Tailoring fenestrated aneurysm clips intraoperatively: Instant solution for a difficult problem.

The anterior communicating artery (AcoA) aneurysms represent the most complex aneurysms of the anterior circulation. For years, surgical challenges including the intricate anatomy and narrow surgical corridor have been overcome using supplementary techniques including extended craniotomies, wide opening of the cisterns, gyrus rectus resection and special clips like fenestrated clips. However, imaginative solutions such as intraoperative clip modification may be inevitable in particular cases for safe clipping. We retrospectively analyzed clinical records of two patients who required clip modification intraoperatively. Case #1 underwent microsurgical clipping of a ruptured, 4-mm AcoA aneurysm. Unfortunately, given the short distance between the two A2s, it was not possible to clip the aneurysm without a compromise to the contralateral A2 with the available shortest 3mm-fenestrated clip. We then used the clip modification technique intraoperatively by shortening the clip tips with mesh-plaque cutter and smoothening the remaining sharp ends using cautery sanding. Eventually, the aneurysm was clipped successfully with the modified-fenestrated clip. Post-clipping imagings confirmed complete occlusion of the aneurysm and patency of parent arteries. Case 2# underwent microsurgical clipping for a ruptured, 1-mm AcoA aneurysm. Like Case 1#, the initial clipping attempt with the available shortest 4mm-fenestrated clip failed given the excessive length of the tips. The patient, thus, required clip modification as described above. The aneurysm was then clipped successfully using the modified-fenestrated clip, protecting bilateral A2s. Post-clipping imagings demonstrated patency of parent arteries with no residual aneurysm filling. Clip modification seems to be an effective option in clipping the AcoA aneurysms when available clips are too long to secure them safely.

Unusual neonatal case of superior mesenteric artery syndrome with Meckel's diverticulum and literature review.

Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction which is characterized by compression of the duodenum due to narrowing of the space between the superior mesenteric artery and aorta. Incomplete duodenal obstruction due to SMAS in neonates is rarely reported in the literature. In this case, it is a full-term 2-day-old male with the complaint of recurrent vomiting starting soon after birth. The patient was diagnosed with SMAS and duodenoduodenostomy was performed. Accompanying Meckel's diverticulum was excised.

El síndrome de la arteria mesentérica superior (SMAS) es una causa rara de obstrucción duodenal que se caracteriza por la compresión del duodeno debido al estrechamiento del espacio entre la arteria mesentérica superior y la aorta. La obstrucción duodenal incompleta por SMAS en recién nacidos rara vez se informa en la literatura. En este caso se trata de un varón de 2 días nacido a término que presenta vómitos recurrentes desde poco después del nacimiento. El paciente fue diagnosticado de SMAS y se le realizó duodenoduodenostomía. Se extirpó el divertículo de Meckel que lo acompañaba.

Hemorrhagic shock secondary to ruptured hypogastric artery pseudoaneurysm. A rare complication of colorectal anastomotic leakage.

Massive bleeding due to rupture of hypogastric artery pseudoaneurysm is an exceptional complication of colorectal anastomotic leakage. A 41-year-old woman with history of rectal cancer surgery, who debuted with massive rectorrhagia and hypovolemic shock due to rupture of a hypogastric artery pseudoaneurysm as a late complication of a colorectal anastomosis leak. The ruptured hypogastric artery pseudoaneurysm should be taken into account in the differential diagnosis of patients with massive rectorrhagia and history of colorectal anastomosis leak. Endovascular embolization is considered the first-line treatment.

La hemorragia masiva por rotura de un pseudoaneurisma de la arteria hipogástrica es una complicación muy rara de la fuga anastomótica colorrectal. Mujer de 41 años con antecedentes de cirugía por cáncer de recto, que debutó con un cuadro de rectorragias masivo y shock hipovolémico secundario a la rotura de un pseudoaneurisma de la arteria hipogástrica como complicación tardía de una fuga de la anastomosis colorrectal. La rotura de un pseudoaneurisma de la arteria hipogástrica se debe tener presente en el diagnostico diferencial de pacientes con rectorragia masiva y antecedentes de dehiscencia de anastomosis colorrectal. La embolización endovascular es actualmente el tratamiento de elección.

Factors affecting resolution of oculomotor nerve palsy following endovascular embolization of posterior communicating artery aneurysms / Factores que influyen en el tratamiento de la parálisis oculomotora con embolización endovascular de aneurismas comunicantes posteriores

