Prospective assessment of aneurysmal rupture risk scores in patients with subarachnoid hemorrhage: a multicentric cohort.

PURPOSE: The natural evolution of unruptured intracranial aneurysms (UIA) is indeed difficult to predict at the individual level. OBJECTIVE: In a large prospective multicentric European cohort, we aimed to evaluate whether the PHASES, UCAS, and ELPASS scores in patients with aneurysmal subarachnoid hemorrhage would have predicted a high risk of aneurysmal rupture or growth. METHODS: Academic centers treating patients with intracranial aneurysms were invited to prospectively collect de-identified data from all patients admitted at their institution for a subarachnoid hemorrhage-related to intracranial aneurysmal rupture between January 1 and March 31, 2021 through a trainee-led research collaborative network. Each responding center was provided with an electronic case record form (CRF) which collected all the elements of the PHASES, ELAPSS, and UCAS scores. RESULTS: A total of 319 patients with aneurysmal subarachnoid hemorrhage were included at 17 centers during a 3-month period. One hundred eighty-three aneurysms (57%) were less than 7 mm. The majority of aneurysms were located on the anterior communicating artery (n = 131, 41%). One hundred eighty-four patients (57%), 103 patients (32%), and 58 (18%) were classified as having a low risk of rupture or growth, according to the PHASES, UCAS, and ELAPSS scores, respectively. CONCLUSION: In a prospective study of European patients with aneurysmal subarachnoid hemorrhage, we showed that 3 common risk-assessment tools designed for patients with unruptured intracranial aneurysms would have not identified most patients to be at high or intermediate risk for rupture, questioning their use for decision-making in the setting of unruptured aneurysms.

Intravenous thrombolytic therapy for acute anterior ischemic stroke: Experience at the French Military Teaching Hospital in Toulon from 2003 to 2014.

INTRODUCTION: Intravenous thrombolysis with rt-PA is the key treatment for acute ischemic stroke (IS), and has largely been developed at the Military Teaching Hospital in Toulon since 2003. This report is of the results of our practices compared with those in the literature, as well as our attempts to identify factors predictive of a favorable outcome after thrombolysis. METHODS: All patients treated with rt-PA for IS in the carotid territory between 2003 and 2014 were prospectively included. Disability was assessed at 3 months by modified Rankin Scale (m-RS) scores; outcome was considered unfavorable if the m-RS score was >2. Multivariate analyses were also performed to identify parameters correlating with poor and favorable outcomes. RESULTS: Of the 289 patients prospectively enrolled in the study [mean initial National Institutes of Health Stroke Scale (NIHSS) score: 14.3], 52.5% had an m-RS score >2 at 3 months of follow-up. Three independent predictive factors for poor functional outcomes at the 3-month follow-up were identified: NIHSS score>12 on admission (P=0.048); NIHSS score>8 at discharge (P<0.001); and early neurological worsening within the first 24h (P=0.015). Early neurological improvement within 24h of rt-PA infusion was significantly associated with recanalization of the stroke-related occluded cerebral artery (P<0.001, r=0.37). CONCLUSION: After 12 years of practice, our stroke unit has produced results similar to those of the major clinical studies in terms of safety and efficacy. High NIHSS scores on admission and a lack of neurological improvement during the first 24h of thrombolysis due to failure of early recanalization were identified as independent predictive factors of poor functional outcomes.

A threshold value in Shear Wave elastography to rule out malignant thyroid nodules: a reality?

