Venous Pathologies and Interventions of the Head.

Intracranial venous pathologies are a historically underrecognized group of disorders that can have a devastating impact on patients. Despite advancements in peripheral venous disorders and arterial neurointerventions, intracranial venous pathologies have received comparatively little attention. Understanding the anatomy, physiology, clinical relevance, and treatment options of intracranial venous pathologies is fundamental to evolving therapies and research priorities. This article provides an overview of major intracranial venous pathologies, the respective pathophysiologies, and treatment options.

Thinking ahead: gallbladder intussusception following transperitoneal percutaneous cholecystostomy tube placement.

Percutaneous cholecystostomy (PC) is a common minimally invasive, image-guided procedure performed primarily on high-risk patients with acute cholecystitis for gallbladder decompression. Herein, we present a case of a patient undergoing PC placement using a transperitoneal approach. On subsequent upsizing attempts, the gallbladder fundus was found to invaginate during advancement of replacement drains, causing gallbladder intussusception. The use of a balloon and locked pigtail catheter were required to reposition the gallbladder to proper position. The patient's planned percutaneous cholecystoscopy was delayed by 4 weeks until intended upsizing could be performed. This case demonstrates the advantage of achieving transhepatic gallbladder access to support tract formation and limit procedural complications.

Stretch too far: rectus sheath haematoma secondary to repetitive trauma and increased intra-abdominal pressure.

A 26-year-old man presented with a 4-week history of right lower quadrant abdominal pain which was managed conservatively at home with ibuprofen. Three days later, he presented to the emergency department with worsening pain and swelling following an episode of coughing and slipping in the bathroom. Following his admission, CT angiography showed an active bleed into a 4.6×6.7×11 cm right rectus sheath haematoma, just inferior to the umbilicus. The patient was then referred to interventional radiology for an angiogram and coil embolisation. A superselective branch angiogram showed contrast extravasation from a medial branch of the right inferior epigastric artery, successfully embolised without incident.

Caregiver's Recall of Stroke Discharge Education Exceeds Patients and Is Associated With Greater Satisfaction.

Stroke survivors and their caregivers report not receiving enough information at discharge. To identify strengths and weaknesses of stroke discharge education, we delivered questionnaires that assessed patient and caregiver recall, perceived utility, and satisfaction at discharge as well as 1- and 3-month follow-up. Categorical data of responses were compared between time periods using Fischer exact test. Recall significantly differed between discharge (86%) and 1-month follow-up (54%, P < .05), but not discharge and 3-month follow-up (69%). Patient perceived utility at both 1 month (69%) and 3 months (64%) was lower than at discharge (92%, P < .05). Patient satisfaction was lower at 1 month (69%) and 3 months (54%) than discharge (92%, P < .05). Caregiver recall declined from discharge (81%) to 1 month (65%) but improved from 1 to 3 months (82%, P < .05). Caregiver satisfaction and perceived utility remained positive through the study. The results suggest stroke patients and their caregivers suffer from education recall failure over time that is associated with worse satisfaction and perceived utility by patients. Reinforcement at 1 month may improve caregiver recall. We conclude that education for caregivers may be more reliably reinforced, suggesting a role in continued patient education.

Incidental Pancreatic Solid Pseudopapillary Tumor Masked by Hemorrhagic Trauma.

An 18-year-old female presented to a tertiary care center after sustaining blunt abdominal trauma. Work up, including computer tomography (CT) revealed a hypo-attenuated collection in the pancreatic body with concern for ductal injury on magnetic resonance cholangiopancreatography (MRCP). These findings were consistent with posttraumatic intrapancreatic hematoma. An exploratory laparotomy with distal pancreatectomy and splenectomy were performed with concern for a grade 3 pancreatic injury. Pathology of the excised pancreas showed presence of a solid pseudopapillary tumor in the body of the pancreas which had been obscured by the hematoma on imaging.

Effectiveness of Radiofrequency Ablation in the Treatment of Painful Osseous Metastases: A Correlation Meta-Analysis with Machine Learning Cluster Identification.