Purpose: To investigate the effect of endovascular embolization of posterior communicating artery (Pcom) aneurysms on concomitant oculomotor nerve palsy (OMNP) and factors affecting the effect of treatment. Materials and methods: Patients with the Pcom aneurysms concomitant with OMNP were retrospectively enrolled for endovascular treatment of the aneurysms. All patients had the endovascular management. The clinical effect, degree of OMNP, size of the aneurysm, type of treatment, subarachnoid hemorrhage (SAH), and time from onset to treatment were analyzed on the resolution of OMNP. Results: Ninety-six patients with 99 Pcom aneurysms were enrolled and treated endovascularly, with the success rate of 100%. Immediately after endovascular treatment, 75 aneurysms (75.75%) got complete occlusion, and 24 (24.24%) nearly complete occlusion. Followed up for 3–18 (mean 8.52 ± 0.56) months, complete resolution of the OMNP was achieved in 63 patients (65.63%), partial resolution in 21 (21.88%), and non-recovery in the other 12 (12.50%). The degree of OMNP at onset, SAH, and time from onset to treatment were significantly (P < 0.05) correlated with the resolution of OMNP. Univariate analysis revealed that younger age of the patient, degree of OMNP at onset, presence of subarachnoid hemorrhage, and time from disease onset to treatment were significantly (P < 0.05) associated with the recovery of OMNP. Multivariate analysis revealed that the younger age, degree of OMNP at onset, and time from disease onset to treatment were significantly (P < 0.05) associated with the recovery of OMNP. Conclusion: Endovascular embolization of Pcom aneurysms concomitant with OMNP can effectively improve the OMNP symptoms, especially for patients with moderate and a shorter history of OMNP. Younger age, degree of oculomotor nerve palsy at onset, and time from onset to treatment may significantly affect recovery of oculomotor nerve palsy.(AU)

Objetivo: Investigar la eficacia de la embolización intravascular del aneurisma de comunicación posterior (Pcom) en pacientes con parálisis oculomotora (OMNP) y los factores que influyen en la eficacia. Materiales y métodos: Se analizaron retrospectivamente los datos clínicos de la terapia intravascular en pacientes con aneurismas Pcom con OMNP. Todos los pacientes recibieron tratamiento intravascular. Se analizaron los efectos de la eficacia clínica, el grado de OMNP, el tamaño del aneurisma, el método de tratamiento, la hemorragia subaracnoidea y el tiempo desde el inicio hasta el tratamiento en la regresión de OMNP.Resultados: Un total de 96 pacientes con 99 aneurismas Pcom fueron tratados con éxito. Inmediatamente después del tratamiento intravascular, 75 casos (75,75%) de aneurismas fueron completamente ocluidos y 24 casos (24,24%) casi completamente ocluidos. Durante el seguimiento de 3 a 18 meses (promedio: 8,52 ± 0,56 meses), se logró la resolución completa en 63 casos (65,63%), la resolución parcial en 21 (21,88%) y la no recuperación en los otros 12 (12,50%). El grado de OMNP al inicio, la hemorragia subaracnoidea y el tiempo de inicio a tratamiento se correlacionaron significativamente con la resolución de la OMNP (p < 0,05). El análisis univariado mostró que la menor edad del paciente, el grado de OMNP, la presencia de hemorragia subaracnoidea y el tiempo transcurrido desde el inicio de la enfermedad hasta el tratamiento se correlacionaron significativamente con la recuperación de OMNP (p < 0,05). Conclusión: La embolización intravascular del aneurisma Pcom combinada con OMNP puede mejorar eficazmente los síntomas de OMNP, especialmente en pacientes con OMNP a corto y mediano plazo. La edad temprana, el grado de parálisis del nervio oculomotor al inicio y el tiempo desde el inicio hasta el tratamiento tuvieron un efecto significativo en la recuperación de la parálisis del nervio oculomotor.(AU)

Un caso inusual de oclusión de rama arterial retiniana: posible variante del síndrome de Sneddon / Unusual case of retinal arterial branch occlusion: Possible variant of Sneddon syndrome

El síndrome de Sneddon (SS) se manifiesta por múltiples accidentes cerebrovasculares y livedo reticularis. La vasculopatía livedoide (VL) se caracteriza por una larga historia de ulceración de pies y piernas y una histopatología que indica un proceso trombótico. Se describe una oclusión de rama arterial retiniana en un varón de 52años con VL. No presentó anomalías de laboratorio perceptibles, como anticuerpos antifosfolípidos, ni antecedentes de accidentes cerebrovasculares. La oclusión de arteria retiniana acompañada de VL podría ser una variante del síndrome de Sneddon. Con angiografía por tomografía de coherencia óptica se observó en la mácula en el ojo asintomático una reducción de las capas vasculares, lo que indica cambios microvasculares localizados como marcador evolutivo en la patogénesis del SS.(AU)

Sneddon's syndrome (SS) manifests through multiple strokes and livedo reticularis. Livedoid vasculopathy (LV) is characterized by a long history of foot and leg ulceration and histopathology indicating a thrombotic process. Arterial retinal branch occlusion is described in a 52-year-old male with LV. He did not present noticeable laboratory abnormalities, such as antiphospholipid antibodies, or a history of strokes. Retinal artery occlusion accompanied by LV could be a variant of Sneddon's syndrome. Optical coherence tomography angiography revealed a reduction in the macula's vascular layers in the asymptomatic eye, indicating localized microvascular changes as an evolving marker in the pathogenesis of SS.(AU)

Factors affecting resolution of oculomotor nerve palsy following endovascular embolization of posterior communicating artery aneurysms.

