Aggressive Medical Management Research Articles

Stenting for symptomatic intracranial arterial stenosis with different qualifying arteries: a preplanned pooled individual patient data analysis

BackgroundThe efficacy of percutaneous transluminal angioplasty and stenting (PTAS) relative to medical management in treating symptomatic intracranial arterial stenosis (ICAS) varies based on the qualifying artery. This study aims to...

Use of Onyx Frontier™ for intracranial stenting in stroke patients: A multicenter retrospective study.

Acute ischemic stroke (AIS) due to intracranial atherosclerotic disease (ICAD) carries a high risk of recurrence despite aggressive medical management. The aim of our study is to present our initial experience with the Onyx Frontier™ balloon-mounted drug-eluting stent (Medtronic, Santa Rosa, CA) for AIS due to ICAD. We conducted a multicenter retrospective cohort study describing the technical feasibility, safety, and performance of using the Onyx Frontier™ balloon-mounted drug-eluting stent in patients with acute intracranial vessel occlusion due to ICAD across three comprehensive stroke centers in the United States. We included 23 patients in our study (mean age 67.3 [10.7]; females: n = 13/23, 56.5%). Most patients were Black (n = 14/23, 60.9%). The most common site of vessel occlusion was the M1 branch of the middle cerebral artery (MCA) (n = 14/23, 60.9%), followed by the vertebrobasilar system (n = 5/23, 21.7%), and the internal carotid artery (n = 3/23, 13.0%). Treatment with the Onyx Frontier™ stent was associated with a final mTICI score ≥2b for 100% of patients, with no vessel perforations or distal embolization. None of the patients had any restenosis or re-treatment over a median follow-up of 3.5 months (interquartile range [IQR] 7.8). All cases required a single stent except for one, where two were deployed. Transfemoral access was used in most cases (n = 18/23, 78.3%), with one in-hospital death due to access site complication (n = 1/23, 4.3%). This is the largest multicenter cohort study demonstrating the feasibility and safety of using the Onyx Frontier™ balloon-mounted zotarolimus-eluting stent to treat symptomatic AIS due to ICAD.

1-Year outcomes of Resolute Onyx Zotarolimus-Eluting Stent for symptomatic intracranial atherosclerotic disease: A multicenter propensity score-matched comparison with stenting versus aggressive medical management for preventing recurrent stroke in intracranial stenosis trial.

Intracranial atherosclerotic disease (ICAD) is one of the most prevalent causes of stroke across the world. Endovascular treatment has gained prominence but remains a challenge with unfavorable results. Recent literature has demonstrated that the Resolute Onyx Zotarolimus-Eluting Stent (RO-ZES) is a technically safe option with low complication rates along with 30-day outcomes associated with intracranial stent placement for ICAD with RO-ZES compared to results from the Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. Here, we aim to compare outcomes at one year with the SAMMPRIS trial with a multicenter longitudinal study. Prospectively maintained databases across seven stroke centers were analyzed for adult patients undergoing RO-ZES placement for ICAD between January 2019 and May 2023. The primary endpoint was composite of one-year stroke, ICH, and/or death. These data were propensity score matched using age, sex, hypertension, diabetes mellitus, smoking status, and impacted vessel for comparison between RO-ZES and the SAMMPRIS percutaneous angioplasty and stenting groups (S-PTAS). A total of 104 patients were included, mean age ± SD: 64.9 ± 10.9 years, 25.5% female. Propensity score match analysis of the 104 patients with S-PTAS demonstrated one-year stroke, ICH, and/or death rate of 11.5% in the RO-ZES group and 28.1% in the S-PTAS group (odds ratio 4.17, 95% CI 2.06-8.96, p = 0.001). The RO-ZES system demonstrates strong potential to reduce long-term complications at one year compared with the S-PTAS group. Further prospective multicenter studies are needed to corroborate and build upon these findings.

