Clinical and Radiological Characteristics of Non-Obese Female Patients with Idiopathic Intracranial Hypertension.

While the typical patient with idiopathic intracranial hypertension (IIH) is an obese female of childbearing age, there are unique patient populations, such as non-obese females, that have not been well studied. Characterizing this subpopulation may increase awareness our of it, which may prevent underdiagnosis and improve our understanding of IIH's underlying pathophysiology. We retrospectively reviewed electronic medical records and compared the clinical and radiological characteristics of non-obese (BMI < 30) and obese (BMI > 30) female patients with IIH. Two hundred and forty-six patients (age 32.3 ± 10) met our inclusion criteria. The non-obese patients (n = 59, 24%) were significantly younger than the obese patients (29.4 ± 9.9 vs. 33.2 ± 10.2, p = 0.004) and had higher rates of severe papilledema (Friesen 4-5; 25.4% vs. 11.8%, p = 0.019), scleral flattening (62.7% vs. 36.9%, p = 0.008), and optic nerve dural ectasia (78.0% vs. 55.6%, p = 0.044). Non-obese patients also had a tendency to have a higher lumbar puncture opening pressure (368 ± 92.7 vs. 344 ± 76.4, p = 0.062). Non-obese patients were three times more likely to present with a combination of scleral flattening and optic nerve dural ectasia (OR = 3.00, CI: 1.57-5.72, χ2 = 11.63, α < 0.001). Overall, non-obese females with IIH were found to have a more fulminant presentation, typified by higher rates of severe papilledema and radiological findings typical for IIH.

Improved first-pass effect in acute stroke thrombectomy using Solitaire-X compared to Solitaire-FR.

Background: In acute ischemic stroke (AIS), successful endovascular thrombectomy (EVT) of large vessel occlusion (LVO) necessitates the most suited device. Solitaire-X has longer and larger diameter pusher wires than Solitaire-FR.As the role of a larger pusher-wire diameter is uncertain, we aim to compare procedural, clinical, and radiological outcomes for AIS patients undergoing EVT using either type of Solitaire device. Procedures were performed using the Solumbra technique, which combines a large-bore aspiration catheter with a stentriever. The primary outcome was to compare rates of successful first-pass recanalization (defined as TICI 2b/3 score). The secondary objectives were procedural (rates of successful recanalization), clinical (post-procedural NIHSS and days of hospitalization), and radiological (post-procedural ASPECT score and hemorrhagic transformation) outcome measures. Design: Consecutive AIS patients undergoing EVT for LVO were recruited into a prospective multicenter database at our academic center. We have used Solitaire-FR until October 2020 and Solitaire-X ever since. We retrospectively analyzed our prospective consecutive registry. Included in our analysis are patients undergoing EVT using Solitaire only; patients with tandem lesions or underlying stenosis requiring emergent stenting during the procedure were excluded. The cohort of patients treated with Solitaire-X was compared with a cohort consisting of the most recent consecutive cases undergoing EVT with the Solitaire-FR. Results: A total of 182 (71.9 ± 14, 61% male patients) AIS patients were included in the analysis with both groups (n = 91 each) sharing similar demographic characteristics, premorbid conditions, and stroke characteristics (time from symptom-onset, NIHSS, ASPECTS, occlusion site, and rates of intravenous-tPA treatment). The Solitaire-X group had a higher rate of first-pass recanalization (65.9% vs. 50.5%, p = 0.049). On 24-h post-procedural head-CT, the Solitaire-X group had higher ASPECT scores (6.51 ± 2.9 vs. 5.49 ± 3.4, p = 0.042) and lower post-procedural average bleeding volumes (0.67 ± 2.1 vs. 1.20 ± 3.4 mL, p = 0.041). The Solitaire-X group had shorter duration of hospitalization (16.6 ± 13.1 days vs. 25.1 ± 23.2, p = 0.033). On multivariate analysis, using Solitaire-X was the sole independent predictor of first-pass recanalization (OR 2.17, 95% CI 1.12-4.26, p = 0.023). Conclusion: In our study, the use of the Stentriever-X with a larger pusher-wire diameter was associated with a higher likelihood of first-pass effect and improved procedural, clinical, and radiological outcomes in AIS patients.