PURPOSE: To investigate the effect of endovascular embolization of posterior communicating artery (Pcom) aneurysms on concomitant oculomotor nerve palsy (OMNP) and factors affecting the effect of treatment. MATERIALS AND METHODS: Patients with the Pcom aneurysms concomitant with OMNP were retrospectively enrolled for endovascular treatment of the aneurysms. All patients had the endovascular management. The clinical effect, degree of OMNP, size of the aneurysm, type of treatment, subarachnoid hemorrhage (SAH), and time from onset to treatment were analyzed on the resolution of OMNP. RESULTS: Ninety-six patients with 99 Pcom aneurysms were enrolled and treated endovascularly, with the success rate of 100%. Immediately after endovascular treatment, 75 aneurysms (75.75%) got complete occlusion, and 24 (24.24%) nearly complete occlusion. Followed up for 3-18 (mean 8.52±0.56) months, complete resolution of the OMNP was achieved in 63 patients (65.63%), partial resolution in 21 (21.88%), and non-recovery in the other 12 (12.50%). The degree of OMNP at onset, SAH, and time from onset to treatment were significantly (P<0.05) correlated with the resolution of OMNP. Univariate analysis revealed that younger age of the patient, degree of OMNP at onset, presence of subarachnoid hemorrhage, and time from disease onset to treatment were significantly (P<0.05) associated with the recovery of OMNP. Multivariate analysis revealed that the younger age, degree of OMNP at onset, and time from disease onset to treatment were significantly (P<0.05) associated with the recovery of OMNP. CONCLUSION: Endovascular embolization of Pcom aneurysms concomitant with OMNP can effectively improve the OMNP symptoms, especially for patients with moderate and a shorter history of OMNP. Younger age, degree of oculomotor nerve palsy at onset, and time from onset to treatment may significantly affect recovery of oculomotor nerve palsy.

Internal carotid artery bulb width: a novel potential parameter for the prediction of cerebral vascular diseases.

OBJECTIVE: To investigate the relationship between the width of the internal carotid artery (ICA) bulb and cerebral vascular diseases including stroke and intracranial aneurysms. MATERIAL AND METHODS: In total 300 patients who had supra-aortic computed tomography angiography (CTA) were enrolled in this study from 2015 to 2021. The study groups consisted of 100 ischemic stroke patients, 100 patients with intracranial aneurysms, and 100 control subjects. The intracranial aneurysm patient group was divided into two subgroups according to the presence of subarachnoid hemorrhage (SAH). The largest diameters of the ICA C1 (cervical) and C2 (petrous) segments in all individuals were measured bilaterally on CTA images. The ICA diameter ratios of the cases were measured using the formula C1-C2C1. The relationship between the age and ICA vessel analysis was evaluated as well. RESULTS: The mean ICA bulb width values in the ischemic stroke patient group and the intracranial aneurysm patient group were significantly higher than the control group (p < 0.001). The ICA C1 and C2 segment diameter values and ICA diameter ratio were smaller in the intracranial aneurysm patients with SAH than those who had not (p = 0.7). There was a statistically significant but weak relationship between the age and ICA diameter ratios in all study groups (R-squared value of 0.26, p = 0.03). CONCLUSION: ICA bulb width is a parameter that can be easily evaluated with neuroimaging modalities and is a successful method that may be used for predicting the risk of ischemic stroke or the presence of an intracranial aneurysm.

Comparison of Vertebral Artery Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography in the Diagnosis of Vertebral Artery Stenosis in Patients with Posterior Circulation Ischemia

SUMMARY: The aim of this study was to compare the clinical value of vertebral artery ultrasound (VAU), Magnetic Resonance Angiography (MRA) and Digital Subtraction Angiography (DSA) on vertebral artery stenosis in patients with posterior circulation ischemia. Seventy-three patients with posterior circulation ischemia underwent vertebral artery ultrasound and magnetic resonance angiography as well as digital subtraction angiography, and the diagnosis of vertebral artery stenosis (VAS) and the degree of stenosis (normal, mild stenosis, moderate stenosis, severe stenosis, and occlusion) were recorded and compared between digital subtraction angiogram and vertebral artery ultrasound and magnetic resonance angiography. The vertebral artery stenosis rates on digital subtraction angiography and vertebral artery ultrasound were 87.30 % (55/63) and 49.20 % (31/63), respectively, and the difference was statistically significant. The rates of vertebral artery stenosis on digital subtraction angiography and, magnetic resonance angiography was 90.38 % (47/52) and 88.46 % (46/ 52), respectively, and the differences was not statistically significant. The sensitivity, accuracy, negative predictive value, and positive predictive value of vertebral artery ultrasound in diagnosing vertebral artery stenosis were 51.35 %, 54.76 %, 18.18 %, and 95.00 %, respectively, lower than those of magnetic resonance angiography, which were 91.89 %, 90.48 %, 57.14 %, and 97.14 %, respectively. Of the noninvasive imaging techniques, vertebral artery ultrasound does not accurately characterize vertebral artery stenosis and its degree of stenosis. Magnetic resonance angiography effectively screens for vertebral artery stenosis and its degree of stenosis, and can be used as a reliable tool for vertebral artery stenosis in posterior circulation cerebral infarction, and can be used in conjunction with digital subtraction angiogram in order to improve diagnostic convenience and accuracy.

