Neck Hematoma Research Articles

Anaesthetic Management of a Spontaneously Ruptured Vertebral Artery Pseudoaneurysm with Dynamic Airway Obstruction

Expanding neck hematoma with progressive airway obstruction is a life-threatening airway emergency. Patients are at risk of cranio-cerebral circulation compromise leading to perioperative cerebrovascular accidents. Furthermore, precipitous fall of blood pressure following neck hematoma exploration mandate the activation of protocols for massive transfusion. We describe the successful anaesthetic management of an extremely rare case of spontaneous rupture of a vertebral artery pseudoaneurysm.

To drain or not to drain following carotid endarterectomy: a systematic review and meta-analysis.

A postoperative neck hematoma can be a life-threatening complication after carotid endarterectomy necessitating urgent surgical decompression to avoid airway compromise. The practice of routine incisional drain placement is variable with few published studies evaluating the "to drain versus not to drain" approach. We conducted a systematic review and meta-analysis of the safety and efficacy of neck drain placement for prevention of neck hematoma requiring re-exploration for decompression. This study is a systematic review and meta-analysis performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pooled odds ratios with 95% confidence intervals were calculated for the outcome of surgical re-exploration for neck decompression among patients receiving or not receiving wound drainage. We identified 5 studies for inclusion, comprising 48,297 patients with 19,832 (41.1%) patients receiving a drain after carotid endarterectomy. Patients in the drain group had a significantly higher re-exploration rate after carotid endarterectomy compared to those who did not receive a drainage (OR=1.24, 95% CI: 1.03-1.49; P=0.02) with no heterogeneity (I2=0%). Routine drain placement does not offer complete protection against neck hematoma development and may give the surgeon a false sense of security in wound drainage. Thus, we conclude that drain placement following carotid endarterectomy should be selective, not routine.

TCTAP C-087 Transradial carotid artery stenting complicated with neck hematoma, conservative is a valid option!

TCTAP C-087 Transradial carotid artery stenting complicated with neck hematoma, conservative is a valid option!

Carotid Endarterectomy

Carotid artery stenosis is associated with an elevated incidence of stroke, and carotid endarterectomy is performed to prevent future strokes in cases of severe carotid artery stenosis. Patients presenting for carotid endarterectomy often have a number of comorbidities that make them challenging to anesthetize. Both regional and general anesthetic techniques may be successfully used, but with either, careful management of hemodynamics throughout the perioperative course is critical. During carotid cross-clamping, it is important to monitor the patient’s neurologic status to ensure adequate perfusion to the ipsilateral hemisphere, and for this, a number of neuromonitoring modalities are available, with EEG monitoring being the most common. Several potential complications require close monitoring of the patient in the immediate postoperative period. This review contains 6 figures, 7 tables, and 49 references. Key Words: carotid artery stenosis, carotid endarterectomy, carotid artery stenting, cerebral hyperperfusion syndrome, cervical plexus block, electroencephalography, neck hematoma, neuromonitoring, preoperative optimization, stroke, transcranial Doppler

Four-level Anterior Cervical Discectomy and Fusions: Results Following Multilevel Cervical Fusion With a Minimum 1-Year Follow-up.

A retrospective review of prospectively collected case series. This is a retrospective review of prospectively collected data regarding the clinical outcomes, complications, and fusion rates of patients who underwent a 4-level (C3-C7) anterior cervical discectomy and fusion (ACDF). The use of multilevel ACDF for cervical spondylosis has been controversial. The literature regarding fusion rates and outcomes have been variable. This study intends to evaluate the outcomes following multilevel ACDF in a large cohort of patients. Between 1994 and 2011, 60 patients underwent a 4-level ACDF by a single surgeon. All patients were followed for a minimum of 12 months, and outcome measures included neurological findings, presence or absence of radiographic fusion, and complication rates. All patients had radiographic documentation of spinal cord stenosis at 4 consecutive cervical levels as well as myelopathy and/or radiculopathy symptoms. Forty-eight patients underwent a single anterior procedure, only 5 patients underwent concurrent anterior and posterior fusion, and 7 patients required a second posterior surgery due to new-onset or residual symptoms or hardware complications after undergoing ACDF. Patients most commonly presented with paresthesias and were diagnosed with cervical stenosis. Overall, 18.3% reported early postoperative dysphagia; however, only 2 patients continued to have mild dysphagia symptoms on long-term follow-up. Other complications included hardware failure (11), residual neck pain (7), residual paresthesias (6), new-onset weakness (3), neck hematoma (1), cellulitis (1), and C5 radiculopathy (1). Overall, 88.3% of patients reported improvement in initial symptoms. Nurick scores were significantly lower following 4-level ACDF. The radiographic fusion rate for all levels was 95%. No patients required reoperation for pseudarthrosis. In appropriate patients, 4-level ACDF is a safe, efficacious method for treating multilevel cervical spinal cord compression, with acceptable complication rates and the ability to achieve neurological improvement and high fusion rates.

