Urgent Surgical Repair Research Articles

Self-supervised contrastive learning improves machine learning discrimination of full thickness macular holes from epiretinal membranes in retinal OCT scans.

There is a growing interest in using computer-assisted models for the detection of macular conditions using optical coherence tomography (OCT) data. As the quantity of clinical scan data of specific conditions is limited, these models are typically developed by fine-tuning a generalized network to classify specific macular conditions of interest. Full thickness macular holes (FTMH) present a condition requiring urgent surgical repair to prevent vision loss. Other works on automated FTMH classification have tended to use supervised ImageNet pre-trained networks with good results but leave room for improvement. In this paper, we develop a model for FTMH classification using OCT B-scans around the central foveal region to pre-train a naïve network using contrastive self-supervised learning. We found that self-supervised pre-trained networks outperform ImageNet pre-trained networks despite a small training set size (284 eyes total, 51 FTMH+ eyes, 3 B-scans from each eye). On three replicate data splits, 3D spatial contrast pre-training yields a model with an average F1-score of 1.0 on holdout data (50 eyes total, 10 FTMH+), compared to an average F1-score of 0.831 for FTMH detection by ImageNet pre-trained models. These results demonstrate that even limited data may be applied toward self-supervised pre-training to substantially improve performance for FTMH classification, indicating applicability toward other OCT-based problems.

Suture repair versus mesh repair in elderly populations with incarcerated or strangulated groin hernia.

Tension-free hernia repair is the gold standard for groin hernia repair. However, the optimal surgical treatment for incarcerated or strangulated groin hernia in elderly populations is controversial. The aim of this study is to compare the clinical efficacy of mesh repair and suture repair in the treatment of incarcerated or strangulated groin hernia in elderly patients. Patients ≥ 65years who underwent urgent surgical repair for incarcerated or strangulated groin hernia from January 2012 to June 2022 were included. Patients' demographic data and postoperative outcomes were retrospectively analyzed. Patients with limited life expectancy were screened from the elderly population for subgroup analysis. A total of 103 patients (median age: 84years old, range 65-96; mean follow-up time: 36.8 ± 24.8months) were included, involving 42 cases in the suture repair group and 61 cases in the mesh repair group. Suture repair and mesh repair had similar lengths of ICU and hospital stay, and rates of small bowel resection, chronic pain, surgical site infection, and surgical-related death. However, suture repair had a significantly higher recurrence rate than mesh repair (7% vs. 2%, P = 0.04). In our subgroup analysis, for patients with limited life expectancy (41 patients; median age: 88yearsold, range: 80-96), suture repair had no statistical difference in postoperative outcomes compared with mesh repair. Mesh repair is suitable for elderly patients with acutely incarcerated or strangulated groin hernias. However, for elderly patients with limited life expectancy, suture repair and mesh repair showed similar clinical outcomes.

Where next for type B aortic dissection?

In April 2021 the acute aortic dissection toolkit was launched by NHS England.1 It was designed to improve the care of patients with acute aortic dissection (AD) by raising awareness of the condition and introduced seven key principles of management including better governance, 24/7 rotas and specialist care. Each NHS region in England was encouraged to form an AD group, benchmark their current service against the toolkit principles and then try to improve their management of these patients by addressing deficiencies. The toolkit provided tools for self-assessment together with protocols to improve deficiencies by sharing best practice. A regular series of regional meetings has been held with clinicians and managers to advise and help progress – engagement with the process and feedback has been good. National key performance indicators are being developed to monitor the overall effect of the toolkit. Although the toolkit applies to all dissections, there is inevitably a bias towards management of type A dissections because many need urgent cardiac surgical repair. So where next and what about type B dissections?

Abstract 11711: Factors Predicting Acute Ischemic Stroke Following Surgical Repair of Acute Type A Aortic Dissection (ATAAD) in Adults