El objetivo de este estudio fue comparar el valor clínico de la ecografía de la arteria vertebral (VAU), la angiografía por resonancia magnética (ARM) y la angiografía por sustracción digital (DSA) en la estenosis de la arteria vertebral en pacientes con isquemia de la circulación posterior. A 73 pacientes con isquemia de la circulación posterior se les realizó una ecografía de la arteria vertebral y una angiografía por resonancia magnética, así como una angiografía por sustracción digital, y se les diagnosticó estenosis de la arteria vertebral (EVA) y el grado de estenosis (normal, estenosis leve, estenosis moderada, estenosis grave, y oclusión) se registraron y compararon la angiografía por sustracción digital y la ecografía de la arteria vertebral y la angiografía por resonancia magnética. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la ecografía de la arteria vertebral fueron del 87,30 % (55/63) y del 49,20 % (31/63), respectivamente, y la diferencia fue estadísticamente significativa. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la angiografía por resonancia magnética fueron del 90,38 % (47/52) y del 88,46 % (46/52), respectivamente, y las diferencias no fueron estadísticamente significativas. La sensibilidad, precisión, valor predictivo negativo y valor predictivo positivo de la ecografía de la arteria vertebral en el diagnóstico de estenosis de la arteria vertebral fueron 51,35 %, 54,76 %, 18,18 % y 95,00 %, respectivamente, inferiores a los de la angiografía por resonancia magnética, que fueron 91,89 %, 90,48 %, 57,14 % y 97,14 %, respectivamente. De las técnicas de imagen no invasivas, la ecografía de la arteria vertebral no caracteriza con precisión la estenosis de la arteria vertebral y su grado de estenosis. La angiografía por resonancia magnética detecta eficazmente la estenosis de la arteria vertebral y su grado de estenosis, y puede usarse como una herramienta confiable para la estenosis de la arteria vertebral en el infarto cerebral de circulación posterior, y puede ser utilizada junto con la angiografía por sustracción digital para mejorar el diagnóstico y la exactitud.

Anesthetic management of pulmonary artery banding in adult patient with single ventricle and uncorrected transposition of the great arteries.

Pulmonary artery banding (PAB) is a procedure mainly performed during the neonatal period as an initial stage to definitive palliative reconstruction, a scenario in which the criteria for banding adjustment are well defined. However, the indication for BAP in the adult is extraordinarily rare, even more in patients with single ventricle and unrepaired transposition of the great arteries (TGA), and there are no established criteria for banding adjustment. Due to the small number of these procedures, there is limited experience in their anesthetic management and complications. We describe a case of a 29-year-old patient diagnosed with a cyanotic congenital heart disease of double-inlet left ventricle with TGA and unrepaired mitral stenosis, who underwent to a hybrid procedure of PAB and enlargement of the communication between the two atria.

Continuous Intraoperative Nerve Monitoring of a Non-Recurrent Laryngeal Nerve: Real-Life Data of a High-Volume Thyroid Surgery Center.

Thyroid surgery is associated with a risk of injury to the recurrent laryngeal nerve, especially in the presence of anatomical variants such as a non-recurrent laryngeal nerve (NRLN). Injury to the nerve leads to transient or permanent vocal cord palsy (VCP). A novel method to prevent VCP is continuous intraoperative nerve monitoring (cIONM), but less is known about the applicability of this method in patients with NRLN. The aim of this study was to evaluate our own data regarding feasibility and detailed characteristics of cIONM in NRLN patients. We performed a monocentric retrospective cohort analysis including clinical data and intraoperative nerve monitoring data (measured by Inomed Medizintechnik GmbH, Emmendingen, 'C2' and 'C2 Xplore' device) of all thyroid surgery patients, showing NRLN between 2014 and 2022. Of 1406 patients who underwent thyroid surgery with cIONM between 2014 and 2022, 12 patients (0.9%) showed NRLN intraoperatively. Notably, cIONM was feasible in eight patients (67%). In all cases the onset latency of the right vagus nerve was shorter (<3.0 ms) than usually expected, suggesting that a short latency might be suitable to distinguish NRLN. None of the patients had a post-operative VCP. Overall, cIONM appears to be feasible and safe in NRLN patients and provides helpful information to prevent VCP.

