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1.
Oper Neurosurg (Hagerstown) ; 20(2): 174-182, 2021 01 13.
Article in English | MEDLINE | ID: covidwho-1455340

ABSTRACT

BACKGROUND: Carotid-cavernous fistulas (CCFs) are acquired pathological shunting lesions between the carotid artery and the cavernous sinus leading to elevated intraocular pressure (IOP). CCFs are commonly treated via endovascular embolization, which theoretically restores physiological pressure differentials. OBJECTIVE: To present our institutional data with CCF treated with embolization and discuss endovascular routes, recurrence rates, and dynamic IOP changes. METHODS: Retrospective analysis of 42 CCF patients who underwent Onyx (Covidien, Irvine, California) embolization and pre- and postoperative IOP measurement at a single institution. RESULTS: CCFs were 19.0% direct (type A) and 81.0% indirect (types B, C, or D). Onyx-18 liquid embolisate was used during all embolizations. Overall rate of total occlusion was 83.3% and was statistically similar between direct and indirect fistulas. Preoperative IOP was elevated in 37.5%, 100.0%, 75.0%, and 50% in type A, B, C, and D fistulas, respectively. Average ΔIOP was -7.3 ± 8.5 mmHg (range: -33 to +8). Follow-up time was 4.64 ± 7.62 mo. Full angiographic occlusion was a predictor of symptom resolution at 1 mo (P = .026) and 6 mo (P = .021). Partial occlusion was associated with persistent symptoms postoperatively at 1 mo (P = .038) and 6 mo follow-up (P = .012). Beyond 6 mo, negative ΔIOP was associated with continued symptom improvement. Recurrence occurred in 9.5% of patients, all of which were indirect CCFs. CONCLUSION: Onyx embolization of CCF is an effective treatment for CCF and often results in the reversal of IOP elevation. Full occlusion predicts favorable clinical outcomes up to 6 mo. Postoperative IOP reduction may indicate favorable long-term clinical outcomes.


Subject(s)
Carotid-Cavernous Sinus Fistula , Cavernous Sinus , Embolization, Therapeutic , Carotid-Cavernous Sinus Fistula/diagnostic imaging , Carotid-Cavernous Sinus Fistula/therapy , Humans , Intraocular Pressure , Retrospective Studies
3.
Open Access Emerg Med ; 13: 207-211, 2021.
Article in English | MEDLINE | ID: covidwho-1256176

ABSTRACT

BACKGROUND: Anticoagulant therapy for patients with severe coronavirus disease (COVID-19) pneumonia is considered to improve the hypercoagulable and inflammatory state. However, bleeding complications should also be considered. CASE PRESENTATION: A 77-year-old man with a history of falls was diagnosed with COVID-19. Owing to his severe condition, he was intubated and transferred to our hospital for intensive care. Favipiravir, tocilizumab, unfractionated heparin, and ART-123 were administered to treat COVID-19 and manage the antithrombotic prophylaxis for paroxysmal atrial fibrillation (Af). On the 6th day after admission, a hematoma was noted on the left chest wall. Computed tomography (CT) revealed multiple hematomas, including hematomas on his chest wall and obturatorius internus muscle. Emergency angiography transcatheter embolization (TAE) was performed. The patient was transferred to another hospital 23 days after TAE, without complications. CONCLUSION: Our findings show that anticoagulation therapy and a history of falls induced multiple hematomas in a COVID-19 patient and that the condition was managed with TAE. When anticoagulants are considered in the management of Af and COVID-19 associated coagulopathy, it is necessary to closely monitor potential bleeding complications.

4.
Radiol Case Rep ; 16(7): 1777-1779, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1213488

ABSTRACT

The coronavirus disease 2019 (COVID-19) is characterized by viral pneumonia with mild to moderate symptoms. Emerging studies suggest that some patients may experience uncommon complications, such as thrombotic or hemorrhagic episodes. Here we present a 59-year-old male patient who had a hemorrhage episode from a branch of the pulmonary arteries and was treated by interventional embolization. Our case report demonstrates the importance of early diagnosis of hemorrhagic complications of COVID-19 and the possible benefits of early vascular intervention.

