Initial Diagnostic Workup Research Articles

ESC guidelines 2015 on pulmonary hypertension

The European Society of Cardiology (ESC) and European Respiratory Society (ERS) guidelines published in 2015 include the most important recommendations for the diagnosis and treatment of pulmonary hypertension (PH). The classification of PH into five groups remained unchanged as compared to the previous recommendations; however, there are minor shifts within the groups. Accordingly, a distinction is made between pulmonary arterial hypertension (PAH), PH due to left heart disease, PH due to chronic hypoxia or lung disease, chronic thromboembolic PH and PH due to unclear or multifactorial mechanisms. The diagnosis of PH is based on right heart catheterization where PH is defined as a mean pulmonary arterial pressure ≥ 25mmHg at rest. For the definition of PAH, in addition to a pulmonary capillary wedge pressure ≤ 15mmHg, a pulmonary vascular resistance > 3 Wood units is obligatory. Echocardiography is considered to be the most important non-invasive procedure within the diagnostic algorithm and for patients with collagen vascular disease. This is recommended during initial diagnostic work-up and should be followed-up annually. Several novel drugs which were approved since publication of the previous guidelines, were included in the new recommendations. For the first time there is a recommendation for a targeted drug for inoperable chronic thromboembolic PH. An important part of the guidelines is the discussion on PAH upfront combination therapy.

Is Dominant‐Side Onset Associated With a Better Motor Compensation in Parkinson's Disease?

Unilateral onset and persistent asymmetry of motor signs are unique features of PD. The dominant hemisphere may have more efficient motor networks with greater neural reserve to cope with pathological changes. Therefore, this study compared dominant-side onset and non-dominant-side onset PD to evaluate whether dominant-side onset patients have greater neural reserve and fewer motor deficits despite similar pathological changes. We included the data of 157 consecutive, de novo PD patients with documented right-handedness who underwent dopamine transporter PET scans for an initial diagnostic workup. Among them, 118 patients with significant asymmetric motor deficits were selected for the analyses. Dominant-side patients (i.e., the majority of motor deficits on the right side) showed significantly fewer motor deficits (i.e., the part III score of the UPDRS) than non-dominant-side patients (18.0 ± 8.1 and 22.9 ± 10.1, respectively; P = 0.005). Other variables, including symptom duration and striatal dopaminergic activities, were similar between the two groups. A general linear model showed that this difference in motor deficits remained statistically significant after controlling for patient age, sex, symptom duration, and striatal dopaminergic activity in the posterior putamen (P = 0.013). These results suggest that dominant-side patients have greater neural reserve, allowing them to better cope with PD-related pathological changes (i.e., fewer motor deficits despite similar dopamine reduction) compared to non-dominant-side patients.

Gender Differences in Age-Related Striatal Dopamine Depletion in Parkinson's Disease.

ObjectiveGender differences are a well-known clinical characteristic of Parkinson’s disease (PD). In-vivo imaging studies demonstrated that women have greater striatal dopamine transporter (DAT) activity than do men, both in the normal population and in PD patients. We hypothesize that women exhibit more rapid aging-related striatal DAT reduction than do men, as the potential neuroprotective effect of estrogen wanes with age.MethodsThis study included 307 de novo PD patients (152 men and 155 women) who underwent DAT scans for an initial diagnostic work-up. Gender differences in age-related DAT decline were assessed in striatal sub-regions using linear regression analysis.ResultsFemale patients exhibited greater DAT activity compared with male patients in all striatal sub-regions. The linear regression analysis revealed that age-related DAT decline was greater in the anterior and posterior caudate, and the anterior putamen in women compared with men; we did not observe this difference in other sub-regions.ConclusionsThis study demonstrated the presence of gender differences in age-related DAT decline in striatal sub-regions, particularly in the antero-dorsal striatum, in patients with PD, presumably due to aging-related decrease in estrogen. Because this difference was not observed in the sensorimotor striatum, this finding also suggests that women may not have a greater capacity to tolerate PD pathogenesis than do men.

Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC.