Alta frecuencia de trombo endoluminal en pacientes con ictus isquémico tras la infección por coronavirus 2019 / High frequency of endoluminal thrombus in patients with ischaemic stroke following SARS-CoV-2 infection

Introducción El ictus isquémico puede ser una complicación grave en los pacientes con infección por SARS-CoV-2. Estudiar y caracterizar los diferentes subtipos etiológicos, las características clínicas y el pronóstico funcional podrá resultar útil en la selección de pacientes para un manejo y tratamiento óptimos. Métodos La recogida de variables se hizo de forma retrospectiva en pacientes consecutivos con infección por SARS-CoV-2 que desarrollaron un episodio de isquemia cerebral focal (entre el 1 de marzo del 2020 y el 19 de abril del 2020). Se llevó a cabo en un hospital universitario de tercer nivel en la Comunidad de Madrid (España). Resultados Durante el período de estudio 1.594 pacientes fueron diagnosticados de infección por SARS-CoV-2. Identificamos a 22 pacientes con ictus isquémico (1,38%); de estos, no cumplieron los criterios de inclusión 6. Un total de 16 pacientes con isquemia cerebral focal constituyeron la serie del estudio (15 con ictus isquémico y uno con accidente isquémico transitorio). En la valoración basal en el National Institutes of Health Stroke Scale la mediana fue de 9 (rango intercuartil: 16), la edad media ± desviación estándar fue de 73 ± 12,8 años; 12 pacientes fueron varones (75%). El tiempo desde los síntomas de COVID-19 hasta el ictus fue de 13 días. Se encontró oclusión de gran vaso en 12 pacientes (75%). El dímero-D estuvo elevado en el 87,5% y la proteína C reactiva en el 81,2% de los casos. La etiología más frecuente del ictus isquémico fue la aterotrombosis (9 pacientes, 56,3%) con un subtipo predominante que fue el trombo endoluminal sobre placa de ateroma (5 pacientes, 31,2%), 4 de ellos en la arteria carótida interna y uno de ellos en el arco aórtico. La mortalidad en nuestra serie fue del 44% (7 de 16 pacientes). Conclusiones En los pacientes con ictus y COVID-19 la etiología más frecuente fue la aterotrombótica, con una elevada frecuencia de trombo endoluminal sobre placa de ateroma... (AU)

Background Ischaemic stroke may be a major complication of SARS-CoV-2 infection. Studying and characterising the different aetiological subtypes, clinical characteristics, and functional outcomes may be valuable in guiding patient selection for optimal management and treatment. Methods Data were collected retrospectively on consecutive patients with SARS-CoV-2 infection who developed acute focal brain ischaemia (between 1 March and 19 April 2020) at a tertiary university hospital in Madrid (Spain). Results During the study period, 1594 patients were diagnosed with COVID-19. We found 22 patients with ischaemic stroke (1.38%), 6 of whom did not meet the inclusion criteria. The remaining 16 patients were included in the study (15 cases of ischaemic stroke and one case of transient ischaemic attack). Median baseline National Institutes of Health Stroke Scale score was 9 (interquartile range: 16), and mean (standard deviation) age was 73 years (12.8). Twelve patients (75%) were men. Mean time from COVID-19 symptom onset to stroke onset was 13 days. Large vessel occlusion was identified in 12 patients (75%). We detected elevated levels of D-dimer in 87.5% of patients and C-reactive protein in 81.2%. The main aetiology was atherothrombotic stroke (9 patients, 56.3%), with the predominant subtype being endoluminal thrombus (5 patients, 31.2%), involving the internal carotid artery in 4 cases and the aortic arch in one. The mortality rate in our series was 44% (7 of 16 patients). Conclusions In patients with COVID-19, the most frequent stroke aetiology was atherothrombosis, with a high proportion of endoluminal thrombus (31.2% of patients). Our clinical and laboratory data support COVID-19–associated coagulopathy as a relevant pathophysiological mechanism for ischaemic stroke in these patients. (AU)

Alta frecuencia de trombo endoluminal en pacientes con ictus isquémico tras la infección por coronavirus 2019 / High frequency of endoluminal thrombus in patients with ischaemic stroke following SARS-CoV-2 infection

Introducción El ictus isquémico puede ser una complicación grave en los pacientes con infección por SARS-CoV-2. Estudiar y caracterizar los diferentes subtipos etiológicos, las características clínicas y el pronóstico funcional podrá resultar útil en la selección de pacientes para un manejo y tratamiento óptimos. Métodos La recogida de variables se hizo de forma retrospectiva en pacientes consecutivos con infección por SARS-CoV-2 que desarrollaron un episodio de isquemia cerebral focal (entre el 1 de marzo del 2020 y el 19 de abril del 2020). Se llevó a cabo en un hospital universitario de tercer nivel en la Comunidad de Madrid (España). Resultados Durante el período de estudio 1.594 pacientes fueron diagnosticados de infección por SARS-CoV-2. Identificamos a 22 pacientes con ictus isquémico (1,38%); de estos, no cumplieron los criterios de inclusión 6. Un total de 16 pacientes con isquemia cerebral focal constituyeron la serie del estudio (15 con ictus isquémico y uno con accidente isquémico transitorio). En la valoración basal en el National Institutes of Health Stroke Scale la mediana fue de 9 (rango intercuartil: 16), la edad media ± desviación estándar fue de 73 ± 12,8 años; 12 pacientes fueron varones (75%). El tiempo desde los síntomas de COVID-19 hasta el ictus fue de 13 días. Se encontró oclusión de gran vaso en 12 pacientes (75%). El dímero-D estuvo elevado en el 87,5% y la proteína C reactiva en el 81,2% de los casos. La etiología más frecuente del ictus isquémico fue la aterotrombosis (9 pacientes, 56,3%) con un subtipo predominante que fue el trombo endoluminal sobre placa de ateroma (5 pacientes, 31,2%), 4 de ellos en la arteria carótida interna y uno de ellos en el arco aórtico. La mortalidad en nuestra serie fue del 44% (7 de 16 pacientes). Conclusiones En los pacientes con ictus y COVID-19 la etiología más frecuente fue la aterotrombótica, con una elevada frecuencia de trombo endoluminal sobre placa de ateroma... (AU)