5.
Surg Neurol Int ; 12: 188, 2021.
Article in English | MEDLINE | ID: covidwho-1210044

ABSTRACT

BACKGROUND: Brain abscess usually occurs secondary to trauma, through contiguous spread (e.g.; dental infections, [paranasal] sinusitis, otitis, and mastoiditis), after intracranial neurosurgical procedures, or through hematogenous spread in case of an arteriovenous (AV) shunt, for example; atrial septum defect. Although uncommon, another possible cause of AV shunt which can facilitate brain abscess is a pulmonary arteriovenous malformation (PAVM). We report a case of brain abscess secondary to a solitary PAVM and review the literature. CASE DESCRIPTION: A 74-year-old male patient presented with headaches, fatigue, low-grade fever, and homonymous hemianopsia. He was diagnosed with a brain abscess in the left occipital lobe. A chest computed tomography (CT) with intravenous (IV) contrast was performed because of fever and respiratory insufficiency in a period where screening for COVID-19 in suspected patients was important. A solitary PAVM of the left lung was diagnosed. Initial stereotactic burr hole drainage of the abscess was insufficient and resection of the abscess was deemed necessary. Routine workup did not reveal any additional pathology apart from the PAVM. After treatment of the cerebral abscess, the PAVM was treated with embolization using an endovascular plug. CONCLUSION: It is recommended to screen for PAVM by chest CT with IV contrast in patients with brain abscess when no obvious source of infection can be identified.

6.
Eur J Radiol Open ; 8: 100346, 2021.
Article in English | MEDLINE | ID: covidwho-1188522

ABSTRACT

Pulmonary artery pseudoaneurysms are uncommon and can cause severe, life-threatening haemoptysis. We present a case of a 74-year-old gentleman who was being treated for COVID-19 pneumonitis and a concomitant segmental pulmonary artery thrombus with conventional treatment and anticoagulation. The patient developed significant haemoptysis during admission. A repeat computed tomography pulmonary angiogram revealed an 8 mm left upper lobe pulmonary artery pseudoaneurysm. Anticoagulation was withheld and the pseudoaneurysm was successfully treated with endovascular embolisation with an Amplatzer® IV plug, leading to resolution of the haemoptysis. To our knowledge this is the first case of a pulmonary artery pseudoaneurysm secondary to COVID-19.

7.
Am J Emerg Med ; 47: 316.e1-316.e3, 2021 Sep.
Article in English | MEDLINE | ID: covidwho-1141562

ABSTRACT

While primarily a respiratory illness, infection with the novel coronavirus (COVID-19) is associated with pathologic changes in coagulation, characterized by both thromboembolic and bleeding events. We present the case of a 22-year-old female diagnosed with renal angiomyolipoma (AML) rupture 2 weeks after COVID-19 infection, ultimately requiring admission for hemorrhage control via endovascular embolization. Emergency medicine physicians should maintain a high index of suspicion for renal AML rupture and other spontaneous bleeding events in patients with recent COVID-19 infection due to a possible correlation between the two.


Subject(s)
Angiomyolipoma/complications , COVID-19/complications , Hemorrhage/etiology , Kidney Neoplasms/complications , Angiomyolipoma/diagnostic imaging , Angiomyolipoma/therapy , Embolization, Therapeutic/methods , Female , Hemorrhage/diagnostic imaging , Hemorrhage/therapy , Humans , Kidney Neoplasms/diagnostic imaging , Kidney Neoplasms/therapy , Rupture , SARS-CoV-2 , Young Adult
8.
Eur Heart J Case Rep ; 5(2): ytaa525, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-1069251

