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BACKGROUND: Trans-radial (TRA) access has become increasingly prevalent in neurointervention. Nonetheless, mediastinal hematoma after TRA is an infrequent yet grave complication associated with a notably elevated mortality rate. While our review found no reported mediastinal hematoma cases managed conservatively within neuro-interventional literature, similar complications are documented in cardiac and vascular interventional radiology, indicating its potential occurrence across disciplines.
METHODS: Carotid computed tomography angiography (CTA) showed calcified plaques with stenosis (Left: Severe, Right: Moderate) in the bilateral internal carotid arteries (ICAs) of an 81-year-old male presented with paroxysmal weakness in the right upper limb. Dual antiplatelet therapy with aspirin and clopidogrel was administered. On day 7, DSA of the bilateral ICAs was performed via TRA. Post-DSA, the patient experienced transient loss of consciousness, chest tightness, and other symptoms without ECG or MRI abnormalities. Hemoglobin level decreased from 110 g/L to 92 g/L. Iodinated contrast-induced laryngeal edema was suspected, and the patient was treated with intravenous methylprednisolone. Neck CT indicated a possible mediastinal hemorrhage, which chest CTA confirmed. The patient\'s treatment plan involved discontinuing antiplatelet medication as a precautionary measure against the potential occurrence of an ischemic stroke instead of the utilization of a covered stent graft and surgical intervention. Serial CTs revealed hematoma absorption. Discharge CT showed a reduced hematoma volume of 35 × 45 mm.
CONCLUSIONS: This case underscores the need for timely identification and precise manipulation of guidewires and guide-catheters through trans-radial access. The critical components of successful neuro-interventional techniques include timely examination, rapid identification, proper therapy, and diligent monitoring.

BACKGROUND There has been an increase in the use of inhalation methods to abuse drugs, including freebasing crack cocaine (alkaloid) and inhaling methamphetamine vapor. This report is of a 25-year-old man with a history of substance abuse presenting with pneumomediastinum due to methamphetamine vapor inhalation. Acute pneumomediastinum is an extremely rare complication of methamphetamine use. CASE REPORT A 25-year-old man was treated for polysubstance abuse following 9 days of methamphetamine abuse. EKG did not show any ST &T change. D-dimer was normal, at 0.4 mg/L, so we did not do further work-up for pulmonary embolism. His chest pain worsened in the Emergency Department (ED), and a physical exam demonstrated crepitation of the posterior neck, trapezius, and right scapula. A portable chest X-ray revealed subcutaneous air over the right scapular region, in addition to pneumomediastinum. The urine drug screen test was positive for methamphetamine. A chest CT was ordered, which showed a moderate-volume pneumomediastinum with soft-tissue air tracking into the lower neck and along the right chest wall. The patient underwent an esophagogram, which showed no air leak, and Boerhaave\'s syndrome was ruled out. His symptoms improved and he did not require any surgical intervention. CONCLUSIONS Considering the higher rates of illicit substance use, especially methamphetamine, it is important to pay attention to the associated pathologies and to keep spontaneous pneumomediastinum on the list of differentials for patients using methamphetamine, particularly those who inhale it, which can cause pneumomediastinum, even without Boerhaave\'s syndrome.

BACKGROUND: Sinus histiocytosis with massive lymphadenopathy, also known as Rosai-Dorfman disease, is a rare, self-limiting disease that predominantly affects children and young adults. Moreover, the disease is characterized by painless bilateral cervical lymphadenopathy in 95% of the patients. However, few reports are available on the Rosai-Dorfman disease of the thymus.
METHODS: We report a rare case of thymic Rosai-Dorfman disease detected using computed tomography. During a medical examination, a 50-year-old man underwent a chest computed tomography scan, which revealed an anterior mediastinal single mass with fat in the thymus. A thymectomy was performed to completely remove the tumor using a thoracoscopic technique due to a clinical suspicion of thymoma. Furthermore, Rosai-Dorfman disease was confirmed using histological and immunohistochemical analyses.
CONCLUSIONS: To the best of our knowledge, this is the sixth case of thymus-affecting solitary Rosai-Dorfman disease with histological and immunohistochemical evidence. Fat in the thymus, as was present in this case, has never been described in Rosai-Dorfman disease previously. Our results highlight the challenge of diagnosing this uncommon tumor before surgery, and more cases need to be reported to help with the preoperative diagnosis of such a rare tumor.