Chest pain and acute dyspnoea are frequent causes of emergency medical services activation. The pre-hospital management of these conditions is heterogeneous across different regions of the world and Europe, as a consequence of the variety of emergency medical services and absence of specific practical guidelines. This position paper focuses on the practical aspects of the pre-hospital treatment on board and transfer of patients taken in charge by emergency medical services for chest pain and dyspnoea of suspected cardiac aetiology after the initial assessment and diagnostic work-up. The objective of the paper is to provide guidance, based on evidence, where available, or on experts' opinions, for all emergency medical services' health providers involved in the pre-hospital management of acute cardiovascular care.

Traumatic right diaphragmatic rupture with hepatothorax: a diagnostic challenge!

Traumatic injuries of the diaphragm remain an entity of difficult diagnosis especially when it comes to the right diaphragm. It is a recognized consequence of high velocity blunt trauma to the abdomen, usually as a result of road traffic collisions or lateral intrusions into the vehicle and occasionally, penetrating thoraco-abdominal trauma. It has been reported that the rate of initial missed diagnosis of traumatic diaphragmatic injury ranges from 12% to 63% on CT (1). A missed diagnosis is associated with a mortality of 30% to 60% due to late presentation of intrathoracic visceral herniation and strangulation (2,3). After a high speed motor vehicle accident, a 30-year-old Saudi male was received in the trauma room. He was confused, hypotensive and in respiratory distress. The initial diagnostic workup included chest X-ray and full body non-contrast spiral CT scan, revealing fracture of the nasal bone and right hemothorax. No other radiological findings were detected in the initial assessment. Due to an assumed massive rightsided hemothorax ( Figure 1 ), a thoracic tube was inserted and 750 mL of blood coming in the chest drain. After initial stabilization the patient was then transferred to the surgical unit of Sabya General Hospital, Saudi Arabia.

Troubles neuropsychiatriques inexpliqués : penser aux encéphalites dysimmunitaires. À propos d’une observation d’encéphalite à anticorps anti-leucine rich glioma inactivated 1 (LGI-1)

IntroductionAnti-leucine rich glioma inactivated 1 encephalitis is a common and a treatable etiology of autoimmune encephalitis. Its diagnosis is a challenge because the initial diagnostic work-up is often normal. Case reportA 48-year-old man experienced cognitive and behavioral troubles, facio-brachial dystonic seizures and a syndrome of inappropriate antidiuretic hormone secretion. First line tests excluded infectious, neoplastic, systemic inflammatory, endrocrine or toxic etiologies. Cerebral 18Fluoro-desoxy-glucose (FDG) position emission tomography and research of specific antibodies in cerebro-spinal fluid and serum led to diagnose an anti-leucine rich glioma inactivated 1 encephalitis. Intravenous immunoglobulins and corticosteroids were partially effective. Cyclophosphamid permitted a good recovery. ConclusionIn the presence of acute neuropsychiatric disorders with a negative etiologic research, physician should think about dysimmune encephalitis. Facio-brachial dystonic seizures and syndrome of inappropriate antidiuretic hormone secretion are highly evocative of anti-leucine rich glioma inactivated 1 encephalitis. The diagnosis needs specific diagnostic tests (cerebral 18FDG position emission tomography and antibodies research in cerebro-spinal fluid and in serum), after the exclusion of alternative diagnoses. Extensive and repeated diagnostic work-up for neoplasia is required. Immunosupressive therapies are effective in most cases.

Retrobulbar Spot Sign Predicts Thrombolytic Treatment Effects and Etiology in Central Retinal Artery Occlusion.

Transorbital sonography may help establish diagnosis of central retinal artery occlusion (CRAO). Next to Doppler sonographic proof of CRAO, an intra-arterial spot sign can be detected in some cases. We hypothesized that it reflects calcified components. It may be associated with embolization from atherosclerotic plaques and may negatively influence thrombolysis. Prospective monocenter study of 46 patients with ophthalmologically confirmed CRAO. Systemic tissue-type plasminogen activator thrombolysis was performed when appropriate. All patients received etiologic workup. CRAO was confirmed by Doppler in all patients. Fifty-nine percent of patients with arterio-arterial embolization were spot sign-positive compared with 20% from cardiac source (P<0.05) and none with vasculitis. Eleven patients underwent thrombolysis. Clinically relevant visual improvement was only found in absence of a spot sign (P<0.05). Transbulbar ultrasound is valuable for initial diagnosis and diagnostic workup of CRAO. In the light of inconsistent results of previous thrombolysis trials, ultrasound may identify patients more likely to benefit from thrombolytic treatment.

