Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial.

BACKGROUND: The optimum systolic blood pressure after endovascular thrombectomy for acute ischaemic stroke is uncertain. We aimed to compare the safety and efficacy of blood pressure lowering treatment according to more intensive versus less intensive treatment targets in patients with elevated blood pressure after reperfusion with endovascular treatment. METHODS: We conducted an open-label, blinded-endpoint, randomised controlled trial at 44 tertiary-level hospitals in China. Eligible patients (aged ≥18 years) had persistently elevated systolic blood pressure (≥140 mm Hg for >10 min) following successful reperfusion with endovascular thrombectomy for acute ischaemic stroke from any intracranial large-vessel occlusion. Patients were randomly assigned (1:1, by a central, web-based program with a minimisation algorithm) to more intensive treatment (systolic blood pressure target <120 mm Hg) or less intensive treatment (target 140-180 mm Hg) to be achieved within 1 h and sustained for 72 h. The primary efficacy outcome was functional recovery, assessed according to the distribution in scores on the modified Rankin scale (range 0 [no symptoms] to 6 [death]) at 90 days. Analyses were done according to the modified intention-to-treat principle. Efficacy analyses were performed with proportional odds logistic regression with adjustment for treatment allocation as a fixed effect, site as a random effect, and baseline prognostic factors, and included all randomly assigned patients who provided consent and had available data for the primary outcome. The safety analysis included all randomly assigned patients. The treatment effects were expressed as odds ratios (ORs). This trial is registered at ClinicalTrials.gov, NCT04140110, and the Chinese Clinical Trial Registry, 1900027785; recruitment has stopped at all participating centres. FINDINGS: Between July 20, 2020, and March 7, 2022, 821 patients were randomly assigned. The trial was stopped after review of the outcome data on June 22, 2022, due to persistent efficacy and safety concerns. 407 participants were assigned to the more intensive treatment group and 409 to the less intensive treatment group, of whom 404 patients in the more intensive treatment group and 406 patients in the less intensive treatment group had primary outcome data available. The likelihood of poor functional outcome was greater in the more intensive treatment group than the less intensive treatment group (common OR 1·37 [95% CI 1·07-1·76]). Compared with the less intensive treatment group, the more intensive treatment group had more early neurological deterioration (common OR 1·53 [95% 1·18-1·97]) and major disability at 90 days (OR 2·07 [95% CI 1·47-2·93]) but there were no significant differences in symptomatic intracerebral haemorrhage. There were no significant differences in serious adverse events or mortality between groups. INTERPRETATION: Intensive control of systolic blood pressure to lower than 120 mm Hg should be avoided to prevent compromising the functional recovery of patients who have received endovascular thrombectomy for acute ischaemic stroke due to intracranial large-vessel occlusion. FUNDING: The Shanghai Hospital Development Center; National Health and Medical Research Council of Australia; Medical Research Futures Fund of Australia; China Stroke Prevention; Shanghai Changhai Hospital, Science and Technology Commission of Shanghai Municipality; Takeda China; Hasten Biopharmaceutic; Genesis Medtech; Penumbra.

Capsaicin combined with ice stimulation improves swallowing function in patients with dysphagia after stroke: A randomised controlled trial.

BACKGROUND: Dysphagia is a common condition after stroke, and it is associated with many complications. Early and effective treatments are essential to the prognosis of patients with dysphagia. We aimed to evaluate the effects and safety of capsaicin combined with ice stimulation in patients with dysphagia after stroke. METHODS: Patients with dysphagia admitted to our hospital from December 2017 to December 2019 were included. The control group received the ice stimulation, and the experimental group received the combined capsaicin and ice stimulation. The grade of water swallowing test (WST), standard swallowing assessment (SSA) scores and the serum substance P level was compared between control (ice only) and experimental group (capsaicin plus ice). RESULTS: No differences before treatment and significance following treatment in each group (before and after) and between groups (capsaicin plus ice vs ice only) were found (all P > .05); the SSA scores were significantly reduced after intervention for both groups (all P < .001), and after intervention, SSA score in experimental group was significantly less than that of control group (P < .001). After intervention, the number of patients graded as WST level I-II in experimental group was significantly more than that of control group (P < .001); the serum substance P level was significantly increased after intervention for both groups (all P < .05), and after intervention, the serum substance P level in experimental group was significantly higher than that of control group (P = .007). CONCLUSIONS: The combined use of capsaicin with ice stimulation is beneficial to the recovery of swallowing function of patients with dysphagia, which should be included into the clinical practice.