Background Ischaemic stroke may be a major complication of SARS-CoV-2 infection. Studying and characterising the different aetiological subtypes, clinical characteristics, and functional outcomes may be valuable in guiding patient selection for optimal management and treatment. Methods Data were collected retrospectively on consecutive patients with SARS-CoV-2 infection who developed acute focal brain ischaemia (between 1 March and 19 April 2020) at a tertiary university hospital in Madrid (Spain). Results During the study period, 1594 patients were diagnosed with COVID-19. We found 22 patients with ischaemic stroke (1.38%), 6 of whom did not meet the inclusion criteria. The remaining 16 patients were included in the study (15 cases of ischaemic stroke and one case of transient ischaemic attack). Median baseline National Institutes of Health Stroke Scale score was 9 (interquartile range: 16), and mean (standard deviation) age was 73 years (12.8). Twelve patients (75%) were men. Mean time from COVID-19 symptom onset to stroke onset was 13 days. Large vessel occlusion was identified in 12 patients (75%). We detected elevated levels of D-dimer in 87.5% of patients and C-reactive protein in 81.2%. The main aetiology was atherothrombotic stroke (9 patients, 56.3%), with the predominant subtype being endoluminal thrombus (5 patients, 31.2%), involving the internal carotid artery in 4 cases and the aortic arch in one. The mortality rate in our series was 44% (7 of 16 patients). Conclusions In patients with COVID-19, the most frequent stroke aetiology was atherothrombosis, with a high proportion of endoluminal thrombus (31.2% of patients). Our clinical and laboratory data support COVID-19–associated coagulopathy as a relevant pathophysiological mechanism for ischaemic stroke in these patients. (AU)

The tortuous course of the anterior ethmoidal artery in the orbit: A cadaveric study.

AIM: The study aimed to define the coursing pattern of the anterior ethmoidal artery in the orbit to minimize complications during endoscopic interventions. MATERIALS AND METHODS: A total of ten formalin-fixed cadaveric halves were included in the study. Orbital regions were shown with a superior approach. The superior rectus and superior oblique muscles, as well as the connective tissue and vessels were removed to observe the path of the anterior ethmoidal artery. Measurements such as the width of the artery, the anterior-posterior length of the U formation, the length of the intraorbital part of the ophthalmic artery, and the distance of the AEA from its opthalmic origin to the anterior ethmoidal foramen were made. RESULTS: Ten of the AEAs originated from the ophthalmic artery. The AEA branches originated from the ophthalmic artery approximately 18.4 mm after the orbital artery entered the orbital, and the mean width of the AEAs was 0.82 mm. In seven of the total anterior ethmoidal arteries, they coursed in the intraethmoidal cavities below the cranial base. The mean distance from the origin of AEAs to the medial wall of the orbit was 4.9 mm. After leaving the ophthalmic artery, seven of the AEAs were coursing forward and turned back ('U' turn formation), which have proximately 1.5 mm in anteroposterior direction. CONCLUSION: The anterior ethmoidal artery is 0.8 mm wide, originates from the distal part of the ophthalmic artery, entering the orbit after a 1.5 mm U-turn.

Veno-arterial extracorporeal membrane oxygenation (ECMO VA) as part of a multimodal approach for the protection of spinal cord ischemia in surgical repair of a thoracoabdominal aneurysm.

Spinal cord ischaemia leading to paraplegia or paraparesis is one of the most devastating complications of aortic surgery. The risk of ischaemia is particularly high in repairs involving both the thoracic and abdominal segments, because in these cases blood flow to the spinal arteries can be interrupted. Multimodal protocols have now been developed to reduce the incidence of this complication, and include measures such as cerebrospinal fluid (CSF) drainage, avoidance of hypotension and anaemia, systemic hypothermia, neuromonitoring, maintaining distal perfusion during proximal clamping of the aorta, and reimplantation of intercostal or lumbar arteries, whenever feasible. We describe a case in which, due to the special characteristics of the surgery, veno-arterial extracorporeal membrane oxygenation (VA ECMO) was used to maintain distal blood flow in the lumbar, inferior mesenteric, and hypogastric arteries during aortic clamping. This approach reduced the risk of spinal cord and visceral ischaemia, and also eliminated the need for thoracotomy because partial left bypass was not required.

Body Core Temperature Assessment in Emergency Care Departments.