OC-111 Diagnostic yield of endoscopic ultrasound (EUS) in the evaluation of idiopathic pancreatitis. a single tertiary referral centre experience

<h3>Introduction</h3> Idiopathic acute pancreatitis (IAP) represents a diagnostic and therapeutic challenge. IAP is prone to high recurrence and understanding its aetiology may assist in preventing recurrent episodes and its related morbidity and mortality. Appropriate investigations help to determine the underlying aetiology and can guide further effective management. We describe our experience to evaluate the role of endoscopic ultrasound (EUS) in patients with unexplained acute pancreatitis in whom cross sectional imaging and conventional laboratory testing had failed to identify the aetiology in a tertiary pancreatico-biliary referral centre. <h3>Method</h3> We retrospectively identified all patients who underwent EUS for assessment of idiopathic acute or recurrent pancreatitis during the period Jan 2007–Dec 2013. All patients had appropriate radiological investigations and no underlying cause identified on transabdominal ultrasound, computed tomography (CT) and on magnetic resonance cholangiopancreatography (MRCP). Patients with risk factors known to precipitate pancreatitis including alcohol excess, medications, metabolic or autoimmune conditions, were excluded. <h3>Results</h3> 44 patients (male 32, female 12) were identified with a mean age of 50 years (range 21–79 years). 33 (75%) patients had recurrent attacks of acute pancreatitis whereas 11 (25%) patients were referred for EUS after a single attack of acute pancreatitis. EUS revealed a cause of pancreatitis in 21/44 (47.7%) patients. Pancreatic duct stones were detected in 10 (22.7%); biliary duct microlithiasis in 4 (9%); pancreatic divisum in 3 (6.8%) and peri-ampullary lesions in 2 (4.5%) patients. One each had a pancreatic duct stricture, biliary duct stricture and one patient was diagnosed with IPMN (intra-papillary mucinous neoplasm). No underlying cause could be found in 23 (52.3%) patients. <h3>Conclusion</h3> EUS demonstrated aetiology in almost half of patients with unexplained acute or recurrent pancreatitis. Our findings support the emerging evidence that EUS is a valuable diagnostic tool in the evaluation of patients with idiopathic pancreatitis and should be considered where initial diagnostic workup including cross sectional imaging remains inconclusive. <h3>Disclosure of interest</h3> None Declared.

A multicenter survey of enteroscopy for the diagnosis of intestinal follicular lymphoma.

The importance of enteroscopy examinations to investigate the entire length of the small intestines has been emphasized in follicular lymphoma patients with intestinal involvement. The aim of the present study was to determine the current state of enteroscopy examinations, including the performance rate, and the prevalence of small intestinal lesions in a patient population in Japan. A retrospective multicenter survey of 17 institutions collected the case information of 110 follicular lymphoma patients with gastrointestinal involvement. The results of the enteroscopy examinations were reviewed, and in order to identify potential factors affecting the performance rate of enteroscopy, patient gender, age at lymphoma diagnosis, histopathological grade, clinical stage, the date of the initial diagnosis and the annual volume of enteroscopy at the institution were compared between the patients who underwent one or more enteroscopy procedures and the patients who did not undergo enteroscopy. A total of 34 patients (30.9%) underwent enteroscopy, and 24 of these (70.6%) presented with involvement in the jejunum and/or ileum. It was found that more patients diagnosed in recent years and more patients treated at an ultra-high volume institution (≥101 enteroscopy examinations/year) underwent an enteroscopy. In conclusion, although the prevalence of small intestinal lesions was high (70.6%) in the follicular lymphoma patients presenting with intestinal involvement, the performance rate of enteroscopy was only 30.9%, and thus the majority of the patients have not undergone enteroscopy examinations. Further investigation is required to define the clinical significance of enteroscopy at the initial diagnostic work-up and during the follow-up period of these patients.