Mucor thriving on iron in beta thalassemia major: A case of rhino-orbital mucormycosis

Mucormycosis is a dreaded condition with high mortality rates noted in immunocompromised hosts. Though iron overload is a known risk factor, children with transfusion-dependent thalassemia have been rarely reported with invasive mucormycosis. We present an 8-year-old girl with transfusion-dependent thalassemia with hypersplenism and iron overload. She had invasive rhino-sino-orbital mucormycosis with a fatal outcome despite aggressive surgical and medical management.

Hyperglycemia and Venous Thromboembolism.

Patients with diabetes mellitus (DM) have chronically increased blood glucose and multiple physiologic alterations that place them at elevated risk for vascular disease. Traditionally, this vascular risk has mainly referred to chronic atherosclerosis and embolic arterial disease. Retrospective studies have suggested an increased risk of a pulmonary embolism (PE) and deep vein thrombosis (DVT), collectively termed venous thromboembolism (VTE), in patients with DM, but this association has been difficult to demonstrate with comorbidities such as obesity in meta-analysis. Clinical studies have demonstrated worse outcomes for patients with DM who suffer from VTE. In vitro studies show multiple physiologic abnormalities with chronic inflammation, endothelial dysfunction, dysfunction in the coagulation cascade, as well as other changes that drive a vicious cycle of hypercoagulability. Aggressive medical management of DM can improve vascular outcomes, and some anti-hyperglycemic therapies may modify VTE risk as well. Anticoagulation strategies are similar for patients with DM, but with some added considerations, such as high rates of comorbid renal dysfunction. More research is needed to definitively categorize DM as a risk factor for VTE and elucidate specific therapeutic strategies.

Fournier's Gangrene reconstruction in black patients using SCIP flap and split thickness skin graft: 2 case reports and a literature review

Fournier's gangrene is a potentially life-threatening infectious disease involving the perineum and genitals. Aggressive surgical and medical management is often required, leaving the patient with large integumentary defects. The multiplicity of reconstructive options reported highlights the lack of consensus on the best covering option. Functional and aesthetic considerations are in play, and the literature is scarce on male black patients. We report here two cases of dark-skinned patients presenting with scrotal and penile integumentary defects that were respectively reconstructed with a superficial circumflex iliac artery propeller perforator flap and a split-thickness meshed skin graft and discuss the available literature on the topic.

Paediatric idiopathic intracranial hypertension: Epidemiology, clinical features and treatment outcomes in a tertiary care centre in Western Australia.

This retrospective study aims to analyse the epidemiology, clinical and neuroimaging features, treatment modalities, and outcomes of paediatric idiopathic intracranial hypertension (IIH) in a tertiary care centre in Australia. Using the International Classification of Diseases Diagnostic Criteria for IIH, we identified and analysed a cohort of children diagnosed with IIH over a 5-year period (2017-2022). Data on patient demographics, symptomatology, examination findings, investigative results, treatments and outcomes were collected from medical records and electronic health records. A total of 45 cases were analysed. The pre-pubertal group saw a male predominance and the post-pubertal a female one. Increased body mass index was an associated comorbidity in majority of patients. Headaches (89%) and visual symptoms (56%) were the most common symptoms, with tinnitus also seen in 20% of patients. Papilledema was detected in 91% of the cases examined. The commonest neuroimaging features were optic nerve sheath distention (78%) and empty sella (49%). Acetazolamide was the primary treatment, with most patients responding well. Only a minority required surgical intervention. Long-term resolution of headaches was achieved in 89% of patients. The incidence of paediatric IIH in the West Australian population appears relatively high. It presents with subtle symptoms, emphasising the need for increased awareness among health-care providers. Younger children may represent a distinct subgroup with unique clinical features. Timely diagnosis and aggressive medical management lead to favourable outcomes. However, weight loss interventions showed limited effectiveness. This study underscores the importance of early recognition and management of paediatric IIH to optimise patient outcomes.

Comparative Effectiveness of Therapies in 2665 Elderly Patients with Ruptured Intracranial Aneurysms.

