Artery of Percheron Infarct: A Rare Case Presentation and Recovery.

The artery of Percheron (AOP) is a congenital anatomical irregularity of the cerebrovasculature responsible for perfusing the thalamus and midbrain. These defects account for a small percent of all ischemic strokes and present with widely variable symptomatology, ranging from confusion to coma. We present a case of an acute AOP infarct and recovery in a 68-year-old male with atrial fibrillation without anticoagulation. It is our hope that this case report serves to alert diagnosticians to the presence of AOP infarcts, the wide clinical presentation, and the prognosis of this rare and critical type of ischemic stroke.

Papillary Fibroelastoma of the Right Ventricle in the Setting of Multifocal Pulmonary Hemorrhages and Pulmonary Embolization in a 39-Year-Old Man: A Case Report.

BACKGROUND Papillary fibroelastoma accounts for approximately 24% of all primary cardiac tumors and is the third most common primary cardiac neoplasm. It mostly involves the cardiac valves; however, there have been cases of involvement of the endocardium. Papillary fibroelastoma, although typically benign, can cause a plethora of complications, including systemic embolization, myocardial infarction, arrhythmia, and sudden cardiac death. In this article we present a unique case of a man diagnosed with a papillary fibroelastoma of the right ventricle in the setting of multifocal pulmonary hemorrhages and pulmonary embolization. CASE REPORT A 39-year-old man presented with hemoptysis and dyspnea due to bilateral lower-lobe pneumonia and a left pleural effusion. Further imaging throughout his hospitalization revealed worsening multifocal consolidations, pulmonary hemorrhages, and a pulmonary embolus. A mobile cardiac mass measuring 30.2×20 mm, detected by echocardiography, was found in the right ventricle, partially fixed to the intraventricular septum via a 14.4-mm stalk, which was surgically excised and was found to be consistent with papillary fibroelastoma. He underwent an IVC filter and was discharged on warfarin, which he tolerated well. CONCLUSIONS Papillary fibroelastomas are benign infrequent findings but carry a high risk of systemic complications, as demonstrated in our patient. He had no known cardiac disease or risk factor for tumor growth, yet developed a papillary fibroelastoma of the right ventricle, which is rare. Given the potential of fatal outcomes, it is imperative that patients with unexplained embolic phenomena undergo early diagnosis by echocardiography and early surgical treatment.

Chronic Cavitary Pulmonary Aspergillosis: A Case Report and Review of the Literature.

BACKGROUND Aspergillus spores have the ability to affect patients with or without intact immune systems; because of this disease's wide patient involvement it deserves a place on the differential diagnosis list, with endocarditis and tuberculosis, for those presenting with new pulmonary nodules or cavitation. CASE REPORT This case report involves the presentation, diagnosis, and treatment of a 69-year-old female who presented with new rapidly progressing cavitary lung lesions in the setting of copious administration of systemic steroid use. Given the patient's past history of alcoholism and environmental exposure, her case was not straight forward in regard to a diagnosis. Ultimately, she was diagnosed with chronic cavity pulmonary aspergillosis in the setting of chronic immunosuppression secondary to systemic steroid administration. Due to her convoluted medical history and the poor differential diagnosis list, there was a delay in final diagnosis. CONCLUSIONS This case report and clinical review aims to prevent anchoring when the patient's presentation is not straight forward and aims to remind the clinician of the importance of a differential diagnosis.

A Novel Approach to Screening for Alpha-1 Antitrypsin Deficiency: Inpatient Testing at a Teaching Institution.

Chronic obstructive pulmonary disease (COPD) currently affects more than 16 million Americans and it is estimated that roughly 100,000 Americans have undiagnosed, severe alpha-1 antitrypsin deficiency (AATD) (Chest. 2005;128[3]:1179-1186) (Chest. 2002;122[5]:1818-1829). Patients with AATD have an accelerated rate of decline of lung function caused by proteolytic enzymes. The morbidity associated with this inherited disorder is preventable due to the availability of augmentation therapy. Appropriate inpatient screening of patients with COPD for AATD is lacking and most screening is exclusively limited to outpatient pulmonary clinics. Between May 2016 and February 2017, genetic screening was completed on 54 individuals who were admitted with either a former diagnosis of COPD or active COPD exacerbation to Arnot Ogden Medical Center (AOMC) in Elmira, New York. The incorporation of inpatient genetic screening by resident physicians for AATD in COPD patients led to a high rate of screened and newly diagnosed AATD carriers with a variety of AATD genotypes. It is recommended that there should be an expansion of screening for AATD in hospitalized patients with COPD, regardless of age or smoking history.

Cerebral Oximetry During Cardiac Arrest: A Multicenter Study of Neurologic Outcomes and Survival.