ABSTRACT

BACKGROUND: COVID-19 (severe acute respiratory syndrome coronavirus 2) infected patients have increased risk for thrombotic events, which initially may have been under recognized. The existence of cardiovascular emboli can be directly life threatening when obstructing the blood flow to vital organs such as the brain or other parts of the body. The exact mechanism for this hypercoagulable state in COVID-19 patients yet remains to be elucidated. CASE SUMMARY: A 72-year-old man critically ill with COVID-19 was diagnosed with a free-floating and mural thrombus in the thoracic aorta. Subsequent distal embolization to the limbs led to ischaemia and necrosis of the right foot. Treatment with heparin and anticoagulants reduced thrombus load in the ascending and thoracic aorta. DISCUSSION: One-third of COVID-19 patients show major thrombotic events, mostly pulmonary emboli. The endothelial expression of angiotensin-converting enzyme-2 receptors makes it feasible that in patients with viraemia direct viral-toxicity to the endothelium of also the large arteries results in local thrombus formation. Up to date, prophylactic anticoagulants are recommended in all patients that are hospitalized with COVID-19 infections to prevent venous and arterial thrombotic complications.

10.
J Stroke Cerebrovasc Dis ; 30(3): 105542, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-965527

ABSTRACT

OBJECTIVE: To report six consecutive patients with confirmed coronavirus disease-2019 (COVID-19) who underwent Transcranial Doppler (TCD) ultrasonography evaluation for cerebral microemboli in the setting of suspected or confirmed acute ischemic stroke. METHODS: Patient data were obtained from medical records from Northwestern Memorial Hospital, Chicago, IL between May and June 2020. All patients with confirmed COVID-19 who underwent clinical TCD ultrasonography for microemboli detection were included. RESULTS: A total of eight TCD studies were performed in six patients with COVID-19 (4 men and 2 women, median age 65±5), four with confirmed ischemic stroke and two with refractory encephalopathy. Microemboli were detected in three male patients, two patients had suffered a confirmed ischemic stroke and one who developed prolonged encephalopathy. Microemboli of varying intensity were identified in multiple vascular territories in two patients, and microemboli persisted despite therapeutic anticoagulation in a third patient. Of the three patients without evidence of microemboli on TCD ultrasonography, two patients had suffered a confirmed ischemic stroke, while one remained with refractory encephalopathy. CONCLUSIONS: TCD ultrasonography for microemboli detection identified three patients with confirmed COVID-19 with evidence of cerebral arterial microemboli, including one who was therapeutically anticoagulated. TCD ultrasonography provides a non-invasive method for evaluating cerebral microemboli in patients with COVID-19 and may be useful in assessing response to treatment in cases with suspected or confirmed disorders of hypercoagulability. Further studies investigating the prevalence of cerebral microemboli and associated risk factors are needed to characterize their pathogenic mechanism and guide therapeutic interventions in hospitalized COVID-19 patients.


Subject(s)
COVID-19/complications , Intracranial Embolism/diagnostic imaging , Intracranial Embolism/etiology , Aged , Anticoagulants/therapeutic use , Brain Diseases/diagnostic imaging , Brain Diseases/etiology , Cerebral Angiography , Diabetes Mellitus, Type 2/complications , Female , Humans , Infarction, Middle Cerebral Artery/etiology , Infarction, Middle Cerebral Artery/therapy , Intracranial Embolism/therapy , Ischemic Stroke/diagnostic imaging , Ischemic Stroke/etiology , Ischemic Stroke/therapy , Kidney Failure, Chronic/complications , Male , Middle Aged , Thrombectomy , Ultrasonography, Doppler, Transcranial
11.
J Neurointerv Surg ; 13(2): e1, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-883391

ABSTRACT

This is a report of the first three cases of endovascular aneurysm treatment that were proctored by a remote interventionalist using a novel high-resolution low-latency streaming technology. The proctor was located in a neurovascular centre and supported the treating interventional teams in two distant cities (up to 800 km/500 miles apart). All aneurysms were treated using the Woven EndoBridge (WEB) embolisation system, either electively or following subarachnoid haemorrhage. On-site proctoring was not possible due to travel restrictions during the COVID-19 pandemic. WEB placement was feasible in all cases. Good rapport between proctors and treating physicians was reported, enabled by the high-resolution image transmission and uninterrupted feedback/discussion via audiostream. No clinical complications were encountered. Short-term follow-up revealed adequate occlusion of all treated aneurysms. The employed streaming technology provided effective remote proctoring during complex aneurysm cases, including the management of technical complications.


