Parálisis facial periférica posterior a bloqueo de glosofaríngeo: reporte de un caso / Peripheral facial palsy following glossopharyngeal block: a case report

La neuralgia del nervio glosofaríngeo es una entidad clínica dolorosa, secundaria a diferentes etiologías de carácter compresivo sobre el nervio. Puede llegar a generar un deterioro importante sobre la calidad de vida por sus síntomas sensitivos a nivel facial, siendo menos frecuente que la neuralgia del nervio trigémino y requiriendo el cumplimiento de criterios diagnósticos para su confirmación clínica. El tratamiento de esta entidad puede ser farmacológico, quirúrgico o intervencionista por vía percutánea con guía ecográfica. Las complicaciones de las técnicas intervencionistas son poco frecuentes. En este caso se presenta una parálisis facial periférica, con resolución completa en 12 horas posterior a un bloqueo percutáneo del nervio glosofaríngeo con guía ecográfica. Esta complicación muy poco reportada en la literatura médica puede deberse a la difusión local del medicamento anestésico o las múltiples variantes anatómicas del nervio facial, además de la posibilidad de ramas extra petrosas que comunican al nervio facial con el glosofaríngeo. Se puede considerar a la parálisis facial periférica un efecto secundario esperado, poco frecuente de este procedimiento en pacientes con variantes anatómicas, que no modifica la efectividad de la intervención o la seguridad del paciente.(AU)

Glossopharyngeal nerve neuralgia is a painful clinical entity, secondary to different etiologies of compressive character on the nerve. It can generate an important deterioration in the quality of life, due to its sensitive symptoms at the facial level; being less frequent than trigeminal nerve neuralgia, and requiring the fulfillment of diagnostic criteria for its clinical confirmation. The treatment of this entity can be pharmacological, surgical, or interventional by percutaneous route with ultrasound guidance. Complications of interventional techniques are rare, in this case, we present peripheral facial paralysis; with complete resolution in 12 hours after a percutaneous block of the glossopharyngeal nerve with ultrasound guidance. This complication is very rarely reported in the medical literature may be due to the local diffusion of the anesthetic drug or the multiple anatomical variants of the facial nerve in addition to the possibility of extra petrosal branches that communicate the facial nerve with the glossopharyngeal nerve. Peripheral facial paralysis can be considered an expected side effect, infrequent of this procedure in patients with anatomical variants, which does not modify the effectiveness of the intervention or the patient’s safety.(AU)

Prognostic significance of post-clopidogrel platelet reactivity assessed by a point-of-care assay on thrombotic events after drug-eluting stent implantation.

AIMS: The aim of this study was to determine whether platelet reactivity on clopidogrel therapy, as measured by a point-of-care platelet function assay, is associated with thrombotic events after percutaneous coronary intervention (PCI) with drug-eluting stents (DESs). METHODS AND RESULTS: Platelet reactivity on clopidogrel (post-treatment reactivity) was measured with the VerifyNow P2Y12 assay (Accumetrics Inc., San Diego, CA, USA) in 380 patients undergoing PCI with sirolimus-eluting stents. Receiver-operating characteristic curve analysis was used to derive the optimal cut-off value for post-treatment reactivity in predicting 6 month out-of-hospital cardiovascular (CV) death, non-fatal MI, or stent thrombosis. The mean post-treatment reactivity was 184 +/- 85 PRU (P2Y12 reaction units). The optimal cut-off for the combined endpoint was a post-treatment reactivity > or =235 PRU [area under the curve 0.711 (95% confidence interval 0.529-0.893), P = 0.03], which was similar to the threshold of the upper tertile (231 PRU). Patients with post-treatment reactivity greater than the cut-off value had significantly higher rates of CV death (2.8 vs. 0%, P = 0.04), stent thrombosis (4.6 vs. 0%, P = 0.004), and the combined endpoint (6.5 vs. 1.0%, P = 0.008). CONCLUSION: High post-treatment platelet reactivity measured with a point-of-care platelet function assay is associated with post-discharge events after PCI with DES, including stent thrombosis. Investigation of alternative clopidogrel dosing regimens to reduce ischaemic events in high-risk patients identified by this assay is warranted.

