Arterial intracranial thrombosis as the first manifestation of vaccine-induced immune thrombotic thrombocytopenia (VITT): a case report.

OBJECTIVE: We describe a severe case of vaccine-induced immune thrombotic thrombocytopenia (VITT) after the first dose of the ChAdOx1 nCoV-19 vaccine leading to massive ischemic stroke. METHODS: A 42-year-old woman developed acute left hemiparesis (NIHSS 12) 9 days after the first vaccine dose. RESULTS: The blood tests revealed low platelets (70 103/µL) and severe increment of D-dimer (70,745 ng/mL FEU). Brain non-contrast computed tomography and multiphasic CT angiography demonstrated a right middle cerebral artery occlusion. The patient was treated with primary thrombectomy, steroids, immunoglobulin, and fondaparinux. Despite the treatment, the neurological status deteriorated and underwent decompressive hemicraniectomy. She was transferred to the rehab's unit 52 days after the onset. DISCUSSION: Healthcare providers should be aware of the possibility of ischemic stroke as a manifestation of VITT. Awareness on this very rare and possibly fatal complication should be reinforced on both the vaccine recipients and general practitioners.

Conservative management of trachea-to-innominate artery transfixion with a guidewire during percutaneous tracheostomy: a case report.

BACKGROUND: Tracheostomy is a standard procedure in critically ill patients requiring mechanical ventilation or airway protection for extended periods. The main cause of death is haemorrhage, most commonly owing to a trachea-to-innominate artery fistula, usually requiring surgical treatment. CASE PRESENTATION: Here we report the case of an 83-yr-old woman with a subarachnoid haemorrhage, who incurred a trachea-to-innominate artery transfixion following percutaneous tracheostomy, successfully and conservatively managed by interventional radiology. CONCLUSIONS: The use of peri-procedural ultrasound examination of the neck can reduce the risk of complications related to vessel anatomical variants. When the tracheostomy is complicated by bleeding, the procedure should be stopped in order to diagnose the vascular iatrogenic injury and to evaluate the best therapeutic approach by a multidisciplinary team.

Intracranial Pressure Monitoring in Poor-Grade Patients with Aneurysmal Subarachnoid Hemorrhage Treated by Coiling.

OBJECTIVE: The main objective of the present study was to analyze the intracranial pressure (ICP) and cerebral perfusion pressure (CPP) changes during coiling. We also evaluated the prevalence of rebleeding and outcomes for patients monitored before and after coiling. METHODS: Ninety-nine consecutive poor-grade patients with aneurysmal subarachnoid hemorrhage (aSAH; World Federation of Neurological Surgeons grade IV and V) were enrolled in our prospective observational study. For 31 patients, ICP and CPP monitoring was started immediately after the diagnosis of aSAH, and the values were recorded every 15 minutes during coiling (early ICP group). For 68 patients, ICP and CPP monitoring began after coiling (late ICP group). The outcomes were evaluated at 90 days using the modified Rankin scale. RESULTS: At the beginning of coiling, the ICP was >20 mm Hg in 10 patients (35.7%). The median ICP was 18 mm Hg (range, 5-60 mm Hg). The CPP was <60 mm Hg in 6 patients (24%). The median CPP was 70 mm Hg (range, 30-101 mm Hg). Despite medical treatment and/or cerebrospinal fluid drainage, 51.6% of the patients monitored during coiling had at least one episode of intracranial hypertension (defined as ICP >20 mm Hg), and 51.6% had at least one episode of reduced CPP (defined as CPP <60 mm Hg). Early monitoring (before aneurysm repair) was not associated with rebleeding. At 90 days, the functional recovery was better in the early ICP group (P = 0.004). CONCLUSIONS: During coiling, patients with poor-grade aSAH can experience episodes of intracranial hypertension and reduced CPP. Early and appropriate treatment of elevated ICP was not associated with rebleeding and might have improved the outcomes.

Ultrasound- versus landmark-guided subclavian vein catheterization: a prospective observational study from a tertiary referral hospital.

This was a single-center, observational, prospective study designed to compare the effectiveness of a real-time, ultrasound- with landmark-guided technique for subclavian vein cannulation. Two groups of 74 consecutive patients each underwent subclavian vein catheterization. One group included patients from intensive care unit, studied by using an ultrasound-guided technique. The other group included patients from surgery or emergency units, studied by using a landmark technique. The primary outcome for comparison between techniques was the success rate of catheterization. Secondary outcomes were the number of attempts, cannulation failure, and mechanical complications. Although there was no difference in total success rate between ultrasound-guided and landmark groups (71 vs. 68, p = 0.464), the ultrasound-guided technique was more frequently successful at first attempt (64 vs. 30, p < 0.001) and required less attempts (1 to 2 vs. 1 to 6, p < 0.001) than landmark technique. Moreover, the ultrasound-guided technique was associated with less complications (2 vs. 13, p < 0.001), interruptions of mechanical ventilation (1 vs. 57, p < 0.001), and post-procedure chest X-ray (43 vs. 62, p = 0.001). In comparison with landmark-guided technique, the use of an ultrasound-guided technique for subclavian catheterization offers advantages in terms of reduced number of attempts and complications.