Subject(s)
COVID-19 , Endovascular Procedures/methods , Intracranial Aneurysm/surgery , Neurosurgical Procedures/methods , Pandemics , Telemedicine/methods , Blood Vessel Prosthesis Implantation , Communication , Embolization, Therapeutic , Feedback , Humans , Treatment Outcome , Videoconferencing
12.
BMJ Case Rep ; 13(10)2020 Oct 04.
Article in English | MEDLINE | ID: covidwho-814252

ABSTRACT

This is a report of the first three cases of endovascular aneurysm treatment that were proctored by a remote interventionalist using a novel high-resolution low-latency streaming technology. The proctor was located in a neurovascular centre and supported the treating interventional teams in two distant cities (up to 800 km/500 miles apart). All aneurysms were treated using the Woven EndoBridge (WEB) embolisation system, either electively or following subarachnoid haemorrhage. On-site proctoring was not possible due to travel restrictions during the COVID-19 pandemic. WEB placement was feasible in all cases. Good rapport between proctors and treating physicians was reported, enabled by the high-resolution image transmission and uninterrupted feedback/discussion via audiostream. No clinical complications were encountered. Short-term follow-up revealed adequate occlusion of all treated aneurysms. The employed streaming technology provided effective remote proctoring during complex aneurysm cases, including the management of technical complications.


Subject(s)
Betacoronavirus , Coronavirus Infections/prevention & control , Endovascular Procedures/methods , Intracranial Aneurysm/therapy , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Telemedicine/methods , Angiography, Digital Subtraction/methods , COVID-19 , Humans , Intracranial Aneurysm/diagnostic imaging , SARS-CoV-2
13.
CVIR Endovasc ; 3(1): 61, 2020 Sep 05.
Article in English | MEDLINE | ID: covidwho-745027

ABSTRACT

BACKGROUND: We found no data in the literature on the embolization of the bronchial arteries in the context of hemoptysis associated with severe acute respiratory syndrome coronavirus 2. We therefore decided to share this experience. CASE PRESENTATION: A 62-year-old patient with no significant medical history was admitted with acute respiratory distress. Chest computed tomography showed diffuse bilateral ground-glass opacities with limited consolidations. Diagnostic tests confirmed severe acute respiratory syndrome coronavirus 2 infection. The severity of respiratory failure required the implantation of veno-venous extracorporeal membrane oxygenation. The patient developed severe haemoptysis, which was successfully treated by bronchial artery embolisation. CONCLUSIONS: In the case of coronavirus-19 pneumonia, our experience suggests that the treatment of severe haemoptysis by bronchial artery embolisation is feasible and effective. The survival benefit should be assessed in the future.

14.
Thromb Res ; 196: 206-208, 2020 12.
Article in English | MEDLINE | ID: covidwho-738764

ABSTRACT

There is increasing evidence that Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection causes an unusual pneumonia and a pro-coagulant state that significantly increases the risk of arterial and venous thromboembolism. We hypothesize that, in select patients, some complications of COVID-19 may be due to right-to-left (RTL) shunt. Shunt may be intra-pulmonary, or extra-pulmonary, and can cause paradoxical embolization, hypoxia and platypnoea orthodeoxia. Saline microbubble contrast echocardiography is a minimally invasive, inexpensive, bedside test that can detect, quantify, and define the anatomical substrate of intra-pulmonary and intra-cardiac shunts. The prevalence of patent foramen ovale (PFO) in the general population is high (20-30%) but is even higher in patients who have a stroke (50%). Thus, the striking absence of data on patients with PFO who develop COVID-19 suggests that this is being under-diagnosed. This may be because physicians and sonographers currently feel that screening for shunt is unnecessary. This could be an unintended consequence of guidance from several specialist societies to defer procedures to close PFO until after the pandemic. This may be counterproductive. Patients with shunt may be at particularly high risk of complications from COVID-19 and interventions to minimise RTL shunt could prevent paradoxical embolization and improve hypoxia in select high risk patients with COVID-19.