A systematic review and meta-analysis of pain response after radiofrequency (RF) ablation over time for osseous metastases was conducted in 2019. Analysis used a random-effects model with GOSH plots and meta-regression. Fourteen studies comprising 426 patients, most with recalcitrant pain, were identified. Median pain reduction after RF ablation was 67% over median follow-up of 24 weeks (R2 = -.66, 95% confidence interval -0.76 to -0.55, I2 = 71.24%, fail-safe N = 875) with 44% pain reduction within 1 week. A low-heterogeneity subgroup was identified with median pain reduction after RF ablation of 70% over 12 weeks (R2 = -.75, 95% confidence interval -0.80 to -0.70, I2 = 2.66%, fail-safe N = 910). Addition of cementoplasty after RF ablation did not significantly affect pain scores. Primary tumor type and tumor size did not significantly affect pain scores. A particular, positive association between pain after RF ablation and axial tumors was identified, implying possible increased palliative effects for RF ablation on axial over appendicular lesions. RF ablation is a useful palliative therapy for osseous metastases, particularly in patients with recalcitrant pain.

Atherosclerotic cardiovascular disease in inflammatory bowel disease: The role of chronic inflammation.

Inflammatory bowel disease (IBD) causes systemic vascular inflammation. The increased risk of venous as well as arterial thromboembolic phenomena in IBD is well established. More recently, a relationship between IBD and atherosclerotic cardiovascular disease (ASCVD) has been postulated. Systemic inflammatory diseases, such as rheumatoid arthritis and systemic lupus erythematosus, have well characterized cardiac pathologies and treatments that focus on prevention of disease associated ASCVD. The impact of chronic inflammation on ASCVD in IBD remains poorly characterized. This manuscript aims to review and summarize the current literature pertaining to IBD and ASCVD with respect to its pathophysiology and impact of medications in order to encourage further research that can improve understanding and help develop clinical recommendations for prevention and management of ASCVD in patients with IBD.

Prolonged Peripheral Hypoperfusion Promotes Neuroprotection in Ischemic Stroke.

Objectives Sublethal, transient occlusion of peripheral vessels, called remote ischemic preconditioning (RIPC), induces a neuroprotective state against brain infarction. Recent studies suggest chronic hypoperfusion in patients with peripheral vascular disease (PVD) has analogous effects. We hypothesized a positive correlation between the severity of chronic hypoperfusion and the extent of neuroprotection. To determine if this correlation exists, we compared stroke volumes and clinical measures of modified ranking scale (mRS) and National Institute of Health Stroke Scale (NIHSS) between cases with and without PVD, subgrouping PVD cases by ankle-brachial-index (ABI) values. Patients and methods Cases of ischemic stroke with and without PVD were sampled retrospectively from a local institutional data base. Charts were manually reviewed for demographics (age, sex, ethnicity), comorbidities (diabetes, hypertension, hyperlipidemia, coronary artery disease, smoking, and stroke history), clinical measures (admission NIHSS, prior mRS, three-month mRS, and survival) and stroke volumes in each case. Those diagnosed with PVD and ABI indicating active disease were grouped as PVD cases; those not diagnosed with PVD or having ABI indicating absence of disease were used as controls. PVD cases were subgrouped by disease severity per ABI values: mild (ABI 0.8-0.9), moderate (ABI 0.5-0.9) and severe (ABI < 0.5). Data were analyzed in R using adjusted logarithmic-multivariate models. Adjusted cox proportional hazards models were used to estimate associations between survival and PVD. Results A total of 105 patients, 50 PVD cases and 55 controls, were collected. Mean age was 72.54 years, 51.4% were males and 48.6% females, and 94% were Caucasian. There were 17 mild, 22 moderate, and 11 severe cases of PVD. A higher incidence of comorbidities was present in PVD cases. The mean admission NIHSS was 4.44 and did not differ significantly between groups. Stroke volumes were significantly lower (p = .021) in PVD cases (4.39 ± 8.97 ml) compared to controls (19.33 ± 44.31 ml). There was also a significant difference (p = .04) between volumes of mild (3.86 ± 5.47 ml) and severe (0.63 ± 0.76 ml) PVD cases. There were significant differences (p = .012) in the incidence of good outcomes in moderate to severe PVD cases (100%) compared to controls (83.3%). There was no difference in survival between groups (p = .538). Conclusion Increasing degrees of hypoperfusion related to PVD have a potential neuroprotective effect in acute ischemic stroke quantified by lower stroke volumes and better clinical outcomes at three months as seen in other preclinical models of RIPC.