Sa2054 Influence of Diabetes Mellitus on Postoperative Survival for Pancreatic Ductal Adenocarcinoma: A Systematic Review and Meta-Analysis

pancreatic adenocarcinoma in diabetic patients using maximum standardized uptake value (SUVmax) whether it is also influenced by DM.Materials & Methods : From January 2009 to December 2013, we identified first diagnosed pancreatic adenocarcinoma patients who performed 18F-FDG PET/CT as a initial diagnostic work-up and had a metastatic lesion in a distant organ. Patients with metastatic lesions to liver, bone, lung, lymph node and peritoneum were included. Results : Total 86 patients were included, and DM patients were 48 (55.8%). Mean SUVmax of primary lesion was significantly lower in DM group than in non-DM group (4.740 vs. 5.961, respectively, P = 0.009). Of all PDAC patients, liver metastasis was identified in 18 patients. Liver to pancreas SUVmax ratio was significantly high in hyperglycemic patients comparing to euglycemic peoples regardless of DM (1.44 vs. 0.96, respectively, P = 0.012). As SUVmax of primary lesion increases, SUVmax of metastatic lesion of liver (Spearman's rho = 0.492, P = 0.001), lymph node (Spearman's rho = 0.380, P = 0.002), and peritoneum (Spearman's rho = 0.385, P = 0.017) also increases. But, SUVmax of bone and lung lesions were not. Conclusions : In PDAC patients, DM itself contributes low SUVmax of primary lesion, regardless of plasma glucose level. On contrast, all metastatic sites did not influenced by DM, but only hepatic lesion had a tendency to increase as blood glucose level rises. It is suggested that blood glucose level is an important factor affecting the FDG uptake of metastatic hepatic lesion in PDAC patients. So, the result of 18F-FDG PET/CT should be carefully interpreted in metastatic PDAC patients with DM and hyperglycemia.

CE: critical care recovery center: an innovative collaborative care model for ICU survivors.

Five million Americans require admission to ICUs annually owing to life-threatening illnesses. Recent medical advances have resulted in higher survival rates for critically ill patients, who often have significant cognitive, physical, and psychological sequelae, known as postintensive care syndrome (PICS). This growing population threatens to overwhelm the current U.S. health care system, which lacks established clinical models for managing their care. Novel innovative models are urgently needed. To this end, the pulmonary/critical care and geriatrics divisions at the Indiana University School of Medicine joined forces to develop and implement a collaborative care model, the Critical Care Recovery Center (CCRC). Its mission is to maximize the cognitive, physical, and psychological recovery of ICU survivors. Developed around the principles of implementation and complexity science, the CCRC opened in 2011 as a clinical center with a secondary research focus. Care is provided through a pre-CCRC patient and caregiver needs assessment, an initial diagnostic workup visit, and a follow-up visit that includes a family conference. With its sole focus on the prevention and treatment of PICS, the CCRC represents an innovative prototype aimed at modifying post-critical illness morbidities and improving the ICU survivor's quality of life.

A tick-borne illness unmasking asymptomatic Brugada syndrome

Brugada syndrome is an important cause of sudden cardiac death and should be recognized in asymptomatic patients with characteristic electrocardiographic (ECG) findings. We report a case of a 59-year-old male who presented with fever and generalized malaise after a camping trip with confirmed tick exposure. Initial diagnostic work-up included an ECG, which showed incidental ST-segment elevation in the right precordial leads consistent with a type 1 ECG pattern seen in Brugada syndrome. He was diagnosed with fever-induced Brugada syndrome and treated with doxycycline and antipyretics. The type 1 ECG pattern resolved a few hours later with a resultant right bundle branch block. Implantable cardioverter–defibrillator implantation was not indicated after risk stratification. The case highlights the importance of considering Brugada syndrome in patients with characteristic ECG changes in the setting of fever, and reviews the latest criteria for diagnosis, management and risk stratification of this fatal condition.

