Nontraumatic Neurosurgical Emergencies.

Most neurosurgical emergencies involve management of intracranial pressure, decompression of brain parenchyma, or diversion of cerebrospinal fluid. These interventions aim to prevent progression and reverse damage to neural structures. The pathologies that require emergent treatment either develop acutely or may progress over days until they reach a critical point causing decompensation. The risk of any intervention need to be weighed against potential benefits and should involve discussions with the family. Interventions have shown to be effective and facilitate patients' return to improved functionality. However, while neurosurgical interventions are lifesaving, surviving patients may have a severe residual disability. This article presents an overview of commonly seen nontraumatic neurosurgical emergencies. Each section presents key facets of presentation, initial workup, management, and role of surgical intervention.

Surgical Emergencies in the ICU.

Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.

COVID-19: An Update on the Epidemiological, Clinical, Preventive, and Therapeutic Management of 2019 Novel Coronavirus Disease.

The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) remains a serious issue for global health, given widespread infectivity and a high contagion rate. A tremendous amount of data has been generated since it was first identified in December 2019. It is vital to keep up with these data from across the world at a time of uncertainty and continuously evolving guidelines and clinical practice. This review provides an update on recent developments concerning epidemiology, clinical presentation, treatment options, and scientific advancements to combat the COVID-19 pandemic.

Surgical Interventions for COPD.

Chronic obstructive pulmonary disease (COPD) treatment is aimed at managing the disease rather than cure, with a focus on improving quality of life and decreasing exacerbations. Interventional therapies, including lung volume reduction surgery, bullectomy, lung transplantation, and bronchoscopic lung volume reduction treatment using endobronchial valves, are treatment options for patients with COPD who are symptomatic due to hyperinflation despite optimal medical management. We will review the current literature to provide a comprehensive summary of the currently available scientific data, discuss typical treatment-related side effects, and evidence-based management approach and recommendations for patient selection in clinical practice.

Systemic Complications of COVID-19.

Coronavirus disease-2019 (COVID-19) creates severe respiratory distress and often a cascade of other systemic complications impacting several organ systems. The immune response includes a cytokine storm that creates many life-threatening problems including coagulopathies, arrhythmias, and secondary infections. This article discusses the multisystem responses to the physical insults created by this corona virus.

Extracorporeal Membrane Oxygenation in ARDS.

Extracorporeal membrane oxygenation (ECMO) has become a key tool in the management of cardiac and/or respiratory failure refractory to conventional management. Although ECMO has multiple indications, it has been widely studied for the management of acute respiratory distress syndrome in adults. ECMO provides rest and support while the damaged lungs heal. It is an invasive modality with risks of serious complications; therefore, clinicians should be vigilant during patient selection. Furthermore, users should be familiar with different components of the ECMO machinery and the management of different organ systems while patients are on the circuit. ECMO is a relatively new modality that has shown good results when used in certain circumstance, and its use is becoming more popular across the United States.

A Novel Case of Cardiac Tamponade after Percutaneous Pulmonary Embolectomy Using the FlowTriever Retrieval/Aspiration System.

Introduction: Percutaneous embolectomy using the percutaneous large-bore aspiration embolectomy FlowTriever system (INARI Medical, Irvine, CA, USA) is a promising method for reducing high clot burden in patients with intermediate- to high-risk pulmonary embolism (PE). Case Description: A 45-year-old woman with intermediate- to high-risk PE underwent percutaneous intervention using the FlowTriever retrieval/aspiration system. After the procedure, she experienced several cardiac arrests from pericardial tamponade and required pericardiocentesis, leading to haemodynamic stabilization. Discussion: To our knowledge, this is the first documented case of the use of the FlowTriever system causing micro-perforation of the right ventricle, resulting in tamponade and cardiac arrest. Conclusion: Percutaneous embolectomy has shown promise results in reducing clot burden and improving haemodynamic stability but has risks and limitations and requires specialized knowledge and training. In addition, more data are required from centres using the FlowTriever system to ensure adequate training and safety. LEARNING POINTS: Percutaneous mechanical thrombectomy using the FlowTriever or similar devices can be paramount in reducing morbidity and mortality from an intermediate- to high-risk pulmonary embolism given the immediate improvement in haemodynamics that cannot be achieved by anticoagulation alone.Cardiac micro-perforation is a potential complication of catheter-based embolectomy devices such as FlowTriever and should be suspected in the setting of pericardial effusion following the procedure.

