Outcomes of endovascular thrombectomy in patients selected by computed tomography perfusion imaging - a matched cohort study comparing nonagenarians to younger patients.

BACKGROUND: Endovascular thrombectomy (EVT) is efficacious for appropriately selected patients with large vessel occlusions (LVO) up to 24 hours from symptom onset. There is limited information on outcomes of nonagenarians, selected with computed tomography perfusion (CTP) imaging. METHODS: We retrospectively analyzed data from a large academic hospital between December 2017 and October 2019. Patients receiving EVT for anterior circulation LVO were stratified into nonagenarian (≥90 years) and younger (<90 years) groups. We performed propensity score matching on 18 covariates. In the matched cohort we compared: primary outcome of inpatient mortality and secondary outcomes of successful reperfusion (TICI ≥2B), symptomatic intracranial hemorrhage (sICH), and functional independence. Subgroup analysis compared CTP predicted core volumes in nonagenarians with outcomes. RESULTS: Overall, 214 consecutive patients (26 nonagenarians, 188 younger) underwent EVT. Nonagenarians were aged 92.8±2.9 years and younger patients were 74.5±13.5 years. Mortality rate was significantly greater in nonagenarians compared with younger patients (43.5% vs 10.4%, OR 9.33, 95% CI 2.88 to 47.97, P<0.0001) and a greater proportion of nonagenarians developed sICH (13.0% vs 3.0%, OR 6.00, 95% CI 1.34 to 55.20, P=0.02). There were no significant differences for successful reperfusion (P=1.00) or functional independence (P=0.75). Nonagenarians selected with smaller ischemic core volumes had decreased mortality rates (P=0.045). CONCLUSIONS: Nonagenarians were noted to have greater mortality and sICH rates following EVT compared with matched younger patients, which may be ameliorated by selecting patients with smaller CTP core volumes. Nonagenarians undergoing EVT had similar rates of successful reperfusion and functional independence compared with the younger cohort.

Rapid Arterial Occlusion Evaluation Scale Agreement between Emergency Medical Services Technicians and Neurologists.

BACKGROUND: Rapid arterial occlusion evaluation (RACE) scale is a valid prehospital tool used to predict large vessel occlusion of major cerebral arteries in patients with suspected acute stroke. RACE scale administered by Emergency medicine services (EMS) technicians in the prehospital setting correlates well with NIH Stroke Scale score after patient arrival at a hospital. Despite this, the RACE scale is often characterized as too difficult for EMS technicians to accurately utilize. There are no data examining RACE scale accuracy in the prehospital setting comparing EMS technicians with neurologists. We sought to examine agreement between RACE scores calculated by EMS technicians and stroke neurologists in the prehospital setting during telestroke consultation. METHODS: Data for this observational cohort study were prospectively collected and retrospectively analyzed. EMS technicians in person and stroke specialized neurologists via televideo connection independently assessed suspected stroke patients and calculated RACE scores in the prehospital setting. We used a linearly weighted Cohen's kappa (kw) to estimate the extent of agreement for RACE score between EMS technicians and stroke neurologists. RESULTS: Thirty-one patients with stroke symptoms were independently examined and assessed with the RACE scale by EMS technicians and stroke neurologists in the prehospital setting. Exact agreement on the RACE score was found in 24 of 31 (77%) patients. We found very good agreement between EMS technicians and stroke neurologists, kw = .818 (95% CI, .677-.960), P< .001. CONCLUSIONS: EMS technicians provide reliable RACE assessments in patients with suspected stroke, with agreement similar to stroke specialized neurologists in the prehospital setting.

Eggshell calcification of the heart in constrictive pericarditis.

Constrictive pericarditis (CP) is an inflammatory disease of pericardium. Pericardial calcification in X-ray provides a clue for the diagnosis of CP. An extensive "eggshell" type of calcification is rarely seen in CP. We hereby report a case of CP with eggshell calcification of pericardium, encircling whole of the heart. A need for multimodality imaging and hemodynamic assessment followed by surgical pericardiectomy is discussed.

From "head to heart: " reconstruction of a sternal cleft with split calvarial bone graft in a 15-month-old child.

Sternal cleft is a rare anomaly and has been variously managed by using either autogenous tissue or synthetic materials for bony reconstruction. We report the reconstruction of sternal cleft in a 15-month-old child with a single-piece outer-table cranial bone graft that was harvested by splitting in situ. The reconstructed sternum was covered with bilateral pectoralis major advancement muscle flaps.

Early and six-month assessment of bi-ventricular functions following surgical closure of atrial septal defect.

BACKGROUND: The effect of surgical closure of atrial septal defect (ASD) on biventricular functions is not well studied. We studied effect of surgical closure of ASD on bi-ventricular functions. METHODS: Patients undergoing surgical closure of ASD from December 2007 to June 2009 had 3 sequential echocardiograms examination: pre-procedure, post surgery at 1-month and at 6-month of follow up. Pulse Doppler velocities across mitral and tricuspid valves were measured as peak early diastolic (E wave) and peak late diastolic (A wave). Tissue Doppler velocities across lateral wall of both right ventricle (RV) and left ventricle (LV) were measured as peak early diastolic (E'), peak late diastolic (A'), and peak systolic (S') wave. Radionuclide angiography was performed to assess RV and LV ejection fraction at baseline and at 1-month follow up. RESULTS: The mean age of 20 enrolled patients was 21.85 ± 10.9 years; 8 females & 12 males. Trans-tricuspid flow velocities significantly decreased following surgery at one and 6-month (p < 0.005). There was no significant change in trans-mitral flow velocities at one and 6-months. Tricuspid and mitral E/A ratio and E/E' ratio also had an insignificant change following surgery. There was no significant change in LV ejection fraction as assessed by echocardiography (p = 0.132) and radionuclide scan (p = 0.143). Right ventricular ejection fraction had a significant improvement at 1-month of follow up (p = 0.005). CONCLUSIONS: There was a significant improvement in RV systolic function and an insignificant change in RV and LV diastolic functions following surgical closure of ASD.

