Background:We report herein a case of cavernous sinus (CS)-dural arteriovenous fistula (DAVF) with brainstem venous congestion that was successfully treated by transarterial embolization, followed by radiotherapy.Case Description:An 80-year-old woman presented with right eye chemosis and left hemiparesis. T2-weighted magnetic resonance imaging showed hyperintensity of the pons. Diagnostic cerebral angiography demonstrated CS-DAVF draining into the right superior orbital vein and petrosal vein, and fed by bilateral internal and external carotid arteries. Transarterial embolization was performed and followed by radiotherapy, resulting in resolution of the pontine lesion and neurological and ophthalmological symptoms within 5 months.Conclusions:We also review the literature regarding therapy for CS-DAVF with brainstem venous congestion. Once CS-DAVF with venous congestion of the brainstem has been definitively diagnosed, immediate therapy is warranted. Treatment with transarterial embolization followed by radiation may be an important option for elderly patients when transvenous or transarterial embolization is not an option.
A 39 years old woman was admitted to our hospital with a status epilepticus, with high fever of 41°C. Magnetic resonance Imaging (MRI) revealed high signal intensities of both sides of thalami and hypothalami in T2 weighted and fluid attenuated inversion recovery (FLAIR) images. A needle biopsy of the thalamic lesion was consistent with neuromyelitis optica spectrum disorder although her serum antibody to aquaporin-4 was negative. The level of orexin in celebrospinal fluid (CSF) was reduced. She presented hypersomnia, which didn't improve even after intravenous methylprednisolone 1 g daily for 3 days. Administration of oral modafinil extended her waking time. There is a number of reports about neuromyelitis optica (NMO) with hypothalamic lesions. We report this case as important suggestion of treatment of these cases.
Objective: To evaluate whether proper diagnoses were made at an emergency department to elderly patients who presented with abdominal pain, and to identify factors associated with acute surgical condition. Methods: A two-year retrospective review of patients aged 65 years and older complaining of abdominal pain who presented to the emergency department. Results: 189 patients were enrolled. The over all accuracy rate for emergency department diagnoses was 79%. Of the 13 (7.1%) patients with a very different diagnosis from the first diagnosis after admission, six cases were not initially recognized as an acute surgical condition, and surgery was delayed. Factors associated with acute surgical condition by univariate analyses included tachypnea, hypothermia, persistent pain, perspiration, hyperglycemia, hypoalbuminemia, hypocalcemia, and the presence of systemic inflammatory response syndrome. A multivariate, logistic regression analysis indicates that persistent pain is a possible predictive factor indicating an acute surgical condition. In all six cases where such a condition initially went unrecognized, the abdominal CT was a key resource in revealing an acute surgical condition. Conclusions: In the emergency department, diagnosis of abdominal pain in the elderly with less specific symptoms is difficult and less accurate. Persistent pain is a possible predictive factor indicating an acute surgical condition and patients with persistent pain should be evaluated by abdominal CT scan early in the evaluative process.
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