Safety and outcomes of different endovascular treatment techniques for anterior circulation ischaemic stroke in the elderly: data from the Imperial College Thrombectomy Registry.

BACKGROUND: Although previous studies investigated the main predictors of outcomes after endovascular thrombectomy (EVT) in patients aged 80 years and older, less is known about the impact of the procedural features on outcomes in elderly patients. The aim of this study was to investigate the influence of EVT technical procedures on the main 3-month outcomes in a population of patients aged 80 years and older. METHODS: This observational, prospective, single-centre study included consecutive patients with acute LVO ischaemic stroke of the anterior circulation. The study outcomes were functional independence at 3 months after EVT (defined as a mRS score of 0-2), successful reperfusion (mTICI ≥ 2b), incidence of haeamorrhagic transformation, and 90-day all cause of mortality. RESULTS: Our cohort included 497 patients with acute ischaemic stroke due to LVO treated with EVT. Among them, 105 (21.1%) patients were aged ≥ 80 years. In the elderly group, multivariable regression analysis showed that thromboaspiration technique vs stent-retriever was the single independent predictor of favourable post-procedural TICI score (OR = 7.65, 95%CI = 2.22-26.32, p = 0.001). CONCLUSIONS: Our study suggests that EVT for LVO stroke in the elderly could be safe. The use of thromboaspiration was associated with positive reperfusion outcome in this population. Further studies in larger series are warranted to confirm the present results and to evaluate the safety and efficacy of EVT in the elderly and oldest adults.

Outcomes of mechanical thrombectomy in acute stroke patients with atrial fibrillation detected after stroke versus known atrial fibrillation.

We aim to compare the outcomes in patients with atrial fibrillation detected after stroke (AFDAS) and their counterparts with known AF (KAF) presenting with large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). This observational, prospective study included consecutive patients with acute LVO ischemic stroke of the anterior circulation with AFDAS, KAF and without AF. The primary study outcome was functional independence at 90 days after stroke. The secondary study outcomes were variation of the NIHSS score at 24 h, rate of successful reperfusion, death at 90 days and rate of immediate complications post-procedure. Overall, our cohort included 518 patients with acute ischemic stroke and LVO treated with MT, with 289 (56.8%) without a diagnosis of AF; 107 (21%) with AFDAS; 122 (22.2%) with KAF. There was no significant difference in terms of functional independence at 90 days after stroke between the three groups. Regarding the secondary study outcome, the rate of symptomatic intracranial haemorrhage (sICH) and/or parenchymal hematoma (PH) were significantly higher in the group of patients without AF (respectively, P = 0.030 and < 0.010). Logistic regression analysis showed that the subtypes of AF were not statistically significantly associated with functional independence at 90 days after stroke and with the likelihood of any ICH. Our results suggest that the subtypes of AF are not associated with clinical and safety outcomes of MT in patients with acute stroke and LVO. Further studies are needed to confirm our findings.

Recurrent Granulosa Cell Tumor in a Postmenopausal Woman: A Case Report and Literature Review.

Ovarian cancer is among the most common types of cancer suffered by the female population. As of United States Cancer Statistics (USCS) 2019, the National Cancer Institute reports the prevalence of ovarian cancer as 11.4 cases per every 100,000 each year. The highest prevalence is in the seventh decade of life. Of all the types, sex cord-stromal tumors (SCSTs) account for 5-8% of cases. They are a heterogeneous group of rare neoplasms originating from the ovarian matrix, and nearly 90% of the hormone-producing tumors are SCSTs. Hence, patients with SCSTs are known to present with excess estrogen and androgen signs and symptoms. Many SCSTs are known for their indolent course and tendency to affect the unilateral ovary. The prognosis of the malignancy depends on the subtype of SCST, the stage of the patient's disease, and age. Among all the types, 20-50% of the ovaries' granulosa cell tumors tend to recur decades after the initial presentation, and 70% of the recurrences end up with a very poor prognosis. This case will discuss a 68-year-old woman who presented with a recurrence of an adult granulosa cell tumor after 13 years in remission. The patient had been previously diagnosed with an adult granulosa cell tumor of the right ovary at age 55 and had undergone surgical resection along with chemotherapy.

Outcomes of mechanical thrombectomy in orally anticoagulated patients with anterior circulation large vessel occlusion: a propensity-matched analysis of the Imperial College Thrombectomy Registry.

