The Use of POCUS-Obtained Optic Nerve Sheath Diameter in Intracerebral Hemorrhage.

Background: Intracerebral hemorrhage (ICH) is associated with high morbidity and mortality. ICH causes increased intracranial pressure (ICP), leading to brain herniation as the disease progresses. Neurological physical exam and monitoring of the disease progression can be challenging due to the impaired consciousness and routine clinical management in this patient population. Given the continuity of the intracranial cavity with the optic nerve subarachnoid space, an increased ICH leads to distension of the optic nerve sheath. We herein examined the correlation between the ICH volume and the optic nerve sheath diameter (ONSD) measured by point of care ultrasound (POCUS). Methods: Patients with ICH diagnosed with a head computed tomography (CT) scan were prospectively enrolled in this study. A portable ultrasound was used to measure the (ONSD); the volume of ICH hematoma, the Acute Physiology And Chronic Health Evaluation IV score, and the Intracerebral Hemorrhage score were collected. A Spearman rank correlation coefficient test was used to assess the relationship between continuous variables. A Wilcoxon rank sum test was used to assess differences in continuous variables between two groups. A p-value less than 0.05 was deemed as statistically significant. Results: A total of 28 subjects were enrolled. A moderate positive correlation was detected between hemorrhage volume and the average ONSD (correlation = 0.4214, p = 0.0255). A weak positive correlation was detected between average ONSD and APACHE IV (correlation = 0.2347, p = 0.2294). A weak moderate positive correlation was detected between average ONSD and ICH score (correlation = 0.1160, p = 0.5566). Conclusions: In this study we demonstrate that ONSD is moderately correlated with hematoma size. A potential application may include serial measurements of the ONSD with ultrasound. This may offer a quick, non-invasive technique that can be used in an intracerebral hemorrhage to monitor the stability or expansion of a hematoma indirectly, and potentially catch a catastrophic event like cerebral herniation.

Unilateral pulmonary edema and acute severe mitral regurgitation associated with operatively repaired aortic coarctation.

Cardiogenic pulmonary edema classically presents bilaterally and with a symmetric distribution. Occasionally, cardiogenic pulmonary edema can present unilaterally, which carries an independent risk for mortality, possibly due to the delayed diagnosis. The most common cardiogenic cause of unilateral pulmonary edema is acute mitral regurgitation, frequently described in the setting of acute coronary syndrome. Here we describe a case of unilateral pulmonary edema caused by acute mitral regurgitation outside the setting of acute coronary syndrome.

Subclavian artery aneurysm: a rare cause of massive haemoptysis.

A 35-year-old man was admitted to the intensive care unit with massive haemoptysis. CT of the chest revealed a necrotic right upper lobe mass. Angiography of his thoracic vasculature revealed a pseudoaneurysm in the right subclavian artery with active contrast extravasation. This anatomic deformity was stented and coiled with the assistance of interventional radiology. Bronchoscopy with lavage and brushings of the right upper lobe mass revealed fungal hyphae and positive galactomannan, supporting that the patient developed invasive pulmonary aspergillosis leading to a mycotic pseudoaneurysm of the right subclavian artery followed by massive haemoptysis.

Bronchobiliary fistula caused by diaphragmatic invasion of a hepatic tumour.

A 71-year-old man presented with a productive cough consisting of yellow fluid. He had previously been treated for pneumonia without resolution in his symptoms. Sputum was tested for bilirubin using a urine dipstick given its similar appearance to bile, which was positive. Hepatobiliary scintigraphy scan revealed uptake of radiotracer in the right lower lobe of the lung. Endoscopic retrogade cholangiopancreatography confirmed diagnosis of a bronchobiliary fistula. The patient had a stent placed in the common bile duct promoting anterograde bile flow with complete resolution of symptoms.

Clinical Features of Extrapulmonary Sarcoidosis Without Lung Involvement.

BACKGROUND: Compared with pulmonary sarcoidosis, sarcoidosis without lung involvement may involve other immunopathologic mechanisms and be associated with other demographic and clinical features. METHODS: This was a retrospective analysis of clinical data collected in real time on 1,686 patients with biopsy-proven sarcoidosis from two large university sarcoidosis outpatient clinics in the United States. We compared differences in demographics characteristics and clinical presentation between pulmonary and nonpulmonary sarcoidosis (NPS). Patients were considered to have NPS only if they had normal chest imaging and no features consistent with pulmonary involvement on the basis of currently accepted criteria. RESULTS: A total of 8.3% of this sarcoidosis cohort met criteria for NPS. NPS was significantly more common in white than black patients, and more common in women than men. The skin was the most common organ involved, and was observed in nearly one-half of patients with NPS. Isolated skin sarcoidosis was the overwhelmingly most common pattern of organ involvement seen in the NPS group (25%), and no other pattern of involvement was found in more than 5% of patients with NPS. CONCLUSIONS: Significant demographic and sex differences were observed between patients with pulmonary and nonpulmonary sarcoidosis. These differences reflect previous data concerning differences between patients with skin and lung sarcoidosis because the skin was the major organ involved with NPS. Although the lungs are likely the primary site of exposure in pulmonary sarcoidosis, the high prevalence of skin involvement in NPS suggests the skin is the most conducive site of antigen capture outside of the respiratory tract.