Emergent cerebral venous stenting: A valid treatment option for fulminant idiopathic intracranial hypertension.

BACKGROUND: Fulminant idiopathic intracranial hypertension (FIIH) is characterized by rapid, severe, progressive vision loss and often treated surgically. Cerebral transverse venous stenting (CTVS) is efficacious in IIH patients, but emergent CTVS in FIIH is rarely reported. We present our experience with emergent CTVS in patients with FIIH. METHODS: Since 01/2019, an institutional protocol allowed emergent CTVS in FIIH patients with bilateral transverse sinus stenosis and gradient pressure > 15 on digital subtraction angiography (DSA). We retrospectively analyzed a prospective registry of all IIH patients with details of neurological and neuro-ophthalmological assessments before and after treatment, and subjective assessments of headache and tinnitus were made pre-and post-procedure. RESULTS: 259 IIH patients, including 49 who underwent CTVS, were registered. Among them, five female patients met inclusion criteria for FIIH and underwent emergent CTVS. FIIH patients were younger (18.8 ± 1.64 vs 27.7 ± 4.85, p < 0.01), mean BMI was lower (30.8 ± 10.57 vs 34.6 ± 4.3, p < 0.01), and lumbar puncture opening pressure higher (454 ± vs 361 ± 99.4, p < 0.01) than that of IIH patients. They presented with acute visual loss, severe headache, papilledema, significant bilateral transverse sinus stenosis on CT-venography, and mean dominant side gradient pressure of 26.4 ± 6.2 on DSA. CTVS was performed without significant complications, resulting in remarkable improvement in headache, optical coherence tomography, and visual fields within 1 week. At 1-year follow-up (four patients) and 6-month follow-up (1 patient), there was complete resolution of papilledema and headache, and marked improvement in visual acuity. CONCLUSIONS: In these patients, emergent-CTVS was a safe and effective treatment option for FIIH. Further evaluation is warranted.

Relieving pain and distress symptoms in the outpatient burn clinic: The contribution of a medical clown.

CONTEXT: High levels of pain and emotional distress characterize the experience of patients, at burn outpatient clinic and reflect on their accompanying persons and the medical personal. OBJECTIVES: To examine the effect of a medical clown presence on: the patients' pain and distress levels as perceived by the patient and by their accompanying persons, and the emotional response of healthcare personnel. METHODS: A yearlong prospective observational comparative study in the burn outpatient clinic, operating twice a week, with a medical clown's presence once a week [Exposure Group - EG] versus clinic without clown presence [Non exposure Group- NEG]. Patients and accompanying persons filled pain [WBS, VAS] and emotional distress [SUDS] questionnaires regarding the patient's experience: before (T1) and after treatment (T2). The clinic personnel filled SUDS at the beginning and the end of the clinic working hours. RESULTS: Significantly lower WBS, VAS, and SUDS scores were reported at T2 in the EG as compared to the NEG both in patients and in the accompanying persons' evaluations. Personnel SUDS were affected in a similar manner. CONCLUSION: Presence of a medical clown induced a positive atmosphere in the clinic. It is possible that the effect of humor through stress reduction mechanism lessened agony. Furthermore, the distraction the clown evoked played a role in the decrease of pain and emotional distress. We recommend implementing psychosocial oriented interventions such as those performed by a medical clown to improve the emotional atmosphere in the ambulatory clinic of patients, accompanying persons and healthcare personnel.

A Comparison Between Pressure Wire and Microcatheter Measurements for Evaluating the Cerebral Venous Pressure Gradient.

Introduction: A pressure gradient of over 8 mm Hg across the stenosis (usually located in the transverse-sigmoid junction) is one of the criteria for cerebral venous stenting in idiopathic intracranial hypertension (IIH) patients. The possible inaccuracy of the traditional microcatheter-based pressure measurements has been discussed in previous studies. In the cardiology field, a dual-sensor pressure wire is routinely used for the evaluation of stenotic lesions. Using a pressure wire for cerebral vasculature was previously discussed in a small case series and case reports. In this study, we compared venous pressure measurements obtained using both a microcatheter and a pressure wire in patients who were candidates for stenting. Methods: A retrospective study was conducted, comparing the two methods of pressure measurements in 26 patients with venous stenosis. Altogether, 120 measurements were performed using both methods. Demographic characteristics, medical history, procedural details, medications, indications for the procedure, and complications were collected from the patient charts. Results: Based on an 8-mm Hg pressure gradient cutoff indication, 19 patients were found eligible to go through unilateral venous stenting based on catheter measurements alone. The wire results corroborated the catheter results in detecting all cases indicated for a stent. This finding implies a sensitivity equal to 100% for the wire measurements. There were no wire-related complications, demonstrating its safety. Conclusions: We conclude that the pressure wire is as safe as the microcatheter and can identify cases requiring intervention. A larger-scale study is needed to assess the measurement accuracy of the pressure wire in brain vasculature.