Percutaneous Full Endoscopic Management of Spinal Foraminal Schwannomas: Case Series.

BACKGROUND: Schwannoma, a benign peripheral nerve sheath tumor, is perhaps only secondary to degenerative pathology as the most common lesion at neural foramen. The surgical dilemma here is either risking nerve injury because of inadequate exposure or the need for internal fixation because of facet joint sacrifice. OBJECTIVE: To evaluate the feasibility and safety of management of foraminal schwannomas by percutaneous full-endoscopic technique. METHODS: A single-center retrospective review was conducted on patients who underwent full-endoscopic resection of neural foraminal schwannomas. Tumors were grouped into either medial type or lateral type based on relevant location to the neural foramen, and respective surgical approaches were adopted. Data including preoperative neurological status, tumor size, surgery time, the extension of resection, and clinical outcomes were collected. The learning curve was plotted as surgical time/tumor size against case number. RESULTS: A total of 25 patients were treated between May 2015 and March 2022. Gross total resection was achieved in 24 patients, and near-total resection in 1 case, with 1 patient experienced transient voiding difficulty. No tumor recurrence or spinal instability was detected in the short-term follow-up (median follow-up 22 months, range 3 months-6 years). Surgical efficiency improved with the number of cases operated on and remained stable after the initial 10 cases. CONCLUSION: Percutaneous full-endoscopic technique is a safe and minimally invasive technique for the resection of foraminal schwannomas.

Effect of stroke etiology on endovascular thrombectomy with or without intravenous alteplase: a subgroup analysis of DIRECT-MT.

BACKGROUND: Stroke etiology might influence the clinical outcomes in patients with large vessel occlusion receiving endovascular treatment (EVT) with or without thrombolysis. OBJECTIVE: To examine whether stroke etiology resulted in different efficacy and safety in patients treated with EVT-alone or EVT preceded by intravenous alteplase (combined therapy). METHODS: We assessed the efficacy and safety of treatment strategy based on prespecified stroke etiology, cardioembolism (CE), large-artery atherosclerosis (LAA), and undetermined cause (UC) for patients enrolled in the DIRECT-MT trial. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Multivariate ordinal logistic regression analysis was used to calculate the adjusted common OR for a shift of better mRS score for EVT-alone versus combined therapy. A term was entered to test for interaction. RESULTS: In this study, 656 patients were grouped into three prespecified stroke etiologic subgroups. The adjusted common ORs for improvement in the 90-day ordinal mRS score with EVT-alone were 1.2 (95% CI 0.8 to 1.8) for CE, 1.6 (95% CI 0.8 to 3.3) for LAA, and 0.8 (95% CI 0.5 to 1.3) for UC. Compared with CE, EVT-alone was more likely to result in an mRS score of 0-1 (pinteraction=0.047) and extended Thrombolysis in Cerebral Infarction ≥2b (pinteraction=0.041) in the LAA group. The differences in mortality and symptomatic intracranial hemorrhage within 90 days were not significant between the subgroups (p＞0.05). CONCLUSIONS: The results did not support the hypothesis that a specific treatment strategy based on stroke etiology should be used for patients with large vessel occlusion (NCT03469206).

Sodium valproate induced acute pancreatitis in a bipolar disorder patient: a case report.