Introduction: Acute type A Aortic dissection (ATAAD) may require urgent surgical repair, and a major complication is acute ischemic stroke (AIS) post-surgery. Aim: To explore characteristics associated with AIS in ATAAD patients post-surgical repair (PSR). Hypothesis: We assessed the hypothesis that multiple factors influence events of AIS in ATAAD patients PSR. Method: Multivariate regression analysis for factors influencing AIS in adults with a principal diagnosis of ATAAD and undergoing surgical repair was performed via the 2016-2020 National Inpatient Sample. Results: Among the 20335 ATAAD cases with surgical repair, 14.7%(2985 cases) reported an event of AIS. Individuals ≥60 years (vs. ages 18-39 years, aOR 1.323, p=0.007) and presence of hypertension (aOR 1.228, P<.001), acute kidney injury (AKI) (aOR 1.353, P<.001), Charlson Comorbidity Index (CCI) ≥3 (aOR 15.129, p<.001), and Private insurances (vs. Medicare, aOR 1.454, p<.001) or Medicaid (vs. Medicare, aOR 1.673, p<.001) showed higher odds of developing AIS. On the contrary, smoking (aOR 0.613, p<.001), obesity (aOR 0.882, p=0.027), cirrhosis (aOR 0.309, p<.001), dyslipidemia (aOR 0.732, p<.001), diabetes (DM) (aOR 0.508, p<.001), peripheral vascular disease (PVD) (aOR 0.615, p<.001), Chronic Kidney Disease (CKD) (aOR 0.446, p<.001), prior MI (aOR 0.461, p<.001) and prior stroke (aOR 0.788, p=0.04) and Black race (aOR 0.736, p<.001) indicated lower odds. No significant difference was seen in age 40-59 (aOR 1.06, p=0.545), drug abuse (aOR 1.093, p=0.451), alcohol abuse (aOR 0.925, p=0.476), Females (vs. Males, aOR 0.973, p=0.579), and Hispanics (vs. Whites, aOR 1.102, p=0.285). Conclusion: In conclusion, a 14.7% rate of AIS in ATAAD PSR was observed. Ages ≥60, hypertension, AKI, CCI ≥3, and Private and Medicaid insurance holders appeared prone to AIS following such events, while smoking, obesity, cirrhosis, dyslipidemia, DM, PVD, CKD, prior MI, prior stroke, and Blacks had reduced odds.

Acute-on-Chronic Aortic Dissection: Management and Outcomes of the Unstable “Triple-Lumen” Aorta

BackgroundThe impact of acute aortic dissection of the chronically dissected distal aorta is unknown. This study sought to describe the incidence and characteristics of the triple-lumen aortic dissection and its impact on survival. MethodsFrom 2010 to 2021, a query of a single-institution aortic database identified 1149 patients with chronic distal aortic dissection. Thirty-three (2.9%) patients with at least 3 distinct lumens and 2 separate “primary” intimal tears were identified by analysis of contrast-enhanced cross-sectional imaging. Triple-lumen patients were exactly matched with a cohort of double-lumen patients on a 1:1 ratio using 5 preoperative variables, and outcomes between the groups were assessed. ResultsThe median age at time of initial dissection in patients with a triple-lumen dissection was 46 years. Initial dissection was a type A in 33% and a type B in 67% of patients. The median time from initial dissection to triple-lumen diagnosis was 4.2 years. On diagnosis of the triple-lumen aorta, 85% of patients required urgent aortic repair for rapid growth (36%), aortic diameter ≥55 mm (30%), malperfusion (6%), intractable pain (6%), and rupture/type A (6%). Thirty-day mortality after triple lumen dissection was 12%. ConclusionsAcute-on-chronic distal dissection resulting in a triple-lumen aorta should be classified as a “complicated” type B dissection as these patients typically have large aneurysms and a high incidence of rapid false lumen expansion requiring urgent surgical repair.

Early Detection and Urgent Surgical Repair of Pharyngeal Injury after Anterior Cervical Surgery: A Case Report

This case report addresses pharyngeal perforation, an uncommon complication after anterior cervical discectomy and fusion (ACDF). A 78-year-old male, who initially presented with quadriparesis, underwent ACDF. Post-surgery, the porridge he consumed was observed in the drain tube, leading to complications such as respiratory distress and fever. An emergency exploratory surgery was performed, and a suspected pharyngeal perforation was identified and treated with primary repair and sternocleidomastoid flap. Through thorough post-operative observation, we identified critical signs requiring immediate intervention, allowing for a successful recovery without additional complications. This report emphasizes the importance of early detection and intervention for complications following ACDF, providing valuable insights for clinical practice in neurosurgical intensive care.