Revascularization for Posterior Cerebral Artery Infarction in Decompensated Moyamoya Disease.

Moyamoya disease is a rare pathological disorder characterized by progressive intracranial artery stenosis and collateral vessel formation. Posterior cerebral artery involvement is rare with a predilection towards infarction. Herein we present a case of a young female with moyamoya disease treated with bilateral encephalomyosynangiosis which subsequently progressed to posterior cerebral artery involvement, requiring encephalomyosynangiosis to prevent further infarction.

Effects on Stroke Metrics and Outcomes of a Nurse-led Stroke Triage Team in Acute Stroke Management.

Background Timely administration of healthcare in acute stroke, congruent with national stroke metrics, relates to better patient outcomes. A nurse-led stroke triage team instituted at our facility was hypothesized to improve metrics and outcomes. To evaluate the effect of the nurse-led stroke triage team we compared specific stroke metrics and patient outcomes before and after the program initiation.  Methods In retrospective review, we analyzed stroke metrics one year prior to the start of the triage program (controls) and one year after the start of the program (cases), including the following metrics: patient arrival, emergency department assessment, neurology contact, head computed tomography (CT) scan, and delivery of tissue plasminogen activator (tPA) or puncture for mechanical thrombectomy. Primary outcome measures were improved metric times.  Results Ninety-five acute stroke events were analyzed: 26 controls and 69 cases. Cohort demographics included means of age 72.82 years, National Institutes of Health Stroke Scale (NIHSS) 15.96, discharge and 90-day mRS 3.71 and 3.55 respectively, and length of stay 5.98 days. There were significantly different improvements in metrics between arrival time to CT start, emergency room physician evaluation to CT start, neurology contact to CT start, and neurology contact to tPA initiation for cases post-triage team institution. No significant differences during this period were seen for other metrics. Multivariate analysis controlling for age, sex and NIHSS found no significant difference for discharge or 90-day mRS scores.  Conclusions An interdisciplinary approach to acute stroke management can impact stroke metrics. These data support the integration of specially trained stroke nurses in acute stroke triage for quality improvement efforts.

Opinions, Views, and Expectations Concerning the Radiology Report: A Rural Medicine Report.

This study seeks to examine a potential agreement and/or discordance of specific aspects of the radiology report between referring clinicians and radiologists within a medical group in a predominately rural setting. This study also aims to compare results with similar studies conducted in other geographic regions. This was done using a previously validated survey tool that examines five different aspects of the radiology report: importance, clinical correlation, clinicians' satisfaction, content, structure, and style. Dichotomized results were statistically analyzed using χ 2 or Fischer's exact test and showed significant differences in the areas of importance and content. Non-dichotomized results unique to clinicians and radiologists were assessed qualitatively. Most clinicians found the radiology report to be useful in their clinical decision making and that they received radiology reports in a timely enough fashion to affect their decision making. These results were largely found to be in accordance with similar studies, but significant differences unique to the sampled population were present. Based on these findings, we have included specific recommendations that may enhance the clinical efficiency of radiology reports as used by clinicians and potentially reduce medical errors secondary to clinical information not always fully captured in radiology reports.

Antidepressant Use for Improving Functional Ischemic Stroke Outcomes.