BACKGROUND: Sodium valproate is one of the most widely used antiepileptics and mood stabilizers. However, this drug may induce acute pancreatitis. Few cases have been reported so far, mainly on the pediatric patients who underwent antiepileptic treatment. Hereby, we present a case of bipolar disorder with sodium valproate-induced acute pancreatitis. CASE PRESENTATION: The patient is a 54-year-old Chinese male. He was diagnosed with bipolar disorder for more than 39 years. Since the first onset of the disease, he had several relapses. The patient had had sodium valproate to stabilize mood swings for a year before the occurrence of acute pancreatitis. But he did vomit once during the inpatient care period. Then he was referred to another hospital following a notably high level of amylase. The results of computed tomography demonstrated an increased pancreatic volume and swollen peripancreatic fat tissue. As a result, the patient was diagnosed with acute pancreatitis. Unlike other cases reported in literatures, the high amylase level did not revert to normal after the withdrawal of medications. The patient was discharged from hospital with a high level of amylase, and was placed under follow-up observations. CONCLUSION: Acute pancreatitis is considered as one of the idiosyncratic adverse reactions to antiepileptic drugs. Previous reports were mainly on the pediatric patients with increased propensity to idiosyncratic drug effects, or the adult chronic renal failure patients with sodium valproate-induced pancreatitis due to the retention of intermediate metabolites in their bodies. In this study, even though our patient exhibited no high risk of developing pancreatitis, he was treated for drug-induced acute pancreatitis in three hospitals. As rare as drug-induced acute pancreatitis can be, it should not be overlooked, Moreover, the mechanism of how sodium valproate induces acute pancreatitis remains unknown. Therefore, physicians need to consider the medical history of patients before prescribing this medication.

Percutaneous Endoscopic Removal of Cervical Foraminal Schwannoma via Interlaminar Approach: A Case Report.

BACKGROUND AND IMPORTANCE: Cervical foraminal schwannomas commonly originate from spinal nerves that pass through the intervertebral foramen of the cervical vertebrae. Because of the proximity of this type of tumor to the vertebral artery and spinal nerves, surgical management remains a major challenge. Conventional open spine surgery usually requires the removal of the articular process and is supplemented by a simultaneous posterolateral spine fusion surgery. To decrease the associated risks of surgical complications by further reducing invasiveness, percutaneous spinal endoscopy may be used for resection of foraminal spinal neoplasm. CLINICAL PRESENTATION: A 52-yr-old female who presented with neck pains with duration of 1 yr was admitted to our hospital. Physical examination revealed moderate rigidity in the neck and grade 5 muscle strength in both upper and lower limbs. Preoperative magnetic resonance imaging (MRI) scans demonstrated a left-sided lesion at the C3-C4 intervertebral foraminal area. Under C-arm fluoroscopy navigation and neuromonitoring, the endoscope was properly positioned on the same side of the tumor, and a small part of the left C3 inferior and C4 superior lamina were first removed by an endoscopic drill to enlarge the interlaminar space. Next, through an endoscopic working canal, the left intervertebral ligamentum flavum was removed to fully expose the tumor. The tumor mass was finally resected in a piecemeal approach. Postoperative MRI confirmed complete tumor resection. CONCLUSION: This is the first case report of a total removal of a cervical foraminal schwannoma with a percutaneous spinal endoscopic procedure.

Percutaneous Endoscopic Removal of a Lumbar Epidural Angiolipoma via Interlaminar Approach: A Technical Report.

BACKGROUND: Although percutaneous endoscopic technique has been routinely used in the treatment of disk herniation, there are few reports on its application in the management of intraspinal tumors. We present a case report of lumbar epidural angiolipoma that was totally removed by percutaneous endoscopic technique. CASE DESCRIPTION: A 63-year-old man presented with a 4-month history of progressively worsening low back pain. No abnormal neurologic finding was noted on physical examination, and magnetic resonance imaging demonstrated a dorsally located L2-3 epidural lesion, suggestive of a noninfiltrating angiolipoma. During the operation, an 8-mm skin incision was made, and a dilator was bluntly inserted toward the interlaminar space, followed by insertion of a working cannula onto the ligamentum flavum and placement of the endoscope. The interlaminar space was enlarged by resection of part of the lower rim of the right L2 vertebral laminae, and the right side of the interlaminar ligamentum flavum was removed to expose the tumor. The tumor was totally removed piecemeal under endoscopic guidance, and pathologic examination confirmed the diagnosis of angiolipoma. CONCLUSIONS: This report supports the application of percutaneous endoscopic technique in the surgical resection of noninfiltrating extradural lumbar angiolipoma.