D-dimer for the diagnosis of upper extremity deep and superficial venous thrombosis

BackgroundD-dimer role is well established in the diagnostic work-up for lower limb deep vein thrombosis (DVT), however it has not been formally tested for clinically suspected upper extremity DVT and/or superficial vein thrombosis (SVT). AimTo ascertain D-dimer diagnostic accuracy for upper extremity DVT and/or SVT. Study designWe performed a single centre management study in outpatients referred by emergency or primary care physicians for clinically suspected upper extremity DVT. All patients underwent D-dimer testing (cut-off value: ≤500ng/mL), and a B-mode and color Doppler ultrasonography examination. In case of either technical problems or anatomical barriers, ultrasonography was repeated after 5-7days. All patients were followed up for three months for the occurrence of symptomatic DVT and/or SVT and/or pulmonary embolism. ResultsWe enrolled 239 patients (F: 63.6%; mean±SD age: 58.3±16.8). At the initial diagnostic work-up, DVT was detected in 24 (10%) patients while SVT in 35 (14.6%) patients. During follow-up, one upper extremity DVT was found. D-dimer levels were higher in patients with DVT than in those without. Sensitivity and specificity of D-dimer for DVT were 92% (95%CI: 73-99%) and 60% (95%CI: 52-67%) respectively, with a negative predictive value of 98% (95%CI: 93-100%), whereas for SVT they were 77% (95%CI: 59-89%) and 60% (95%CI: 52-67%) respectively, with a negative predictive value of 93% (95%CI: 86-97%). ConclusionsD-dimer has a negative predictive value ≥93% for excluding DVT in symptomatic outpatients and it can be a useful test in the diagnostic work-up of suspected upper extremity DVT.

Hyperprolinemia in Type 2 Glutaric Aciduria and MADD-Like Profiles.

Classical neonatal-onset glutaric aciduria type 2 (MAD deficiency) is a severe disorder of mitochondrial fatty acid oxidation associated with poor survival. Secondary dysfunction of acyl-CoA dehydrogenases may result from deficiency for riboflavin transporters, leading to severe disorders that, nevertheless, are treatable by riboflavin supplementation. In the last 10 years, we identified nine newborns with biochemical features consistent with MAD deficiency, only four of whom survived past the neonatal period. A likely iatrogenic cause of riboflavin deficiency was found in two premature newborns having parenteral nutrition, one of whom recovered upon multivitamin supplementation, whereas the other died before diagnosis. Four other patients had demonstrated mutations involving ETF or ETF-DH flavoproteins, whereas the remaining three patients presumably had secondary deficiencies of unknown mechanism. Interestingly, six newborns among the seven tested for plasma amino acids had pronounced hyperprolinemia. In one case, because the initial diagnostic workup did not include organic acids and acylcarnitine profiling, clinical presentation and hyperprolinemia suggested the diagnosis. Analysis of our full cohort of >50,000 samples from >30,000 patients suggests that the proline/alanine ratio may be a good marker of MAD deficiency and could contribute to a more effective management of the treatable forms.

Parinaud Oculoglandular Syndrome 2015: Review of the Literature and Update on Diagnosis and Management

Parinaud oculoglandular syndrome (POGS) is an ocular granulomatous inflammatory condition characterized by unilateral follicular bulbar or palpebral conjunctivitis. Although POGS often presents as an atypical manifestation of cat scratch disease (CSD), other infectious and autoimmune etiologies have been described. Due to the rare nature of this ocular syndrome and scarcity of literature on this topic, POGS is often missed on the initial diagnostic workup. Here, we provide a brief description of disease process, and present a review of the literature on POGS in the past two decades to understand the trends in etiology of disease. Based on the results of this review, we also suggest an algorithm for diagnosis and management of POGS.

Abdominal Tuberculosis: An Immigrant's Disease in the United States.

