Hyperacute Patients Research Articles

Early results of bare metal extension stent for thoracoabdominal aortic dissection.

ObjectivesDebakey type I and IIIb aortic dissections are complicated by extension along the full length of the aorta. Over the long term, the thoracoabdominal aorta in these patients often continues to degenerate, requiring endovascular or open repair. The purpose of this investigation is to determine the early clinical outcome on aortic remodeling using a composite thoracic stent graft and thoracoabdominal bare metal extension stenting strategy.MethodsFrom April 2019 to April 2021, 73 patients with Debakey I/IIIb aortic dissection underwent endovascular stent graft repair of the descending thoracic aorta and repair of the thoracoabdominal aorta using bare metal extension stenting. Preoperative and follow-up surveillance computed tomography imaging scans were analyzed.ResultsFifty-three (73%) patients had a Debakey I aortic dissection, and 50 (69%) patients underwent surgery during the chronic (time to surgery >30 days) dissection phase. Mortality at 30 days was 4% (3 hyperacute patients). Stroke occurred in 3 (4%), paraparesis in 2 (2.7%), and acute renal failure requiring dialysis occurred in 2 (2.7%) patients. On postoperative and follow-up computed tomography, there was a significant increase in false lumen thrombosis (P < .001). This coincided with a significant increase in true lumen fraction suggestive of positive aortic remodeling (P < .001) at the time of latest follow-up.ConclusionsAltering the course of aortic remodeling, with placement of a dissection stent in the thoracoabdominal aorta simultaneous with descending thoracic aortic repair may promote true lumen re-expansion and false lumen thrombosis during acute and chronic dissection phases.

Diffusion-Weighted Imaging Combined with Cervical Vascular Ultrasound in the Elderly Patients with Multiple Cerebral Infarction.

Objective This study is aimed at evaluating the diagnostic value of diffusion-weighted imaging combined with cervical vascular ultrasound in the elderly patients with multiple cerebral infarctions and at demonstrating whether the diagnostic value is affected by the history of diabetes. Methods From January 2020 to November 2021, the case data of 30 elderly patients with multiple cerebral infarction diagnosed in our hospital were included. Diffusion-weighted magnetic resonance imaging (DWI) and cervical vascular ultrasound (CAU) were performed, respectively. The diagnosis rates of the simple diffusion-weighted imaging group, the simple cervical vascular ultrasound group, and the diffusion-weighted imaging combined with cervical vascular ultrasound group were compared. Results The median onset time of 30 patients was 26.5 (4.75, 43.0) hours. There were 10 hyperacute patients and 20 acute patients. The proportion of diagnosable patients in the diffusion-weighted imaging group was 83.8% (25/30), which was lower than the proportion of diagnosable patients in the diffusion-weighted imaging combined with cervical vascular ultrasound group, which was 90% (27/30). The difference was statistically significant (χ2 = 16.667; P < 0.001). The ratio of diagnosable patients in the cervical vascular ultrasound group alone was 66.7% (20/30), which was lower than 90% (27/30) in the diffusion-weighted imaging combined with cervical vascular ultrasound group. The difference was statistically significant (χ2 = 6.7; P = 0.010). In the hyperacute phase, the proportion of diagnosable patients in the diffusion-weighted imaging combined with cervical vascular ultrasound group was higher than that in the diffusion-weighted imaging group alone (χ2 = 5.833; P = 0.016) and the cervical vascular ultrasound group alone (χ2 = 2.500; P = 0.004). In the acute phase, the proportion of diagnosable patients in the diffusion-weighted imaging combined with cervical vascular ultrasound group was also higher those that in the diffusion-weighted imaging group alone (χ2 = 9.474; P = 0.002) and the cervical vascular ultrasound group alone (χ2 = 3.158; P = 0.006). The diagnostic accuracy of diffusion-weighted imaging combined with cervical vascular ultrasound was not significantly different between patients with history of diabetes and without history of diabetes (χ2 = 1.014; P = 0.314) Conclusion The combined application of diffusion-weighted imaging and cervical vascular ultrasound has important value in improving the diagnosis rate of multiple cerebral infarction in the elderly, regardless of diabetes history, and it is worthy of clinical application.

Meningeal blood-brain barrier disruption in acute traumatic brain injury.