Implementation of the ACS/ASE simulation-based basic airway skills module in medical school curriculum: experience from Saudi Arabia

Background: Simulation-based basic airway management training may enhance the learner's competence and offer practitioners the opportunity to practice infrequently applied skills in cases with difficult airway management. Here, we aimed to examine the effectiveness of implementing the American College of Surgeons/ Association for Surgical Education (ACS/ASE) simulation-based Basic Airway Management module in the current medical school curriculum in PNU. Methods: This is a quasi-experimental study in which 44 students were enrolled in the training course; the instructors comprised six practicing physicians and technicians from the anesthesia and emergency departments. The students were divided among six groups for a 20-minutes hands-on training. Cognitive assessment and performance rating scale were conducted after the introduction of the module. An independent t-test was applied to analyze the pre- and post-test training scores for the cognitive assessment and performance rating scale. Statistical significance was set at p < 0.05. Results: There was a significant improvement in the post-training cognitive assessment scores, especially for basic maneuvers to establish the airway in a restrained and unrestrained driver, and in a patient with neck hematoma. A significant difference was also observed in pre- and post-training procedural steps, product characteristics, and global rating score. Conclusions: The ACS/ASE surgical skills curriculum for basic airway skills training is a feasible and effective approach for teaching basic airway management skills to medical students in PNU and other local universities.

A Case Report of a Transected Carotid Artery Caused by a Stab Wound to the Neck.

Trauma, stab wound, neck hematoma, deviated trachea, carotid artery injury, carotid artery transection.

Iatrogenic Brachiocephalic Artery Trunk Perforation Successfully Treated with Percutaneous Implantation of Covered Stent

Percutaneous coronary intervention through right radial artery access significantly reduces vascular complications compared to femoral access—an 80-year-old woman presented with non-ST segment elevation acute coronary syndromes (NSTE ACS). Coronary angiography performed using right radial artery access showed left anterior descendent artery disease with multiple stenoses, which was treated percutaneously. Ten minutes after the procedure, the patient presented dyspnea, hypotension, neck edema, and jugular turgor. She was immediately intubated and treated with invasive ventilation, fluid expansion, corticosteroids, and vasopressors. Urgent computerized tomography showed brachiocephalic artery trunk dissection and perforation with extravascular hemorrhage in the mediastinum and neck with venous compression without any sign of aortic, carotid, or subclavian dissection. Two days later, the percutaneous endovascular repair was performed, and a covered self-expanding stent was successfully positioned in the brachiocephalic trunk, sealing the perforation and treating the dissection. The patient progressively recovered and was discharged for rehabilitation. We provided the first report of a brachiocephalic trunk perforation using a radial approach, causing mediastinal and neck hematoma treated with percutaneous endovascular repair showing that vascular complications can be successfully treated percutaneously if be performed by an experienced team.

Ensemble machine learning for the prediction of patient-level outcomes following thyroidectomy

BackgroundAccurate prediction of thyroidectomy complications is necessary to inform treatment decisions. Ensemble machine learning provides one approach to improve prediction. MethodsWe applied the Super Learner (SL) algorithm to the 2016–2018 thyroidectomy-specific NSQIP database to predict complications following thyroidectomy. Cross-validation was used to assess model discrimination and precision. ResultsFor the 17,987 patients undergoing thyroidectomy, rates of recurrent laryngeal nerve injury, post-operative hypocalcemia prior to discharge or within 30 days, and neck hematoma were 6.1%, 6.4%, 9.0%, and 1.8%, respectively. SL improved prediction of thyroidectomy-specific outcomes when compared with benchmark logistic regression approaches. For postoperative hypocalcemia prior to discharge, SL improved the cross-validated AUROC to 0.72 (95%CI 0.70–0.74) compared to 0.70 (95%CI 0.68–0.72; p < 0.001) when using a manually curated logistic regression algorithm. ConclusionEnsemble machine learning modestly improves prediction for thyroidectomy-specific outcomes. SL holds promise to provide more accurate patient-level risk prediction to inform treatment decisions.

