Functionality of Monoclonal Antibody Therapy in SARS-CoV-2.

The coronavirus disease 2019 (COVID-19) pandemic emerged as a world crisis in 2019 and started a global search for optimal therapeutic regimen including vaccines, antiviral agents, and recently monoclonal antibody therapy. Clinical trials are currently underway for the efficacy of several neutralizing monoclonal antibodies against COVID-19. The evolution of new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants with immune evasion capacity has created a challenge for the healthcare workers with urgent need for prospective studies to determine functionality of monoclonal antibody therapy and their role in the reduction of hospitalization for disease severity. Herein, we report three cases of COVID-19 during the beginning of the spread of Omicron variants that were hospitalized after treatment with monoclonal antibody therapy in the emergency department. All the patients showed progression of the disease on imaging and were treated with dexamethasone, remdesivir and anticoagulation based on the symptoms and contraindications. Two of the patients recovered and were discharged with out-patient follow-up; however, one patient expired in the hospital. Monoclonal antibody therapy is a promising treatment to limit the progression of COVID-19 and reduce the hospital strain specifically in small community hospitals. Limited information is available about their efficacy in the new viral variants. These cases emphasize the need of future prospective study and randomized controlled trials to illustrate the utilization of monoclonal antibodies as a therapeutic modality in patients infected with the variants of SARS-CoV-2.

Assessment of Cerebral Vasodilatory Capacity as Part of Catheter-Based Cerebral Angiography.

BACKGROUND AND PURPOSE: Cerebral vasodilatory capacity assessment for risk stratification in patients with extracranial arterial stenosis or occlusion may be useful. We describe a new method that assesses cerebral vasodilatory capacity as part of catheter-based cerebral angiography. METHODS: We prospectively assessed regional cerebral blood volume (rCBV) in the arterial distribution of interest using a controlled contrast injection in the common carotid or the subclavian arteries. rCBV maps were created using a predefined algorithm based on contrast distribution in the venous phase (voxel size: .466 mm3 ). rCBV maps were acquired again after selective administration of intra-arterial nicardipine (2.0 mg) distal to the stenosis. Two independent observers graded the change in rCBV in 10 predefined anatomical regions within the tributaries of the artery of interest (0 = reduction, 1 = no change, 2 = increase) and total rCBV change scores were summated. RESULTS: Twenty-five patients with internal carotid artery stenosis (n = 18; 0-90% in severity) or extracranial vertebral artery stenosis (n = 7; 0-100% in severity) were assessed. There was an increase in rCBV in a tributary of the artery of interest in 18 of 25 after intra-arterial nicardipine (mean score: 11.98; range 0-19.5). There was no change or decrease in rCBV in 7 of 25 patients. The mean rCBV change score was similar in patients with an assessment of internal carotid artery or vertebral artery distributions (12.2 ± 5.3; 11.4 ± 2.5; P = .68). CONCLUSION: Selective vasodilatory response to intra-arterial nicardipine in the affected arterial distribution during catheter-based cerebral angiography may provide new data for risk stratification.

Effect of epidural blood injection on upright posture intolerance in patients with headaches due to intracranial hypotension: A prospective study.

BACKGROUND: We performed a prospective study to quantify changes in various aspects of upright posture intolerance in patients with intracranial hypotension. METHODS: Six patients were provided a standard questionnaire before, immediately after epidural blood patch injection and at follow-up visit within 1 month after epidural blood injection inquiring: (a) How long can they stand straight without any support? (b) Do they feel any sense of sickness when they sit or lie down after standing? (c) How long do they have to wait before they are comfortable standing again after they have stood straight? (d) How effectively and fast can they get up from sitting or lying position to stand straight? and (e) Rate their activities in upright posture without support on a standard vertical visual analogue scale between 100 (can do everything) and 0 (cannot do anything). RESULTS: All patients responded that they could not stand straight for ≥30 min (four responding <5 min) on pretreatment evaluation. All patients reported improvement in this measure immediately postprocedure with two reporting ≥30 min. At follow-up, three patients reported further improvement and one patient reported worsening in this measure. The magnitude of improvement ranged from 10 to 80 points increase immediately postprocedure in their ability to perform activities, while they are standing without any support on visual analogue scale. At follow-up, four patient reported additional improvement in their ability to perform activities, while they are standing without any support (ranged from 10 to 20 points increase compared with immediately postprocedure rating). CONCLUSIONS: We present semiquantitative data on various aspects of upright posture intolerance in patients with intracranial hypotension before and after epidural blood injection.

Chest Pain as a Manifestation of Intracranial Hypotension: Report of Four Cases.

BACKGROUND: Chest pain has not been recognized as a manifestation of intracranial hypotension secondary to cerebrospinal fluid leakage. CASE REPORT: We report on 4 patients with intracranial hypotension diagnosed by the pattern of headaches, temporal proximity to dural puncture, magnetic resonance imaging findings, and resolution of symptoms after epidural blood patch who presented with chest pain. The chest pain was episodic, located in the sternal and interscapular region for the first 3 patients, with no radiation to any other region and no clear relationship to exertion. The fourth patient had episodic chest pain located in the subclavicular and suprascapular region. Two patients reported dyspnea with chest pain. Underlying coronary artery ischemia was excluded using a combination of the electrocardiogram and cardiac enzyme assays. The pain resolved after epidural blood patch treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians should be aware of chest pain that can be seen with intracranial hypotension and cerebrospinal leakage to ensure appropriate diagnostic tests and treatment.

Long Acting Liposomal Bupivacaine for Percutaneous Sympathetic Stellate Ganglion Blockade: A Technical Note.

INTRODUCTION: We describe the use of long acting liposomal bupivacaine for percutaneous stellate ganglion blockade to treat severe headaches following internal carotid artery dissection. METHODS: A 43-year old woman developed right-sided refractory headache after right internal carotid artery dissection. Patient underwent percutaneous stellate ganglion block using bupivacaine hydrochloride (0.25%-20 ml) in the past with short acting relief. Liposomal bupivacaine (EXPAREL) 13.3 mg/mL (1.3%) solution diluted with preservative-free normal saline: a total solution of 20 ml (52 mg of bupivacaine) was injected at the level of the lower portion of body of the sixth cervical vertebra, medial to the right internal carotid artery. The response to sympathetic block was assessed by a neurologist not involved in the procedure. RESULTS: After the stellate ganglion block with bupivacaine hydrochloride, patient was headache free immediately after the block but with recurrence of pain on Day 3 with return to peak intensity by Day 4. After the stellate ganglion blockade with liposomal bupivacaine hydrochloride, patient reported recurrence of pain on Day 15 post injection with return to peak intensity by Day 17. The patient reported an episode of aura which consisted of visual scintillations on Day 2 which lasted for five days and resolved spontaneously. CONCLUSION: Liposomal bupivacaine injection for stellate ganglion blockade can result in a more prolonged effect compared with bupivacaine hydrochloride.