Background:Abdominal tuberculosis (TB) is an uncommon condition in the United States (US) except for patients with human immunodeficiency virus (HIV). An increasing number of cases have been reported in western countries amongst immigrants. It is important to be aware of the data and clinical characteristics in the immigrant population.Aims:The purpose of this study is to determine the epidemiologic characteristics of abdominal TB among immigrants in the US and to review the clinical presentations of abdominal TB with a focus particularly on unusual features.Materials and Methods:In a community teaching hospital in New Jersey, patients diagnosed with abdominal TB were examined and included in this report. All nine patients were immigrants from countries with high prevalence of TB and a majority had resided in the US for at least 5 years. None had clinical evidence of HIV and those that were tested were not found to be positive for HIV. Initial examination, diagnostic workup, and response to therapy were all pertinent to the management and diagnosis of these patients.Results:Three patients had atypical clinical presentations with normal chest X-rays and either negative or unknown tuberculin tests leading to delayed diagnosis and inappropriate therapy in at least one patient. With antituberculous therapy, all except for one patient had satisfactory outcomes. Immigrant patients with a diagnosis of abdominal TB had no evidence of HIV infection or other associated conditions in contrast to native-born individuals.Conclusion:Atypical presentations may cause diagnostic difficulties. Failure to perform appropriate tests may lead to inappropriate therapy with adverse outcomes. Although there is a decline in the number of TB cases in the US and screening for latent pulmonary infection in foreigners has been implemented effectively, the diagnosis of abdominal TB continues to be under diagnosed.

Comparison of fine-needle aspiration technique with Ziehl-Neelsen stains in diagnosis of tuberculous lymphadenitis

Background: Lymphadenopathy is one of the most common clinical presentation among patients. In developing countries such as India, tuberculous (TB) lymphadenitis is one of the common causes of lymphadenopathy. Cytomorphology with acid-fast staining is a valuable diagnostic tool in cases of tuberculosis. Objective: To describe pattern of TB lymphadenitis presentation, and to compare results of fine needle aspiration cytology (FNAC) and Ziehl–Neelsen (ZN) stain in the diagnosis of TB lymphadenitis. Materials and Methods: Total 351 patients of lymphadenopathy referred to the Department of Pathology, GMERS Medical College & Hospital, Vadodara, Gujarat, India, between March 2011 and December 2013included. FNAC was performed in all these patients and smears were prepared. Smears were stained with hematoxylin and eosin stain. ZN staining for acid-fast bacilli (AFB) was carried out on separate slide. Results: Maximum number of patients (162; 46.15%) were from age group of 11–30 years. Total 351 cases [179 (50.99%) females and 172 (49.00%) males] were included in the study. Of 351 cases, 173 (49.28%) had tuberculosis, 141 (40.17%) had lymphadenitis other than tuberculosis, and 37 (10.54%) had malignant lymphadenopathy, including 2 (0.56%) cases of primary malignancy (i.e., lymphoma) and 35 (09.97%) of metastasis to lymph nodes. Overall, 119 (33.90%) cases were found to be positive for AFB on ZN staining. Conclusion: FNAC is an optimally selected, efficient, easy to perform, and economical test for initial diagnostic workup in patients with TB lymphadenitis. Supplementation of ZN stain with FNAC increases the rates of diagnosis.

A statistical analysis and cytohistologic correlation of fine needle aspiration cytology in lesions of male breast

Background and Objectives: Fine needle aspiration cytology is a widely used first line investigation for breast lesions in surgical practice. Gynecomastia is the most common lesion of male breast. FNAC is usually asked for male breast lesions in case of unilateral breast enlargement to rule out malignancy. This study was done to obtain sensitivity, specificity, other statistical parameters and cytohistological correlation in FNAC of male breast lesions so as to know its diagnostic utility. Methods: Study was performed at Goa medical college over a period of seven years. Only the cases with availability of histological diagnosis were included in the study. All slides were stained with Hematoxylin and eosin after fixation in alcohol-ether mixture. Results: Sensitivity, specificity, accuracy, positive predictive value and negative predictive value were 100% for FNAC of male breast lesions. Excellent cytohistologic correlation was also observed. Conclusion: These results indicate that FNAC of male breast lesions shows excellent specificity, sensitivity and cytohistologic correlation. Hence, it can be used in initial diagnostic workup of lesions of male breast. Keywords: Fine needle aspiration cytology, Male Breast lesions, Statistical analysis

Small bowel capsule endoscopy in the management of established Crohn's disease: clinical impact, safety, and correlation with inflammatory biomarkers.