CHALLENGE THYROIDECTOMY MANUAL DELIVERY VERSUS STERNOTOMY IN RETROSTERNAL GOITER

The study was carried out on 40 patients presented with thyroid swelling admitted at KobryEl-Kobba Military Medical Compass over two years. Eighteen of them suffered from retrosternalgoiter and were divided into two groups. GI: 4 males were treated by sternotomy andtotal thyroidectomy, which histopathological examination showed multinodular goiter. GII: 14patients (12 males & 2 females) were treated by cervical incision and manual retrosternal goiterdeli- very. Patients in both groups were followed up 2 weeks over three months and thenone month over a year post-operation for thyroid profile, serum Ca level, and histopathologicalspecimens showed multinodular goiter without malignancy.In GI, one patient developed wound secondary infection and was treated by antibiotic. Anotherone showed post-operative hypocalcemia and was treated by oral vitamin D and Ca 500mg and improved after 6 months. In GII, six male patients showed complications; two showedtransient hypocalcemia post-operative and were treated by I.V. Ca gluconate 10% every 12hrfor 2 days followed by oral Ca every 12hr for another week and then one vitamin D and oneCa- tablet for 6 months. One patient showed neck hematoma and exploration was done toevacuate hematoma and bleeding control. Two patients showed nerve problem in the form ofvoice change, difficult in swallowing and aspiration. One was managed by endotracheal intubationfor 48hr and the second was managed by Oxygen therapy and steroid. One patientshowed mild infection and skin edema that was managed by antibiotic and anti-edematousagent. The last one showed sinus formation and was treated by curettage and antibiotic. Thehospital stay was long in GI than in GII, as in GI 48hr ventilation used post-operative comparedto 24hr in GII, but neither tracheomalacia treatment nor tracheostomy in both groups.

CHALLENGE THYROIDECTOMY MANUAL DELIVERY VERSUS STERNOTOMY IN RETROSTERNAL GOITER

The study was carried out on 40 patients presented with thyroid swelling admitted at KobryEl-Kobba Military Medical Compass over two years. Eighteen of them suffered from retrosternalgoiter and were divided into two groups. GI: 4 males were treated by sternotomy andtotal thyroidectomy, which histopathological examination showed multinodular goiter. GII: 14patients (12 males & 2 females) were treated by cervical incision and manual retrosternal goiterdeli- very. Patients in both groups were followed up 2 weeks over three months and thenone month over a year post-operation for thyroid profile, serum Ca level, and histopathologicalspecimens showed multinodular goiter without malignancy.In GI, one patient developed wound secondary infection and was treated by antibiotic. Anotherone showed post-operative hypocalcemia and was treated by oral vitamin D and Ca 500mg and improved after 6 months. In GII, six male patients showed complications; two showedtransient hypocalcemia post-operative and were treated by I.V. Ca gluconate 10% every 12hrfor 2 days followed by oral Ca every 12hr for another week and then one vitamin D and oneCa- tablet for 6 months. One patient showed neck hematoma and exploration was done toevacuate hematoma and bleeding control. Two patients showed nerve problem in the form ofvoice change, difficult in swallowing and aspiration. One was managed by endotracheal intubationfor 48hr and the second was managed by Oxygen therapy and steroid. One patientshowed mild infection and skin edema that was managed by antibiotic and anti-edematousagent. The last one showed sinus formation and was treated by curettage and antibiotic. Thehospital stay was long in GI than in GII, as in GI 48hr ventilation used post-operative comparedto 24hr in GII, but neither tracheomalacia treatment nor tracheostomy in both groups.