OBJECTIVES: To evaluate the ability of a threshold value in ShearWave™ elastography to rule out malignant thyroid nodules while studying its pertinence in association with morphological signs. EQUIPMENT AND METHODS: 148 patients (110 women and 38 men; 52.5 y.o. 15.8) referred for surgery of thyroid nodules underwent standard ultrasound as well as elastography. Characteristics of the morphological signs and maximum elastographic index were calculated in relation to histology. Association of morphological signs alone and then of elastography was also evaluated. One hundred and fifty one nodules were studied on a double-blind basis. RESULTS: 297 nodules were studied. Thirty-five cancers were detected (11.6%). Elastographic index was higher in malignant nodules (115 kPa 60.4) than in benign nodules (41 kPa 25.8) (p<0.001, Student's t-test). Cut off value of 66 kPa was the best to discriminate malignant nodules with a sensitivity of 80% (CI 95%, 62.5; 90.9) and a specificity of 90.5% (CI 95%, 86.1; 93.6) (p=0.0001). Association of elastography and morphological ultrasound signs presented a sensitivity of 97% (CI 95%, 83.3; 99.8) and a negative predictive value of 99.5% (CI 95%, 95.6; 99.9). Interobserver reproducibility proved to be excellent with an interclass correlation of 0.97 (CI 95%, 0.96; 0.98) (p<0.001). CONCLUSION: The 66 kPa threshold in Shear Wave elastography is the best ultrasound sign to rule out malignant thyroid nodules. The method is simple, quantitative, reproducible and usable in the study of nodules larger than 3 cm. Progress must still be made in the study of calcified nodules and follicular tumors.

What is the contribution of elastography to thyroid nodules evaluation?

The determination of elasticity index by elastography has been recently proposed in the evaluation of thyroid nodules, since malignancy is correlated with stiffness of the nodules. The aim of this report is to give an overview on different techniques and results reported by eleven groups active on the field. Advantages and limitations of elastography are also discussed. In our opinion, further studies, preferentially multicentric, are necessary before being able to conclude about the place of elastography in thyroid nodules evaluation, versus fine-needle aspiration cytology (FNAC), the gold standard. Indeed, elastography could reduce FNAC or at least allow to select nodule's (or nodular zone's) for aspirations.

Solitary fibrous tumour of the larynx: a case report.

INTRODUCTION: Solitary fibrous tumour (SFT) of the larynx is a rare benign mesenchymal tumour of adults. The diagnosis is based on a combination of histological and immunohistochemical signs. CASE REPORT: The authors report the case of a patient with chronic laryngeal dysphonia and dyspnoea related to supraglottic SFT. DISCUSSION/CONCLUSION: The main challenge of surgery is to ensure healthy resection margins to avoid recurrence while preserving the functions of the upper aerodigestive tract. Surgery is the treatment of choice and provides an excellent prognosis. Long-term clinical follow-up is required to detect rare recurrences.

Perforation of the piriform sinus after sneezing with cervical subcutaneous emphysema and pneumomediastinum.

INTRODUCTION: Cervical subcutaneous emphysema and pneumomediastinum are often secondary to trauma, surgery or infection. More rarely, they can be spontaneous with no identified cause, but forced Valsalva manoeuvres are a known predisposing factor. Any forced effort with a closed glottis, such as sneezing, can cause rupture of the mucosa leading to the formation of cervical subcutaneous emphysema and pneumomediastinum. CASE REPORT: The authors report the case of a 30-year-old man with cervical subcutaneous emphysema complicated by pneumomediastinum due to fistula of the piriform sinus following sneezing while simultaneously obstructing both nostrils. DISCUSSION/CONCLUSION: Rupture of the mucosa of the piriform sinus is an extremely rare complication of this type of manoeuvre. This condition requires management in hospital due to the risk of infection with cervical cellulitis progressing to mediastinitis. Simultaneously obstructing both nostrils during sneezing is a dangerous manoeuvre that should be avoided.

Clear-cell renal carcinoma metastasis to the base of the tongue and sphenoid sinus: Two very rare atypical ENT locations.

INTRODUCTION: Kidney cancer, and especially clear cell carcinoma, has an unpredictable clinical course, with metastatic potential that is variable over time and in location. Six percent of atypical locations are ENT. The three most frequent sites are the thyroid, sinus and parotid gland. CASE REPORT: We report two rare locations: the base of the tongue, and the sphenoid sinus. DISCUSSION: First-line treatment is surgical, due to low radiosensitivity, with radiation therapy as a possible second line. Functional impact is a prime issue, to avoid functional mutilation. CONCLUSION: Such metastases may sometimes occur years after the discovery of the primitive renal tumor; any history of kidney cancer should, therefore, be noted in patients with suspect ENT lesions.