Stress hyperglycemia as a modifiable predictor of futile recanalization in patients undergoing mechanical thrombectomy for acute ischemic stroke.

Introduction: Mechanical thrombectomy (MT) is the first line treatment in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Approximately half of patients treated with MT does not have a favorable outcome 3 months after stroke. The aim of this study was to identify predictors of futile recanalization (FR) in patients with LVO treated with MT. Methods: A retrospective analysis of consecutive patients with acute ischemic stroke due to anterior circulation LVO who underwent MT. Patients with a TICI score of 2b or 3 were included. We distinguished two groups, FR and meaningful recanalization (MR), according to patients' disability three months after stroke (FR: mRS score > 2; MR: mRS score < 2). Results: We enrolled 238 patients (FR, n = 129, 54.2%; MR, n = 109, 45.8%). Age (OR 1.05, 95% CI 1.01-1.09, p = 0.012), female sex (OR 2.43, 95% CI 1.12-5.30, p = 0.025), stress hyperglycemia, as measured by the GAR index, (OR 1.17, 95% CI 1.06-1.29, p = 0.002), NIHSS at admission (OR 1.15, 95% CI 1.07-1.25, p = 0.001) and time from symptoms onset to MT (OR 1.01, 95% CI 1.00-1.01, p = 0.020) were independent predictors of FR. The AUC for the model combining age, female sex, GAR index, NIHSS at admission and time from symptoms onset to MT was 0.81 (95% CI 0.76-0.87; p < 0.001). The optimal GAR index cut-off score to predict FR was 17.9. Discussion: FR is common after MT. We recognized older age, female sex and baseline NIHSS as non-modifiable predictors of FR. On the other hand, time from symptoms onset to MT and stress hyperglycemia were modifiable pre- and post-MT factors, respectively. Any effort should be encouraged to reduce the impact of these modifiable predictors.

Silk Vista Baby Is a Safe and Technically Feasible Flow Diverting Stent for Distal Aneurysm Treatment.

Background and Purpose: Flow diverting stents are designed to divert blood flow from the aneurysm sac, allowing for eventual occlusion following endovascular therapy. This case series reports clinical experience using the Silk Vista Baby (SVB, Balt Extrusion, Montmorency, France), a flow diverter (FD) designed to treat intracranial aneurysms in small, distal vessels. Methods: All patients who underwent treatment with SVB at the University Hospital "Santa Maria della Misericordia" of Udine between July 2018 and September 2020 were retrospectively identified. Baseline patient and aneurysm characteristics, intraprocedural technical outcomes, periprocedural complications, modified Rankin Scale (mRS) at discharge, magnetic resonance imaging (MRI) results at 3-month follow-up, and angiographic results at 6-month follow-up were collected. Results: A total of 18 patients (55.6% [10/18] male; mean age 62.6 years, range: 42-77 years) were retrospectively identified, receiving treatment for 22 aneurysms. Most patients were symptomatic (14/18, 77.8%) and approximately half had subarachnoid hemorrhage (10/18, 55.6%). Sufficient aneurysm coverage was achieved in 88.9% (16/18) of patients with a single device. Mortality did not occur (0/18, 0%); adverse device-related events included side branch occlusion (1/18, 5.6%) and in-stent thrombosis (1/18, 5.6%). At discharge, 77.8% (14/18) had an mRS of 0. In most cases, patients showed complete occlusion (10/15, 66.7%) or a small aneurysmal remnant (3/15, 20.0%) upon MRI; upon angiography, most showed complete occlusion (10/13, 76.9%) or only a small aneurysmal remnant (2/13, 15.4%). Conclusion: This case series showed that the SVB FD is safe and feasible to use in patients with aneurysms in small, distal vessels. Additional randomized, prospective studies with larger cohorts are needed for the SVB.

Incidental cardiac aspergillomas in an immunocompromised woman.

We report a case of 3 autopsy proven incidental cardiac aspergillomas, a rare and yet deadly manifestation caused by Aspergillus. A 48-year-old Caucasian woman affected by a large B-cell lymphoma was referred to our institute for a whole-body fluorine-18 fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography restaging examination, which demonstrated 3 intracardiac masses. The patient was hospitalized, and both a transthoracic echocardiogram and a cardiac magnetic resonance imaging examination were performed. None of the imaging modalities provided a definitive diagnosis. A positive serum galactomannan assay allowed for the initiation of antifungal therapy, but, nevertheless, the patient died a few days later. This case highlights the need to consider cardiac aspergilloma in the differential diagnosis of cardiac masses, especially in immunocompromised patients. Though noninvasive imaging modalities and cardiac magnetic resonance imaging, in particular, help determine the nature of a cardiac lesion, cardiac aspergilloma shows no distinctive radiological features. A high degree of clinical suspicion is therefore key to achieving a timely diagnosis. Histopathological examination with microbiological confirmation remains the diagnostic gold standard.

Bone islands incidentally detected on computed tomography: frequency of enostosis and differentiation from untreated osteoblastic metastases based on CT attenuation value.