The optimal treatment strategy for elderly patients with ruptured intracranial aneurysms (IAs) remains controversial. We evaluated a national, multihospital database to compare the outcomes of aggressive treatment and medical management for those patients. We performed a retrospective analysis of 2665 elderly patients with ruptured IAs admitted to 11 hospitals in China. Patients were divided into three age groups (60-69, 70-79, and 80 years or older). Multiple logistic regression was used to estimate the odds ratio for favorable and unfavorable outcomes. Patients between 60 and 69 years old undergoing endovascular treatment (EVT) had significantly decreased morbidity (13.7% versus 19.7% and 29.9%), compared to those who underwent clipping and medical management, similar mortality to patients who underwent clipping (3.6% versus 2.6%), and decreased mortality (3.6% versus 8.7%) to patients who underwent medical management. Coiled patients 70 to 79 years old had lower morbidity (21.3% versus 33.8%) and mortality (2.8% versus 11.3%) compared to patients who underwent medical management and similar mortality (21.3% versus 27.2%) and mortality (2.8% versus 4.8%) to patients who underwent clipping. Multivariate logistic regression analysis demonstrated that factors associated with discharge status were age, poor mFisher grade, poor WFNS grade, hypertension, diabetes, smoking, aneurysms 4 mm or larger, and middle cerebral artery aneurysms. Elderly patients treated with EVT had significantly less morbidity and mortality than those treated with clipping and medical management. A comprehensive assessment of the general state of elderly patients and IAs characteristic may help us to predict patients' prognosis.

Overview of Mycotic Keratitis.

Keratomycosis is a serious corneal infection associated with high ocular morbidity that can lead to severe vision loss. It is estimated to affect more than 1 million patients annually, most commonly occurring in tropical climates, and represents a growing threat to patients worldwide. Despite aggressive medical management, fungal infections have a higher rate of perforation requiring surgical intervention compared with other infectious etiologies. Early diagnosis and appropriate treatment are keys to preserving vision and saving patients' eyes.Timely diagnosis of fungal keratitis helps minimize corneal damage and scarring and increases the likelihood of a favorable outcome. Studies have shown that correct identification of fungal infections is often delayed up to 2 to 3 weeks after initial presentation. This leads to incorrect or ineffective treatment for many patients. Diagnostic techniques explored in this study include corneal scrapings with staining and culture, visualization with in vivo confocal microscopy, molecular diagnostic techniques including polymerase chain reaction, and recently developed omics-based technologies.Treatment of fungal keratitis begins with topical antifungals. Medical management has been proven to be effective, but with limitations including poor drug penetration and low bioavailability. Cases that do not respond to topical therapy require more invasive and novel treatments to control the infection. We review the clinical trials that have shaped current practice patterns, with focus on the efficacy of topical natamycin as the primary therapy for filamentous fungal keratitis. We explore additional management strategies such as localized intrastromal and intracameral injections of antifungal medications, photodynamic therapy, and surgical intervention.

Development and evaluation of a prediction model for peripheral artery disease-related major adverse limb events using novel biomarker data