Safety and Efficacy of Tocilizumab 4 or 8 mg/kg in Hospitalized Patients With Moderate to Severe Coronavirus Disease 2019 Pneumonia: A Randomized Clinical Trial.

BACKGROUND: Tocilizumab, an interleukin 6 receptor (IL-6R) antagonist monoclonal antibody, has shown efficacy in patients with coronavirus disease 2019 (COVID-19) pneumonia, but the optimal dose is unknown. METHODS: Patients hospitalized for moderate to severe COVID-19 pneumonia were randomized 1:1 to receive standard of care treatment and 1-2 doses of intravenous tocilizumab 4 mg/kg or 8 mg/kg (open-label). Primary pharmacokinetic and pharmacodynamic end points were serum concentrations of tocilizumab and soluble interleukin 6 receptor (sIL-6R), IL-6, ferritin, and C-reactive protein (CRP), from baseline to day 60. The secondary end point was safety. Key exploratory efficacy end points included clinical status, time to discharge, mortality rate, and incidence of mechanical ventilation. RESULTS: Of 100 patients randomized, 49 received tocilizumab 4 mg/kg and 48 received 8 mg/kg. In pharmacokinetic and sIL-6R assessments, dose-dependent differences were seen in patients who received 1 or 2 doses of 4 or 8 mg/kg. Serum concentrations of IL-6, ferritin, and CRP and safety outcomes were comparable between groups. Through day 60, serious adverse events were reported in 30.6% and 25.0% of patients in the 4- and 8-mg/kg groups, respectively. Eight patients (16.3%) in the 4-mg/kg group and 6 (12.5%) in the 8-mg/kg group died. Exploratory time-to-event outcomes favored 8 mg/kg within the first 2 weeks. CONCLUSIONS: In patients with moderate to severe COVID-19 pneumonia who received tocilizumab 4 or 8 mg/kg, pharmacokinetic and sIL-6R assessments showed expected dose-dependent effects; pharmacodynamic assessments and safety were comparable, with no new safety signals. Further study is required before a lower dose of tocilizumab can be recommended in patients with COVID-19 pneumonia. CLINICAL TRIALS REGISTRATION: NCT04363736.

Vaping associated spontaneous pneumothorax - A case series of an enigmatic entity!

The use of electronic nicotine delivery devices (ENDDs) has risen to an epidemic level among high schoolers and people aged 18-34. To our knowledge there are only 7 reported cases of spontaneous pneumothorax (SP-PTX) associated with vaping, and herein we describe 4 additional cases. We propose identifying this disease process as a novel entity, Vaping-Associated Spontaneous Pneumothorax (VASP). VASP requires early interventional treatment and has a high recurrence rate, and we suggest that vaping cessation and early interventional treatment including tube thoracostomy and surgical treatment is necessary in most cases to prevent recurrences.

Possible role of COVID-19 in the relapse of Klein-Levin Syndrome.

Klein-Levin Syndrome (KLS) is an extremely rare neurological disorder which can manifest as recurring spells of sleepiness, cognitive disturbances and behavioral changes. We present a novel case of KLS relapse in the setting of Coronavirus disease-19 (COVID-19). A 36-year-old male who had a known history of KLS since adolescence was admitted with sleepiness and behavioral disturbances. Brain imaging and autoimmune encephalitis work was unremarkable. The patient was diagnosed with a relapse of KLS secondary to COVID-19 based on symptomology and lack of any other precipitating factor. The patient required 8 days of hospitalization and was treated with benzodiazepines due to a history of robust response to lorazepam during a prior episode. The patient progressively improved and was discharged home on lorazepam taper. We report that similar to other neurotropic viruses, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could be the culprit in instigating KLS relapse.

Human Granulocytic Anaplasmosis as a COVID-19 Mimicker.