Multiple studies have established the superior diagnostic accuracy of video capsule endoscopy (VCE) for the diagnosis of small bowel (SB) Crohn's disease (CD). However, data on the clinical impact of VCE in patients with established CD are scarce. The aim of this study was to examine the impact and safety of VCE on the clinical management of patients with established CD. A retrospective, multicenter, cross-sectional study. The study cohort included consecutive patients with established SB CD who underwent VCE in 4 tertiary referral centers (1 Canada, 1 Sweden, and 2 United Kingdom) from January 2008 to October 2013. Patients were excluded if VCE was performed as a part of the initial diagnostic workup. The presence of SB mucosal inflammation was quantified using the Lewis score. Inflammatory biomarkers (C-reactive protein and fecal calprotectin) were measured and correlated with the Lewis score. The study included 187 patients. No SB inflammation was observed in 28.4%, mild-to-moderate inflammation in 26.6%, and moderate-to-severe inflammation in 45% of the patients (median Lewis score, 662; range, 0-6400). A change in management was recommended in 52.3% of the patients based on VCE findings. Elevated C-reactive protein, fecal calprotectin, or the combination of both were poorly correlated with significant SB inflammation. SB capsule retention occurred in 4 patients (2.1%). VCE in patients with established CD is safe, and the results often have a significant clinical impact. VCE should not be limited to CD patients with positive inflammatory markers because their predictive value for significant SB inflammation is poor.

Medical and Endovascular Treatment of Patients with Large Vessel Occlusion Presenting with Mild Symptoms: An Observational Multicenter Study

Background: A significant proportion of stroke patients presenting with mild symptoms does not have a successful recovery, especially when a large vessel is occluded. IV thrombolysis is safe and may benefit patients presenting with mild symptoms. In this study, we tested whether endovascular therapy (ET) is superior to medical therapy in these patients. Methods: Observational, prospectively collected, multicenter study of 78 consecutive patients admitted from 2009 to 2012 within 6 h of stroke, with NIHSS ≤5 at presentation or during initial diagnostic work-up and large vessel occlusion. Data for patients undergoing ET and/or IV thrombolysis were taken from the SONIIA registry of reperfusion therapies in Catalonia, or from our local stroke registry if no reperfusion therapy was delivered. We compared risk factors, clinical course, collateral circulation, revascularization rates, hemorrhagic complications, infarct volume, and the functional outcome at 3 months of patients treated with ET and those not receiving ET. Ordinal regression was used to assess the independent effect of ET on functional outcome. Results: Baseline characteristics were similar for ET (n = 34) and medically (n = 44) treated patients, except for older age in the latter. The occlusions were located in the terminal internal carotid artery (1%), M1 segment of the middle cerebral artery (33%), M2 segment (30%), posterior circulation (31%), and 5% of the patients had tandem lesions, with no significant differences between groups. Most patients in both treatment groups had good collateral flow. The rate of successful revascularization (91.2 vs. 63.4%; p = 0.006) and the risk of symptomatic intracranial hemorrhage (11.8 vs. 0%; p = 0.033) were higher in the ET group. The NIHSS scores were similar at hospital arrival, after initial neuroimaging, and at 24 h in both treatment groups and there were no significant differences in the infarct volume in a follow-up MRI. At 3 months, 35.9% of the patients had some disability. The functional outcome was similar in both treatment groups in univariate analysis and also in models adjusted for age and initial NIHSS or for variables associated to functional outcome on univariate comparison. Conversely, IV thrombolysis was associated with significantly greater chances of full recovery after adjusting for baseline differences (OR 3.70, p = 0.015). Conclusions: One third of stroke patients with mild symptoms and large vessel occlusions do not have a successful recovery. ET is effective to recanalize the occluded vessel but increases the risk of serious bleeding significantly without improving the functional outcome, and is therefore not justified routinely in these patients.