ObjectivePrognostic tools for individuals with peripheral artery disease (PAD) remain limited. We developed prediction models for 3-year PAD-related major adverse limb events (MALE) using demographic, clinical, and biomarker data previously validated by our group. MethodsWe performed a prognostic study using a prospectively recruited cohort of patients with PAD (n = 569). Demographic/clinical data were recorded including sex, age, comorbidities, previous procedures, and medications. Plasma concentrations of three biomarkers (N-terminal pro-B-type natriuretic peptide [NT-proBNP], fatty acid binding protein 3 [FABP3], and FABP4) were measured at baseline. The cohort was followed for 3 years. MALE was the primary outcome (composite of open/endovascular vascular intervention or major amputation). We trained three machine learning models with 10-fold cross-validation using demographic, clinical, and biomarker data (random forest, decision trees, and Extreme Gradient Boosting [XGBoost]) to predict 3-year MALE in patients. Area under the receiver operating characteristic curve (AUROC) was the primary model evaluation metric. ResultsThree-year MALE was observed in 162 patients (29%). XGBoost was the top-performing predictive model for 3-year MALE, achieving the following performance metrics: AUROC = 0.88 (95% confidence interval [CI], 0.84-0.94); sensitivity, 88%; specificity, 84%; positive predictive value, 83%; and negative predictive value, 91% on test set data. On an independent validation cohort of patients with PAD, XGBoost attained an AUROC of 0.87 (95% CI, 0.82-0.90). The 10 most important predictors of 3-year MALE consisted of: (1) FABP3; (2) FABP4; (3) age; (4) NT-proBNP; (5) active smoking; (6) diabetes; (7) hypertension; (8) dyslipidemia; (9) coronary artery disease; and (10) sex. ConclusionsWe built robust machine learning algorithms that accurately predict 3-year MALE in patients with PAD using demographic, clinical, and novel biomarker data. Our algorithms can support risk stratification of patients with PAD for additional vascular evaluation and early aggressive medical management, thereby improving outcomes. Further validation of our models for clinical implementation is warranted.

Demographic Characteristics, Clinical Presentations, and Risk Factors Impacting Visual Outcomes in Peripheral Ulcerative Keratitis.

To assess the demographic characteristics, ophthalmic and systemic presentations, and risk factors impacting the outcomes in patients diagnosed with peripheral ulcerative keratitis (PUK). This retrospective study includes patients diagnosed with PUK at a tertiary care center over 13 years. A descriptive analysis of the demographics, clinical history, and presentation was performed. A reverse risk analysis was performed to assess the PUK resolution in patients with underlying autoimmune and non-autoimmune etiologies. Finally, we evaluated the correlation between treatment duration and final best corrected visual acuity (BCVA) and continuous and categorical variables. A total of 58 eyes of 51 patients with a mean age of 59.67 ± 13.41 years diagnosed with PUK were included in the study; 58.82% were female. The resolution duration was significantly shorter in patients with autoimmune etiologies (vs. non-autoimmune etiologies, P = 0.028) and female patients (vs. male patients, P = 0.008). The BCVA worsened in patients with non-autoimmune etiologies after treatment (P = 0.17). Despite worse BCVA at presentation in patients with underlying autoimmune etiologies, significantly better final vision outcomes were observed (P = 0.04). Linear regression analysis showed that longer treatment duration (P = 0.001; R2 = 0.1704) and worse vision (P = 0.002; R2 = 0.1502) at presentation were the primary risk factors of poor vision outcomes. Similarly, the treatment duration was significantly longer in male compared with female patients (P < 0.001; R2 = 0.2027). The clinical outcomes in PUK with underlying autoimmune disorders were observed to be better than non-autoimmune etiologies, which may be attributed to the early detection of the PUK-related changes and aggressive medical management. A delayed diagnosis of PUK leads to poor vision outcomes.

Abstract WMP39: Incorporation of Automated Robotic Transcranial Doppler to Screen for Patent Foramen Ovale and Quantify Right to Left Shunt Severity in the Evaluation of Ischemic Stroke Patients for Stroke Etiology at a Comprehensive Stroke Center