Increased risk for incisional hernia following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

The incidence of incisional hernias (IH) after midline laparotomy varies from 11% to 20%. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is potentially prone to hernias because a Xiphoid to pubis laparotomy incision performed on patients who have undergone previous abdominal surgeries with the addition of chemotherapy and its related adverse effects. We performed a retrospective analysis on a prospectively maintained single institution database from March 2015 to July 2020. The inclusion criteria were patients who underwent CRS-HIPEC and had at least 6 months postoperative follow-up with post-operative cross-sectional imaging study. Two hundred and one patients were included in the study. All patients underwent CRS-HIPEC with resection of previous scar and umbilectomy. Fifty-four patients were diagnosed with IH (26.9%). The major risk factors for IH in multivariate analysis were higher American society of Anesthesiologists score (ASA) (OR 3.9, P = 0.012), increasing age (OR 1.06, P = 0.004) and increasing BMI (OR 1.1, P = 0.006). Most of the hernia sites were median (n = 43, 79.6%). Eleven (20.4%) patients had lateral hernias due to stoma incisions or drain sites. Most of the median hernias were at the level of the resected umbilicus 58.9% (n = 23). Five (9.3%) of the patients with IH necessitated an urgent surgical repair. We have demonstrated that more than a quarter of the patients after CRS-HIPEC suffer from IH and up to 10% of them may require surgical intervention. More research is needed to find the appropriate intraoperative interventions to minimize this sequela.

An Uncommon Case of an Acute Onset Growing Skull Fracture: Case Report and Review of Literature

Growing skull fractures (GSF) are rare complications of pediatric skull fractures with a reported incidence of 0.05–1.6%. They are most commonly seen in children less than 5 years of age. Most commonly, the onset of symptoms from the time of trauma ranges from weeks to months, with very few cases reported in literature which have an acute onset within a few days. Here we present a case of a 2-year child with a history of traumatic linear skull fracture who had an acute onset of scalp swelling within 4 days of trauma. An MRI scan showed the presence of a GSF and urgent surgical repair in the form of duraplasty and cranioplasty was undertaken. Awareness regarding the possibility of an acute onset of GSF is important for neurosurgeons as early surgical repair has been shown to reduce neurological complications.

Prevention of cardiac tamponade during CLOSE-protocoll guided ablation of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation (CA) with radiofrequency (RF) energy using the CLOSE protocol has proven safety and efficacy in a large prospective multicenter study(1) with the rate of pericardial tamponade (PT) as low as 0.9%. PT may still become hazardous in the era of uninterrupted anticoagulation and may require urgent surgical repair. Steam pop is the major cause of PT during Pulmonary vein Isolation (PVI) with RF ablation and is usually preceded by steep impedance rise measured between tissue and tip of the RF catheter. The STOCKERT SMARTABLATE RF Generator as a core part of technology for CLOSE protocol guided PVI offers the opportunity to automatically stop RF energy delivery within 0.5 seconds if catheter impedance rises above a predefined value: impedance spike cut off (ISCO). The standard – manufacturer recommended – value for ISCO is 50 Ω per 0.5 seconds. Purpose To investigate the effect of reduced ISCO during CLOSE protocol guided catheter ablation of AF on the occurrence of acute PT and pericardial effusion (PE) in a large single center series. Methods We performed CLOSE protocol guided PVI procedures using Biosense Webster CARTO PRIME 3D navigation system, Smarttouch SF ablation catheter, VIZIGO steerable sheath, invasive blood pressure measurement via radial artery. We changed the STOCKERT SMARTABLATE generator settings to ISCO of 25Ω per 0,5 seconds. Cut off during the ablation procedure by ISCO led the operator to reduce contact force, angulation/orientation of catheter/steerable sheath, changing to jet ventilation if mechanical ventilation was present. Investigation for PT by echo was performed for every drop <90mmHg systolic blood pressure. PE detection immediately after and the day after ablation procedure was performed by transthoracic echo. A retrospective analysis of all CLOSE protocoll procedures was performed. Statistical analysis was performed on the evaluable population. Results During 43 months of observation we performed 980 CLOSE protocol guided procedures: 516 PVI only, 464 PVI with additional ablations (VT, cavotricuspid isthmus, slow pathway, additional LA lines, ethanol ablation of vein of marshall). We observed 4 (0.4%) PT immediately at the end of the procedure and no additional relevant PE the day after CA. Of the 4 PT, 1 patient needed urgent surgical repair and 3 were managed conservatively with pericardiocentesis and retransfusion. Conclusions CLOSE protocol guided PVI is an effective and safe intervention for treatment of AF. The VISITAX trial reported 3 events of PT per 329 patients (0.9%). By reducing ISCO to 25 Ω per 0,5 seconds, we found less than half of the rate of PT (0.4%) compared with the VISITAX trial. The generator cut off at ISCO of 25 Ω per 0.5 seconds automatically stops a potentially dangerous ablation and can indicate potientially dangerous ablation sites. Our data are limited due to the retrospective monocentric design and therefore should be evaluated prospectively.