Clopidogrel desensitization after drug-eluting stent placement.

OBJECTIVES: We hypothesized that a standardized outpatient clopidogrel desensitization protocol would be safe and effective. BACKGROUND: Adverse reactions to clopidogrel are not uncommon, and affected patients must switch to ticlopidine after drug-eluting stent placement, despite its more malignant side-effect profile, because of the risk of ischemic events associated with premature discontinuation of dual antiplatelet therapy. METHODS: Patients with suspected clopidogrel sensitivity were treated with escalating doses of clopidogrel administered orally in solution until either a clinically significant reaction occurred or the full 75-mg tablet of clopidogrel was tolerated. Desensitization was performed on an outpatient basis except in cases in which the subjects were inpatients at the time of enrollment. Follow-up was performed at 2 to 4 weeks and 6 months after treatment. Successful desensitization was defined as the ability to take clopidogrel 75 mg daily without a mucocutaneous, bronchial, or anaphylactic response. RESULTS: We enrolled 24 consecutive patients with suspected reactions to clopidogrel after DES implantation, 20 of whom were outpatients. During desensitization, allergic-type reactions occurred in 4 patients and angina occurred in 1 patient. Desensitization was acutely successful in all 24 patients, and by 6-month follow-up, 1 patient had persistent but improved pruritus controlled with oral antihistamines and 23 remained asymptomatic, with only 2 patients requiring repeat desensitization. CONCLUSIONS: Clopidogrel desensitization is safe and effective, induces a sustained remission, and could be advantageous in treating outpatients who are at-risk for premature discontinuation of dual antiplatelet therapy.

Efficacy and safety of triple antiplatelet therapy with and without concomitant anticoagulation during elective percutaneous coronary intervention (the REMOVE trial).

Adjunctive glycoprotein IIb/IIIa inhibition decreases ischemic events after percutaneous coronary intervention (PCI) but is associated with increased bleeding. We hypothesized that maximal antiplatelet therapy with aspirin, a thienopyridine, and a glycoprotein IIb/IIIa inhibitor without unfractionated heparin (UFH) would result in fewer bleeding complications and maintain efficacy in elective PCI. A total of 159 patients undergoing elective PCI were randomized to intraprocedural eptifibatide alone or eptifibatide plus UFH. Patients received aspirin 325 mg and clopidogrel 300 mg before the procedure. The primary end point was the Landefeld bleeding index. Secondary end points included the composite clinical outcome of in-hospital death, myocardial infarction, urgent target vessel revascularization, and Thrombolysis In Myocardial Infarction major bleeding, and a composite bleeding outcome of major, minor, and nuisance bleeding. The Landefeld bleeding index was significantly lower in the eptifibatide-only group compared with the eptifibatide-plus-UFH group (3.0 vs 3.9, p = 0.03). There was no significant difference in the composite clinical end point between groups (eptifibatide only 17% vs eptifibatide plus UFH 15%, p = 0.7). There was a trend toward a decrease in the composite bleeding end point in the eptifibatide-only compared with the eptifibatide-plus-UFH group (43% vs 56%, p = 0.10). In conclusion, during elective PCI, a strategy of aggressive antiplatelet therapy using aspirin, clopidogrel, and eptifibatide without anticoagulant therapy appears to decrease bleeding complications.

Utility of three-dimensional reconstruction of coronary angiography to guide percutaneous coronary intervention.

OBJECTIVE: The goal of this study was to determine whether three-dimensional (3D) reconstruction of traditional coronary angiography could optimize the choice of drug-eluting stent (DES) length and number during percutaneous coronary intervention (PCI). BACKGROUND: Coronary angiography is subject to significant foreshortening artifact that limits the ability of the operator to accurately determine lesion length. METHODS: The angiographic images of the target vessels of consecutive PCI procedures were postprocessed using a 3D reconstruction algorithm. The appropriate length and optimal number of DES to span each target lesion were calculated and compared with the number and length of DES actually chosen by the operator. RESULTS: A total of 42 target vessels were analyzed, and 3D reconstruction was successful in 38/42 (90.5%) of cases. The results of 3D analysis would have changed operator decision making in six cases (16%): in four cases, the stent chosen by the operator was too short requiring an additional DES; in two cases, the chosen DES was too long and exchanged for a shorter one. In each of these six cases, 3D analysis would have determined the correct stent length prior to stent selection. The optimal stent number derived by 3D reconstruction was significantly less than the actual number of stents per lesion used by the operator (1.31 +/- 0.47 versus 1.54 +/- 0.68, P = 0.01), and the optimal stent length trended less than the actual stented length (27.5 +/- 12.8 mm versus 28.7 +/- 14.7 mm, P = 0.23). CONCLUSIONS: 3D reconstruction algorithm of standard coronary angiography is a promising technique to improve DES utilization during PCI.

