A case of "smoldering" immune-mediated thrombotic thrombocytopenic purpura manifesting as recurrent cardioembolic stroke.

Prompt recognition and treatment for thrombotic thrombocytopenic purpura (TTP) are critical to prevent the irreversible manifestations of this rare and quickly fatal hematologic disorder. Untreated TTP is typically a rapid-onset disease with mortality exceeding 90% within days in the absence of appropriate treatment. In the current report, we describe a case of immune-mediated TTP (iTTP) in a 62-year-old man manifesting as longstanding thrombocytopenia, recurrent cardioembolic strokes, and valvular thrombogenesis over a period of 3 years. We provide correlative evidence to support the potential contribution of adalimumab, a TNFα inhibitor, to the development of iTTP. We offer several educational insights regarding the identification of atypical presentations of iTTP owing to the longstanding disease course and numerous clinical comorbidities seen in this patient.

The Utility of Intraoperative Lateral Spread Recording in Microvascular Decompression for Hemifacial Spasm: A Systematic Review and Meta-Analysis.

BACKGROUND: Microvascular decompression (MVD) is the surgical treatment of choice for hemifacial spasm (HFS). During MVD, monitoring of the abnormal lateral spread response (LSR), an evoked response to facial nerve stimulation, has been traditionally used to monitor adequacy of cranial nerve (CN) VII decompression. OBJECTIVE: To assess the utility of LSR monitoring in predicting spasm-free status after MVD postoperatively. METHODS: We searched PubMed, Web of Science, and Embase for relevant publications. We included studies reporting on intraoperative LSR monitoring during MVD for HFS and spasm-free status following the procedure. Sensitivity of LSR, specificity, diagnostic odds ratio, and positive predictive value were calculated. RESULTS: From 148 studies, 26 studies with 7479 patients were ultimately included in this meta-analysis. The final intraoperative LSR status predicted the clinical outcome of MVD with the following specificities and sensitivities: 89% (0.83- 0.93) and 40% (0.30- 0.51) at discharge, 90% (0.84-0.94) and 41% (0.29-0.53) at 3 mo, 89% (0.83-0.93) and 40% (0.30-0.51) at 1 yr. When LSR persisted after MVD, the probability (95% CI) for HFS persistence was 47.8% (0.33-0.63) at discharge, 40.8% (0.23-0.61) at 3 mo, and 24.4% (0.13-0.41) at 1 yr. However, when LSR resolved, the probability for HFS persistence was 7.3% at discharge, 4.2% at 3 mo, and 4.0% at 1 yr. CONCLUSION: Intraoperative LSR monitoring has high specificity but modest sensitivity in predicting the spasm-free status following MVD. Persistence of LSR carries high risk for immediate and long-term facial spasm persistence. Therefore, adequacy of decompression should be thoroughly investigated before closing in cases where intraoperative LSR persists.

Perioperative Stroke in Carotid Artery Stenting as a Surrogate Marker and Predictor for 30-day Postprocedural Mortality - A Pooled Analysis of 156,000 Patients with Carotid Artery Disease.

BACKGROUND: Carotid artery stenosis (CAS) is being recognized as an effective alternative for carotid endarterectomy (CEA). CAS is especially preferred over CEA in high-risk surgical patients with severe carotid stenosis. However, CAS carries an increased risk of stroke and transient ischemic attack (TIA). OBJECTIVE: To assess the association between periprocedural stroke/TIA and 30-day mortality in carotid stenosis patients undergoing CAS. METHODS: We searched PubMed, Embase, and World Science for relevant publications. Studies reporting on perioperative neurologic status (stroke/TIA) and 30-day mortality in patients undergoing CAS were included. Sensitivity, specificity, pooled odds ratio (OR), and relative risk (RR) of perioperative stroke in predicting 30-day mortality following CAS were calculated. RESULTS: 146 studies with 156,854 patients were included in the meta-analysis. The mean patient age was 70.7 years, and 57.6% were males. Only 26.5% of the CAS cohort were symptomatic and 15.2% had bilateral carotid disease. The incidence of perioperative TIA and stroke were 2.4 and 2.7 per 100 CAS procedure, respectively. Around 11.8% of stroke-events were fatal. The pooled OR of 30-day mortality after perioperative stroke was 24.58 (95% CI, 19.92-30.32) and the pooled RR was 21.65 (95% CI, 17.87-26.22). Perioperative stroke had a sensitivity of 42.0% (95% CI 37.8-46.4%) and specificity of 97.0% (95% CI 96.7-97.3%) in predicting 30-day mortality. CONCLUSIONS: Perioperative stroke drastically increases the risk of 30-day mortality. The occurrence of perioperative stroke exhibited high specificity but modest sensitivity in predicting 30-day mortality following CAS. This highlights the importance of neurophysiologic monitoring to detect intraoperative cerebral ischemia and perform timely interventions.