Cerebrovascular risks with rapid blood pressure lowering in the absence of hypertensive emergency.

STUDY OBJECTIVE: In the Emergency Department (ED) setting, clinicians commonly treat severely elevated blood pressure (BP) despite the absence of evidence supporting this practice. We sought to determine if this rapid reduction of severely elevated BP in the ED has negative cerebrovascular effects. METHODS: This was a prospective quasi-experimental study occurring in an academic emergency department. The study was inclusive of patients with a systolic BP (SBP) > 180 mm Hg for whom the treating clinicians ordered intensive BP lowering with intravenous or short-acting oral agents. We excluded patients with clinical evidence of hypertensive emergency. We assessed cerebrovascular effects with measurements of middle cerebral artery flow velocities and any clinical neurological deterioration. RESULTS: There were 39 patients, predominantly African American (90%) and male (67%) and with a mean age of 50 years. The mean pre-treatment SBP was 210 ±â€¯26 mm Hg. The mean change in SBP was -38 mm Hg (95% CI -49 to -27) mm Hg. The average change in cerebral mean flow velocity was -5 (95% CI -7 to -2) cm/s, representing a -9% (95% CI -14% to -4%) change. Two patients (5.1%, 95% CI 0.52-16.9%) had an adverse neurological event. CONCLUSION: While this small cohort did not find an overall substantial change in cerebral blood flow, it demonstrated adverse cerebrovascular effects from rapid BP reduction in the emergency setting.

Balloon-Assisted Retrieval of a Retained Vascular Sheath during Complex Inferior Vena Cava Filter Removal.

A potential complication of complex endovascular procedures is retained foreign bodies such as fragmented catheters, wires, stents, or sheaths in the intravascular space. Different techniques are available for retrieval of intravascular foreign bodies including snares, forceps, baskets, tip-deflecting wires, and balloon catheters. The aim of this article is to describe our experience in which a lost large intravascular sheath was retrieved using balloon assistance. We also provide a review of different techniques used for intravascular large sheath retrieval and methods to avoid this complication during endovascular procedures such as complex inferior vena cava filter removal.

Cardiac Stroke Volume Index Is Associated With Early Neurological Improvement in Acute Ischemic Stroke Patients.

Early neurological improvement as assessed with the NIH stroke scale (NIHSS) at 24 h has been associated with improved long-term functional outcomes following acute ischemic stroke (AIS). Cardiac dysfunction is often present in AIS, but its association with outcomes is incompletely defined. We performed a pilot study to evaluate the association between non-invasively measured cardiac parameters and 24-h neurological improvement in prospectively enrolled patients with suspected AIS who presented within 12 h of symptom-onset and had an initial systolic blood pressure>140 mm Hg. Patients receiving thrombolytic therapy or mechanical thrombectomy were excluded. Non-invasive pulse contour analysis was used to measure mean arterial blood pressure (MAP), cardiac stroke volume index (cSVI), cardiac output (CO) and cardiac index (CI). Transcranial Doppler recorded mean middle cerebral artery flow velocity (MFV). We defined a decrease of 4 NIHSS points or NIHSS ≤ 1 at 24-h as neurological improvement. Of 75 suspected, 38 had confirmed AIS and did not receive reperfusion therapy. Of these, 7/38 (18.4%) had neurological improvement over 24 h. MAP was greater in those without improvement (108, IQR 96-123 mm Hg) vs. those with (89, IQR 73-104 mm Hg). cSVI, CO, and MFV were similar between those without and with improvement: 37.4 (IQR 30.9-47.7) vs. 44.7 (IQR 42.3-55.3) ml/m2; 5.2 (IQR 4.2-6.6) vs. 5.3 (IQR 4.7-6.7) mL/min; and 39.9 (IQR 32.1-45.7) vs. 34.4 (IQR 27.1-49.2) cm/s, respectively. Multivariate analysis found MAP and cSVI as predictors for improvement (OR 0.93, 95%CI 0.85-0.98 and 1.14, 95%CI 1.03-1.31). In this pilot study, cSVI and MAP were associated with 24-h neurological improvement in AIS.

Percutaneous cryoablation of adrenal metastases: technical feasibility and safety.

