Is intraprocedural intravenous aspirin safe for patients who require emergent extracranial stenting during mechanical thrombectomy?

BACKGROUND: Intraoperative antiplatelet therapy is recommended for emergent stenting during mechanical thrombectomy (MT). Most patients undergoing MT are also given thrombolysis. Antiplatelet agents are contraindicated within 24 hours of thrombolysis. We evaluated outcomes and complications of patients stented with and without intravenous aspirin during MT. METHODS: All patients who underwent emergent extracranial stenting during MT at the Royal Stoke University Hospital, UK between 2010 and 2020, were included. Patients were thrombolysed before MT, unless contraindicated. Aspirin 500 mg intravenously was given intraoperatively at the discretion of the operator. Symptomatic intracranial haemorrhage (sICH) and the National Institutes for Health Stroke Scale score (NIHSS) were recorded at 7 days, and mortality and functional recovery (modified Rankin Scale: mRS ≤2) at 90 days. RESULTS: Out of 565 patients treated by MT 102 patients (median age 67 IQR 57-72 years, baseline median NIHSS 18 IQR 13-23, 76 (75%) thrombolysed) had a stent placed. Of these 49 (48%) were given aspirin and 53 (52%) were not. Patients treated with aspirin had greater NIHSS improvement (median 8 IQR 1-16 vs median 3 IQR -9-8 points, p=0.003), but there were no significant differences in sICH (2/49 (4%) vs 9/53 (17%)), mRS ≤2 (25/49 (51%) vs 19/53 (36%)) and mortality (10/49 (20%) vs 12/53 (23%)) with and without aspirin. NIHSS improvement (median 12 IQR 4-18 vs median 7 IQR -7-10, p=0.01) was greater, and mortality was lower (4/33 (12%) vs 6/15 (40%), p=0.05) when aspirin was combined with thrombolysis, than for aspirin alone, with no increase in bleeding. CONCLUSION: Our findings based on registry data derived from routine clinical care suggest that intraprocedural intravenous aspirin in patients undergoing emergent stenting during MT does not increase sICH and is associated with good clinical outcomes, even when combined with intravenous thrombolysis.

Utility of thoracic computed tomography to predict need for early surgery and recurrence after first episode of primary spontaneous pneumothorax.

INTRODUCTION: CT imaging is not advocated by British Thoracic Society guidelines after first episode of primary spontaneous pneumothorax (PSP). There is emerging evidence that emphysema-like changes and CT-based dystrophy severity score (DSS) can predict need for early surgery and recurrence. OBJECTIVES: We aimed to assess the role of DSS during first episodes of PSP in predicting the need for early surgery and recurrence. METHODS: We conducted a retrospective analysis of consecutive PSP episodes (n=197) admitted to our institution from 1 January 2012 to 31 December 2017. DSS was calculated based on type, number and distribution of blebs and bullae. Patients were categorised as low-grade (0-3) or high-grade (4-6) DSS assessed by a thoracic radiologist. RESULTS: Forty-five PSP patients had CT at first presentation. Eight patients had low-grade DSS; all were managed non-surgically and none had recurrence over 12 months. Thirty-seven patients had high-grade DSS. Of these, 25 (67.5%) were managed surgically, with three having contralateral recurrence over 12 months; 12 (32.5%) were managed non-surgically, and of these two patients had ipsilateral recurrence over 12 months. CONCLUSION: DSS seems to predict the need for early surgery and recurrence and CT can be used to risk-stratify patients after a first episode of PSP.

Massive haemoptysis secondary to mycotic pulmonary artery aneurysm in subacute invasive aspergillosis.

A 68-year-old man, presented with 3 week history of infective symptoms and mild haemoptysis. Past medical history included severe emphysema and a chronic right upper lobe (RUL) cavity. He was discharged from follow-up a year ago in view of clinical and radiological stability; previous bronchoscopic examinations yielded no specific diagnosis. CT scan on admission confirmed complex cavitary consolidation of RUL. He developed massive haemoptysis requiring intubation and ventilation. CT pulmonary angiogram (CTPA) revealed 16 mm RUL pulmonary artery (PA) aneurysm which was successfully embolized. Sputum cultures, aspergillus antigen and rapidity of clinical progression suggested a diagnosis of subacute invasive aspergillosis (SAIA), prompting treatment with Voriconazole. Bronchoscopy showed blood ooze from RUL even after embolization. Unfortunately, patient continued to deteriorate and succumbed to profound septicaemia.

Unusual case of hemidiaphragmatic paralysis secondary to cervical herpes zoster.

Hemidiaphragmatic paralysis is usually caused by surgery, malignancy or trauma and rarely by viral infections. Herpes zoster (shingles) results in varied neurological complications, but peripheral motor involvement or diaphragmatic paralysis is rare. We report the case of an 87-year-old male who presented with worsening breathlessness soon after an episode of shingles, affecting his right neck and upper chest. He had no alarm symptoms, history of trauma or malignancy. Skin lesions resolved after a few weeks, but his breathing did not improve. Chest X-ray revealed a new finding of elevated right hemidiaphragm; diaphragmatic ultrasound confirmed paradoxical cranial movement of right hemidiaphragm on sniff testing. CT scan showed no lung mass and complete collapse of right lower lobe due to elevated right hemidiaphragm. Patient has required no treatment and is under regular follow-up with the ventilation clinic.