Percutaneous management of atrial wall perforation during transeptal puncture with an Amplatzer vascular plug in 3 patients: keep calm, think fast

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial wall perforation is a rare but serious complication of transeptal puncture in AF catheter ablation procedure. In patients with uninterrupted anticoagulation associated to non-fractionated heparin bolus this may lead to cardiac tamponade and dramatic consequences. Urgent surgical drainage and repair is mandatory in the most dramatic cases. We report the successful closure of such complication by an Amplatzer vascular plug leading to a rapid and total recovery in 3 patients. Methods Three patients (male, 43, 77 and 84 yo) referred for persistent atrial fibrillation ablation (1 RF and 2 cryoablations). After transeptal puncture, they became severely hypotensive with echographic evidence of tamponade. Results Heart perforation with massive leakage of contrast in the pericardial space was evident. The perforation was anterior near aorta in one, on the posterior wall of the right atrium in one and on the posterior wall of the left atria though the right atria in one. After heparin antagonization by protamin, the pericardial space was drained percutaneously (1 to 3 l drained and in 1 reinjected through a "cell saver" system). Rapidly, a 0,035 J guide wire was passed through the perforation and an Amplatzer vascular Plug 2 (4 mm in 2 patients and 6 mm in one) was released resulting in an immediate closure of the leak and recovery of the patient after completion of the pericardial drainage. The drainage was monitored 24h and patients were discharged on Day 2 with a good evolution over a median follow-up of 1.5 year. CT scan at 3 and 6 month showed total recovery. Conclusion In patients with left atrial wall perforation and tamponade related to failed transeptal puncture in patients under uninterrupted oral anticoagulation for AF ablation, rapid release of a closure device and pericardial evacuation allowed to successfully manage the cardiac tamponade and avoid a surgical option.

Endotracheal suture through extending tracheostoma for post-tracheostomy tracheal laceration: a case report

BackgroundTracheal laceration is very rare but can be life-threatening if proper treatment is not provided. The general concept for the management of tracheal laceration is surgical repair through cervical incision or via thoracotomy. However, in the case of tracheal laceration after tracheostomy, tracheostoma could be extended to avoid urgent surgical repair and additional incision.Case presentationA 30-year-old Asian woman suffered intracerebral hemorrhage. Tracheostomy was necessary for prolonged ventilator care. While tracheostomy was performed, the posterior tracheal wall was torn. After observing that, we reinserted endotracheal tube through the oral orifice. Following bronchoscopy showed torn posterior tracheal wall. The tearing wound was 5–6 cm in length, from the middle to distal parts of the trachea. We used minimally invasive procedure for extending the already existing tracheostoma.ConclusionsIn the case of tracheal laceration related to tracheostomy, a new incision is not necessary because the tracheal opening already exists. Using the extended tracheostomy technique, tracheal laceration can be repaired by endotracheal suture method.

Re-evaluating the Timing of Surgery after Isolated Orbital Floor Fracture

Background: Orbital floor fractures are among the most common facial injuries. Although urgent surgical repair may be indicated, most patients require interval follow-up to assess for symptom onset and need for definitive operative intervention. This study aimed to evaluate the time to operative indication after these injuries. Methods: A retrospective review was conducted of all patients with isolated orbital floor fractures at a tertiary academic medical center from June 2015 to April 2019. Patient demographic and clinical data were recorded from the medical record. Time until operative indication was evaluated by the Kaplan-Meier product limit method. Results: Of 307 patients meeting inclusion criteria, 9.8% (30/307) developed indications for repair. Among these, 60% (18/30) were recommended surgery on the day of initial evaluation. Of 137 follow-up patients, 8.8% (12/137) developed operative indications based on clinical evaluation. The median period to decision for surgery was 5 days (range, 1–9). No patients developed symptoms suggesting the need for surgery beyond 9 days after trauma. Conclusions: Our investigation demonstrates that only about 10% of patients presenting with isolated orbital floor fracture develop an indication for surgery. For patients undergoing interval clinical follow-up, we found that patients demonstrated symptoms within 9 days of trauma. No patients demonstrated need for surgery beyond 2 weeks of injury. We believe these findings will assist to establish standards of care and inform clinicians on the appropriate length of follow-up for these injuries.