Direct Puncture of the Carotid Artery as a Bailout Vascular Access Technique for Mechanical Thrombectomy in Acute Ischemic Stroke—The Revival of an Old Technique in a Modern Setting

To describe our single-center experience of mechanical thrombectomy (MTE) via a direct carotid puncture (DCP) with regard to indication, time metrics, procedural details, as well as safety and efficacy aspects. DCP thrombectomy cases performed at our center were retrospectively identified from a prospectively maintained institutional MTE database. Various patient (age, sex, stroke cause, comorbidities), clinical (NIHSS, mRS), imaging (occlusion site, ASPECT score), procedural (indication for DCP, time from DCP to reperfusion, materials used, technical nuances), and outcome data (NIHSS, mRS) were tabulated. Among 715 anterior circulation MTEs, 12 DCP-MTEs were identified and analyzed. Nine were left-sided M1 occlusions, one right-sided M1 occlusion, and two right-sided M2 occlusions. DCP was successfully carried out in 91.7%; TICI 2b/3-recanalization was achieved in 83.3% via direct lesional aspiration and/or stent-retrieval techniques. Median time from DCP to reperfusion was 23 min. Indications included futile transfemoral catheterization attempts of the cervical target vessels as well as iliac occlusive disease. Neck hematoma occurred in 2 patients, none of which required further therapy. MTE via DCP in these highly selected patients was reasonably safe, fast, and efficient. It thus represents a valuable technical extension of MTE, especially in patients with difficult access.

Risk Score of Neck Hematoma: How to Select Patients for Ambulatory Thyroid Surgery?

The risk of postoperative compressive hematoma is the major limitation for a wide development of ambulatory thyroidectomy (AT). The aim of this study was to establish a risk score of hematoma on the basis of preoperative criteria. All patients who underwent thyroidectomy between 2002 and 2017 were reviewed in a high-volume endocrine surgery center. Multivariate analysis of risk factors associated with hematoma was performed in lobectomy and total thyroidectomy (TT). We assigned the risk factors identified by multivariate analysis weighted points proportional to the regression coefficient values. A simple sum of all accumulated points for each patient calculated the total score. For lobectomy [31 hematoma among 3912 patients (0.8%)], the weighted points of Vit K antagonist (VKA) were 3 (OR 9.86), and 1 in male gender (OR 2.4). For TT [162 hematoma among 13,903 patients (1.2%)], the weighted points of VKA were 4 (OR 12.18), 1 in male gender (OR 1.89), and 1 for diabetes (OR 1.86). Other factors weighted 0 in both groups. A total score >1 was linked to a risk of hematoma > 1.3% for lobectomy or TT. AT should not be proposed to any patient under VKA, and in case of TT, to male patients with diabetes. Prospectively, patients had AT from May 2018 to February 2020, 529 patients underwent ambulatory TL (483) or TT (46) and only one patient experienced neck hematoma. We established a simple and reproducible predictive score of early discharge for lobectomy and TT that could be useful for patients' management.

Analyzing the ATA statement on outpatient thyroidectomy using the NSQIP database

IntroductionThe aim of this study is to examine the outcomes of outpatient thyroidectomy per the American Thyroid Association (ATA) statement on this procedure using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database. MethodsA retrospective study using NSQIP database (2016 2017) comparing outpatient (OP) and inpatient (IP) thyroidectomies based on the ATA statement. ResultsThere were 382 inpatient and 628 outpatient thyroidectomies. A vessel sealing device and intraoperative nerve monitoring were more commonly used in OP group. Drain use was less common in OP group.There was no difference in the rate of recurrent laryngeal nerve injury, neck hematoma, or postoperative hypocalcemia within 30 days after surgery. IP group had a higher rate of readmissions (3.4% vs 1.8%, p = 0.004). Logistic regression showed OP surgery was associated with a lower risk of readmission OR 0.38 (CI 0.15–0.97; p = 0.04). ConclusionThe ATA criteria can be used to identify good candidates for outpatient thyroidectomy.