The meninges serve as a functional barrier surrounding the brain, critical to the immune response, and can be compromised following head trauma. Meningeal enhancement can be detected on contrast-enhanced MRI in patients presenting with acute traumatic brain injury, even when head CT is negative. Following head trauma, gadolinium-based contrast appears to extravasate from the vasculature, enhancing the dura within minutes, and later permeates the subarachnoid space. The aims of this study were to characterize the initial kinetics of the uptake of contrast agent after injury and the delayed redistribution of contrast enhancement in the subarachnoid space in hyperacute patients. Neuroimaging was obtained prospectively in two large ongoing observational studies of patients aged 18 years or older presenting to the emergency department with suspected acute head injury. Dynamic contrast-enhanced MRI studies in a cohort of consecutively enrolling patients with mild traumatic brain injury (n = 36) determined that the kinetic half-life of dural-related meningeal enhancement was 1.3 ± 0.6 min (95% enhancement within 6 min). The extravasation of contrast into the subarachnoid space was investigated in a cohort of CT negative mild traumatic brain injury patients initially imaged within 6 h of injury (hyperacute) who subsequently underwent a delayed MRI, with no additional contrast administration, several hours after the initial MRI. Of the 32 patients with delayed post-contrast imaging, 18 (56%) had conspicuous expansion of the contrast enhancement into the subarachnoid space, predominantly along the falx and superior sagittal sinus. Patients negative for traumatic meningeal enhancement on initial hyperacute MRI continued to have no evidence of meningeal enhancement on the delayed MRI. These studies demonstrate that (i) the initial enhancement of the traumatically injured meninges occurs within minutes of contrast injection, suggesting highly permeable meningeal vasculature, and that (ii) contrast in the meninges redistributes within the subarachnoid space over the period of hours, suggesting a compromise in the blood-brain and/or blood-cerebrospinal barriers. Data from the parent study indicate that up to one in two patients with mild traumatic brain injury have traumatic brain injury on acute (<48 h) MRI, with a higher prevalence seen in patients with moderate or severe traumatic brain injury. The current study's findings of traumatic meningeal enhancement and the subsequent delayed extravasation of contrast into the subarachnoid spaces indicate that a substantial percentage of patients with even mild traumatic brain injury may have a transient disruption in barriers separating the vasculature from the brain.

Abstract TMP90: Frequency and Risk Factors for Early Neurological Deterioration Among Hyperacute Cerebral Ischemia Patients Treated With and Without Thrombolysis

Background: Early neurological deterioration (END) is a feared complication of acute cerebral ischemia. However, estimates of END frequency vary widely, rates have not been systematically examined in hyperacute patients presenting within the first 2h of onset, nor separately in patients treated with and without thrombolysis, and risk factors for END have not been well delineated. Methods: We analyzed patients with a final diagnosis of acute cerebral ischemia in the NIH FAST-MAG Phase 3 multicenter clinical trial. END was defined as worsening post-admission by ≥ 4 NIHSS points up to Day 4. We separately analyzed patients who did and did not receive IV tPA. Results: Among 1245 acute cerebral ischemia patients transported by EMS to 55 stroke centers, time from last known well (LKW) to ED arrival was median 59 mins (IQR 80-46), and 36.1% received IV tPA. Overall, 211 (16.9%) experienced END by Day 4, with a greater proportion of END in tPA than non-tPA patients (21.2% vs 14.5%, p=0.003). In multivariate analysis, from 26 candidate variables, among tPA recipients, independent predictors of END were: age (OR 1.03/year, 95%CI 1.01-1.05), diastolic BP (OR 1.01/mm Hg, 95%CI 1.00-1.03), prior stroke (OR 1.65, 95%CI 0.98-2.77), glucose (OR 11.06/10 fold increase, 95%CI 1.90-64.44), and worse ASPECTS score (OR 0.85/point, 95%CI 0.78-0.92). Among non-tPA recipients, independent predictors of END were: more severe NIHSS (OR 1.08/point, 95%CI 1.05-1.11), glucose (OR 8.88/10 fold increase, 95%CI 1.83-43.12), and h/o hypertension (OR 2.62/mm Hg, 95%CI 1.25-5.48), with Akaike information criteria identifying SBP, shorter LKW-to-ED time, and absence of anticoagulant agents as additional contributors. C statistics for these models were 0.68 for tPA patients and 0.73 for non-tPA patients. Conclusions: Among hyperacute cerebral ischemia patients, END occurs in 1 in 5 who receive tPA, and 1 in 7 who do not receive tPA. Greater initial stroke severity (on neurologic exam or imaging), higher glucose, and hypertension increase risk of END for both lytic and non-lytic patients, with older age and prior stroke additionally increasing END risk with tPA. Models based on these risk factors show fair to good performance identifying patients who will experience END after hospital admission.