BACKGROUND: Mechanical thrombectomy (MT) remains an effective treatment for patients with acute ischemic stroke receiving oral anticoagulation (OAC) and large vessel occlusion (LVO). However, to date, it remains unclear whether MT is safe in patients on treatment with OAC. AIMS: In our study, we performed a propensity-matched analysis to investigate the safety and efficacy of MT in patients with acute ischemic stroke receiving anticoagulants. A propensity score method was used to target the causal inference of the observational study design. METHODS: This observational, prospective, single-centre study included consecutive patients with acute LVO ischemic stroke of the anterior circulation. Demographic, neuro-imaging and clinical data were collected and compared according to the anticoagulation status at baseline, patients on OAC vs those not on OAC. The primary study outcomes were the occurrence of any intracerebral haemorrhage (ICH) and symptomatic ICH. The secondary study outcomes were functional independence at 90 days after stroke (defined as modified Rankin Scale (mRS) scores of 0 through 2), mortality at 3 months and successful reperfusion rate according to the modified treatment in cerebral infarction (mTICI) score. RESULTS: Overall, our cohort included 573 patients with acute ischemic stroke and LVO treated with MT. After propensity score matching, 495 patients were matched (99 OAC group vs 396 no OAC group). There were no differences in terms of clinical characteristics between the two groups, except for the rate of intravenous thrombolysis less frequently given in the OAC group. There was no significant difference in terms of the rate of any ICH and symptomatic ICH between the two groups. With regards to the secondary study outcome, there was no significant difference in terms of the rate of successful recanalization post-procedure and functional independence at 3 months between the two groups. Patients in the OAC group showed a reduced mortality rate at 90 days compared to the patients with no previous use of anticoagulation (20.2% vs 21.2%, p = 0.031). Logistic regression analysis did not reveal a statistically significant influence of the anticoagulation status on the likelihood of any ICH (OR = 0.95, 95% CI = 0.46-1.97, p = 0.900) and symptomatic ICH (OR = 4.87, 95% CI = 0.64-37.1, p = 0.127). Our analysis showed also that pre-admission anticoagulant use was not associated with functional independence at 90 days after stroke (OR = 0.76, 95% CI = 0.39-1.48, p = 0.422) and rate of successful reperfusion (OR = 0.81, 95% CI = 0.38-1.72, p = 0.582). CONCLUSION: According to our findings anticoagulation status at baseline did not raise any suggestion of safety and efficacy concerns when MT treatment is provided according to the standard guidelines. Confirmation of these results in larger controlled prospective cohorts is necessary.

Cardiac Symptoms During the Russia-Ukraine War: A Google Trends Analysis.

Background The 2022 Ukraine-Russian War has led to significant anxiety, anguish, and trauma among the people in Ukraine. The objective of this study was to analyze the Google Trend results of common cardiac symptoms in Ukraine, Russia, and worldwide in 2022 and compare that to 2021 with the hypothesis that common cardiac symptoms in the war-affected regions would be higher compared to the rest of the world. We hypothesize that the search trends of cardiac symptoms would increase in Ukraine given the turmoil caused by the Russian invasion. Methods We queried Google Trends for common cardiac symptoms such as chest pain, dizziness, palpitations, syncope, etc. Google Trends provides results as relative search volume (RSV) displayed in a geographical format. The RSV ranges from 0 to 100, with 0 indicating that the search term is not popular, and 100 indicating the search term's popularity is at its peak. Google Trends of cardiac symptoms in Russia, Ukraine, and worldwide was taken two weeks before and after February 24, 2022, compared with the same period in 2021. To assess the difference in Google Trends between the study periods in 2022 and 2021, the paired t-test was used. Results Overall, Google Trends for cardiac symptoms was lower in Ukraine and Russia than worldwide, in both 2021 and 2022 during the study period. There was a significant reduction in search for chest pain (14 vs. 30.5; p<0.049), pedal edema (40.0 vs 66.6; p approaching 0), and syncope (37.8 vs. 58.4; p<0.002) in Ukraine during the study periods in 2022 compared to 2021. There was a decrease in the searches for dyspnea (44.6 vs. 55.4; p<0.029) in Russia and for dizziness (87.6 vs. 92.8; p<0.005) worldwide. There was an increase in the searches for edema (93.6 vs. 91; p <0.002) and for fatigue (88.6 vs 79.5; p approaching 0) worldwide in study periods in 2022 as compared to 2021. There was no other significant difference between cardiac symptom search trends during the periods evaluated in Ukraine, Russia, and worldwide. Conclusion There appears to be a significant reduction in searching for a few cardiovascular symptoms, namely, chest pain, pedal edema, and syncope in Ukraine, which may be due to a focus on other immediate problems related to war and the availability of the Internet.

Renal Amyloid-Associated (AA) Amyloidosis in a Sickle Cell Patient: A Case Report and Literature Review.