OBJECTIVES: Cardiac arrest is associated with morbidity and mortality because of cerebral ischemia. Therefore, we tested the hypothesis that higher regional cerebral oxygenation during resuscitation is associated with improved return of spontaneous circulation, survival, and neurologic outcomes at hospital discharge. We further examined the validity of regional cerebral oxygenation as a test to predict these outcomes. DESIGN: Multicenter prospective study of in-hospital cardiac arrest. SETTING: Five medical centers in the United States and the United Kingdom. PATIENTS: Inclusion criteria are as follows: in-hospital cardiac arrest, age 18 years old or older, and prolonged cardiopulmonary resuscitation greater than or equal to 5 minutes. Patients were recruited consecutively during working hours between August 2011 and September 2014. Survival with a favorable neurologic outcome was defined as a cerebral performance category 1-2. INTERVENTIONS: Cerebral oximetry monitoring. MEASUREMENTS AND MAIN RESULTS: Among 504 in-hospital cardiac arrest events, 183 (36%) met inclusion criteria. Overall, 62 of 183 (33.9%) achieved return of spontaneous circulation, whereas 13 of 183 (7.1%) achieved cerebral performance category 1-2 at discharge. Higher mean ± SD regional cerebral oxygenation was associated with return of spontaneous circulation versus no return of spontaneous circulation (51.8% ± 11.2% vs 40.9% ± 12.3%) and cerebral performance category 1-2 versus cerebral performance category 3-5 (56.1% ± 10.0% vs 43.8% ± 12.8%) (both p < 0.001). Mean regional cerebral oxygenation during the last 5 minutes of cardiopulmonary resuscitation best predicted the return of spontaneous circulation (area under the curve, 0.76; 95% CI, 0.69-0.83); regional cerebral oxygenation greater than or equal to 25% provided 100% sensitivity (95% CI, 94-100) and 100% negative predictive value (95% CI, 79-100); regional cerebral oxygenation greater than or equal to 65% provided 99% specificity (95% CI, 95-100) and 93% positive predictive value (95% CI, 66-100) for return of spontaneous circulation. Time with regional cerebral oxygenation greater than 50% during cardiopulmonary resuscitation best predicted cerebral performance category 1-2 (area under the curve, 0.79; 95% CI, 0.70-0.88). Specifically, greater than or equal to 60% cardiopulmonary resuscitation time with regional cerebral oxygenation greater than 50% provided 77% sensitivity (95% CI,:46-95), 72% specificity (95% CI, 65-79), and 98% negative predictive value (95% CI, 93-100) for cerebral performance category 1-2. CONCLUSIONS: Cerebral oximetry allows real-time, noninvasive cerebral oxygenation monitoring during cardiopulmonary resuscitation. Higher cerebral oxygenation during cardiopulmonary resuscitation is associated with return of spontaneous circulation and neurologically favorable survival to hospital discharge. Achieving higher regional cerebral oxygenation during resuscitation may optimize the chances of cardiac arrest favorable outcomes.

A feasibility study of cerebral oximetry during in-hospital mechanical and manual cardiopulmonary resuscitation*.

OBJECTIVE: A major hurdle limiting the ability to improve the quality of resuscitation has been the lack of a noninvasive real-time detection system capable of monitoring the quality of cerebral and other organ perfusion, as well as oxygen delivery during cardiopulmonary resuscitation. Here, we report on a novel system of cerebral perfusion targeted resuscitation. DESIGN: An observational study evaluating the role of cerebral oximetry (Equanox; Nonin, Plymouth, MI, and Invos; Covidien, Mansfield, MA) as a real-time marker of cerebral perfusion and oxygen delivery together with the impact of an automated mechanical chest compression system (Life Stat; Michigan Instruments, Grand Rapids, MI) on oxygen delivery and return of spontaneous circulation following in-hospital cardiac arrest. SETTING: Tertiary medical center. PATIENTS: In-hospital cardiac arrest patients (n = 34). MAIN RESULTS: Cerebral oximetry provided real-time information regarding the quality of perfusion and oxygen delivery. The use of automated mechanical chest compression device (n = 12) was associated with higher regional cerebral oxygen saturation compared with manual chest compression device (n = 22) (53.1% ± 23.4% vs 24% ± 25%, p = 0.002). There was a significant difference in mean regional cerebral oxygen saturation (median % ± interquartile range) in patients who achieved return of spontaneous circulation (n = 15) compared with those without return of spontaneous circulation (n = 19) (47.4% ± 21.4% vs 23% ± 18.42%, p < 0.001). After controlling for patients achieving return of spontaneous circulation or not, significantly higher mean regional cerebral oxygen saturation levels during cardiopulmonary resuscitation were observed in patients who were resuscitated using automated mechanical chest compression device (p < 0.001). CONCLUSIONS: The integration of cerebral oximetry into cardiac arrest resuscitation provides a novel noninvasive method to determine the quality of cerebral perfusion and oxygen delivery to the brain. The use of automated mechanical chest compression device during in-hospital cardiac arrest may lead to improved oxygen delivery and organ perfusion.