Abstract WP249: Speed of 911 Alarms and EMS Care in Hyperacute Intracranial Hemorrhage and Cerebral Ischemic Patients

Introduction: Among all stroke patients, intracranial hemorrhage (ICH) patients activate the 911 system sooner than cerebral ischemia (CI) patients. However, the temporal profiles of EMS alarm and response among hyperacute patients who may be enrolled in prehospital treatment trials has not been well delineated. Methods: We analyzed all final diagnosis acute cerebrovascular disease patients enrolled in the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) trial, in 315 ambulances transporting to 60 receiving stroke centers. Results: Among 1632 hyperacute cerebrovascular disease patients, final diagnosis was ICH in 23.7% and CI in 76.3%. Compared with CI patients, ICH patients were younger (65.3 vs 70.9, p &lt; 0.001), less often female (33.3% vs 45.3%, p&lt;0.001), and had greater deficits in the field (LAMS 4.1 vs 3.7, p&lt;0.001), and upon ED arrival (NIHSS median 12 vs 7, p&lt;0.001). Intervals from last known well to 911 call (LKW-to-alarm) did not differ between ICH and ACI patients (median 15 vs 16 mins, p=0.32); however, fewer ICH patients had prolonged LKW-to-alarm times ≥ 30 mins (25.1% vs 30.3%, p = .049). Intervals from symptoms first observed to 911 call (SFO-to-alarm) did not differ (11 vs 12 mins, p=0.40). Times from 911 call to paramedic arrival (alarm-to-on patient) were similar for ICH and CI patients (median 6 vs 6 mins, p=0.80), as were times from paramedic arrival on patient to ED arrival (scene-to-door) (median 32 vs 33 mins, p=0.46) and overall 911 call to ED arrival (alarm-to-door) (median 39 vs 39 mins, p=0.51). The nationally recommended alarm-to-on patient interval ≤ 8 minutes was achieved in 76% of ICH and 78% of CI patients. Conclusion: Speed of prehospital care is swift among hyperacute cerebrovascular disease patients, including 911 calls at 15 minutes after last known well, paramedic arrival on patient 6 minutes after 911 activation, and ED arrival 39 minutes after 911 activation. In the hyperacute window, ICH patients call 911 only slightly faster than ACI patients, and subsequent prehospital intervals of care are similar. In a busy metropolitan region, national alarm-to-on patient time targets were achieved in more than three-quarters of patients.

Abstract 6: Frequency, Risk Factors, Causes, and Outcomes of Early Neurological Deterioration in Hyperacute Cerebral Ischemia