BACKGROUND: Boerhaave syndrome is a rare clinical entity associated with high rates of morbidity and mortality. Early recognition of the symptoms, and identification of the site and extension of the injury are key in improving the prognosis.
METHODS: This study presents data on the mortality, morbidity and length of hospital stay in patients diagnosed with Boerhaave syndrome. The data were retrieved from a prospectively collected database in a single surgical unit between 2012 and 2022. The study makes a comparison with the surgical outcomes of the previous decade.
RESULTS: Some 33 patients were diagnosed with Boerhaave syndrome and were treated surgically between 2012 and 2022 in a specialist upper gastrointestinal surgical unit. All patients underwent standard surgical repair (in-theatre diagnostic endoscopy, T-tube placement through thoracotomy and feeding jejunostomy through laparotomy). The mean size of the defects in the oesophageal lumen was 3.3cm. Delayed presentation was noted for 13 patients (39%); 8 patients (24%) died in hospital, and 19 patients (58%) developed postoperative complications. Mortality was similar to the rate recorded for the 20 patients from the previous decade (24% vs 20%, respectively). The mean length of hospital stay was 41 days, and was comparable to the 35.7 days reported between 1997 and 2011.
CONCLUSIONS: Early and aggressive management of spontaneous oesophageal rupture ameliorates the postoperative recovery and prognosis. The surgical results of our unit were found comparable to the previous decade in the population of patients who were treated surgically.

BACKGROUND: Rosai-Dorfman Disease (RDD) is a rare self-limiting histiocytosis, more prevalent in children and young adults. It typically manifests as painless bilateral massive cervical lymphadenopathy but may also extend to extra-nodal sites, with intrathoracic RDD noted in 2% of cases. Distinguishing mediastinal RDD from thymoma on imaging poses challenges, underscoring the reliance on pathological features and immunohistochemical staining for diagnosis.
METHODS: Patient, male, 33 years old, underwent lung a CT revealing an enlarged round soft tissue shadow in the anterior superior mediastinum, compared to a year ago. Surgical resection removed the entire mass, thymus, and part of the pericardium, confirming RDD on pathology. Genetic testing using second-generation testing technology identified a KRAS gene point mutation.
CONCLUSIONS: No established treatment protocol currently exists for this disease. However, as genetic mutation research progresses, a novel therapeutic avenue is emerging: targeted therapy integrated with surgical interventions.

Tracheomediastinal fistula is a rare but life-threatening complication of cancer. We report a case of tracheomediastinal fistula induced by concurrent chemoradiotherapy in limited stage small cell lung cancer. Despite the treatment response, the metastatic paratracheal lymph node increased gradually during concurrent chemoradiotherapy, resulting in the occurrence of tracheomediastinal fistula and mediastinitis. Without any surgical intervention, the patient achieved successful recovery from mediastinitis through antibiotic treatment, although the tracheomediastinal fistula remained open. In this report, we also review previous studies of tracheomediastinal and bronchomediastinal fistulas and summarize the clinical features.