INTRODUCTION: Human granulocytic anaplasmosis (HGA) is a tick-borne illness caused by the bacterium Anaplasma phagocytophilum. HGA has a widely variable clinical presentation and can be life-threatening. CASE DESCRIPTION: A 77-year-old man was transferred from an outside facility with altered mental status, a fever of up to 40.5°C, and shortness of breath. Laboratory analysis revealed a progressively worsening pro-inflammatory state and abnormalities in the patient's coagulation studies. With clinical and laboratory evidence concerning for potential COVID-19 infection, the patient was placed in isolation as a precaution. The results of two COVID-19 tests, given approximately 24 hours apart, were negative. The patient's spouse confirmed a bug bite to his upper extremity while working outdoors. His symptoms resolved completely after a 10-day course of empiric doxycycline. DISCUSSION: The diverse clinical presentations of HGA necessitate a broad differential diagnosis, including viral, bacterial and non-infectious aetiologies. In severe cases, a cytokine-mediated immune cascade can occur (namely, cytokine storm) leading to devastating downstream effects. This cytokine storm can be seen in many other diseases, but most recently it has been demonstrated in the novel coronavirus disease 2019 (COVID-19). CONCLUSION: Here we present a case of HGA in which diagnosis was delayed due to mimicry of COVID-19 infection. This case highlights the importance of taking clinical and social histories, seasonality and geography into account during diagnosis, and maintaining a broad differential with non-specific symptoms. Despite the current COVID-19 pandemic, we recommend that HGA remains in the differential diagnosis of a pro-inflammatory state with an atypical respiratory presentation. LEARNING POINTS: Human granulocytic anaplasmosis (HGA) has a widely variable clinical presentation and can be life-threatening.When presented with non-specific symptoms, it is critical to consider clinical and social histories, seasonality and geography while maintaining a broad differential.Cytokine storm can be seen in HGA and other diseases, but most recently it has been observed in the novel COVID-19. However, despite the prevalence of COVID-19, we recommend that HGA remain in the differential diagnosis of a pro-inflammatory state with an atypical respiratory presentation.

Amidst COVID-19 pandemic: the catastrophic sequelae of an inadvertent carotid artery insertion during central venous catheter placement - a case report.

Introduction: Central venous catheter (CVC) placement is one of the most commonly performed procedures in the intensive care unit for the institution of high-risk medications and nutrients. Despite the frequent use of ultrasound, inadvertent placement of CVC into the carotid artery is still possible. It carries significant morbidity due to the incidence of bleeding, arteriovenous fistula, and stroke. Methods: We present a case of accidental placement of CVC into the right carotid artery, which led to the right-sided temporoparietal stroke. Case Summary: A 71-year-old male was admitted to hospital with symptoms of cough, fatigue, and shortness of breath. He was diagnosed with coronavirus disease-19 and did require mechanical ventilation due to progressive hypoxic respiratory failure. The patient developed distributive shock and underwent CVC placement at the day of admission. On the 24th day of intubation, the patient was unable to move his left upper and lower extremities. Computed tomography (CT) head revealed showed a large temporoparietal stroke. CT Angiogram of head and neck revealed a misplaced CVC within the right common carotid artery . He was transferred to the Neuro ICU at our hospital where the patient underwent catheter removal and carotid artery sheath placement followed by dual antiplatelet therapy. Although the patient survived, he still required long-term facility placement due to the stroke. Conclusion: We reiterate that an experienced clinician must perform the CVC placement with ultrasound guidance and verify its placement with multiple confirmation techniques afterwards. Providers must manage unintentional carotid artery placement promptly to prevent long-term sequelae associated with it.

Primary Esophageal Small Cell Carcinoma Masquerading as Non-Hodgkin Lymphoma in a Young Patient.