Renal amyloid-associated (AA) amyloidosis is a rare occurrence in sickle cell disease (SCD). Very little literature is available on renal AA amyloidosis in sickle cell disease. Nephrotic range proteinuria is associated with higher mortality among patients with SCD. We present a case of a young reproductive-age African American woman who presented with massive nephrotic range proteinuria. Other more common causes of AA amyloidosis such as immunologic and infectious etiologies were ruled out by history, physical examination, radiologic investigation, and serology. Renal biopsy showed mesangial expansion with Congo red-positive material. Staining for immunoglobulins was negative. Electron microscopy showed nonbranching fibrils. These findings were consistent with AA amyloidosis. This case report adds to the rare findings of renal AA amyloidosis in sickle cell disease. The patient refused any intervention to decrease her Glomerular Filtration Rate (GFR) in the hopes of potentially reversing the disabling proteinuria. We report sickle cell disease presenting with nephrotic syndrome secondary to AA amyloid.

Endovascular Thrombectomy with or without Intravenous Thrombolysis for Anterior Circulation Large Vessel Occlusion in the Imperial College London Thrombectomy Registry.

Background and purpose. Mechanical thrombectomy (MT) is the standard of care for eligible patients with a large vessel occlusion (LVO) acute ischemic stroke. Among patients undergoing MT there has been uncertainty regarding the role of intravenous thrombolysis (IVT) and previous trials have yielded conflicting results regarding clinical outcomes. We aim to investigate clinical, reperfusion outcomes and safety of MT with or without IVT for ischemic stroke due to anterior circulation LVO. Materials and Methods. This observational, prospective, single-centre study included consecutive patients with acute LVO ischemic stroke of the anterior circulation. The primary outcomes were the rate of in-hospital mortality, symptomatic intracranial haemorrhage and functional independence (mRS 0-2 at 90 days). Results. We enrolled a total of 577 consecutive patients: 161 (27.9%) were treated with MT alone while 416 (72.1%) underwent IVT and MT. Patients with MT who were treated with IVT had lower rates of in-hospital mortality (p = 0.037), higher TICI reperfusion grades (p = 0.007), similar rates of symptomatic intracranial haemorrhage (p = 0.317) and a higher percentage of functional independence mRS (0-2) at 90 days (p = 0.022). Bridging IVT with MT compared to MT alone was independently associated with a favorable post-intervention TICI score (>2b) (OR, 1.716; 95% CI, 1.076-2.735, p = 0.023). Conclusions. Our findings suggest that combined treatment with MT and IVT is safe and results in increased reperfusion rates as compared to MT alone.

Arrhythmogenic Right Ventricular Cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC), formerly called arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/ARVC), is a myocardial structural abnormality disease with clinical presentation of cardiac arrhythmia. It is characterized by the replacement of the myocardium with fibrofatty tissue. We present a case of a young male who met two major criteria for definite diagnosis of ARVC: early transition inverted t waves in lead V1-V4 and MRI showed right ventricle (RV) dyskinesia with RV ejection fraction (EF) < 40%, both satisfying the two major criteria of EKG and MRI required for definitive diagnosis.

Coronavirus Disease 2019 Associated Acute Myocardial Infarction and Atrial Fibrillation: A Case Report.

In the last two years since the inception of the Coronavirus pandemic, there have been a myriad of reports and studies related to Coronavirus disease 2019 (COVID-19). We present a unique case of COVID-19 associated with both acute myocardial infarction and new-onset atrial fibrillation (AFIB) in an elderly lady which is the first reported case to the best of our knowledge. The patient was symptomatic with acute COVID-19 and developed a type 2 myocardial infarction with new-onset AFIB. The patient also developed sepsis which may have contributed to the development of AFIB.

Acute COVID-19-Associated Cardiac Arrhythmia: A Case Series and Literature Review.

Coronavirus disease 2019 (COVID-19) is a highly contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We report two cases of COVID-19-associated atrial fibrillation (AF) in two elderly females and a case of atrial flutter (AFlutter) in a middle-aged male patient. We believe this case series will contribute to the literature on new-onset AF and AFlutter in patients with acute COVID-19 infection. This case series illustrates various case scenarios of patients developing cardiac arrhythmia with acute COVID-19 infection without any prior history or other explicable cause of AF/AFlutter. The exact mechanism behind COVID-19 infection leading to AF or AFlutter is still unknown. Of the three patients reported, two converted to sinus rhythm following medical management, and one did not convert to sinus rhythm despite medical treatment.

Painless Subacute Thyroiditis in a Patient With Acute COVID-19 Infection: A Transient Event.

