Early antiplatelet therapy used for acute ischemic stroke and intracranial hemorrhage

In this editorial we comment on the article published by Zhang et al in the recent issue of World Journal of Clinical Cases.We evaluate their claims on the benefit of use of Aspirin in the early management of patients with ischemic stroke.We also comment on their contention of using aspirin in the early management of patients with intracranial hemorrhage,a practice not seen in modern medicine.Large clinical trials such as the International Stroke Trial and the Chinese Acute Stroke Trial have shown the benefit of Aspirin use within 48 h of patients with Acute Ischemic Stroke.The findings were corroborated in the open-label trial performed by Zhang et al in a smaller sample group of 25 patients where they showed improvement in functional scores at 90 days without an increase in adverse events.As such,this intervention is also recommended by the American Heart Association stroke guidelines from 2021.With regard to Intracranial hemorrhage,traditional practice has been to discontinue or avoid antiplatelet therapy in these patient groups.However,no studies have been done to evaluate this management strategy that is more borne out of the mechanism behind Aspirin’s effect on the coagulation pathway.Zhang et al evaluate the benefits of Aspirin on patients with low-volume intracranial hemorrhage,i.e.,less than 30 mL on computed tomo-graphy imaging,and show no increase in mortality.The caveat of this finding is that all outcomes were pooled into one group for results,and the number of patients was low.While more studies with larger patient groups are required,the data from Zhang et al suggests that patients with small-volume intracranial hemorrhages may benefit from Aspirin administration in the acute phase of management.

Investigating the relationship between intracranial atherosclerotic plaque remodelling and diabetes using high-resolution vessel wall imaging

BACKGROUND Intracranial atherosclerosis,a leading cause of stroke,involves arterial plaque formation.This study explores the link between plaque remodelling patterns and diabetes using high-resolution vessel wall imaging(HR-VWI).AIM To investigate the factors of intracranial atherosclerotic remodelling patterns and the relationship between intracranial atherosclerotic remodelling and diabetes mellitus using HR-VWI.METHODS Ninety-four patients diagnosed with middle cerebral artery or basilar artery INTRODUCTION Intracranial atherosclerotic disease is one of the main causes of ischaemic stroke in the world,accounting for approx-imately 10%of transient ischaemic attacks and 30%-50%of ischaemic strokes[1].It is the most common factor among Asian people[2].The adaptive changes in the structure and function of blood vessels that can adapt to changes in the internal and external environment are called vascular remodelling,which is a common and important pathological mechanism in atherosclerotic diseases,and the remodelling mode of atherosclerotic plaques is closely related to the occurrence of stroke.Positive remodelling(PR)is an outwards compensatory remodelling where the arterial wall grows outwards in an attempt to maintain a constant lumen diameter.For a long time,it was believed that the degree of stenosis can accurately reflect the risk of ischaemic stroke[3-5].Previous studies have revealed that lesions without significant luminal stenosis can also lead to acute events[6,7],as summarized in a recent meta-analysis study in which approximately 50%of acute/subacute ischaemic events were due to this type of lesion[6].Research[8,9]has pointed out that the PR of plaques is more dangerous and more likely to cause acute ischaemic stroke.Previous studies[10-13]have found that there are specific vascular remodelling phenomena in the coronary and carotid arteries of diabetic patients.However,due to the deep location and small lumen of intracranial arteries and limitations of imaging techniques,the relationship between intracranial arterial remodelling and diabetes is still unclear.In recent years,with the development of magnetic resonance technology and the emergence of high-resolution(HR)vascular wall imaging,a clear and multidimensional display of the intracranial vascular wall has been achieved.Therefore,in this study,HR wall imaging(HR-VWI)was used to display the remodelling characteristics of bilateral middle cerebral arteries and basilar arteries and to explore the factors of intracranial vascular remodelling and its relationship with diabetes.