Background: Patent foramen ovale (PFO) as a source of right-left shunting (RLS) is a recognized risk factor for recurrent stroke in young patients. Current standard care for RLS diagnosis includes transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and manual transcranial Doppler (TCD) which have disadvantages. The purpose of this retrospective review is to evaluate incorporation of an automated robotic TCD (rTCD) into the standard evaluation for RLS as cause of stroke, as prior studies have indicated higher sensitivity and quantification of RLS size to direct cardiology referral for potential PFO closure. Methods: Between Dec 2021-Oct 2022, 200 stroke patients age &lt;65 were included in this retrospective review. Average age was 55.7 ± 11.1 yrs. All patients had standard TTE and an rTCD (NovaSignal) with saline bubble injection at rest and Valsalva strain for assessment of RLS performed by echo and ultrasound technicians. Neurologists read results, including RLS shunt severity using the Spencer Shunt Grading scale (0-5), where Grade 3-5 is considered large. Results: The rate of positive RLS shunt using rTCD was 55.5% (n=111), of which 23.5% (n=47) were Spencer grade 3+ or higher. No bone window rate was 8.5% (n=17), which is lower than reported manual TCD rates. There were no rTCD RLS shunt negative patients who had a positive TTE or TEE. Of patients who had positive rTCD (n=14) and TTE with bubble, only 5 TTE’s were positive (35.7% sensitivity). Of rTCD positive patients (n=23) who also had TEE with bubble, only 11 were positive (48% sensitivity). And of 15 rTCD Grade 3+ RLS, only 11 TEE with bubble were positive (73% sensitivity). Conclusion: We successfully replaced rTCD for TTE with bubble to screen for RLS on patients who were admitted with a stroke or TIA, with the following advantages. Non-TCD technicians could be trained to perform the tests with accuracy. rTCD was more sensitive in detecting RLS than TTE with bubble. Quantification of RLS severity identified stroke patients with potentially higher risk of recurrence, prioritized to more aggressive medical management and cardiology referral for TEE and potential PFO closure.

Emergent Large Vessel Occlusion due to Intracranial Stenosis: Identification, Management, Challenges, and Future Directions.

This comprehensive literature review focuses on acute stroke related to intracranial atherosclerotic stenosis (ICAS), with an emphasis on ICAS-large vessel occlusion. ICAS is the leading cause of stroke globally, with high recurrence risk, especially in Asian, Black, and Hispanic populations. Various risk factors, including hypertension, diabetes, hyperlipidemia, smoking, and advanced age lead to ICAS, which in turn results in stroke through different mechanisms. Recurrent stroke risk in patients with ICAS with hemodynamic failure is particularly high, even with aggressive medical management. Developments in advanced imaging have improved our understanding of ICAS and ability to identify high-risk patients who could benefit from intervention. Herein, we focus on current management strategies for ICAS-large vessel occlusion discussed, including the use of perfusion imaging, endovascular therapy, and stenting. In addition, we focus on strategies that aim at identifying subjects at higher risk for early recurrent risk who could benefit from early endovascular intervention The review underscores the need for further research to optimize ICAS-large vessel occlusion treatment strategies, a traditionally understudied topic.

Optimal Medical Management of Atherosclerotic Intracranial Stenosis.

Reducing the high risk of recurrent stroke in patients with symptomatic intracranial atherosclerotic stenosis (sICAS) has proven to be challenging, but aggressive medical management, with intensive risk factor control and antithrombotic therapy, has been shown to be beneficial. High-intensity statins are recommended for patients with atherosclerotic stroke, including sICAS. Ezetimibe and PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors are beneficial for those who fail to reach low-density lipoprotein targets or those with statin intolerance. The treatment target for sICAS is low-density lipoprotein <70 mg/dL. In neurologically stable patients, blood pressure should be treated to goal <140/90 mm Hg with the use of thiazide diuretics, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers preferentially. For those with diabetes, treat to goal hemoglobin A1C ≤7% for most patients through combination of diet, insulin, and hypoglycemic drugs. Some degree of physical activity (eg, walking, stationary biking with arms or legs, etc) should be encouraged in all patients with sICAS who are not severely disabled. A minimum of 10 minutes of moderate-intensity aerobic activity 4 times a week is recommended for patients who are capable of exercise. For all patients with severe sICAS (70%-99% stenosis), dual antiplatelet therapy for up to 90 days followed by single antiplatelet agent is recommended.