Subject(s)
COVID-19 , Foramen Ovale, Patent , Thrombosis , Foramen Ovale, Patent/complications , Humans , Pandemics , Patients , SARS-CoV-2
15.
Catheter Cardiovasc Interv ; 97(3): E319-E326, 2021 Feb 15.
Article in English | MEDLINE | ID: covidwho-644776

ABSTRACT

OBJECTIVES: To assess changes in characteristics and management among ST-elevation myocardial infarction (STEMI) patients with coronavirus disease (COVID-19) who underwent primary percutaneous coronary intervention. METHODS: Our prospective, monocentric study enrolled all STEMI patients who underwent PPCI during the COVID-19 outbreak (n = 83). This cohort was first compared with a previous cohort of STEMI patients (2008-2017, n = 1,552 patients) and was then dichotomized into a non-COVID-19 group (n = 72) and COVID-19 group (n = 11). RESULTS: In comparison with the pre-outbreak period, patients during the outbreak period were older (59.6 ± 12.9 vs. 62.6 ± 12.2, p = .03) with a delayed seek to care (mean delay first symptoms-balloon 3.8 ± 3 vs. .7.4 ± 7.7, p < .001) resulting in a two-fold higher in-hospital mortality (non COVID-19 4.3% vs. COVID-19 8.4%, p = .07). Among the 83 STEMI patients admitted during the outbreak period, 11 patients were infected by COVID-19. Higher biological markers of inflammation (C-reactive protein: 28 ± 39 vs. 98 ± 97 mg/L, p = .04), of fibrinolysis (D-dimer: 804 ± 1,500 vs. 3,128 ± 2,458 µg/L, p = .02), and antiphospholipid antibodies in four cases were observed in the COVID-19 group. In this group, angiographic data also differed: a thrombotic myocardial infarction nonatherosclerotic coronary occlusion (MINOCA) was observed in 11 cases (1.4% vs. 54.5%, p < .001) and associated with higher post-procedure distal embolization (30.6% vs. 72.7%, p = .007). The in hospital mortality was significantly higher in the COVID-19 group (5.6% vs. 27.3%, p = .016). CONCLUSION: The COVID-19 outbreak implies deep changes in the etiopathogenesis and therapeutic management of STEMI patients with COVID-19. The impact on early and long-term outcomes of systemic inflammation and hypercoagulability in this specific population is warranted.


Subject(s)
COVID-19/complications , ST Elevation Myocardial Infarction/therapy , ST Elevation Myocardial Infarction/virology , Aged , Aged, 80 and over , COVID-19/mortality , COVID-19/therapy , Cohort Studies , Female , France , Hospital Mortality , Hospitalization , Humans , Male , Middle Aged , Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction/mortality , Treatment Outcome
16.
J Clin Med Res ; 12(7): 458-461, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-643250

ABSTRACT

Respiratory failure is presumptively caused by microvascular thrombosis in some patients with coronavirus disease 2019 (COVID-19) requiring therapeutic anticoagulation. Anticoagulation treatment may cause life-threatening bleeding complications such as retroperitoneal hemorrhage. To the best of our knowledge, we report first case of a COVID-19 patient treated with therapeutic anticoagulation resulting in psoas hematoma due to lumbar artery bleeding. A 69-year-old patient presented with fever, malaise and progressive shortness of breath to our hospital. He was diagnosed with COVID-19 by RT-PCR. Due to an abnormal coagulation profile, the patient was started on enoxaparin. Over the course of hospitalization, the patient was found to have hypotension with worsening hemoglobin levels. Computed tomography scan of the abdomen and pelvis revealed a large psoas hematoma. Arteriogram revealed lumbar artery bleeding which was treated with embolization. Anticoagulation therapy, while indicated in COVID-19 patients, has its own challenges and guidelines describing dosages and indications in this disease are lacking. Rare bleeding complications such as psoas hematoma should be kept in mind in patients who become hemodynamically unstable, warranting prompt imaging for diagnosis and treatment with arterial embolization, thus eliminating need of surgical intervention.

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