Emergency Neurosurgery in a Patient with a Large Thoracic Aortic Aneurysm: Sitting on a Bomb

AbstractThoracic aortic aneurysms larger than 5 cm are associated with a fatal risk of rupture, and their diagnosis is usually followed by urgent surgical repair. Other complications associated with this condition include heart failure, myocardial infarction, and stroke. Literature regarding management of these patients for emergency noncardiac surgeries is scarce, with anecdotal reports advising both surgeries in the same sitting. However, neurosurgical procedures present a unique challenge in this situation, since systemic anticoagulation may be associated with a rebleed within the cranial vault. In this case report, we present an extremely rare and challenging scenario, wherein a patient with a 6.2-cm thoracic aortic aneurysm underwent subdural hematoma evacuation prior to aneurysmal repair.

Penetrating cardiac injury presentation and management in resource-limited settings: A case series from Ethiopia

Introduction and importancePenetrating cardiac injury is rare (0.1 % of trauma admissions) but fatal. Presentation is with features of cardiac tamponade or hemorrhagic shock. Urgent clinical evaluation, ultrasound, temporizing pericardiocentesis or surgical repair with cardiopulmonary bypass as back up consist of standard management. In this paper, experience of management of penetrating cardiac injury from a resource limited country is presented. Case presentationsThere were seven patients, five had a stab injury and two had gunshot wound. All were men with mean age of 31.1 years. Patients arrived within 30 min (3), 2 h (2), 4 h (1) and 18 h (1) after injury. Mean initial blood pressure and pulse rates were 83/51 mm Hg and 121, respectively. One patient had pericardiocentesis before referral. Exploration was via left anterolateral thoracotomy. Four (57.1 %) had right ventricle perforation, one had both right and left ventricle, and two (28.5 %) had left ventricle perforation. Suture repair (6) and pericardial patch (1) were done without bypass machine as back up. Mean duration of stay in the intensive care unit and in the surgical wards were 4.4 days (range: 2–15) and 10.8 days (range: 1–48), respectively. All were discharged improved. Clinical discussionPenetrating cardiac injury presents with low blood pressure and tachycardia after stab or gunshot wounds. Right ventricle is mostly affected. Pericardiocentesis can be done as temporary measure. While having bypass machine as back up is recommended, the absence of it should not preclude intervention. Suture repair can be done with left anterolateral thoracotomy. ConclusionPenetrating cardiac injury can be managed in resource limited settings without back up of cardiopulmonary bypass. Early identification and surgical intervention results in favorable outcome.

Incarcerated obturator hernia, an extremely rare cause of intestinal obstruction: case series.

Protrusion of abdominal contents through the obturator foramen is a rare type of abdominal wall hernia. It is usually seen unilaterally and right-sided. Predisposing factors are old age, high intra-abdominal pressure, pelvic floor dysfunction, and multiparity. Obturator hernia has one of the highest mortality rates of all abdominal wall hernias, with a difficult diagnostic process that can be misleading even for the most experienced surgeons. Therefore, to suspect and easily diagnose an obturator hernia, it is important to understand its characteristics. Computerized tomography scanning remains the best diagnostic tool with the highest sensitivity. Conservative ap-proach is not recommended in obturator hernia cases. Once diagnosed, urgent surgical repair is indicated to prevent further ischemia, necrosis, and risk of perforation that can lead to peritonitis, septic shock, and death. Although open repair is a widely used and effective method for reducing abdominal hernias, including obturator, laparoscopic repairs have been described and become preferred. In this study, we present female patients aged 86, 95, and 90 years who were operated with the diagnosis of obturator hernia on computed tomography. The diagnosis of obturatory hernia should always be kept in mind, especially in the presence of acute mechanical intestinal obstruction findings in an elderly woman.