Abstract WP142: Investigating the Association of Intracranial Stenosis With Low Wall Shear Stress

Background: Intracranial atherosclerotic disease (ICAD) is associated with high recurrence rates of stroke despite aggressive medical management. Low wall shear stress (WSS) alters endothelial function and changes in WSS within the post-stenotic region of ICAD lesions is a potential driver of stroke recurrence. Methods: Using the SAMMPRIS imaging dataset, we identified medically managed patients with symptomatic middle cerebral artery (MCA) stenosis measured by CTA. WSS was calculated by creating a 3D volumetric mesh from CTA source imaging. Pulsatile flow profile reference standard boundary conditions were applied at pressure outlets to simulate normal hemodynamics. Arterial segments extending from the stenosis to the MCA bifurcation were captured and quantified. Contralateral arterial segments were matched by length and area. The ratio of area with low WSS (&lt;4 dyne/cm 2 ) on both sides was then calculated. Differences in the mean arterial area with low WSS and ratio of area with low WSS were compared using paired Student’s t-test with data presented as mean ± SD. Results: Of 451 cases in SAMMPRIS, the medical management arm had 105 MCA cases of which 47 cases had CTA available and 33 cases were able to be analyzed by computational flow dynamics. Symptomatic ICAD lesions demonstrated significant differences in post stenosis area with low WSS (24.7±43.4 mm 2 vs 2.8±3.4 mm 2 p=0.003) and differences in the low WSS ratio (0.25±0.26 vs0.04±0.05 p&lt;0.001). There was no statistically significant difference in the length and area of the arterial segment post stenosis to the bifurcation and the control length on the contralateral side (11.6±7.4 mm vs 10.6±6.1 mm p=0.566; 80.7±55.0 mm 2 vs 95.4±58.3 mm 2 p=0.298). Conclusion: Area with low WSS after ICAD stenoses is increased in the SAMMPRIS imaging dataset and may be a marker of symptomatic ICAD. Further studies are needed to evaluate the association of post stenotic WSS with symptomatic recurrent stroke.

Emergency decompressive surgery in patients with transtentorial brain herniation and pupillary abnormalities: the importance of improved pupillary response after osmotherapy and surgery.

The predictors of survival and functional recovery following emergency decompressive surgery in patients with transtentorial brain herniation, particularly those with pupillary abnormalities, have not been established. In this study, the authors aimed to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression. A retrospective chart review was performed of all patients with transtentorial herniation and pupillary abnormalities who underwent craniotomy or craniectomy at two trauma and stroke centers between 2016 and 2022. The functional outcome was determined using the modified Rankin Scale (mRS). Forty-three patients, 34 men and 9 women with a mean age of 47 years (range 16-92 years), were included. The underlying etiology was traumatic brain injury in 33 patients, hemorrhagic stroke in 8 patients, and tumor in 2 patients. The median preoperative Glasgow Coma Scale score was 3 (range 3-8), and the median midline shift was 9 mm (range 1-29 mm). Thirty-two patients (74.4%) had bilaterally fixed and dilated pupils. The median time to surgery (from pupillary changes) was 133 minutes (mean 169 minutes, range 30-900 minutes). Eighteen patients (41.9%) died postoperatively. After a median follow-up of 12 months (range 3-12 months), 11 patients (26.8%) had a favorable functional outcome, while 10 remained severely disabled (mRS score 5). On univariate analysis, younger age (p < 0.001), less midline shift (p = 0.049), and improved pupillary response after osmotic therapy (p < 0.01) or decompressive surgery (p < 0.001) were associated with favorable outcomes at 3 months. With aggressive medical and surgical management, patients with transtentorial brain herniation, including those with bilaterally fixed and dilated pupils, may have considerable rates of survival and functional recovery. Young age, less midline shift, and improved pupillary response following osmotic therapy or decompressive surgery are favorable prognosticators.

