Role of perfusion imaging in differentiating multifocal vasospasm-related ischemia versus thromboembolic stroke in a setting of cocaine abuse.

Cerebrovascular complications related to cocaine abuse are reaching epidemic proportions. Contemporary treatments for acute stroke have made it essential to gather all possible diagnostic information before proceeding with intervention. We describe a cocaine abuser who presented with acute right sided neurological deficits and deteriorating mental status. An MRI demonstrated right sided acute and chronic infarcts in the border zones of the right anterior cerebral arteries (ACA) and middle cerebral arteries (MCAs). Subsequent CT angiography (CTA)/CT perfusion (CTP) identified multifocal cerebral vasospasm of the bilateral ACAs and MCAs, preserved cerebral blood volume (CBV) and decreased cerebral blood flow (CBF) in bilateral frontoparietal regions. Early diagnosis of multifocal vasospasm related ischemia directed appropriate therapy and excluded thrombolytic intervention. After 3 weeks, patient's presenting symptoms gradually resolved. We report a unique case of cocaine induced multifocal vasospasm exhibiting late (>3 weeks) reversibility of focal neurological deficits. Furthermore, we illustrate the benefits of CTA/CTP imaging in the setting of cocaine abuse, differentiating multifocal vasospasm induced hypoperfusion/ischemia from focal thromboembolic ischemia/infarct and allowing for appropriate medical management in the crucial hyperacute setting.

Epidemiology of the association between anticoagulants and intraocular hemorrhage in patients with neovascular age-related macular degeneration.

PURPOSE: To determine the cumulative incidence and annual incidence of intraocular hemorrhage (subretinal hemorrhage or vitreous hemorrhage) in patients with neovascular age-related macular degeneration (AMD) and association with daily antiplatelet or anticoagulant (AP/AC) medication usage (aspirin, clopidogrel, and warfarin), age, gender, hypertension, diabetes mellitus, or bilateral neovascular AMD. METHODS: Retrospective cross-sectional study in a tertiary university setting. Data on 195 eyes of 195 patients without previous intraocular hemorrhage examined over 73 months were reviewed. RESULTS: Ninety-six of 195 patients (49.2%) were taking daily AP/ACs. Of patients taking daily AP/AC agents, 63.5% had hemorrhage compared with 29.2% of patients not taking (odds ratio = 4.21; 95% confidence interval = 1.42-8.46; P < 0.001). The overall annual incidence of intraocular hemorrhage was 0.14% per year. Among patients taking daily AP/AC, the cumulative incidence (61 of 96, 63.5%) and annual incidence (0.10%) of concurrent intraocular hemorrhage were significantly greater compared with patients not taking them (29 of 99, 29.2% and 0.04%, respectively; P < 0.0001). Fourteen of 18 patients (77%) taking more than 1 daily AP/AC had occurrence of intraocular hemorrhage. Antiplatelet or anticoagulant usage was an independent risk factor for the development of intraocular hemorrhage. The use of any agent resulted in a significantly increased risk of developing intraocular hemorrhage. Additionally, presence of bilateral neovascular AMD was a significant association in those taking daily AP/ACs, whereas age was a significant association in those not taking daily AP/AC agents. CONCLUSION: All three daily AP/AC types were significantly associated with an increased risk of the development intraocular hemorrhage in patients with neovascular AMD, whereas gender, hypertension, and diabetes were not. Age was not significantly associated with hemorrhage in patients taking daily AP/AC agents, whereas the presence of bilateral neovascular AMD was significantly associated with hemorrhage. These findings indicate that the AP/AC use may predispose patients with neovascular AMD to intraocular hemorrhage more so than age and duration of disease alone. While the risk that discontinuing these medicines would pose to the patients' health may be too great to justify, ensuring that an appropriate medication dosage is maintained should be a priority within this patient population.

Percutaneous Management of a Contained Annular Rupture Occurring With Self-Expanding Transcatheter Aortic Valve Replacement.

Annular rupture is a rare catastrophic event during transcatheter aortic valve replacement, often life threatening and requiring emergent surgical repair. We describe, herein, a case of contained annular rupture successfully managed percutaneously with coiling and polymer injection. This is a novel technique to manage this complication. (Level of Difficulty: Advanced.).

Thirty-day emergency room visits and hospital admissions after outpatient non-vascular image-guided procedures.

PURPOSE: To evaluate the rate of post-procedure emergency department (ED) visits and hospital admissions following outpatient non-vascular image-guided interventions performed under moderate sedation and to identify common and preventable causes of emergency department visits and hospital admissions. MATERIALS AND METHODS: Institutional review board approval was acquired for this HIPAA-compliant retrospective study with waiver of informed consent. 1426 consecutive patients undergoing 1512 outpatient image-guided procedures under moderate sedation from November 2012 to August 2014 were included. The average patient age was 57.2 ± 15.2 years, and 602 (42%) patients were women. Major procedure categories included ultrasound-guided liver biopsies, ultrasound-guided kidney biopsies, and CT-guided lung biopsies/fiducial placement. Procedure details and medical follow-up within and after 30 days of the procedure were analyzed. RESULTS: A total of 168 (11.8%) patients were admitted to the hospital within 30 days of the procedure, with 29 of the admissions (17.3% of total admissions and 1.9% of total procedures) being procedure related. The most common procedure-related complication that required admission was hemorrhage (10/29, 34.5% of procedure-related admissions, 6.0% of total admissions, and 0.7% of total procedures), followed by pneumothorax (9/29, 31%, 5.4%, 0.6%), infection (4/29, 13.8%, 2.4%, 0.3%), and pain (3/29, 10.3%, 1.8%, 0.2%). Eighteen (62.1%) procedure-related admissions were immediately indicated. Thirty patients visited the ED and were subsequently discharged without admission with eight of the visits being procedure related (8/1512, 0.5%). All the procedure-related ED visits were due to pain. There were two deaths (2/1512, 0.1%) related to procedures, one from a thromboembolic event and another from post-biopsy hemorrhage. CONCLUSION: Outpatient non-vascular image-guided procedures result in a 30-day 1.9% hospital admission, 30-day 0.5% emergency room visit, and 30-day 0.1% mortality rate.