A Myriad of Symptoms After Spinal Anesthesia: A Case Report of Local Anesthetic Systemic Toxicity.

Local anesthetics are widely used by various medical professionals. Although their usefulness is unquestionable, as with any medication, there is a possibility of iatrogenic effects. When local anesthetic systemic toxicity occurs, it might be a life-threatening condition. Knowing its existence and how to act when it arises is crucial. The clinical presentation is wide-ranging, but globally it affects the neurological and cardiovascular system, with cardiac arrest being the extreme of its presentation. The treatment is mainly supportive with an attempt to reverse the effects of the anesthetic by administering a lipid emulsion. Here, we present a clinical case of difficult management with many complications.

Predictors of pneumonia in patients with acute spontaneous intracerebral hemorrhage in Algarve, Southern Portugal.

INTRODUCTION: Following the hyperacute phase of spontaneous intracerebral hemorrhage (SICH), the severest form of stroke, pneumonia emerges as the leading cause of morbidity and mortality. Prevention of stroke associated pneumonia (SAP) is fundamental to improve the prognosis of SICH patients. AIM: Identify clinical, sociodemographic and process of care factors associated with occurrence of SAP after SICH in Algarve, southern Portugal. METHODS: Observational, retrospective study of community representative consecutive case series of patients with SICH admitted to the sole public hospital in the region. Logistic regression was used to identify predictors of SAP after SICH. RESULTS: A total of 525 patients were included. The mean age was 71 ( ± 13) years and 64% were men. SAP occurred in 165 (31.5%). Lower Glasgow Coma Scale score (GCS score): ≤ 8 (OR= 2.087; 95% CI= [1.027;4.424]; p = 0.042) and GCS 9-12 (OR= 1.775; 95% CI= [1.030;3.059]; p = 0.039); prolonged emergency room stay (OR= 8.066; 95%CI=[3.082;21.113]; p < 0.001) and hyperactive delirium (OR=2.860; 95% CI= [1.661;4.925]; p < 0.001) increased the likelihood of SAP. Being younger, ≤ 59 years (OR= 0.391; 95% CI= [0.168; 0.911]; p = 0.029) and 60-71 years (OR= 0.389; 95% CI= [0.185; 0.818]; p = 0.013); and having less severe SICH/intracerebral hemorrhage score (ICH score) ≤ 2 (OR=0.601; 95% CI= [0.370; 0.975]; p = 0.039), decreased the risk of SAP. CONCLUSION: After SICH, SAP occurs in approximately a third of patients. Non preventable (admission severity, ageing) and potentially preventable (prolonged emergency room stay, hyperactive delirium) determine the occurrence of SAP. Intensification of preventive intervention in high-risk patients, delirium prevention and improvement of the process of care can potentially reduce the occurrence of SAP after SICH.

Impact of process of care in the short-term mortality in non-severe intracerebral hemorrhage in southern Portugal.

INTRODUCTION: Patients with spontaneous intracerebral hemorrhage (SICH) face the worse functional and vital prognosis among all stroke subtypes. In cases of severe SICH, therapeutic inertia or nihilism complicates meaningful identification of outcome predictors. Therefore, we sought to investigate clinic-radiological and process of care predictors of short-term mortality in patients with mild to moderate SICH. PATIENTS AND METHODS: Observational retrospective community representative consecutive case series of patients from Algarve, southern Portugal. Logistic regression was used to identify predictors of short-term (30-day) death. RESULTS: Mortality was 23.9% (111/464). Most important predictors of death were unconsciousness at admission (OR = 12.392, 95% CI = 3.816-40.241, p < 0.001), hospital arrival ≥ 6 h after stroke onset (OR = 2.842, 95% CI = 1.380-5.852, p =.005), hematoma volume > 30 cc/cm3 (OR = 3.295, 95% CI 0 1.561-6.953, p =.002), intraventricular extension (OR = 2.885, 95% CI = 1.457-5.712, p =.002) and ≥ 24 h in the Emergency Department (OR = 19.675, 95% CI = 3.682-34.125, p =.009). Stroke Unit (SU) admission reduced the likelihood of death (OR = 0.293, 95% CI = 0.137-0.682, p =.002). CONCLUSION: The observed mortality is high. Apart from the traditional clinic-radiological factors, in mild to moderate SICH, process of care related factors have strong impact on mortality. These results highlight the need of continuous improvement of SICH care to improve the prognosis.