S2151 A Cautionary Tale: Hemosuccus Pancreaticus in a Patient With a History of Chronic Pancreatitis

INTRODUCTION: Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding from the pancreatic duct and is usually secondary to chronic pancreatitis, pancreatic pseudocysts, or tumors. We present a diagnostically challenging case of upper gastrointestinal bleeding (UGIB) from the pancreatic duct in a relatively young patient with a history of recurrent pancreatic injuries and alcohol use. CASE DESCRIPTION/METHODS: A 35-year-old man with recurrent acute and chronic alcohol-induced pancreatitis presented with acute melena and general fatigue. In the emergency department, complete blood count showed a hemoglobin of 6.4 compared to 13 earlier in the year. He received one unit of packed red blood cells, intravenous (IV) fluids, and IV pantoprazole. During his hospital course, he experienced an episode of hematemesis, and he continued to have melena. Subsequently, esophagogastroduodenoscopy (EGD) was performed and revealed blood in the second portion of the duodenum but no other remarkable sources of bleeding. The patient's hemoglobin continued to trend downwards. Tagged red blood cell scan showed blood accumulation in the proximal small bowel of the right hemiabdomen. A repeat EGD was performed, showing blood in the ampulla of Vater. Contrast-enhanced computed tomography angiography and magnetic resonance cholangiopancreatography revealed a likely thrombosed pseudoaneurysm in the gastroduodenal artery with mass effect on the pancreatic neck, severely narrowing the splenoportal vein confluence. Imaging also confirmed evidence of chronic pancreatitis as well as hepatic steatosis. An arteriogram with successful coil embolization of the gastroduodenal artery was performed. The patient’s clinical status improved, and he was discharged home in stable condition. DISCUSSION: Our case represents how hemosuccus pancreaticus can be difficult to diagnose in an acutely anemic patient with risk factors for typical etiologies of UGIB. The delay in diagnosis and treatment can be attributed to repeated endoscopies unable to visualize the source of bleeding as well as the intermittent bleeding itself that can often resolve without intervention.Figure 1.: Esophagogastroduodenoscopy reveals bleeding in the second portion of the duodenum.Figure 2.: Magnetic resonance cholangiopancreatography demonstrates a hematoma in the pancreatic neck, markedly narrowing the pancreatic duct and splenoportal confluence.Figure 3.: Post embolization angiogram at the level of the common hepatic artery shows successful coil embolization of the gastroduodenal artery.

THE KNOCKOUT PUNCH: A RARE CASE OF AGGRESSIVE METASTATIC SARCOMA

SESSION TITLE: Fellows Disorders of the Mediastinum Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Soft tissue sarcomas (STS) are a heterogeneous mix of mesenchymal tumors that account for 1-2% of adult cancers worldwide. Though instances of prior trauma have been described in the literature as the precipitant for sarcoma formation, the pathophysiology is overall poorly understood. CASE PRESENTATION: A 24 year old male presented to the ED with increasing neck pain and progressive swelling following a punch to the neck during a boxing class. A CT of the neck revealed a large right-sided inferior neck hematoma. He was evaluated by vascular surgery, who recommended conservative management, and was subsequently discharged home. Three months following the initial injury, he re-presented to the ED with progressive dyspnea. A CT Chest was performed, revealing a large fluid collection thought to be extension of the hematoma into his right chest wall with associated mass effect on the mediastinum. He was admitted, and underwent a VATS washout with biopsies with cardiothoracic surgery. Pathology from the biopsy demonstrated undifferentiated sarcoma with epithelioid features. After consulting radiation and medical oncology, he began urgent radiation and chemotherapy. Despite this, the tumor was highly aggressive and continued to spread into his lungs and abdomen. Repeat imaging revealed a large loculated hemorrhagic effusion with mediastinal and upper abdominal content shifts. He underwent another VATS washout removing 2.2 liters of congealed blood from his chest. After a prolonged hospital course, he was eventually discharged to a rehab facility. His clinical course was further complicated by two more hospital admissions for dyspnea, revealing progressive disease with distant metastasis to the bowel. Despite aggressive measures including repeated blood transfusions and vasopressors in the ICU, he clinically deteriorated. He was transitioned to comfort measures, and eventually passed away. DISCUSSION: Several studies have explored the supposed correlation between trauma and STS formation. These hypotheses include initiator-promoter models that describe sarcoma formation after an initial genetic shutdown of tumor protein and local injury in mouse models. Autopsy of our patient revealed extensive local and metastatic disease to the neck, pleura, lungs, mediastinum, pericardium, diaphragm, liver, spleen, serosa of the small and large bowel, and the bladder. Could our patient have had an inherited oncogenic insult that predisposed him to sarcoma formation following injury? CONCLUSIONS: This case potentially substantiates a link between traumatic injury and STS formation. Additionally, it highlights that high grade sarcomas may mimic traumatic intramuscular hematomas early in their disease course. Reference #1: Jo VY, Fletcher CD. Pathology. WHO classification of soft tissue tumours: an update based on the 2013 (4th) edition. 2014 Feb; 46(2):95-104. Reference #2: Van Mater D, et al. Acute tissue injury activates satellite cells and promotes sarcoma formation via the HGF/c-MET signaling pathway. Cancer Res. 2015 Feb 1; 75(3):605-14. Reference #3: Gomez P, Morcuende J. High-grade sarcomas mimicking traumatic intramuscular hematomas: a report of three cases. Iowa Orthop J. 2004;24:106–110. DISCLOSURES: No relevant relationships by Rasika Chepuri, source=Web Response No relevant relationships by Anuj Shukla, source=Web Response

