Diagnosis, treatment, and follow-up of patients with cerebral amyloid angiopathy-related inflammation.

PURPOSE: Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a rare potentially reversible encephalopathy associated with an autoimmune process against proteins deposited in the walls of cortical and leptomeningeal brain vessels. Definite diagnosis requires histopathological features of vascular inflammation and amyloid deposition from brain biopsy. Clinical-neuroradiological criteria have been recently introduced and validated to reduce the need for biopsy. The purpose of this paper is to report a historical retrospective review of clinical-neuroradiological follow-up of two patients with probable CAA-ri and five patients with a reasonably probable suspect of CAA-ri (4 females, 3 males, patient's age at admission: 66-79 years) seen at our institution between 2007 and 2021, focusing on clinical and neuroradiological awareness to this entity and variable response to immunotherapy. MATERIALS AND METHODS: Clinical features at presentation included subacute to acute confusion (6/7), seizures (4/7), cognitive impairment (5/7), and focal neurological signs (3/7). Neuroradiology included braincomputed tomography followed by magnetic resonance imaging. Infectious diseases and autoimmune workups were then performed. RESULTS: CSF analysis was performed in two patients. Cerebral angiography was performed in two patients, to rule out vascular malformations. Hemorrhagic posterior reversible encephalopathy syndrome has been suspected in two patients. Four patients underwent immunotherapy with corticosteroids followed by reduction of brain dysfunctions. Three patients did not undergo immunotherapy but underwent clinical and/or neuroradiological remission. CONCLUSIONS: Patients with CAA-ri present a rare steroid-responsive acute to subacute brain dysfunction. Thus, it has to be known and recognized both clinically and neuroradiologically. Spontaneous clinical and/or neuroradiological improvement is possible in patients with mild symptoms.

Recruitment maneuver in prevention of hypoxia during percutaneous dilational tracheostomy: randomized trial.

BACKGROUND: Percutaneous dilational tracheostomy (PDT) can potentially lead to hypoxia and alveolar derecruitment. The aim of this prospective study was to evaluate the efficacy of performing a recruitment maneuver (RM) before tracheostomy, in order to improve oxygenation. METHODS: We enrolled 29 eligible trauma patients with acute lung injury criteria requiring tracheostomy in a university ICU. Subjects were ventilated on volume controlled mechanical ventilation (tidal volume of 6 mL/kg) and F(IO(2)) set at 1.0. Subjects were randomized into 2 groups: RM group (subjects who underwent RM 10 min before PDT, 15 subjects) and no-RM group (subjects without application of RM before PDT, 14 subjects). RM was performed by imposition of continuous positive airway pressure of 40 cm H(2)O for 40 seconds. We collected gas exchange, respiratory, and hemodynamic data 5 times: 1 hour before RM, 5 min after RM, 5 min after PDT, 30 min after PDT, and 6 hours after PDT. RESULTS: Subjects who underwent RM had a significant increase in P(aO(2)); 5 min after the maneuver, P(aO(2)) increased from 222.6 ± 33.4 mm Hg to 341.3 ± 33.1 mm Hg (P < .01) and was always significantly maintained throughout the following times of the study, compared to the no-RM group: in the RM and no-RM groups, respectively, 260.7 ± 35.4 mm Hg vs 108.5 ± 36.9 mm Hg 5 min after PDT; 285.6 ± 29.1 mm Hg vs 188.4 ± 21.4 mm Hg 30 min after PDT; and 226.3 ± 24.8 mm Hg vs 147.6 ± 42.8 mm Hg 6 h after PDT (P < .01). CONCLUSIONS: Our study suggests that application of RM before PDT could be useful to avoid hypoxemia following such procedure, by reducing fall in P(aO(2)) and preventing the decrease in oxygenation values below baseline at 6 hours.

Cardiac arrest after intragastric balloon insertion in a super-obese patient.

A super-obese patient who suffered from severe sleep apnea (SSA) and other comorbidities underwent insertion of a BioEnterics intragastric balloon (BIB) before bariatric surgery. During the night, he was victim of cardiac arrest. After cardiopulmonary resuscitation and return of spontaneous circulation, he was transferred to intensive care unit. Two hours later, he developed an unexpected symptomatic bradycardia, and BIB was removed. The patient had no further cardiac complications, but he had a poor neurological outcome. In our opinion, such a severe cardiac event was the result of several causes. The BIB induces vagal nerve activation by stretching the gastric wall. In addition, super-obese patients with sleep apnea and other comorbitities have an increased risk of potentially fatal cardiac arrhythmias especially during the night. For all these reasons, we think that these patients may benefit from further preoperative cardiac investigations and a more intensive control during the first postinsertion day.