps (especially ICA/CCA) and/ or intraluminal thrombi were more frequently seen in patients undergoing CTA for new postoperative stroke/TIA (85.7%) versus patients undergoing CTA for routine postoperative imaging (14.3%, p = 0.002). coNclusioNs CTA within 24 hours of CEA demonstrates characteristic anatomical findings. CCA step-offs and ECA flaps are relatively common and clinically insignificant, whereas ICA/CCA flaps and thrombi are less frequently seen and are associated with postoperative stroke/TIA.
Introduction: Carotid endarterectomy (CEA) is an established standard of care for patients with significant carotid stenosis today. Pre-op CTA is now frequently used to evaluate and plan for CEA, however no study to date has examined the findings of routine immediate post-CEA CTA. Aim: The aim of our study is to document the normal and abnormal findings on immediate post-op CTA and evaluate for possible clinical associations. Methods: Registry of all the subjects undergoing CEA, from 1 st July 2008 with available post-CEA CTA. Their medical records were reviewed to record details of the procedure and post-op complications. Results: We found 50 patients with post-CEA CTA, of which 16% had CTA ordered because of postoperative neurological deficit. Nearly 88% of CEAs were performed for symptomatic carotid stenosis/occlusion. All CEAs were performed under general anesthesia, 7 involved shunting and an equal number had patch placement. Only 1 CEA involved an eversion procedure. The mean cross clamp time was 69 minutes (SD 23.7 minutes). On post-CEA CTAs, we found that 78% of subjects had 0-20% residual stenosis, 20% had 20-50% residual stenosis, while 1 subject had 50-69% residual stenosis. A total of 5 subjects had a postoperative stroke. Amongst these, 80% were shunted, 100% had placement of a patch and the mean cross clamp time was 10.8 minutes (SD 15.7 minutes). The most commonly noted abnormality on CTA was a transitional step-off at the most proximal site of endarterectomy in the common carotid artery (CCA) (60% - Panel B). No flap, thrombus, or postoperative stroke was associated with this finding. This finding was associated with longer cross clamp times (76.5 mins v/s 58 mins, p=0.011). A total of 16.3% subjects developed post-op hematoma which resolved without intervention. Postop CTA demonstrated flaps (Panel A) in the ECA in 18% of subjects, in the ICA in 6% of patients, and in the CCA in 10% of patients. All patients with an ICA flap and 66.7% patients with a CCA flap developed a thrombus. All patients with a CCA flap and thrombus developed a post-op stroke, and 66.7% of patients with an ICA flap and thrombus developed a post-op stroke. Conclusion: Common carotid artery step off was the most common finding noted on post-operative CTA, and was not associated with any post-operative stroke. ICA and CCA flaps, seen in a small percentage of patients, were associated with thrombus formation and post-op stroke. This association needs to be further verified in a larger cohort.
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