Air pollution and meteorological conditions during gestation and type 1 diabetes in offspring.

BACKGROUND: Growing evidence indicates that air pollution is capable of disrupting the immune system and therefore, might be associated with an onset of Type 1 diabetes (T1D). OBJECTIVES: We explored possible links of T1D with ambient exposures in the population of southern Israel, characterized by hot and dry climate and frequent dust storms. METHODS: We conducted a matched nested case-control study where exposure to environmental pollutants during gestation in T1D cases was compared to that of healthy children. Up to 10 controls were matched to every case by age, gender and ethnicity, in all 362 cases and 3512 controls. Measurements of pollutants' concentrations, nitrogen dioxide (NO2), sulphur dioxide (SO2), ozone (O3) and particulate matter of size less than 10 and 2.5 µm in diameter (PM10 and PM2.5), as well as the mean daily measurements of meteorological conditions were obtained from the local monitoring stations. The association between T1D and pollution, solar radiation (SR), temperature and relative humidity was adjusted for socioeconomic status, temperature, maternal age and pre-gestational maternal DM, using conditional logistic regression. The environmental exposures were presented as indicators of quartiles averaged over whole pregnancy and by trimesters. RESULTS: Exposure to ozone and solar radiation during gestation were both associated with the T1D in offspring, although at borderline significance. Compared to the lowest quartile, the odds ratio (OR) for exposure to 3rd and 4th quartile of O3 was equal 1.61 (95%CI: 0.95; 2.73) and 1.45 (95%CI: 0.83; 2.53), respectively. Likewise, the ORs for exposure to SR were equal 1.83 (95%CI: 0.92; 3.64), 2.54 (95%CI: 1.21; 5.29) and 2.06 (95%CI: 0.95; 4.45) for to 2nd, 3rd and 4th quartiles, respectively. Exposure to SO2 followed a dose-response pattern, but was not statistically significant. Other environmental factors were not independently related to T1D. Analysis of exposures one year prior to the disease onset indicated a positive association between T1D and SR. CONCLUSIONS: We showed that exposure to high ozone levels and solar radiation during gestation might be related to the T1D. More scientific evidence needs to accumulate to support the study findings.

Adjunctive treatment with low dose intra-arterial eptifibatide and intravenous aspirin during carotid stenting: A case series.

PURPOSE: According to most guidelines, medical protocol for carotid stenting includes the administration of oral Aspirin and Clopidogrel at least four days before the procedure, with intraprocedural intravenous (IV) heparin. Some publications have also reported the safety of adding glycoprotein 2b/3a inhibitors to the protocol. In this retrospective study, we evaluate the safety of a new medication protocol that includes IV aspirin and intra-arterial Eptifibatide (glycoprotein 2b/3a inhibitor) during carotid stenting. All patients who underwent carotid stenting at Soroka University Medical Center between January 2015 and May 2020 were included (emergent cases were excluded). We divided patients into two groups-patients treated under the standard protocol, and patients treated under the new protocol. In the latter, patients received both the standard protocol regimen, as well as 150 mg IV aspirin immediately before stenting, and a slow intra-arterial injection of 2-3 mg Eptifibatide (glycoprotein 2b/3a antagonist) immediately after stenting. Forty-four patients were treated according to the standard protocol (group 1), and 41 patients were treated according to the new protocol (group 2). In group 1, six patients had complications, while in group 2, no complications of any kind were noted (p = 0.027). The safety and possible efficacy of this novel protocol was preliminarily demonstrated in the present study. Future studies are needed to prove the safety and efficacy of a specific drug regimen that will further reduce the complication rates of carotid stenting.