Diagnosis of total internal carotid occlusions with duplex ultrasound and ultrasound contrast.

It remains a significant technical challenge for duplex ultrasound to accurately differentiate between total and near total internal carotid artery (ICA) occlusions. We have evaluated the efficacy of an ultrasound contrast agent combined with improved imaging techniques in patients with suspected carotid artery occlusions. Patients identified by conventional duplex ultrasound between January and August 2003 as having a possible ICA occlusion were eligible for study. A 1 mL bolus of ultrasound contrast agent was injected into a 50 mL bag of normal saline and given intravenously at a rate of approximately 4-5 mL/minute. Ultrasound imaging and spectral Doppler analysis were done using tissue harmonic imaging for optimum contrast agent to soft tissue discrimination, or with the direct B-mode imaging of blood flow to maximize the brightness of the circulating contrast agent. Ten patients were identified, 6 men and four women with a mean age of 68.3 years. Nine suspected total ICA occlusions were unilateral and 1 was bilateral. Imaging with contrast agent confirmed occlusion of the ICA in 7 of 10 patients; 3 patients had near-total occlusion with flow detected in the distal ICA by spectral and color Doppler. All 3 of these near-total occlusions were ultimately confirmed by either conventional or magnetic resonance carotid angiography. The contrast agent was most beneficial in improving the detection of minimal flow beyond a severe stenosis and in evaluating flow dynamics in the presence of severely calcified plaque. We conclude that the use of an ultrasound contrast agent with newer duplex ultrasound imaging techniques can reliably distinguish total from near-total internal carotid artery occlusions. Future prospective studies should be able to define the efficacy of ultrasound contrast agents in improving the overall diagnostic accuracy of duplex ultrasound in technically difficult cases and in patients with complex peripheral vascular disease.

Effects of antiplatelet agents on outcomes for elderly patients with traumatic intracranial hemorrhage.

BACKGROUND: Recent literature on elderly patients with traumatic intracranial hemorrhage receiving preinjury antiplatelet agents shows a mortality rate of 47%. METHODS: In a retrospective analysis, patients older than 50 years presenting to the hospital over the past 4 years with traumatic intracranial hemorrhage and the use of aspirin, clopidogrel, or a combination were compared with a control group that had hemorrhage but no antiplatelet medications. Patient demographics, mechanism of injury, and injury scores were recorded. RESULTS: No significant differences were found between the 90 study patients and the 89 control subjects in terms of demographics, mechanism of injury, Injury Severity Score, Glasgow Coma Score, or hospital length of stay. Patients receiving antiplatelet therapy had significantly more comorbid conditions (71% vs. 35%; p < 0.001). In this series, 21 study patients and 8 control patients died (23% vs. 8.9%; p = 0.016). Age older than 76 years and a Glasgow Coma Score lower than 12 were correlated significantly with increased mortality. CONCLUSIONS: The use of antiplatelet agents with elderly trauma patients significantly increases the risk of mortality when head injury involves intracranial hemorrhage.

Use of an indwelling pleural catheter compared with thorascopic talc pleurodesis in the management of malignant pleural effusions.

Therapy for recurrent malignant pleural effusion (MPE) is palliative. Video-assisted thoracic surgery with talc pleurodesis (VATS/TP) is limited to inpatients with completely expandable lung parenchyma. We evaluated the outcomes, safety, and efficacy of an indwelling pleural drainage catheter (PDC) system compared with VATS/TP. Forty-one consecutive patients with symptomatic MPE seen between September 2000 and April 2002 were studied. Patients able to fully re-expand their lungs were treated with VATS/TP; those who could not had PDC placement. Twenty-four (59%) were women. The mean age was 64 +/- 13 years. VATS/TP was performed in only seven patients (17%), and 34 patients had PDC placement. The length of stay (LOS) was 2.8 +/- 5.1 days in the 18 PDC patients who were initially seen as outpatients and 9.4 +/- 9.0 days in the inpatient population (P = 0.013). Short (< 2 days) LOS occurred in 19 (56%) PDC patients but in no VATS/TP patients (P = 0.007). Twenty-eight patients (68%) died during follow-up: three VATS/TP patients (43%) and 25 (74%) PDC patients (P = 0.112). We conclude that the PDC system is an efficacious treatment of patients with MPEs and trapped lungs. The LOS is short in patients initially evaluated as outpatients which contributes to the perception of increased quality of life.