BACKGROUND/AIM: Small cell cancer of the esophagus (SCCE) is an extremely rare entity with an aggressive clinical course, thus early diagnosis and treatment are important for improved survival. CASE REPORT: A 35-year-old male presented with dysphagia, loss of appetite and weight loss. Diagnostic workup revealed an esophageal mass, which was diagnosed as primary non-Hodgkin lymphoma (NHL) on initial biopsy. Despite receiving rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy for 3 months, there was an interval increase in the size of the esophagus mass, which unveiled underlying SCCE. A re-review of the previous biopsy specimen with immunohistochemical staining confirmed the initial diagnosis as SCCE as well. Despite 4 cycles of platinum-based chemotherapy and radiotherapy, the malignancy progressed and proved fatal. CONCLUSION: SCCE and non-Hodgkin lymphomas are rare entities, whose morphologies can be diagnostically challenging, hence they require special immunostaining for accurate diagnosis. Prompt diagnosis and initiation of treatment can confer better quality of life and survival.

IgG4 related lung disease- a rare and novel mimic of malignancy and infections-a case series of three patients with a brief review of updated literature.

IgG4-related lung disease is an extremely rare and novel entity which is still poorly understood. We reviewed the 16 patients diagnosed with IgG4-related disease from October 2014 through December 2019 at our institution. The three cases that showed pulmonary involvement are included in this series. Of these, two patients had cavitary lung disease and developed aspergilloma and chronic cavitating aspergillosis after a prolonged course of steroid therapy, and one had isolated pulmonary nodule and ground glass opacity. We reviewed the updated literature and briefly described disease epidemiology, clinical characteristics, diagnostic approaches, and management strategies for IgG4-related lung disease.

A Retrospective Analysis of Factors Affecting Palliative Care Consults in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

Purpose This study was conducted to determine factors that influence palliative care (PC) consultation in patients receiving cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). Patient and methods We queried our Electronic Medical Record EPIC for a list of patients who underwent cytoreductive surgery with HIPEC or hyperthermic intrathoracic chemotherapy (HITEC) in the hospital from April 2016-April 2019. Data was manually extracted and patients who did not meet our criteria were excluded. Patients were divided on the basis of palliative care consults and differences between the groups were analyzed. Odds ratios (OR) with p-value of 0.05 and confidence interval of (CI) 95% were calculated. Results We identified 55 patients of whom 34 met our inclusion criteria: 11 males and 23 females with an average age of 56 years at the time of diagnosis. Eight patients (23%) had PC, with six having commercial insurance, seven married, and six with more than one comorbid medical issue. Comorbidities >1 (OR: 0.12; CI: 0.02-0.76; p: 0.02) and age >40 (OR: 0.015; CI: 0.0007-0.3029; P: 0.006) were associated with a higher likelihood of PC. Gender, insurance type, and marital status did not have a significant association with PC. Mean age between PC consulted patients versus non-PC consulted patients was 58.5 vs. 55.9 and median age between the two groups was 60.5 vs. 60 which also showed a trend towards higher rates of PC in the older population. Conclusion Approximately one quarter of patients who underwent CRS with HIPEC had a concurrent PC consult. Though this is better than the national average of 11-16%, it continues to be a very small number. Efforts must be made to engage PC early in the course of treatment and recognize it as an integral part of cancer care. PC is not only an end-of-life service, in fact, studies have shown that early consultations lead to higher patient satisfaction, improved quality of life, and better communication.

Retrospective review of total neoadjuvant therapy.