652 SUCCESSFUL SURGICAL REPAIR OF LEFT VENTRICULAR PSEUDOANEURYSM IN A PATIENT WITH SUBACUTE ST-ELEVATION MYOCARDIAL INFARCTION

Abstract A 65-year-old man was admitted to the emergency department for abdominal pain begun 4 days before. Past medical history consisted of ischemic stroke and diabetes mellitus. Of note, he was not taking any medication. Vital signs: blood pressure 90/50 mmHg, heart rate 50/minute, respiratory rate 18/minute, body temperature 36.5°C; saturation oxygen level 93%. High-sensitivity cardiac troponin was mildly elevated (121 pg/mL). Electrocardiogram showed sinus bradycardia, Q waves with ST elevation in antero-lateral leads consistent with subacute STEMI. Transthoracic echocardiogram (TTE) revealed aneurysmatic expansion of apical left ventricular (LV) walls (ejection fraction 30%) with a large apical thrombus (35×15 mm). Coronary angiography showed complete occlusion of proximal left anterior descending artery and a critical stenosis of right coronary artery; percutaneous coronary intervention with stent implantation on right coronary artery was performed. He received triple antithrombotic therapy with aspirin, clopidogrel, intravenous heparin first and then oral anticoagulation with warfarin. During coronary care unit stay, the patient was asymptomatic and hemodynamically stable. However, a control TTE (day 6) in cardiology ward revealed the presence of pseudoaneurysm with an oval out-pouching (23 × 13 mm) from the apical aspect of LV septum, communicating with the LV chamber through a passage measuring 1.6 cm. Partially organized pericardial effusion was evident around right ventricular free wall (Figure 1). Thus, the patient was immediately transferred to the cardiac surgery department for urgent surgical repair. The LV anterior wall rupture with pseudoaneurysm was then treated with endoaneurysmectomy of the LV with dacron patch and freewall reconstruction with prolene sutures and teflon felt stripes. The patient was finally discharged 3 weeks after surgery with betablockers, ace- inhibitors, diuretics, statins and dual antiplatelet therapy with aspirin and clopidogrel. At one month follow-up visit, the patient was hemodynamically stable with acceptable functional capacity. Figure 1Modified five chamber view (a, b) and three chamber view (c, d) showing apical LV pseudoaneurysm (arrows) with moderate pericardial effusion (arrowhead); color Doppler through the passage (arrow) in 3 chamber view (d). LV, left ventricular.

Anaesthetic considerations for the surgical management of ocular hypotony in adults.

Ocular hypotony can occur from many causes, including eye trauma, ophthalmic surgery and ophthalmic regional anaesthesia-related complications. Some of these patients require surgical intervention(s) necessitating repeat anaesthesia. While surgical management of these patients is well described in the literature, the anaesthetic management is seldom discussed. The hypotonous eye may also have altered globe anatomy, meaning that the usual ocular proprioceptive feedbacks during regional ophthalmic block may be altered or lost, leading to higher risk of inadvertent globe injury. In an 'open globe' there is a risk of sight-threatening expulsive choroidal haemorrhage as a consequence of ophthalmic block or general anaesthesia. This narrative review describes the physiology of aqueous humour, the risk factors associated with ophthalmic regional anaesthesia-related ocular hypotony, the surgical management, and a special emphasis on anaesthetic management. Traumatic hypotony usually requires urgent surgical repair, whereas iatrogenic hypotony may be less urgent, with many cases scheduled as elective procedures. There is no universal best anaesthetic technique. Topical anaesthesia and regional ophthalmic block, with some technique modifications, are suitable in many mild-to-moderate cases, whilst general anaesthesia may be required for complex and longer procedures, and severely distorted globes.

Abstract 15051: A Large Mitral Valve Vegetation in a Patient Presented With Low Back Pain and Lower Limb Weakness- A Success Story of a Multidisciplinary Team