OBJECTIVE: The frequency of enostosis incidentally found on CT and CT attenuation value to distinguish them from untreated osteoblastic metastases (UOM). METHODS: Enostosis group: 46 polytrauma patients underwent thoracoabdominal CT. Inclusion criteria: age range 14-35 years. Exclusion criteria: cancer, previous fractures. UOM group: 20 patients with radiological diagnosis of UOM. Analyzed data: number, size, location and density of enostoses and metastases. The density was measured with the broadest possible region of interest at the center of the lesion by two radiologists independently. Receiver operatingcharacteristic analysis to determine the sensitivity and specificity, area under the curve 95% confidence intervals and cutoff values of CT density to differentiate metastases from enostoses. RESULTS: Patients were 28 ± 7 years old (72% males). 41 (89%) patients had 124 enostoses (2-15 mm) with an average density of 1007 ± 122 Hounsfiled unit (HU, observer1) and 1052 ± 107 (observer2). The most common sites of occurrence were the proximal femur (34%), the pelvis (22%), the acetabulum (20%), the proximal humerus (11%), the vertebrae (11%) and the rib (2%). 13 patients had 1 bone island, 8 patients had 2, 9 cases had 3 and 11 cases had more than 3 enostoses. Overall, 114 UOM were evaluated, their average density was 728 ± 163 HU (observer1) and 712 ± 178 HU (observer2). The area under the curve value of mean density to distinguish enostoses from UOM was 0,982. Using a cut-off of 881 HU for mean density, sensitivity was 98% and specificity 95%. CONCLUSION: The frequency of enostosis in this study is 89%. The average density identified can help to distinguish enostoses from UOM. ADVANCES IN KNOWLEDGE: We report the exact frequency of enostosis.

Tracheal diverticula: A retrospective analysis of patients referred for thoracic CT.

To assess the prevalence of tracheal diverticula (TD) in patients referred for thoracic Computed Tomography (CT).1679 consecutive patients subjected to thoracic CT examination for different causes, from January to June 2017, were included in this cohort study. CT was performed with a 64 slice CT, using a standard protocol and Multiplanar Reformat Images (MPR). A TD was defined as a thin-walled air sac at the paratracheal wall with a communication with the tracheal lumen. Congenital or acquired nature of TD was determined by the anatomical location, being usually the congenital ones located 4 to 5 cm below the vocal cords or a few centimeters above the carina in the right paratracheal area, whereas acquired ones were located at the level of the thoracic inlet, in the posterolateral tracheal wall. Presence of TD was assessed and their number and size recorded based on 2 axial diameters and size of neck.One or more TD were found in 96 patients (5.7% of sample), with a slight preponderance (65%) in male gender. Globally, 124 TD were detected; they were solitary in 75% of cases, double in 20.8%, and in about 4.2% they were triple. Average size of the TD was 1.3×4.9 mm with a mean width of the neck of 1.9 mm. The peak of prevalence (9%) was in patients belonging to the fourth-decade group (see ). According to their anatomical location, the majority (97.6%) of TD were acquired in nature and devoided of specific symptoms (see below).(Table is included in full-text article.)Acquired TD were detected in about 1 out of 20 of thoracic CTs and were usually incidentally. Our findings show a slightly higher frequency than previously reported. The most frequent presentation was in male and as a single entity. Clinically, TD was not associated with specific symptoms, in particular with chronic cough or Chronic Obstructive Pulmonary Disease (COPD).

Hyperthermic intrathoracic chemotherapy after extended pleurectomy and decortication for malignant pleura mesothelioma: an observational study on outcome and microcirculatory changes.

BACKGROUND: In the treatment of malignant pleural mesothelioma the Hyperthermic Intra THOracic Chemotherapy (HITHOC) can improve the efficacy of pleurectomy and decortication with a local cytotoxic effect. However its biological impact in patient's hemodynamic and microcirculatory changes were rarely investigated. Aim of this study is to describe our experience with HITHOC after pleurectomy and decortication evaluating the role of sublingual video-microscopy in assessing the microcirculatory changes in the perioperative period. METHODS: This is a prospective and observational study concerning 10 consecutive patients undergoing extended P/D followed by HITHOC. These patients underwent sublingual microcirculatory monitoring, which was adopted as a routine procedure since 2012. Haemodynamic parameters were collected at eight consecutive times: the day before surgery (T1), induction of anaesthesia (T2), surgical phase before HITHOC beginning (T3), 5 and 30 minutes after HITHOC start (T4 and T5, respectively), 5 minutes from HITHOC end (T6), after the admission in ICU (T7), at discharge from the ICU (T8). Cardiac output (CO) was calculated with MostCare. Systemic vascular resistance (SVR), oxygen delivery (DO2), and oxygen extraction rate (O2ER) were calculated using standard formulas. Arterial blood pressure and central venous pressure (CVP) were obtained with standard arterial and venous catheters. At the same times we assessed the sublingual microcirculation with Sidestream Dark Field technique. RESULTS: Hemodynamic and microcirculatory data were collected in 10 patients, 8 male and 2 females (mean age 68.6±9.0, and body surface area of 1.9±0.1 m2). All patients had arterial hypertension, and one patient had diabetes. The mean arterial pressure significantly decreased at T2, with respect to T1 (P=0.05). CO, CVP, DO2, O2ER, and ScvO2, did not change significantly over the time. All patients needed infusion of noradrenalin from T4 to T6. TVD significantly decreased from T1 to T3, T5, and T8. Similarly, PVD significantly decreased from T1 to T3 and T8, and MFI from T1 to T6 and T8. PPV and HI did not change over the study period. No correlation was found between hemodynamic parameters (MAP, CO, CVP, DO2, O2ER, ScvO2) and microcirculatory data (TVD, PVD, PPV, MFI, HI), at any time of the study. CONCLUSIONS: In patients who receive HITHOC the fluid load can reduce the microvascular impairment restoring the normal tissue perfusion. This process takes days but is most evident in the first 72 h. The use of colloid and blood transfusion is much more effective in restoring microcirculation and reducing tissue damaging.