Sex-Specific Differences in Outcomes Following Thyroidectomy: A Population-Based Cohort Study

Introduction: Numbers of thyroidectomies and awareness of postoperative quality measures have both increased. Potential sex-specific variations in clinical outcomes of patients undergoing thyroidectomy are controversial. Objective: The aim of this study was to investigate sex-specific differences in outcomes following thyroidectomy. Methods: This is a population-based cohort study of all adult patients undergoing either hemi- or total thyroidectomy in Switzerland from 2011 to 2015. The primary outcome was all-cause 30-day readmission rate. The main secondary outcomes were intensive care unit (ICU) admission, surgical re-intervention, in-hospital mortality, length of hospital stay (LOS), postoperative calcium disorder, vocal cord paresis, and hematoma. Results: Of 16,776 patients undergoing thyroidectomy, the majority of patients undergoing thyroidectomy were female (79%), with a median age of 52 (IQR 42–64) years. Within 30 days after the surgery, male patients had significantly higher rates of hospital readmission (adjusted risk ratio [RR] 1.38; 95% confidence interval [95% CI] 1.11–1.72, p = 0.008) and higher risks for postoperative ICU admission (RR 1.25; 95% CI, 1.09–1.44, p = 0.003) than female patients. There were no significant differences among sexes in the LOS, rates of surgical re-interventions, or in-hospital mortality. While postoperative calcium disorders due to hypoparathyroidism were less prevalent among male patients (RR 0.63; 95% CI, 0.54–0.72, p < 0.001), a 2-fold higher incidence rate of postoperative hematoma was observed (RR 1.93, 95% CI, 1.51–2.46, p < 0.001). Conclusions: Male patients undergoing thyroidectomy have higher 30-day hospital readmission and ICU admission rates. Following surgery, male patients revealed higher rates of neck hematoma, while hypocalcemia was more frequent among female patients.

Risk Factors and Outcomes of Postoperative Neck Hematomas: An Analysis of 5,900 Thyroidectomies Performed at a Cancer Center.

Introduction Postoperative neck hematoma (PNH) is an uncommon but potentially-lethal complication of thyroid surgery. Objective To identify the risk factors for postthyroidectomy hematoma requiring reoperation, the timing, the source of the bleeding, the related respiratory distress requiring tracheotomy, and the late outcomes. Methods We retrospectively analyzed the records of 5,900 consecutive patients submitted to surgery for thyroid diseases at a single institution. Results In total, PNH occurred in 62 (1.1%) patients. Most cases of bleeding occurred within the first 6 hours after thyroidectomy, but 12.5% of the hematomas were observed after 24 hours. Obvious bleeding points were detected in 58.1% of the patients during the reoperation, with inferior thyroid artery branches and superior thyroid vessels being the most frequent bleeding sources. Only two patients required urgent tracheostomy. There were no hematoma-related deaths. Permanent hypoparathyroidism and recurrent laryngeal nerve injury are more frequent following reoperation for PNH. The factors significantly associated with PNH were: older age, concurrent lymph node dissection, and chronic lymphocytic thyroiditis. Gender, previous neck irradiation, presentation at diagnosis (symptomatic or incidental), substernal goiter, thyroidectomy for hyperthyroidism, prior thyroid surgery, malignant histology, the extent of the surgery (total versus non-total thyroidectomy), the use of energy-based vessel sealing devices, the use of the hemostatic agent Surgicel, and the placement of a surgical drain were not significantly associated with PNH. Conclusion Hematoma after thyroid surgery is an uncommon complication, but it is related to significant postoperative morbidity. A better understanding of the risk factors and of the time until hematoma formation can help target high-risk patients for preventive measures and closer postoperative observation.