Case presentation: A 58-year-old gentleman presented to A&E with low back pain for a few days and lower limb weakness for 24 hours. His background history was not medically significant. On examination, GCS 14/15, lower limbs power 2/5, and palpable urinary bladder. DRE revealed poor anal tone. MRI spine showed epidural abscess at L3-L4 & L5-S1 level and urgent decompressive spinal surgery was performed. IV antibiotics were started and the patient was admitted to the general HDU for vasopressor support. Since the operation, he developed cold, pale, swollen right leg, with no palpable peripheral arteries. A CT aortogram showed occlusion of the right popliteal artery. Right popliteal artery exploration with anterior and posterior tibial embolectomy and fasciotomies were done. As the patient was slow to wake up post-surgery, he was transferred to ICU. MRI brain showed no pathology. Transthoracic echocardiogram revealed no vegetation. As clinical suspicion of infective endocarditis was high, transoesophageal echocardiogram and real-time 3D analysis was done which showed a large highly mobile echogenic mass attached to the left atrial surface of the anterior mitral leaflet (A1 and A2) causing moderate MR. Urgent surgical mitral valve repair and removal of a 2 cm vegetation were performed. Both the blood culture and the culture of the vegetation tissue confirmed the growth of Staphylococcus aureus (MSSA). After 8 weeks of hospital stay, the patient was discharged home. Discussion: The objective of this case presentation is to reemphasize that infective endocarditis is not a single organ disease and can present to different specialities. Transthoracic echocardiography has reduced sensitivity in the critical care setting. So, there should be a relatively low threshold for transoesophageal echocardiography. Although the mortality rate of infective endocarditis is relatively high in ICU patients, multidisciplinary team management may result in favourable outcomes.

PMON120 Clinical Course Of Untreated Giant Invasive Macroprolactinomas- A Case Series

Abstract Introduction Giant invasive prolactinomas are rare pituitary tumours and have a male preponderance of 9: 1. In majority of cases, dopamine agonists (DA) are the treatment of choice in lowering prolactin and tumour shrinkage. Surgery may be opted in those with acute compressive symptoms or visual loss. Prolactinomas are known to invade the sellar floor, sphenoid sinus and clivus. Spontaneous CSF leak is rare in untreated patients with invasive prolactinomas compared to those on DA who respond with rapid tumour shrinkage that causes unplugging of the conduits resulting in CSF rhinorrhoea. We present 5 male patients with untreated giant invasive prolactinomas with skull base destruction where close surveillance was opted over DA treatment. Results Five male patients with median age of 73±10 years were studied. 1 patient presented with headache, vomiting and 6th nerve palsy which spontaneously resolved over weeks. 2 patients were diagnosed during work up of other hormonal deficiencies and in 2 patients giant tumours were incidentally found on imaging for head injury. Prolactin values ranged from 55,641 to 835,800 mIU/L. Hormonal deficiency was present in 3/5; anterior hypopituitarism (1) and symptomatic secondary hypogonadism (2). MRI imaging in all patients showed extensive skull base bony erosion, with tumour invasion into sphenoid sinus and clivus. Additionally, the patient with largest tumour had invasion into right orbital roof and floor of right anterior cranial fossa. In other patients, tumour had also invaded occipital condyles (1), bilateral cavernous sinus (1). All patients were discussed in tertiary neurosurgical MDT. As the risk of CSF leakage due to tumour shrinkage outweighed the benefits of tumour reduction, a decision not for medical treatment was agreed with patients and planned for active surveillance with MRI scans and regular clinical and visual fields assessments. The mean follow-up period was 4±1 years. One patient was very frail and decided not for radiological surveillance. DA treatment is being considered for the patient with the largest tumour which has grown further causing frontal lobe invasion. There was no significant tumour size increase in other 4 patients and none had spontaneous CSF leak. Discussion Risk stratification for CSF leak with DA treatment is difficult as it depends on the invasion, tumour response to DAs and the extent of underlying bony destruction. This may cause a dilemma on whether or not to treat some patients with DAs. The risk of CSF leak, bacterial meningitis and the subsequent need for urgent surgical repair may outweigh the benefits of tumour reduction with DAs particularly in some patients with low symptom burden. In our experience, patient counselling, active radiological surveillance and considering treatment with change in symptoms (visual deterioration, compressive pathology) could be an appropriate management option in such patients. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Timing of Intervention for Aortic Intramural Hematoma

Intramural hematoma (IMH) is one of the acute aortic syndromes along with acute aortic dissection and penetrating aortic ulcer. The three conditions can occur alone or in combination with overlapping presentation. Medical, open surgical, and endovascular treatment is tailored depending on clinical presentation, timing, and location within the aorta. Among patients who present with acute IMH affecting the ascending aorta (Type A), urgent open surgical repair is considered the primary line of treatment in patients who are suitable candidates and unstable. The management of IMH in the descending aorta and aortic arch (Type B) is similar to that applied to treat acute dissections in the same segment. Medical treatment with sequential imaging is recommended in patients with uncomplicated course, and endovascular repair is indicated in patients with rupture, persistent pain, end-organ ischemia, or rapid aortic enlargement. This review discusses the ideal timing for treatment of IMH.