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) followed by resection and postoperative multi-agent chemotherapy (maChT) is the standard of care for locally advanced rectal cancer. Using this approach, maChT administration can be delayed for several months, leading to concern for distant metastases. To counteract this, a novel treatment approach known as total neoadjuvant therapy (TNT) has gained popularity, in which patients receive both maChT and nCRT prior to resection. We utilized the National Cancer Database to examine temporal trends in TNT usage, and any potential effect on survival. AIM: To study the temporal trends in the usage of TNT and evaluate its efficacy compared to neoadjuvant chemoradiation. METHODS: We queried the National Cancer Database for patients with locally advanced rectal cancer, Stage II-III, from 2004-2015 treated with nCRT or TNT. TNT was defined as maChT initiated ≥ 90 d prior to nCRT initiation. Overall survival was calculated from the date of diagnosis to the date of last contact or death using Kaplan-Meier curves to present the cumulative probability of survival, with log-rank statistics to assess significance. Multivariable cox regression was used to identify predictors of survival and propensity score analysis accounted for bias. RESULTS: We identified 9066 eligible patients, with 8812 and 254 patients receiving neoadjuvant chemoradiation followed by maChT and TNT, respectively. Nodal involvement, stage III disease, and treatment in recent years were predictive of TNT use. There was greater use of TNT with more advanced stage, specifically > 1 node involved (odds ratio [OR] = 2.88, 95% confidence interval [CI]: 2.11-3.93, P < 0.01) and stage III disease (OR = 2.88, 95%CI: 2.11-3.93, P < 0.01). From 2010 to 2012 the use of TNT increased (OR = 2.41, 95%CI: 1.27-4.56, P < 0.01) with a greater increase from 2013 to 2015 (OR = 6.62, 95%CI: 3.57-12.25, P < 0.01). Both the TNT and neoadjuvant chemoradiation arms had a similar 5-year survival at 76% and 78% respectively. Multivariable analysis with propensity score demonstrated that increased age, high comorbidity score, higher grade, African American race, and female gender had worse overall survival. CONCLUSION: Our data demonstrates a rising trend in TNT use, particularly in patients with worse disease. Patients treated with TNT and nCRT had similar survival. Randomized trials evaluating TNT are underway.

Primary cerebellar agenesis presenting as isolated cognitive impairment.

Primary cerebellar agenesis is a rare entity. To the best of our knowledge, eleven living cases have been reported till date. Most of these were associated with some degree of motor impairment. We present a case of cerebellar agenesis in a child who presented with cognitive abnormalities leading to poor performance at school. No motor impairment was seen. Among the eleven cases reported earlier, only one case showed lack of motor impairment.

Spectrum of biliary abnormalities in portal cavernoma cholangiopathy (PCC) secondary to idiopathic extrahepatic portal vein obstruction (EHPVO)-a prospective magnetic resonance cholangiopancreaticography (MRCP) based study.

OBJECTIVE: To characterize biliary abnormalities seen in portal cavernoma cholangiopathy (PCC) on MR cholangiopancreaticography (MRCP) and elucidate certain salient features of the disease by collaborating our findings with those of previous studies. METHODS: We prospectively enrolled 52 patients with portal cavernoma secondary to idiopathic extrahepatic portal vein obstruction, who underwent a standard MRCP protocol. Images were analyzed for abnormalities involving the entire biliary tree. Terms used were those proposed by the Indian National Association for Study of the Liver. Angulation of the common bile duct (CBD) was measured in all patients with cholangiopathy. RESULTS: Cholangiopathy was seen in 80.7% of patients on MRCP. Extrahepatic ducts were involved in 95% of patients either alone (26%) or in combination with the intrahepatic ducts (69%). Isolated involvement of the intrahepatic ducts was seen in 4.8% of patients. Abnormalities of the extrahepatic ducts included angulation (90%), scalloping (76.2%), extrinsic impression/indentation (45.2%), stricture (14.3%) and smooth dilatation (4.8%). The mean CBD angle was 113.2 ± 19.8°. Abnormalities of the intrahepatic ducts included smooth dilatation (40%), irregularity (28%) and narrowing (9%). Cholelithiasis, choledocholithiasis and hepatolithiasis were seen in 28.6% (12) patients, 14.3% (6) patients and 11.9% (5) patients, respectively. There was a significant association between choledocholithiasis and CBD stricture, with no significant association between choledocholithiasis and cholelithiasis. A significant association was also seen between hepatolithiasis and choledocholithiasis. CONCLUSION: The spectrum of biliary abnormalities in PCC has been explored and some salient features of the disease have been elucidated, which allow a confident diagnosis of this entity. Advances in knowledge: PCC preferentially involves the extrahepatic biliary tree. Changes in the intrahepatic ducts generally occur as sequelae of involvement of the extrahepatic ducts, although isolated involvement of the intrahepatic ducts does occur. Increased angulation of the CBD and scalloping are most commonly seen. Angulation may predispose to choledocholithiasis and thus development of symptomatic cholangiopathy. Choledocholithiasis and hepatolithiasis occur as sequelae of PCC.