Direct puncture of the carotid artery as a bailout vascular access technique for mechanical thrombectomy in acute ischemic stroke\u2014the revival of an old technique in a modern setting

PurposeTo describe our single-center experience of mechanical thrombectomy (MTE) via a direct carotid puncture (DCP) with regard to indication, time metrics, procedural details, as well as safety and efficacy aspects.MethodsDCP thrombectomy cases performed at our center were retrospectively identified from a prospectively maintained institutional MTE database. Various patient (age, sex, stroke cause, comorbidities), clinical (NIHSS, mRS), imaging (occlusion site, ASPECT score), procedural (indication for DCP, time from DCP to reperfusion, materials used, technical nuances), and outcome data (NIHSS, mRS) were tabulated.ResultsAmong 715 anterior circulation MTEs, 12 DCP-MTEs were identified and analyzed. Nine were left-sided M1 occlusions, one right-sided M1 occlusion, and two right-sided M2 occlusions. DCP was successfully carried out in 91.7%; TICI 2b/3-recanalization was achieved in 83.3% via direct lesional aspiration and/or stent-retrieval techniques. Median time from DCP to reperfusion was 23 min. Indications included futile transfemoral catheterization attempts of the cervical target vessels as well as iliac occlusive disease. Neck hematoma occurred in 2 patients, none of which required further therapy.ConclusionMTE via DCP in these highly selected patients was reasonably safe, fast, and efficient. It thus represents a valuable technical extension of MTE, especially in patients with difficult access.

Direct carotid puncture for mechanical thrombectomy in acute ischemic stroke patients with prohibitive vascular access.

While the benefit of mechanical thrombectomy (MT) for patients with anterior circulation acute ischemic stroke with large-vessel occlusion (AIS-LVO) has been clearly established, difficult vascular access may make the intervention impossible or unduly prolonged. In this study, the authors evaluated safety as well as radiographic and functional outcomes in stroke patients treated with MT via direct carotid puncture (DCP) for prohibitive vascular access. The authors retrospectively studied patients from their prospective AIS-LVO database who underwent attempted MT between 2015 and 2018. Patients with prohibitive vascular access were divided into two groups: 1) aborted MT (abMT) after failed transfemoral access and 2) attempted MT via DCP. Functional outcome was assessed using the modified Rankin Scale at 3 months. Associations with outcome were analyzed using ordinal logistic regression. Of 352 consecutive patients with anterior circulation AIS-LVO who underwent attempted MT, 37 patients (10.5%) were deemed to have prohibitive vascular access (mean age [± SD] 82 ± 11 years, mean National Institutes of Health Stroke Scale [NIHSS] score 17 ± 5, with females accounting for 75% of the patients). There were 20 patients in the DCP group and 17 in the abMT group. The two groups were well matched for the known predictors of clinical outcome: age, sex, and admission NIHSS score. Direct carotid access was successfully obtained in 19 of 20 patients. Successful reperfusion (thrombolysis in cerebral infarction score 2b or 3) was achieved in 16 (84%) of 19 patients in the DCP group. Carotid access complications included an inability to catheterize the carotid artery in 1 patient, neck hematomas in 4 patients, non-flow-limiting common carotid artery (CCA) dissections in 2 patients, and a delayed, fatal carotid blowout in 1 patient. The neck hematomas and non-flow-limiting CCA dissections did not require any subsequent interventions and remained clinically silent. Compared with the abMT group, patients in the DCP group had smaller infarct volumes (11 vs 48 ml, p = 0.04), a greater reduction in NIHSS score (-4 vs +2.9, p = 0.03), and better functional outcome (shift analysis for 3-month modified Rankin Scale score: adjusted OR 5.2, 95% CI 1.02-24.5; p = 0.048). DCP for emergency MT in patients with anterior circulation AIS-LVO and prohibitive vascular access is safe and effective and is associated with higher recanalization rates, smaller infarct volumes, and improved functional outcome compared with patients with abMT after failed transfemoral access. DCP should be considered in this patient population.