Coronavirus 2019 disease (COVID-19) is a highly contagious infectious disease caused by severe acute respiratory coronavirus 2 (SARS-CoV-2). Although several articles have described the non-respiratory effects of COVID-19 in the past two years, there are few reports of COVID-19 associated with thyroiditis. We present a case of a middle-aged female patient with positive COVID-19 PCR associated with acute pulmonary embolism and thyroiditis. Three months ago, her baseline thyroid profile was normal. Thyroiditis induced elevated free thyroxine (FT4) and decreased thyroid-stimulating hormone (TSH) levels resolved with conservative management within six days.

Warfarin Failure in a Patient With Chronic Thromboembolic Pulmonary Hypertension: A Case Report and Literature Review.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension caused by chronic venous thromboembolism (VTE). Venous thromboembolism (VTE) manifests as deep vein thrombosis (DVT), progressing to pulmonary embolism (PE). Pulmonary endarterectomy (PEA) is the preferred therapeutic option as it provides vascular disobliteration. Long-term anticoagulation with warfarin or direct oral anticoagulants (DOACs) is recommended for patients at risk for recurrent DVT in poor surgical candidates. However, treatment failure remains a concern. We present a patient who had VTE despite long-term anticoagulation with warfarin who had failed treatment and developed VTE with a therapeutic dilemma to continue anticoagulation despite supratherapeutic international normalized ratio (INR).

Hypocalcemia Induced Bronchospasm.

Bronchospasm is acute narrowing of the airways of lungs, which gives rise to wheezing and shortness of breath. Commonly seen in obstructive lung disease, but a rare finding in patients with hypocalcemia. This is a case that outlines a rare presentation of hypocalcemia induced bronchospasm in a patient with no known history of asthma or chronic obstructive pulmonary disease (COPD). In this report, we present a case of a 57 years old male with no history of asthma or COPD who presented with intractable bronchospasm. Initial work-up for common entities was negative. Patient was found to be profoundly hypocalcemic and treatment provided resolution of symptoms. Early recognition of hypocalcemia induced bronchospasm is important in clinical practice to optimize management and provide improvement in symptoms.

Subclinical Hypothyroidism Presenting as Myxedema Coma: Case Report and Literature Review.

Myxedema coma is a medical emergency with a high mortality rate. Patients with hypothyroidism may develop myxedema coma if left untreated, although quite rare nowadays owing to regular TSH (thyroid stimulating hormone) monitoring. We present the case of a patient with a known history of subclinical hypothyroidism, defined by normal free T4 (thyroxine) and high TSH, who was found to be in myxedema coma. Clinically, the patient was found to be lethargic, bradycardic, and hypothermic, and in the background of high TSH, myxedema coma was suspected. The patient was admitted to the ICU (Intensive Care Unit) and initially treated with intravenous (IV) hydrocortisone for possible concomitant adrenal insufficiency. This was followed by treatment with IV levothyroxine.

Cocaine and Opioid-Induced Acute Liver Injury: A Rare Case Report.

Drug overdose has been a public health burden in the United States. Repeated use of cocaine and heroin may increase the risk of severe acute liver failure. We present the case of a middle-aged man with no significant past medical condition except a chronic history of drug abuse who presented to our hospital after an overdose of cocaine and heroin. Patient received Narcan by paramedics and continued treatment in the emergency room (ER). Patient has exhibited multiple organ failures, such as acute liver failure, rhabdomyolysis, acute kidney injury, and acute respiratory hypoxic hypercapnic respiratory failure likely due to respiratory center depression. The patient was placed on a non-rebreather mask then a bilevel positive airway pressure (BiPAP) machine. Patient failed the BiPAP trial, was intubated and later extubated after five days, and discharged on room air. The patient was admitted to the intensive care unit due to toxic encephalopathy. Liver enzymes were markedly elevated during admission and trended down after supportive management, Narcan, and N-acetylcysteine treatment.

A Case of Bilateral Hemorrhagic Pleural Effusion Due to Dual Antiplatelet Therapy in a Dialysis Patient.

Etiologies of hemorrhagic pleural effusions (hemithoraces) are multifactorial. They can be traumatic, non-traumatic, or idiopathic in nature. In this report, we present a rare case of a 64-year-old male with end-stage renal disease (ESRD) on chronic hemodialysis and dual antiplatelet therapy (DAPT), due to a recent history of coronary arterial stent placement, who presented with progressive shortness of breath for one month. The CT of the chest revealed bilateral large pleural effusions (left > right) with a complete collapse of the left lung and partial collapse of the right lung. Ultrasound-guided left-sided thoracentesis revealed hemorrhagic pleural effusions. After the discontinuation of DAPT, drainage from the right-sided pleural effusion via a pigtail catheter showed continued drainage of pleural fluid without hemorrhage. The effusion on the left side was also noted to have resolved on the repeat chest X-ray. Prompt recognition of this rare cause of any hemorrhagic pleural effusion is essential for patients on dialysis to avoid complications. This report focuses on the possible etiology and potential complications of a hemorrhagic pleural effusion, followed by a brief discussion on the rare but significant association involving the incidence of a hemorrhagic pleural effusion in a dialysis patient receiving DAPT.