Post-myocardial infarction giant left ventricular pseudoaneurysm presenting with severe heart failure.

Left ventricle (LV) pseudoaneurysm is a late mechanical complication of myocardial infarction. A giant LV pseudoaneurysm is a rare presentation. We report a case of giant LV pseudoaneurysm in a post-MI patient who presented with gross congestive heart failure. The patient had a successful surgical repair of the aneurysm and had a favorable 3-mo outcome. The imaging modality and surgical treatment of the pseudoaneurysm are discussed.

Giant left ventricular pseudoaneurysm presenting with hemoptysis.

Left ventricular (LV) pseudoaneurysm is a late mechanical complication of myocardial infarction (MI). A giant LV pseudoaneurysm is a rare presentation. We report a case of a giant LV pseudoaneurysm in a post MI patient, who presented with hemoptysis. Hemoptysis is a rare clinical presentation of LV pseudoaneurysm. The patient had successful surgical repair of the aneurysm and had a favorable outcome in 9 mo' follow-up. The imaging modalities and surgical treatment of a pseudoaneurysm is discussed.

Paraneoplastic Isaacs' syndrome: a case series and review of the literature.

OBJECTIVE: Isaacs' syndrome is a rare disease resulting from hyperexcitability of peripheral nerves causing continuous muscle fiber activity characterized by muscle twitching and stiffness at rest and delayed muscle relaxation after voluntary contraction. Our objective was to discuss the relationship of Isaacs' syndrome to paraneoplastic syndromes as reported in the available literature and in 3 patients evaluated at our academic medical center. METHODS: We review the literature on Isaacs' syndrome and describe 3 patients in whom Isaacs' syndrome heralded underlying malignancy or benign neoplasm, including their presenting symptoms, electrophysiologic findings, and laboratory and pathology results. RESULTS: In all 3 cases, clinical and electrodiagnostic testing was suggestive of Isaacs' syndrome. Two patients tested positive, and one was negative for voltage-gated potassium channel antibodies. Two of the patients developed malignant tumors, that is, one was diagnosed with metastatic thymoma and one with lymphoplasmacytic lymphoma, ranging from 6 months to 1 year after the diagnosis of Isaacs' syndrome. One patient was diagnosed with a spinal cord hemangioblastoma 5 years after he was diagnosed with Isaacs' syndrome. CONCLUSIONS: Our case series highlights the association of Isaacs' syndrome with a variety of neoplasms both malignant and benign. Our report also underscores the fact that Isaacs' syndrome may be diagnosed several years before a neoplasm is discovered. In our cases, Isaacs' syndrome overlapped with other neuromuscular disorders, that is, myasthenia gravis in a patient with thymoma and chronic inflammatory demyelinating polyneuropathy in a patient with lymphoplasmacytic lymphoma with paraproteinemia. To our knowledge, this is the first report of an association between Isaacs' syndrome with lymphoplasmacytic lymphoma and a spinal cord hemangioblastoma.

Severe mitral annular calcification in rheumatic heart disease: A rare presentation.

Severe mitral annular calcification (MAC) is frequently seen in patients with advanced age and chronic kidney disease, but it is rare in rheumatic heart disease (RHD). We hereby report a case of 45-year-old female with chronic RHD, who had severe MAC and mitral regurgitation. Fluoroscopy revealed a "crown"-like severe calcification of the mitral annulus. Autopsy of the heart revealed a calcified posterior mitral annulus, fused commissures, and calcified nodules at the atrial aspect of the mitral valve.

Comparison of psychosocial factors between patients with benign fasciculations and those with amyotrophic lateral sclerosis.

In this retrospective study, we compared the initial presentation of patients who were eventually diagnosed with either benign fasciculations (BF) or amyotrophic lateral sclerosis (ALS). We found a significantly higher number of patients with BF reporting a past history of psychiatric symptoms, life stressors, and concurrent psychosomatic symptoms. There was no difference between the two groups in patient report of current anxiety or depression symptoms. These findings support our hypothesis that BF are a manifestation of psychological distress due to somatization and that reviewing psychosocial history is important when patients are being evaluated for fasciculations. Patients seeking medical attention for fasciculations and who do not report a history of underlying psychiatric or psychosomatic disorders should be followed closely as fasciculations have been reported to be a presenting feature of ALS.

Intrapulmonary teratoma: an exceptional disease.

Intrathoracic teratomas almost always occur in the mediastinum, but occasionally, they may be found in the lung as intrapulmonary teratomas. Intrapulmonary teratomas have histologic findings that are similar to those of teratoma from other sites. Two successive patients with intrapulmonary teratomas presented to us in a variable manner. The clinical and radiologic features and the histopathologic findings are presented, and the relevant literature is discussed.