Abstract TP31: Identifying Multivariate Nonlinear Bias in Sammpris Using Graph-Based AI Analysis

Background: Clinical trials are the most rigorous way of testing how novel treatments compare with existing ones regarding outcomes. The randomized controlled clinical trial has become the standard means of providing proof of safety and effectiveness across the board in medicine, including stroke. Yet, the risk factors among patients that are randomized might not always be equally distributed such that a bias may occur. In this study, we focus on the SAMMPRIS clinical trial aimed to assess the safety and efficacy of aggressive medical management versus stenting for preventing recurrent stroke in patients with symptomatic intracranial arterial stenosis. Methods: We developed and evaluated a machine learning model to identify potential multivariate bias present in the dataset that could not have been identified using standard statistical tests. Our approach utilizes a machine learning model based on the spectral regression model (SR-KDA) to identify biases created by combinations of variables. SR-KDA is based on a graph representation of the data that is processed via discriminative analysis to identify groups of patients that share common characteristics. By using both the treatment and outcome variables as constraints, the model is able to identify nonlinear relationships between clinical variables and the outcome. It can also be used to identify bias as part of the randomization that could have inadvertently skewed the statistical results with standard methodologies. Results: Our approach was successfully applied to the SAMMPRIS clinical dataset, which includes 121 clinical variables. The algorithm was able to automatically identify 6 clusters of patients that had a different response to treatment when considering the clinical variables. Each group was then assigned a set of the variables' cut-off values that best describe them. Conclusion: We have developed a sophisticated system that is capable of detecting non-linear correlations in clinical data collected during trials. This solution has the potential to mitigate any biases that may arise during the randomization process, which could ultimately improve recruitment efforts. Moving forward, this innovative tool could be applied proactively to future clinical trials.

Thyrotoxicosis Masquerading as Late Onset Mania: A Case Report on Treatment of Mania in Thyroid Storm

Manic episodes, typically associated with Bipolar Affective Disorder (BPAD), can also arise from medical conditions such as thyrotoxicosis, leading to “secondary” or “organic” mania. Thyrotoxicosis, characterised by excessive thyroid hormone levels, can cause neuropsychiatric symptoms and, in severe cases, result in a thyroid storm. Present case is of a middle-aged male patient without a prior psychiatric history who presented with manic symptoms such as overspending, over familiarity, and agitation, alongside physical signs of thyrotoxicosis, including weight loss and tachycardia. He was diagnosed with a thyroid storm secondary to Graves’ disease. Despite the rarity of the condition and the absence of established guidelines, management prioritised controlling sympathetic overactivity and restoring euthyroid status. Lithium, along with antipsychotics were chosen for their minimal impact on the QTc interval, was utilised to effectively address the manic symptoms. Aggressive medical management targeting both thyroid function and manic symptoms led to significant improvement. This case highlights the critical need to consider medical aetiologies in psychiatric presentations and underscores the importance of early diagnosis and multidisciplinary management to reduce morbidity. Collaborative efforts among medical specialties are essential to address the complexities of such cases.

Orbital compartment syndrome following primary scleral buckle surgery.

To illustrate a patient with orbital compartment syndrome following scleral buckle placement that was successfully treated with canthotomy and cantholysis. Observational case report. A 26-year-old male underwent a primary scleral buckle repair for a chronic rhegmatogenous retinal detachment. On post-operative day four, the patient presented to the emergency room with pain and increased intraocular pressure (IOP). Initial treatment with conservative IOP lowering agents was unsuccessful. The patient was diagnosed with delayed orbital compartment syndrome and was successfully managed with lateral canthotomy and inferior cantholysis in addition to aggressive steroid and antibiotic medical management. Following scleral buckle placement with sub-tenon's anesthesia block, there may be a delayed presentation of orbital compartment syndrome. Recognition and management of this rare complication is important for preventing irreversible blindness.

Risk factors associated with progression from papilloedema to optic atrophy: results from a cohort of 113 patients

BackgroundThe aim of this study was to assess the risk factors for atrophic progression of patients with papilloedema secondary to intracranial hypertension, using optical coherence tomography parameters.MethodsA retrospective study was...