Cerebral Air Embolism after Esophagogastroduodenoscopy: Insight on Pathophysiology, Epidemiology, Prevention and Treatment.

BACKGROUND: Air embolism is an extremely rare complication that can follow gastrointestinal endoscopy. The most accepted treatment of cerebral air embolism (CAE) is hyperbaric oxygen (HBO). Limited evidence suggests that lidocaine may have a neuroprotective effect. The exact mechanism does not appear to be well elucidated. METHODS: We conducted a literature search using multiple combinations of keywords from PubMed and Ovid Medline databases according to the PRISMA guidelines. We included articles with cases of air embolism caused by an esophagogastroduodenoscopy (EGD). We excluded cases related to other procedures e.g. colonoscopy, endoscopic retrograde cholangiopancreatography, cholangioscopy, Kasai procedure, bronchoscopy, laparoscopy or thoracoscopy. We were able to identify 30 cases of CAE associated with EGD. We included our experience in treating one patient with CAE after elective EGD. RESULTS: Given the results of our literature search and this patient's characteristics, we chose to treat our patient with HBO and lidocaine infusion. Our case series consists of 31 patients of post EGD CAE, the mean age was 63.7 ± 11.14 years, 38.7% of the patients were women (n = 12). 38.7% of the cases underwent esophageal dilatation (n = 12), while 19.35% had EGD biopsy (n = 6), 9.6% had variceal ligation (n = 3), and 3.22% had variceal banding (n = 1). In 20 out of 31 cases, echocardiography has been documented, 20% of those patients (n = 4) had patent foramen ovale. HBO was used in treatment of 48% of cases (n = 15), among the included patients, 61% survived (n = 19). Our patient showed significant neurological improvement. CONCLUSIONS: Despite the rare incidence of CAE during or after EGD, physicians should be aware of this potential complication. In patients who develop sudden acute neurological symptoms, early diagnosis and intervention may prevent devastating neurological injury and death. The most accepted emergent treatment for CAE includes HBO, consideration of lidocaine, and work-up of source of the air embolism.

High-Risk Features of Delayed Clinical Progression in Cerebral Venous Thrombosis: A Proposed Prediction Score for Early Intervention.

BACKGROUND: Anticoagulation is the mainstay treatment for cerebral venous thrombosis (CVT). A subset of patients might deteriorate despite anticoagulation, and in such cases, endovascular therapy is recommended. METHODS: A retrospective review was performed on subjects with CVT from January 2005 to October 2016. The primary outcome was clinical deterioration. Bivariate analysis, multiple logistic regression modeling, and linear discriminant analysis were used to determine a predictive model for deterioration; the results from these models were used to construct a CVT score in order to measure the individual likelihood of deterioration. RESULTS: We identified 147 subjects with CVT. The majority were treated with anticoagulation (n = 109, 74.15%); 38 (25.85%) were found to have deterioration, 12 (8.16%) of whom underwent endovascular intervention. The most important risk factors of deterioration, per bivariate analysis, included decreased level of consciousness (odds ratio [OR] = 5.76; 95% confidence interval [CI] 2.59-12.77) and papilledema (OR = 4.52; 95% CI 1.55-13.18). The final multivariable model also included CVT location score (number of sinuses involved), oral contraceptive pill use, sodium level, platelet count, and seizure activity on presentation. This model had a predictive ability to identify deterioration of 83.2%, with a sensitivity of 71.4% and a specificity of 76.2%. Patients with a CVT score of ≥5 have at least 50% chance of deterioration. CONCLUSIONS: Decreased mental status, seizure activity, papilledema, number of involved sinuses, as well as sodium level and platelet count are the most important factors in predicting deterioration after CVT. This group may represent a subset of patients in whom early endovascular therapy may be considered.

Cerebral ischemia and deterioration with lower blood pressure target in intracerebral hemorrhage.

OBJECTIVE: To determine the incidence and predictors of acute cerebral ischemia and neurologic deterioration in intracerebral hemorrhage (ICH) patients after an institutional protocol change in systolic blood pressure (SBP) target from <160 to <140 mm Hg. METHODS: We retrospectively compared persons admitted with primary ICH before and after a protocol change in SBP target from <160 to <140 mm Hg. The primary outcomes were presence of acute cerebral ischemia on MRI completed within 2 weeks of ICH and acute neurologic deterioration. RESULTS: Of 286 persons with primary ICH, 119 underwent MRI and met inclusion criteria. Sixty-two had a target SBP <160 mm Hg (group 1) and 57 had a target SBP <140 mm Hg (group 2). There were no differences between the 2 groups in baseline clinical and radiographic characteristics, but over the first 24 hours of hospitalization, group 2 had lower mean SBP (134 vs 143 mm Hg, p < 0.001) and lower minimum SBP over 72 hours (106 vs 112 mm Hg, p = 0.02). Acute cerebral ischemia was more frequent in group 2 than in group 1 (32% vs 16%; p = 0.047) as was acute neurologic deterioration (19% vs 5%; p = 0.022). A minimum SBP ≤120 mm Hg over 72 hours was associated with cerebral ischemia, while no patient with a minimum SBP ≥130 mm Hg had cerebral ischemia. Acute cerebral ischemia was significantly associated with worse discharge NIH Stroke Scale score, while SBP target was not. CONCLUSIONS: Intensive lowering of SBP <140 mm Hg in acute ICH, particularly allowing SBP <120 mm Hg, is associated with increased remote cerebral ischemic lesions and acute neurologic deterioration.

Utility of electronic medical record for recruitment in clinical research: from rare to common disease.

BACKGROUND: Recruitment for clinical trials is a major challenge. Movement disorders, which do not have associated diagnostic laboratory tests, may be especially prone to inaccuracy in coding. Our objective was to evaluate the accuracy of diagnostic codes such as cervical dystonia (CD) and PD in an electronic medical record. METHODS: Retrospective chart review was performed to confirm the ICD-9 diagnoses of PD, CD and diabetes mellitus type 2 (DM-2), using published clinical diagnostic criteria (PD, CD) and hemoglobin A1c ≥ 6.5 (DM-2). RESULTS: 421 charts (n=129, n=142, n=150 for PD, CD and DM-2, respectively) were reviewed. The accuracy rate was different between all diseases examined with an overall p<0.001. In post hoc pairwise comparisons, the accuracy of DM-2 diagnosis by ICD-9 (96.6%) was greater than CD (88.0%) and both greater than PD (55.0%) (p≤0.003). CONCLUSIONS: Using an electronic medical record based screening of clinically diagnosed diseases such as CD may be more accurate than previously thought and may identify potential clinical trial participants even without confirmatory lab tests available.