Early- and medium-term outcomes after paclitaxel-eluting stent implantation for sirolimus-eluting stent failure.

The optimal treatment for sirolimus-eluting stent (SES) restenosis is not known. This study evaluated the safety and clinical outcome of paclitaxel-eluting stent (PES) implantation for SES restenosis. From March 2004 to July 2005, PESs were implanted in 125 patients with 140 lesions with SES restenosis. Acute and 6-month clinical outcomes were determined through review of the medical record and/or telephone interview. In-hospital major adverse cardiac events (death, nonfatal myocardial infarction, or repeat revascularization) occurred in 14 patients (11.2%), driven entirely by postprocedure non-Q-wave myocardial infarction. At a mean clinical follow-up of 7.2 +/- 1.8 months, the incidence of target lesion revascularization (TLR) was 14.0%, and the rate of major adverse cardiac events was 17.2%. Subacute thrombosis occurred in 2 patients (1.6%). Length of PES implanted, postprocedure diameter stenosis, and total occlusion of the target lesion were independent predictors of TLR. In patients with de novo SES restenosis, TLR was only 8.7%. In conclusion, at medium-term follow-up, PES implantation for SES failure appears to be safe and effective, although efficacy is decreased in the setting of total occlusions, greater residual diameter stenosis, and longer PESs.

Evaluación toxicológica aguda de los extractos fluidos al 30 y 80 porciento de Cymbopogon citratus (D.C.) Stapf (caña santa) / Toxicologic acute evaluation of the fluid extracts 30 and 80 porciento of Cymbopogon citratus (D.C.) Stapf (lemon grass)

Se procedió a realizar la evaluación toxicológica aguda de los extractos fluidos al 30 y 80 porciento de Cymbopogon Citratus (D.C.) Stapf (Caña Santa), planta utilizada por su efecto anticatarral, antiasmático, diurético, antitusígeno y en el control de la presión arterial, demostrándose que las manifestaciones de toxicidad son más evidentes a mayor concentración del fluido, las cuales se hicieron más probables en los animales tratados con el extracto fluido al 80 porciento. Los daños observados estuvieron centrados en estómago con congestión vascular ligera e infiltrado hemorrágico focal en la lámina propia, en hígado y riñón, donde los hallazgos histológicos permiten afirmar el efecto hepatotóxico y nefrotóxico de los mismos (AU)

Evaluación toxicológica aguda de los extractos fluidos al 30 y 80 porciento de Cymbopogon citratus (D.C.) Stapf (caña santa) / Toxicologic acute evaluation of the fluid extracts 30 and 80 porciento of Cymbopogon citratus (D.C.) Stapf (lemon grass)

Se procedió a realizar la evaluación toxicológica aguda de los extractos fluidos al 30 y 80 porciento de Cymbopogon Citratus (D.C.) Stapf (Caña Santa), planta utilizada por su efecto anticatarral, antiasmático, diurético, antitusígeno y en el control de la presión arterial, demostrándose que las manifestaciones de toxicidad son más evidentes a mayor concentración del fluido, las cuales se hicieron más probables en los animales tratados con el extracto fluido al 80 porciento. Los daños observados estuvieron centrados en estómago con congestión vascular ligera e infiltrado hemorrágico focal en la lámina propia, en hígado y riñón, donde los hallazgos histológicos permiten afirmar el efecto hepatotóxico y nefrotóxico de los mismos

Lesión cutánea nodular en ama de casa / Subacute endocarditis due to Actinobacillus actinomycetemcomitans

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