BACKGROUND: There is concern that the values provided by devices using infrared thermometry in emergency departments (EDs) do not reflect body core temperature accurately. OBJECTIVES: Evaluation of three thermometers commonly used in the ED. METHODS: Two infrared ear thermometers and an infrared forehead thermometer were evaluated using 1) the Voltcraft IRS-350 calibration device, 2) comparing temperature values to a rectal end-exercise temperature (T-RECT) of 38.1°C in 12 participants, and 3) comparing temperature values to rectal temperature in 133 ED patients. RESULTS: Calibration across the human core temperature range revealed that the ear thermometers underestimated radiant temperature by 0.77 ± 0.39°C and 1.84 ± 0.26°C, respectively, whereas the forehead thermometer overestimated radiant temperature by 0.90 ± 0.51°C. After cycling exercise, all thermometers underestimated T-RECT (0.54 ± 0.27°C and 1.03 ± 0.48°C for the ear thermometers and 1.14 ± 0.38°C for the forehead thermometer). In the ED, the ear thermometers underestimated T-RECT by 0.31 ± 0.37°C and 0.46 ± 0.50°C, whereas the forehead thermometer exhibited a nonsignificant overestimation of 0.04 ± 0.46°C. If the threshold for fever in all systems had been set to 37.5°C instead of 38.0°C, the sensitivity and specificity of the systems for real fever (T-RECT ≥ 38°C) are, respectively, 71% and 96% (ear thermometer 1), 57% and 97% (ear thermometer 2), and 86% and 90% (forehead thermometer). CONCLUSION: We conclude that the investigated thermometers are not reliable as devices to measure radiant temperature, cannot be used to assess body core temperature during exercise, but may be used as a screening device, with 37.5°C as a threshold for fever in emergency care settings.

Aberrant mediastinal basal pulmonary artery encountered at anatomical lung resection: A case report and review of the literature.

INTRODUCTION: Abnormal branching of the pulmonary artery is often encountered in anatomical lung resection, which can potentially result in accidental vessel injury with life-threatening bleeding or extra lung resection. The mediastinal basal pulmonary artery (Arteria Praebronchialis, AP) is a very rare but potentially critical variant. PRESENTATION OF CASE: We present the case of a patient with lung cancer accompanied by the left basal segmental pulmonary artery, independent A8a+9, which was liable to be injured during lower lobectomy with poor interlobar fissure development. This variation was preoperatively recognized using three-dimensional contrast-enhanced computed tomography (3D-CECT) angiography, and vessel injury was avoided. DISCUSSION AND LITERATURE REVIEW: 3D-CECT angiography was effective in identifying this rare but potentially critical variation, and it is desirable to perform it routinely before anatomical lung resection. A review of 31 AP cases revealed that the branching pattern of AP was independent (15 patients, 48 %) and common trunk type (16 patients, 52 %), one half for each. Mediastinal branching of the lingular artery was more frequent among the reported AP cases (71 %) than in general reports. CONCLUSION: When mediastinal branches of left pulmonary artery are encountered, the possibility that it is AP should be always taken into account.

Unusual case of retinal arterial branch occlusion: possible variant of Sneddon syndrome.

Sneddon's syndrome (SS) manifests through multiple strokes and livedo reticularis. Livedoid vasculopathy (VL) is characterized by a long history of foot and leg ulceration and histopathology indicating a thrombotic process. Arterial retinal branch occlusion is described in a 52-year-old male with VL. He did not present noticeable laboratory abnormalities, such as antiphospholipid antibodies, or a history of strokes. Retinal artery occlusion accompanied by VL could be a variant of Sneddon's syndrome. Optical coherence tomography angiography revealed a reduction in the macula's vascular layers in the asymptomatic eye, indicating localized microvascular changes as an evolving marker in the pathogenesis of SS.

Rendimiento diagnóstico de un nuevo software de aprendizaje profundo para corrección de atenuación en la imagen de perfusión miocárdica utilizando una cámara CZT cardiodedicada. Experiencia en la práctica clínica / Diagnostic performance of a novel deep learning attenuation correction software for MPI using a cardio dedicated CZT camera: Experience in the clinical practice

Objetivo Evaluar el rendimiento diagnóstico de un nuevo software de aprendizaje profundo para corrección de atenuación (SAPCA) en imágenes de perfusión miocárdica (IPM) utilizando una cámara cardiodedicada de cadmio-cinc-telurio (CZT) con correlación con angiografía coronaria (AC) para el diagnóstico de enfermedad arterial coronaria (EAC) en una población de alto riesgo. Métodos Estudio retrospectivo de 300 pacientes (196 varones [65%], edad media de 68 años) desde septiembre de 2014 hasta octubre de 2019. Posteriormente realizaron una IPM, seguida de AC dentro de los 6 meses posteriores a la IPM. La probabilidad media pretest para EAC según los criterios de la Sociedad Europea de Cardiología fue del 37%. La IPM se realizó en una cámara CZT cardio dedicada (D-SPECT® Spectrum Dynamics) usando un protocolo de 2 días, de acuerdo con las guías de la Sociedad Europea de Medicina Nuclear (EANM). La IPM fue evaluada con y sin el SAPCA. Resultados La precisión diagnóstica global de la IPM sin el SAPCA para identificar pacientes con cualquier EAC obstructiva en la AC fue del 87%, sensibilidad del 94%, especificidad del 57%, valor predictivo positivo del 91% y valor predictivo negativo del 64%. Utilizando el SAPCA, la precisión diagnóstica global fue del 90%, la sensibilidad del 91%, la especificidad del 86%, el valor predictivo positivo del 97% y el valor predictivo negativo del 66%. Conclusión El uso del novel SAPCA mejora el rendimiento diagnóstico de la IPM usando la cámara CZT D-SPECT®, especialmente reduciendo el número de resultados falsos positivos al reducir los artefactos (AU)