Stroke-Associated Cortical Deafness: A Systematic Review of Clinical and Radiological Characteristics.

BACKGROUND: Stroke is the leading cause of cortical deafness (CD), the most severe form of central hearing impairment. CD remains poorly characterized and perhaps underdiagnosed. We perform a systematic review to describe the clinical and radiological features of stroke-associated CD. METHODS: PubMed and the Web of Science databases were used to identify relevant publications up to 30 June 2021 using the MeSH terms: "deafness" and "stroke", or "hearing loss" and "stroke" or "auditory agnosia" and "stroke". RESULTS: We found 46 cases, caused by bilateral lesions within the central auditory pathway, mostly located within or surrounding the superior temporal lobe gyri and/or the Heschl's gyri (30/81%). In five (13.51%) patients, CD was caused by the subcortical hemispheric and in two (0.05%) in brainstem lesions. Sensorineural hearing loss was universal. Occasionally, a misdiagnosis by peripheral or psychiatric disorders occurred. A few (20%) had clinical improvement, with a regained oral conversation or evolution to pure word deafness (36.6%). A persistent inability of oral communication occurred in 43.3%. A full recovery of conversation was restricted to patients with subcortical lesions. CONCLUSIONS: Stroke-associated CD is rare, severe and results from combinations of cortical and subcortical lesions within the central auditory pathway. The recovery of functional hearing occurs, essentially, when caused by subcortical lesions.

Gastric Volvulus: A Multidisciplinary Approach and Conservative Treatment.

Gastric volvulus can be defined as an abnormal rotation of the stomach. It can be both an emergency and a chronic intermittent problem. Being such a rare clinical entity and a difficult condition to diagnose, it is commonly diagnosed at the time of surgery or even at autopsy. We present the case of an 82-year-old independent female with a past medical history of hiatal hernia, who came to the emergency department with hematemesis and severe epigastric pain. An abdominal CT scan revealed an organoaxial stomach volvulus within the intrathoracic cavity. After initial treatment with gastric decompression, IV fluids and proton pump inhibitors, the patient was informed that the surgical intervention would be the only definitive curative treatment for her condition and denied the procedure. She was then discharged after clinical and analytical improvement. She was offered a conservative treatment and follow up by the internal medicine team. After a few months, the patient reported moderate improvement of her symptoms and less episodes of epigastric pain. She was pleased with the conservative management and denied any surgical or invasive procedures. A proximity contact was established with the family doctor, which she maintains. This case report is proof that rare entities can happen to patients presenting common symptoms and better resolutions come from multidisciplinary approaches.

Recognizing dysphagia: implementation of an in-hospital screening protocol.

BACKGROUND: Dysphagia affects up to 30% of hospitalized patients, and it is associated with numerous complications. AIMS: Assess the impact of a 24/7 dysphagia screening protocol in an Internal Medicine Unit regarding respiratory complications (such as aspiration pneumonia) as the primary outcome. Length of stay and discharge destination were secondary outcomes. METHODS: Case-control hospital-based analysis comparing the outcomes before and after the implementation of the screening protocol. We analysed demographic data (such as age and gender) and clinical data (presence of dysphagia, vascular risk factors and other comorbidities, respiratory complications, in hospital length of stay and discharge destination). Patients with at least one of the following risk factors were included: COPD (chronic obstructive pulmonary disease), neurodegenerative disorders including dementia, acute stroke or chronic cerebrovascular disease, head and neck neoplasms/surgery or radiotherapy. Statistical analysis was performed with SPSS®. RESULTS: One hundred twenty-eight consecutive patient files were reviewed as the historical control, while 125 consecutive patients were evaluated after the screening protocol was implemented. Even though the second group had less evidence of dysphagia (33 vs 36), since it was detected earlier, respiratory complications were significantly lower (11.7% before vs 2.4%, p < 0.001), allowing more patients to be discharged home (65.6% vs 84%, p = 0.005) and less mortality (15.6% vs 4%, p = 0.005). CONCLUSIONS: Despite its limitations, this study demonstrates that dysphagia screening produces a significant impact on patients' lives, as well as healthcare professionals and resources. We hope that our results will encourage others to adopt a patient-centred multidisciplinary approach that includes a dysphagia screening protocol.