Persistent Hypokalemia in a Patient With Ogilvie's Syndrome.

Ogilvie's syndrome, also known as acute colonic pseudo-obstruction (ACPO), is a rare disease characterized by acute dilatation of the colon in the absence of anatomic intestinal obstruction. It is of clinical importance because of its preponderance in elderly males in the seventh decade of life who may present with constipation or diarrhea. We present an 80-year-old male who presented with diarrhea, with laboratory investigations showing hypokalemia and a CT abdomen revealing colonic distension. The patient was wasting potassium both from colon and renal losses, despite low aldosterone levels. The patient was treated with Neostigmine, which helped relieve abdominal distention. Subsequently, potassium was corrected with aggressive replacement. This case sheds light on newer modalities of treatment such as neostigmine, as in this case.

Ketamine infusion as a sedative-analgesic in severe ARDS (KISS).

RATIONALE: Ketamine has been used as a sedative analgesic in trauma setting, but data regarding its efficacy and safety is lacking in severe ARDS. This retrospective study aims to determine if Ketamine is safer as a sedative agent in mechanically ventilated patients. During the COVID pandemic, as there was a shortage of sedative agents, Ketamine was used. OBJECTIVES: The primary objective was to compare the safety of ketamine to other sedatives. The secondary objective was to compare the effect of ketamine to other sedatives regarding the need for vasopressor, incidence of delirium, infectious complications, acute kidney injury, hospital length of stay, and length of ventilator days. METHODS: A retrospective, observational cohort study was conducted. MEASUREMENTS AND MAIN RESULTS: One hundred and twenty-four patients (63 men and 61 women) were included. Thirty-four patients received ketamine, while 90 patients received other traditionally used sedatives such as propofol and midazolam. The patients' median age was 64 years in the ketamine group and 68 years in the non-ketamine group. Seventeen patients in the ketamine group (50%) and 65 patients (72%) in the non-ketamine group had mortality (p < 0.02). The hospital length of stay was 22.85 days (± 16.36) in the ketamine group and 15.62 days (± 14.63) in the non-ketamine group (p < 0.02). There was no statistically significant difference among the outcomes of the need for vasopressor, the incidence of delirium, infectious complications, and acute kidney injury. CONCLUSIONS: Ketamine as a sedative-analgesic agent in COVID-19 patients with severe acute respiratory distress syndrome demonstrated safety with reduced mortality. The ketamine group had a higher hospital length of stay, but a similar complication profile compared to the non-ketamine group. Further prospective randomized controlled trials are warranted to confirm these findings.

A Rare Case of Intrapulmonary Sequestration With Multiple Feeding Arteries and an Anomalous Pulmonary Vein Draining Into the Azygos Vein.

Pulmonary sequestration is an isolated mass of lung tissue that has no identifiable bronchial communication and that receives its blood supply from one or more anomalous systemic arteries. The feeding vessel is the aorta or its major vessels and venous drainage usually is to the pulmonary veins to the left atrium. We present a rare case of intralobar sequestration in a 65-year-old man with multiple feeding arteries from the aorta and partial anomalous venous return draining into the azygos vein. He remained asymptomatic and this anomaly was detected incidentally when computed tomography (CT) scan of the chest with contrast was done to rule out pulmonary embolism.

Clinical and Radiological Dissociation in Massive Barium Aspiration.

Barium studies are commonly used to rule out gastrointestinal (GI) pathologies and sometimes they are associated with complications such as barium aspiration with heterogeneity in clinical features ranging from mild to severe symptoms. We present a case of large volume barium aspiration in a 73-year-old male with past medical history of dysphagia diagnosed with diffuse esophageal spasm. Barium is an inert material commonly used for GI tract study. Although complications associated with barium studies are rare, aspiration of barium can have dramatic findings resulting in mild to severe symptoms. Clinically patient had very minimal symptoms but radiographic studies appeared dramatic. Therefore, a clinical and radiographic paradox must be kept in mind when evaluating patients and reviewing large volume barium aspiration imaging. Our case remained asymptomatic and had no respiratory complaints, nor did he develop any respiratory distress post barium aspiration.