A pilot study examining the role of regional cerebral oxygen saturation monitoring as a marker of return of spontaneous circulation in shockable (VF/VT) and non-shockable (PEA/Asystole) causes of cardiac arrest.

BACKGROUND: Non-invasive monitoring of cerebral perfusion and oxygen delivery during cardiac arrest is not routinely utilized during cardiac arrest resuscitation. The objective of this study was to investigate the feasibility of using cerebral oximetry during cardiac arrest and to determine the relationship between regional cerebral oxygen saturation (rSO2) with return of spontaneous circulation (ROSC) in shockable (VF/VT) and non-shockable (PEA/asystole) types of cardiac arrest. METHODS: Cerebral oximetry was applied to 50 in-hospital and out-of-hospital cardiac arrest patients. RESULTS: Overall, 52% (n=26) achieved ROSC and 48% (n=24) did not achieve ROSC. There was a significant difference in mean±SD rSO2% in patients who achieved ROSC compared to those who did not (47.2±10.7% vs. 31.7±12.8%, p<0.0001). This difference was observed during asystole (median rSO2 (IQR) ROSC versus no ROSC: 45.0% (35.1-48.8) vs. 24.9% (20.5-32.9), p<0.002) and PEA (50.6% (46.7-57.5) vs. 31.6% (18.8-43.3), p=0.02), but not in the VF/VT subgroup (43.7% (41.1-54.7) vs. 42.8% (34.9-45.0), p=0.63). Furthermore, it was noted that no subjects with a mean rSO2<30% achieved ROSC. CONCLUSIONS: Cerebral oximetry may have a role as a real-time, non-invasive predictor of ROSC during cardiac arrest. The main utility of rSO2 in determining ROSC appears to apply to asystole and PEA subgroups of cardiac arrest, rather than VF/VT. This observation may reflect the different physiological factors involved in recovery from PEA/asytole compared to VF/VT. Whereas in VF/VT, successful defibrillation is of prime importance, however in PEA and asytole achieving ROSC is more likely to be related to the quality of oxygen delivery. Furthermore, a persistently low rSO2 <30% in spite of optimal resuscitation methods may indicate futility of resuscitation efforts.

A feasibility study evaluating the role of cerebral oximetry in predicting return of spontaneous circulation in cardiac arrest.

UNLABELLED: To date there has been no reliable noninvasive real time monitoring available to determine cerebral perfusion during cardiac arrest. OBJECTIVES: To investigate the feasibility of using a commercially available cerebral oximeter during in-hospital cardiac arrest, and determine whether this parameter predicts return of spontaneous circulation (ROSC). METHODS: Cerebral oximetry was incorporated in cardiac arrest management in 19 in-hospital cardiac arrest cases, five of whom had ROSC. The primary outcome measure was the relationship between rSO(2) and ROSC. RESULTS: The use of cerebral oximetry was found to be feasible during in hospital cardiac arrest and did not interfere with management. Patients with ROSC had a significantly higher overall mean ± SE rSO(2) (35 ± 5 vs. 18 ± 0.4, p<0.001). The difference in mean rSO(2) between survivors and non-survivors was most pronounced in the final 5 min of cardiac arrest (48 ± 1 vs. 15 ± 0.2, p<0.0001) and appeared to herald imminent ROSC. Although spending a significantly higher portion of time with an rSO(2)>40% was found in survivors (p<0.0001), patients with ROSC had an rSO(2) above 30% for >50% of the duration of cardiac arrest, whereas non-survivors had an rSO(2) that was below 30%>50% of their cardiac arrest. Patients with ROSC also had a significantly higher change in rSO(2) from baseline compared to non-survivors (310% ± 60% vs. 150% ± 27%, p<0.05). CONCLUSION: Cerebral oximetry may have a role in predicting ROSC and the optimization of cerebral perfusion during cardiac arrest.

Retropharyngeal calcific tendonitis: report of two cases.

Retropharyngeal calcific tendonitis is an inflammatory process of the superior oblique tendons of the longus colli muscle, a neck flexor in the upper cervical spine, caused by deposition of calcium hydroxyapatite crystals; the definitive diagnostic test is computed tomography (CT). Presented in this article are two cases seen at our institution. Patients typically present with acute onset of neck pain/spasm, odynophagia, dysphagia, and/or low grade fevers. Leukocytosis and elevated erythrocyte sedimentation rate may be noted. It is important to understand this entity because its signs and symptoms are mimickers of those of the more serious condition of retropharyngeal space abscess. Calcific tendonitis is managed conservatively whereas retropharyngeal abscess requires incision and drainage. Some may argue that this entity is a zebra because its reported incidence in the literature is low. However, most of these studies were done in an era when CT was not yet in vogue. With today's widespread use of CT and its superb ability to visualize the calcification, the true incidence of this condition is probably higher and, thus, it is important for the family practitioner to be aware of this entity. The astute clinician may save the patient from unnecessary diagnostic workup, undue anxiety, and delays in hospital discharge.