Prevalence, predictors and prognosis of incidental intracranial aneurysms in patients with suspected TIA and minor stroke: a population-based study and systematic review.

INTRODUCTION: Unruptured intracranial aneurysms (UIAs) are common incidental imaging findings, but there are few data in patients with transient ischaemic attack (TIA)/stroke. The frequency of UIA might be higher due to shared risk factors, but rupture risk might be reduced by intensive secondary prevention. We determined the prevalence and prognosis of UIA in patients with suspected TIA/minor stroke. METHODS: All patients referred to the population-based Oxford Vascular Study (2011-2020) with suspected TIA/minor stroke and non-invasive angiography were included. We determined the prevalence of incidental asymptomatic UIA and the risk of subsequent subarachnoid haemorrhage (SAH) by follow-up on intensive medical treatment, with guideline-based monitoring/management. We also did a systematic review of UIA prevalence/prognosis in cohorts with TIA/stroke. FINDINGS: Among 2013 eligible patients, 95 (4.7%) had 103 previously unknown asymptomatic UIA. Female sex (OR 2.3, 95% CI 1.5 to 3.7), smoking (2.1, 1.2 to 3.6) and hypertension (1.6, 1.0 to 2.5) were independently predictive of UIA, with a prevalence of 11.1% in those with all three risk factors. During mean follow-up of 4.5 years, only one SAH occurred: 2.3 (95% CI 0.3 to 16.6) per 1000 person-years. We identified 19 studies of UIA in TIA/stroke cohorts (n=12 781), all with either symptomatic carotid stenosis or major acute stroke. The pooled mean UIA prevalence in patients with TIA/stroke was 5.1% (95% CI 4.8 to 5.5) and the incidence of SAH was 4.6 (95% CI 1.9 to 11.0) per 1000 person-years. INTERPRETATION: The 5% prevalence of UIA in patients with confirmed TIA/minor stroke is likely higher than that in the general population. However, the risk of SAH on intensive medical treatment and guideline-based management/monitoring is low.

Pneumocephalus Associated with Aggressive Pneumococcal Meningitis.

A 44-year-old woman presented with headache and delirium. Brain tomography indicated pneumocephalus, while blood and cerebrospinal fluid cultures revealed Streptococcus pneumoniae. Despite antibiotic treatment and admission to the intensive care unit, the patient died 3 days later. Pneumocephalus in association with meningitis is very rare and may be caused by gas produced by microorganisms. LEARNING POINTS: Non-traumatic pneumocephalus should raise the suspicion of meningitis and prompt suitable treatment.Previous pneumococcal saccharide conjugate vaccine administration does not exclude the possibility of serious pneumococcal infection.

Determinants of the Need for Tracheostomy in Neurocritical Patients.

BACKGROUND: Given the difficulties in predicting the need for prolonged intubation and the timing of tracheostomy, the stroke-related early tracheostomy score (SETscore) was developed, and this tool has demonstrated moderate accuracy in predicting intensive care unit (ICU) length of stay (LoS), ventilation duration, and need for tracheostomy. We aim to assess the usefulness of SETscore in a more heterogeneous population that includes trauma patients to whom this score has not yet been applied. MATERIAL AND METHODS: A retrospective consecutive analysis of all neurocritical patients who were admitted to our medical-surgical ICU between 2016 and 2018 and who required endotracheal intubation within 48 h of admission was performed in this study. Clinicodemographic data, as well as tracheostomy timing, imaging results, and SETscore were evaluated. RESULTS: The medical records of 732 neurocritical patients were reviewed, but only 493 patients were included, 68 of whom were tracheostomized (TR). These TR patients presented longer LoS and ventilation and antibiotic duration, lower Glasgow Coma Scale (GCS) score at admission, and more respiratory comorbidities. Severity scores, including SETscore, were higher in the TR group. A SETscore of >10 demonstrated 92.6% sensitivity and 79.1% specificity in predicting the need for tracheostomy. The majority of patients were tracheostomized after the seventh day of ICU admission. No significant differences in SETscore as well as in severity scores, age, and gender were observed between the early and late TR groups. However, the need for tracheostomy was significantly associated with lower ICU death rate even after controlling for GCS at admission, gender, age, and duration of invasive mechanical ventilation. CONCLUSION: SETscore can be applied to a heterogeneous population. However, more data and prospective analyses are needed to validate their clinical usefulness on a daily basis. Nevertheless, the present data are expected to contribute to the management of neurocritical patients, particularly in the setting of ICUs managing a broad spectrum of critically ill patients.