Objective To assess the effect of antidepressants on functional post-stroke recovery, we conducted a retrospective analysis among acute ischemic stroke patients with a subgroup analysis of severe stroke cases, assessing outcomes through 18 months. Methods A retrospectively gathered ischemic stroke population was obtained from an institutional database. Grouping was via intention-to-treat with antidepressant use post-stroke or lack thereof. Patients with severe stroke (NIHSS ≥ 21) were further analyzed independently. The primary and secondary outcomes were modified Rankin scale (mRS) and survival over 18 months, respectively. Patient demographics and NIHSS were obtained. Data were analyzed in R using adjusted logarithmic-multivariate models. Adjusted Cox proportional hazards models were used to estimate associations between survival and antidepressants. Results Eight-hundred six patients (52 severe strokes) received antidepressants post-stroke while 948 (56 severe) did not. The antidepressant group was more female (56% to 43.5%) and had significantly better survival rates (88% vs. 79%, HR 0.62, p < 0.01) but not mRS scores (2.13 vs 2.24, p = 0.262) by the end of the study period. Among severe stroke cases, those receiving antidepressants showed better survival rates (79% vs. 60%, HR 0.36, p=0.026) and most recent mRS score (3.9 vs 5, p < 0.01). The analysis controlling for demographics variables retained significance. Conclusion Antidepressant use post-stroke may improve functional outcomes in patients suffering from severe stroke and may decrease all-cause mortality for strokes of any severity.

Amiodarone-induced Hemoptysis: A Rare Presentation of Amiodarone-induced Pulmonary Toxicity Occurs at a Low Dose.

Amiodarone-induced pulmonary toxicity (APT) is one of the most feared and underappreciated adverse effects of this commonly prescribed antiarrhythmic. APT has a variable presentation, among the rarest of these is amiodarone-induced diffuse alveolar hemorrhage with hemoptysis. Though previous cases confirmed with biopsy averaged a dose of 570 mg PO daily, APT can occur at any dose. Previous literature has suggested the importance of cumulative exposure to amiodarone rather than the patient's actual dose. The presented case describes amiodarone-induced hemoptysis occurring at a dose of 200 mg PO daily for five years. Additionally described is the treatment regimen which managed a patient with metabolic syndrome and elevated A1c while addressing the recommended treatment of extended high-dose steroids for APT with complicated respiratory status. To the best of the authors' knowledge, only two biopsied cases have been described at a dose this low. Furthermore, this case describes a more typical timeline for APT than those two cases.

Pulmonary Arteriovenous Malformations: A Rare Cause of Ischemic Stroke.

A 24-year-old woman was admitted for seizures. Magnetic resonance imaging revealed a subacute infarct of the right frontal operculum. Transthoracic echocardiogram showed evidence of patent foramen ovale (PFO). Further study with transesophageal echocardiogram showed no PFO, but signs of a pulmonary arteriovenous malformation (PAVM) that was confirmed on ensuing chest CT angiogram. May-Thurner syndrome (MTS) was suspected and confirmed by magnetic resonance venography showing 70% narrowing of the left common iliac vein. The PAVM was successfully coiled and the patient was discharged without deficits. Noncontrast CT at one-month follow up showed no residual PAVM sac. Literature shows there is a median two-year delay from cerebral event to diagnosis of PAVM. Over 80% of PAVMs are related to hereditary hemorrhagic telangiectasia (HHT) and are generally seen in multiples, but may also been seen as an idiopathic and/or isolated defect. The risk of neurological complications rises with a patient's age and the quantity of PAVMs. Initial workup should include screening with transthoracic contrast echocardiography followed by CT angiography for definitive diagnosis. Embolotherapy is considered gold standard as it reduces the risk of paradoxical emboli and other complications.

Jejunal varices: an unconsidered cause of recurrent gastrointestinal haemorrhage.

A 78-year-old woman presented with melaenic stool and severe anaemia 4 years after a pancreaticoduodenectomy for adenocarcinoma of the pancreas. Initial workup revealed haemorrhage from the choledochojejunostomy site. Despite multiple endoscopic clips to the region, bleeding reoccurred multiple times over a period of several months. Due to ongoing haemorrhage, her case was urgently presented at the hospital's multidisciplinary hepatobiliary conference. The contrast-enhanced abdominal CT revealed severe stenosis of the extrahepatic portal vein and large afferent jejunal varices at the choledochojejunostomy, suspected as the cause of her persistent bleed. The recommendation was a percutaneous transhepatic approach for stenting of the portal vein stenosis that resulted in rapid decompression of the jejunal varices and control of her haemorrhage.