urpose To evaluate the diagnostic performance of a novel deep learning attenuation correction software (SAPCA) for myocardial perfusion imaging (MPI) using a cadmium-zinc-telluride (CZT) cardio dedicated camera with invasive coronary angiography (ICA) correlation for the diagnosis of coronary artery disease (CAD) in a high-risk population. Methods Retrospective study of 300 patients (196 males [65%], mean age 68 years) from September 2014 to October 2019 undergoing MPI, followed by ICA and evaluated by means of quantitative angiography software, within six months after the MPI. The mean pre-test probability score for coronary disease according to the European Society of Cardiology criteria was 37% for the whole cohort. The MPI was performed in a dedicated CZT cardio camera (D-SPECT® Spectrum Dynamics) with a two-day protocol, according to the European Association of Nuclear Medicine guidelines. MPI was retrospectively evaluated with and without the SAPCA. Results The overall diagnostic accuracy of MPI without SAPCA to identify patients with any obstructive CAD at ICA was 87%, Sensitivity 94%, Specificity 57%, positive predictive value 91% and negative predictive value 64%. Using SAPCA the overall diagnostic accuracy was 90%, sensitivity 91%, specificity 86%, positive predictive value 97% and negative predictive value 66%. Conclusion Use of the novel SAPCA enhances performance of the MPI using the CZT D-SPECT® camera and achieves improved results, especially avoiding artefacts and reducing the number of false positive results (AU)

Clinical results of percutaneous coronary intervention in chronic total occlusions of the right coronary artery.

INTRODUCTION AND OBJECTIVES: Coronary chronic total occlusions (CTOs) of the right coronary artery (RCA) are a relatively common finding in the context of coronary angiography. However, the benefit of revascularization remains controversial. METHODS: A single-center retrospective cohort analysis prospectively collected outcomes of CTO patients undergoing percutaneous coronary intervention (PCI) in 2019 and 2020. Patients were divided into two groups according to the CTO vessel treated (left coronary artery [LCA]-CTO or RCA-CTO). The primary outcome was defined as the recurrence of angina and/or heart failure (HF) symptoms and secondary outcomes were myocardial infarction (MI) and all-cause mortality. RESULTS: A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome occurred in 28 (16.6%) patients and was significantly more frequent in RCA-CTO patients (19, 24.7%, p=0.010) in a mean follow-up of 18 months. This was mainly driven by recurrence of HF symptoms (12, 15.6%, p=0.013). Treated RCA-CTO was an independent predictor of the primary outcome (p=0.019, HR 2.66, 95% CI 1.17-6.05). MI and mortality rates were no different between groups (RCA-CTO with 1.3%, p=0.361 and 2.6%, p=0.673, respectively, on survival analysis). Left ventricular ejection fraction was an independent predictor of mortality (p=0.041, HR 0.93, 95% CI 0.87-0.99). CONCLUSIONS: Revascularization of CTO lesions by PCI was associated with low rates of symptom recurrence, and clinical outcomes showed no differences regardless of which artery was treated. Recanalization of RCA-CTO was less beneficial in reducing the recurrence of HF symptoms.

Síndrome de Wilkie como reto diagnóstico en obstrucción intestinal: reporte de caso / Wilkie syndrome as a diagnostic challenge in intestinal obstruction: case report

RESUMEN El síndrome de Wilkie es una patología poco frecuente que genera un cuadro de obstrucción intestinal, debido a la disminución del ángulo aortomesentérico comprometiendo la tercera porción del duodeno. Describimos el caso de una paciente de 18 años de edad, diagnosticada con síndrome de Wilkie, con cuadro clínico de obstrucción intestinal y pérdida de peso. El diagnóstico se realizó con tomografía abdominal. El síndrome de Wilkie es una patología rara, que se vuelve un reto diagnóstico, por presentar un cuadro similar a otras patologías más comunes. Recomendamos que se sospeche ante un cuadro de obstrucción duodenal.

ABSTRACT Wilkie syndrome is a rare pathology that generates intestinal obstruction due to a decrease of the aortomesenteric angle compromising the third portion of the duodenum. We describe a case of an 18-year-old female patient, diagnosed with Wilkie syndrome, with clinical symptoms of intestinal obstruction and weight loss. The diagnosis was made with abdominal CT. Wilkie syndrome is a rare pathology, which becomes a diagnostic challenge because it presents a similar picture to other more common pathologies. We recommend that it should be suspected in the presence of duodenal obstruction.