Late Hospital Arrival for Thrombolysis after Stroke in Southern Portugal: Who Is at Risk?

BACKGROUND: Delayed hospital arrival remains the main reason for the low rates of thrombolysis in eligible acute ischemic stroke (AIS) patients. The role of socioeconomic and clinical factors for the prehospital delay of AIS remains poor and has never been studied in Portugal. OBJECTIVES: Describe the socioeconomic and clinical factors leading to delayed hospital admission of AIS patients eligible to thrombolysis. METHODS: A case-control study with a consecutive thrombolyzed AIS patients from 2010 to 2015. Controls were patients who did not receive thrombolysis because of late hospital arrival. Logistic regression with stepwise forward regression analysis was used to identify independent predictors of delayed admission to receive thrombolysis with intravenous tissue-type plasminogen activator (rtPA). RESULTS: Of the 1247 patients admitted with AIS, 76 (6%) arrived on-time and received intravenous rtPA. Controls were 65.8% (146/222) of the total number of patients included in the study. Overall, the mean age was 73 years (±11, 61), a minority were below 60 years, and 43.7% were women. Being beneficiary of social insertion income (odds ratio [OR]: .286; .124-.662, P = .003), not having any telephone contact (OR: .145; .039-.536, .004) or having exclusive landline (.055; .014-.210, <.001) and posterior circulation stroke (OR: .266; .087-.811, P = .020) decreased the likelihood of hospital arrive on-time rtPA. The use of prehospital ambulance services increased (OR: 6.478; 2.751-15.254, P < .001) the odds of ER on-time arrival for thrombolysis. CONCLUSIONS: Poverty, lack of stroke awareness, or difficulties in requesting immediate medical help are the main factors implicated in late-hospital admission for thrombolysis in AIS. Stroke awareness campaigns, promotion of activation of national emergency number and stroke code can increase the rate of thrombolysis.

Vanishing Pseudotumoral White Matter Lesions Presenting as Aphasia and Altered Mental Status in a 71-Year-Old Male.

Acute disseminated encephalomyelitis (ADEM) is a demyelinating disorder that usually affects the central nervous system (CNS) after an infection and/or vaccination. It is more common in infancy. Here we present a case of late onset ADEM. A 71-year-old male was admitted to the emergency department due to speech difficulty and somnolence. Upon neurological examination he had a mixed aphasia. He performed a brain computed tomography which showed multiple white matter hypodense lesions. After admission to the neurology ward, he performed a lumbar puncture which showed a mildly inflammatory cerebrospinal fluid, negative serological testing and negative oligoclonal bands. Brain magnetic resonance imaging (MRI) confirmed the presence of multiple T2 hyperintense lesions, extensive bilateral frontoparietal lesions with abundant perilesional edema, four with gadolinium enhancement in an open-ring pattern and no mass effect. Anti-aquaporin 4 antibody, virologic and bacteriologic blood testing, screening of autoimmune disorders and occult neoplasm were all unremarkable. He was treated with intravenous methylprednisolone (1 gr) during five days and started to recover, maintaining a slight verbal fluency deficiency. Post-treatment brain MRI showed reduction of previous lesions, corroborating the probable inflammatory/demyelinating etiology. After discharge he maintained follow-up at the neurology outpatient clinic and he is currently asymptomatic with no new lesions and further reduction of the previous ones on follow-up MR scan. Both clinical follow-up of the patient, revealing a monophasic course with complete recovery, and temporal evolution of his brain lesions were essential to establish a diagnosis of ADEM in a septuagenarian patient, in whom other diagnoses have to be considered.