Boerhaave\'s syndrome, or the spontaneous transmural perforation of the esophagus, is typically thought to be due to an increase in esophageal pressure such as that which occurs during vomiting or retching. Another common etiology of esophageal perforation is esophageal instrumentation, such as during esophagogastroduodenoscopy or transesophageal echocardiography. This life-threatening condition requires prompt diagnosis and treatment to prevent patient demise. While a history of vomiting can aid in diagnosis, this history can be difficult to elicit in an unconscious patient or may be altogether absent. Additionally, Boerhaave\'s syndrome can present similarly to more common upper gastrointestinal or cardiac conditions. Since mortality increases with delays in diagnosis and treatment, it is imperative that clinicians maintain a high level of suspicion for Boerhaave\'s syndrome and initiate treatment urgently.
This report presents a 76-year-old man who presented to the emergency department after a history of several syncopal episodes and was found to be in complete heart block. Two days later, he acutely developed abdominal distention and coffee ground emesis. As the medical team was able to gather more history from the patient and his family, it was revealed that he had associated vomiting with his episodes of syncope. CT scan of the abdomen and pelvis demonstrated pneumomediastinum concerning for esophageal perforation. His clinical status subsequently deteriorated. He was intubated and a temporary transvenous pacer was placed before being transferred to our facility for emergent surgery.
Complete heart block in the setting of Boerhaave\'s syndrome is exceptionally rare, with only 2 cases reported in the literature. The decision to place a pacemaker in the setting of esophageal perforation/sepsis is complicated and depends on the patient\'s bacteremia status related to noncardiac comorbidities. Clearly this case represents the need for excellent multidisciplinary decision-making processes with excellent communication between hospital staff and all caretakers. Expeditious diagnosis and treatment of esophageal perforation is essential to prevent leaking of gastric contents into the mediastinum and worsening of cardiac complications and sepsis. Additionally, critical timing of various surgical procedures, especially the need for a permanent pacemaker implant with bacteremia is a complicated process not well described in the surgical literature.

BACKGROUND Fish bone ingestion is the most common cause of esophageal perforation (12%). However, it rarely causes esophageal perforation and mediastinal abscess. Most studies recommend surgical intervention for patients with esophageal perforation and thoracic abscess. However, surgery may not be suitable for extremely critical cases or may have limited effectiveness. In such cases, a combination of surgery and conservative treatment is crucial. The use of double cannula irrigation and drainage in conservative treatment has shown promising results in pus removal. CASE REPORT We report a 28-year-old man with a perforated esophagus with abscess and mediastinal abscess due to fish bone. Emergency surgery was performed after admission. Symptoms of septic shock developed after surgery, and a significant amount of pus was still present in the chest cavity and mediastinum. Conservative treatment was adopted, with double cannula irrigation and drainage. By employing anti-infection measures and continuous irrigation and drainage, the patient was cured after 42 days. CONCLUSIONS In this case, surgical intervention did not yield satisfactory results. However, after using double cannula irrigation and drainage to clear the thoracic and mediastinal abscesses, the patient\'s infection levels returned to normal. Additionally, the patient was successfully weaned off the ventilator, and the tracheotomy catheter was removed. After discharge, the patient resumed to normal life, without any significant complications during 1 year of follow-up. Double cannula drainage played a vital role in this patient\'s treatment; however, further clinical evidence is required to determine its suitability for other patients with esophageal perforation complicated by mediastinal abscess.

BACKGROUND: Acute phlegmonous esophagitis (APE) is bacterial infection of the submucosal and muscularis layers of the esophagus. APE is a rare but life-threatening disease, and few studies have reported it.
METHODS: A 63-year-old Korean woman was admitted to the emergency department complaining of chest pain. Contrast-enhanced computed tomography revealed diffuse esophageal wall thickening with low attenuation and paraesophageal fluid collection in the mediastinum. Esophagomyotomy, mediastinal abscess drainage with a right thoracotomy, and left 3-port video-assisted thoracoscopy were performed in the operating room.
METHODS: Contrast-enhanced computed tomography revealed diffuse esophageal wall thickening with low attenuation and paraesophageal fluid collection in the mediastinum.
METHODS: Esophagomyotomy, mediastinal abscess drainage with a right thoracotomy, and left 3-port video-assisted thoracoscopy were performed in the operating room.
RESULTS: The patient followed up through an outpatient visit 4 days later discharged. The patient progress was good, and she decided to visit the patient if she had pain afterwards.
CONCLUSIONS: As APE is rare but deadly, strategies to identify APE in patients with chest pain or dysphagia are needed in emergency department.