PURPOSE: To assess the technical feasibility and outcomes of adrenal metastases cryoablation. MATERIALS AND METHODS: This is an IRB approved retrospective review of adrenal metastases cryoablation between April 2003 and October 2018. Forty percutaneous cryoablation procedures were performed on 40 adrenal metastases in 34 patients. Histology, tumor size, ablation zone size, major vessel proximity, local recurrences, complications, and anesthesia-managed hypertension monitoring was collected. Complications were graded according to the Common Terminology of Complications and Adverse Events (CTCAE). RESULTS: Mean tumor and ablation size was 3.2 cm and 5.2 cm, respectively. Local recurrence rate was 10.0% (N = 4/40) for a mean follow-up time of 1.8 years. Recurrences for tumors > 3 cm (21.0%, N = 4/19) was greater than for tumors ≤ 3 cm (0.0%, N = 0/21) (p = 0.027). Proximity of major vasculature (i.e., IVC & aorta) did not statistically effect recurrence rates (p = 0.52), however, those that recurred near vasculature were > 4 cm. Major complication (≥ grade 3) rate was 5.0% (N = 2/40), with one major complication attributable to the procedure. Immediate escalation of blood pressure during the passive stick phase (between freeze cycles) or post procedure thaw phase was greater in patients with residual adrenal tissue (N = 21/38) versus masses replacing the entire adrenal gland (N = 17/38), (p = 0.0020). Lower blood pressure elevation was noted in patients with residual adrenal tissue who were pre-treated with alpha blockade (p = 0.015). CONCLUSIONS: CT-guided percutaneous cryoablation is a safe, effective and low morbidity alternative for patients with adrenal metastases. Transient hypertension is related only to residual viable adrenal tissue but can be safely managed and prophylactically treated.

Assessing Fluid Responsiveness in Spontaneously Breathing Patients.

OBJECTIVES: The primary objective of this study was to test if fasting volunteers exhibit fluid responsiveness using noninvasive hemodynamic measurements. The secondary objective was to test a passive leg raise (PLR) maneuver as a diagnostic predictor of fluid responsiveness. METHODS: This was a quasi-experimental design involving healthy volunteers. Subjects were excluded for pregnancy and congestive heart failure. Following a 12-hour fast, subjects had baseline hemodynamic monitoring recorded using noninvasive, continuous pulse contour analysis. Subjects then had a PLR maneuver performed, followed by an intravenous bolus of crystalloid. A rise in stroke volume ≥ 10% from baseline with the bolus was considered consistent with fluid responsiveness, and the same rise with a PLR was consistent with a positive PLR maneuver. The primary outcome was the change in stroke volume with a fluid bolus. Univariate analysis assessed changes in hemodynamic parameters. Logistic regression analysis determined the test characteristics of the PLR in predicting subjects who were ultimately fluid responsive. RESULTS: Forty subjects completed the study. The mean change in stroke volume with a crystalloid bolus was 19% (95% confidence interval [CI] = 16% to 21%). Thirty-six (90%) subjects were fluid responsive. The mean PLR response for the overall cohort was 16% (95% CI = 12% to 19%), and 26 (65%) subjects had a positive PLR maneuver. The PLR was 72% sensitive (95% CI = 55% to 85%) and 100% specific (95% CI = 40% to 100%) for predicting the presence of fluid responsiveness. CONCLUSIONS: Noninvasive assessment of fluid responsiveness in healthy volunteers and prediction of this response with a PLR maneuver is achievable. Further work is indicated to test these methods in acutely ill patients.

Delayed intracranial hemorrhage in the anticoagulated patient: A systematic review.

BACKGROUND: A significant population of elderly Americans on warfarin is at risk for immediate and delayed intracranial hemorrhage. This qualitative systematic review ascertains the delayed intracranial hemorrhage risk associated with minor head injury and preinjury warfarin use. METHODS: A systematic review using MEDLINE, EMBASE, and the Cochrane Library was performed in August 2014. Cohort studies evaluating delayed intracranial hemorrhage in patients with minor head injuries on warfarin were eligible for inclusion. The definition of delayed hemorrhage was any intracranial bleeding detected subsequent to initial negative brain imaging result following the head injury. Three authors screened and abstracted the data and evaluated methodological quality. Data abstraction also included clinical characteristics that could identify risk factors for delayed intracranial hemorrhage. RESULTS: The search retrieved 294 unique articles, of which 5 studies constituted the final review. The studies included data on 1,257 patients. Among higher-quality studies, the incidence of delayed intracranial hemorrhage ranged from 5.8 to 72 per 1,000 cases of patients on warfarin with minor head injury. Population age was an influential factor in this range of incident rates. International normalized ratio levels had no clear association with individual risk for delayed intracranial hemorrhage. CONCLUSION: The incidence of delayed intracranial hemorrhage is low among patients on warfarin with minor head injury. Trauma centers should consider the characteristics of the population they serve compared with the published studies when determining management strategies for these patients. LEVEL OF EVIDENCE: Systematic review, level III.