Background: Early neurological deterioration (END) is a feared complication of acute cerebral ischemia, but studies have provided widely varying estimates of END frequency, have often not systematically investigated END mechanism, and have not characterized END frequency among hyperacute patients presenting within the first 2h of onset, during the period of greatest neurologic deficit lability. Methods: We analyzed subjects with a final diagnosis of acute cerebral ischemia in the NIH Field Administration of Stroke Therapy-Magnesium Phase 3 multicenter clinical trial. END was defined as worsening by ≥ 4 NIHSS points up to Day 4. Causes of worsening were adjudicated by a central expert panel reviewing detailed medical records and imaging studies. Results: Among 1245 acute cerebral ischemia patients transported by EMS to 55 receiving stroke centers, time from last known well to ED arrival was median 59 mins (IQR 80-46). Overall, 211 (16.9%) experienced END by Day 4, including 17.4% within the first 6 hours of ED arrival, 32.2% between 6-24h, and 50.3% between 24h-Day 4. Patient features associated with END included older age (73.1 vs 70.5, p=0.01), worse initial deficits (NIHSS 13.1 vs 8.4, p&lt;0.0001), history of hypertension, diabetes, higher serum glucose, BUN, and creatinine. Arrival imaging findings associated with END included more advanced acute ischemic change (ASPECTS 7.8 vs 8.8, p&lt;0.0001) and presence of prior infarction. Leading causes of END were: extension of initial cerebral infarct (contributing in 50.6% of END patients), cerebral edema (25.3%), hemorrhagic transformation (23.0%), and infection (8.4%). END was associated with substantially reduced functional independence (mRS 0-2) at 90 days, 9.1% vs 67.9%, p&lt;0.0001, and increased 90-day mortality, 42.1% vs 6.5%, p&lt;0.0001). Conclusions: END occurs in 1 in 6 hyperacute cerebral ischemia patients, and is associated with dramatic reductions in functional independence and increases in mortality by 3 months. The leading causes of END are ischemia progression, cerebral edema, and hemorrhagic transformation, which collectively contribute to 4 in 5 of all END events, and are important treatment targets to improve ischemic stroke outcome.

Influence of Timing After Thoracic Endovascular Aortic Repair for Acute Type B Aortic Dissection

This study aimed to analyze the influence of the timing of intervention from presentation of symptoms to thoracic endovascular aortic repair (TEVAR) and its relation to major complications. Data were collected from the Japan Adult Cardiovascular Surgery Database. We retrospectively analyzed the data of 680 patients who underwent TEVAR for acute and subacute type B dissection between January 2008 and January2013. Thoracic endovascular aortic repair for type B dissection was performed in 680 patients: 295 repairs were performed within 24 hours of presentation of symptoms (hyperacute); 97 between 24 hours and 14 days (acute); and 288 between 14 days and 6 weeks (subacute). Hyperacute patients more frequently had immediate life-threatening complications from type B dissection such as rupture or malperfusion than did acute or subacute patients (41.0% [121 of 295] versus 7.2% [7 of 97] versus 4.2% [12 of 288]; p < 0.001; and 17.3% [51 of 295] versus 8.3% [8 of 97] versus 5.6% [16 of 288]; p < 0.001, respectively). Operative mortality and severe complications including aortic dissection were more common among hyperacute patients (11.9% [35 of 295] versus 0% [0 of 97] versus 1.7% [5 of 288]; p < 0.001; and 32.5% [96 of 295] versus 10.3% [10 of 97] versus 8.3% [24 of 288]; p < 0.001, respectively) and did not differ significantly between acute and subacute patients (p= 0.191 and p= 0.553, respectively). Although TEVAR performed for aortic dissection within 24 hours of presentation of symptoms was associated with worse outcomes, TEVAR performed between 24 hours and 14 days, as compared with TEVAR between 14 days and 6 weeks, does not appear to increase the risk of perioperative complications.

Response to Letter by Urra and Chamorro

Response: We completely agree with Urra and Chamorro that stroke severity measured by the National Institutes of Health Stroke Scale (NIHSS) and infarct volumes are very closely correlated. In our data, the application of infarct volumes instead of admission NIHSS improved the multiple regression model fit and thereby the accuracy of predicting stroke-associated infections. We absolutely assent that performing an NIHSS is done much quicker than applying infarct volumetry. This is particularly true for applying CT in hyperacute patients with stroke in which it may be impossible to predict final infarct …

Discussion on the Painful Shoulder

Three or four definite types are separated from among the many examples of painful shoulder and their treatment is debated:- (1) ADHESIONS AROUND THE JOINT.: Characterized by limitation of movement at the shoulder-joint, through the outer half of its range. Curable by manipulative surgery. (2) TENDONITIS.: Characterized by painful movements through a small arc in the middle of the normal range. Curable in the hyperacute patient by operation, in the acute by rest in partial abduction with the assistance of time. (3) OSTEO-ARTHRITIS OF THE SHOULDER-JOINT.: Characterized by painful extremes of movement. Incurable but capable of alleviation by physiotherapy. (4) SUBACUTE ARTHRITIS OF THE SHOULDER-JOINT.: Characterized by muscle spasm at the commencement of movement. To be treated by rest on an abduction splint, and the eradication of septic foci.