Current Epidemiology of Intracranial Metastases in Two University Teaching Reference Hospitals of the Town of Yaounde, Cameroon: Analysis of 35 Cases Recorded in the Neurosurgery Departments

Background: The incidence of intracranial metastases (ICMET) has been steadily rising, and its frequency with respect to primary brain tumours is relatively high. Objective: The objectives of this study were to elucidate the current epidemiology and describe the clinical, diagnostic and therapeutic features of ICMET in Yaounde. Method and findings: A descriptive cross-sectional study was done in the neurosurgery departments of the General and Central Hospitals of Yaounde during the period from January 2016 to December 2022. We included all medical booklets of patients admitted for a tumoral intracranial expansive process with our target population being patients with histological evidence of ICMET, and did a retrospective inclusion of data using a pre-established technical form aimed at collecting sociodemographic data, clinical data, paraclinical data, and the treatment procedures. Analysis was done using the SPSS statistical software. A total of 614 cases of intracranial tumors were included among whom 35 presented histological evidence of ICMET. This gives a frequency of 5.7%. The sex ratio was 0.94, the mean age was 55.68 +/- 14.4 years, extremes 28 and 86 years and the age range 50 - 59 was affected in 28.57% of cases. The clinical presentation included signs of raised intracranial pressure (headache, blurred vision, vomiting) in 26 cases (74.3%), motor deficit 48.6%, seizures 17.1%. The mode of onset was metachronous in 71.4% and synchronous in 28.6%. The imaging techniques were cerebral CT scan in 82.9%, cerebral MRI in 40%, TAP scan in 22.9%. The metastatic lesions were supratentorial in 94.3% and single in 62.9%. The primary cancers found were breast cancer (31.4%), lung cancer (25.7%), prostate cancer (17.1%), thyroid cancer (5.7%), colon cancer (2.9%), and melanoma (2.9%). The therapeutic modalities were total resection (68.6%), radiotherapy (37.1%). Conclusion: Intracranial metastases are relatively frequent. There is a female sex predominance and the age group 50 - 59 years is the most affected. Brain metastases mostly occur in patients with a history of known primary tumor. The clinical signs mainly include signs of raised intracranial pressure, motor deficit, seizures and mental confusion. Cerebral CT Scan is the main imaging technique used. Most of the lesions are single and supratentorially located. The primary cancers most represented include breast cancer, lung cancer and prostate cancer. Surgery is the main treatment procedure. The adjuvant treatment (radiotherapy, chemotherapy) was limited.

Analysis of the Effect of the Comprehensive Nursing Model on Patients with Moyamoya Disease Undergoing Intracranial and Extracranial Revascularization Surgery

Objective:To explore the effect of a comprehensive nursing model on patients with Moyamoya disease who underwent intracranial and extracranial revascularization surgery.Methods:110 cases were divided into control and observation groups with 55 cases each.The control group received routine perioperative care,and the observation group received perioperative care along with comprehensive nursing care.The two groups’disease cognition levels,anxiety,symptoms,daily living ability scores,and postoperative complication rates were compared.Results:The anxiety score and total postoperative complications of the observation group upon discharge were lower than that of the control group,and the disease cognition level and daily living ability upon discharge were higher than that of the control group(P<0.05).Conclusion:Applying the comprehensive nursing model in conjunction with perioperative care for patients undergoing surgery can effectively improve their anxiety,strengthen activities of daily living,and reduce the risk of postoperative complications.

Cardiac Manifestations with Chemotherapeutic Agents: 5 Fluorouracil-Induced Coronary Artery Vasospasm

5-fluorouracil (5-FU) is a fluorinated, pyrimidine analog, antineoplastic agent that is used in the treatment of several solid organ cancers. Cardiotoxicity is uncommon but life-threatening manifestations such as myocardial infarction may manifest owing to 5-FU-induced coronary artery spasm. Administering smaller doses of the drug, more frequently than not, decreases the risk of cardiotoxicity compared to large doses or with continuous infusions. We present a case of ST-segment elevation in a patient without known coronary artery disease who had presented following continuous 5-FU infusion. Coronary angiogram confirmed absence of coronary artery disease and intravenous calcium channel blockers administration was commensurate with the patient’s improvement in symptoms. We discuss the literature on 5-FU and its association with coronary artery spasm, and also briefly review chemotherapy-induced cardiotoxicities to help better prepare internists and other primary health care providers to face similar challenges, particularly of the uncommon but potentially life-threatening manifestations.

Rare cause of cerebral venous sinus thrombosis:Spontaneous intracranial hypotension syndrome:A case report

BACKGROUND Spontaneous intracranial hypotension syndrome is a relatively uncommon neurological disorder of unknown etiology with a good prognosis.Cerebral venous sinus thrombosis is a specific type of cerebrovascular disease caused by multiple etiologies of cerebral venous sinus or vein thrombosis that obstructs cerebral venous return and is associated with impaired cerebrospinal fluid absorption;this entity is rarely seen clinically.Spontaneous intracranial hypotension syndrome is one of the causes of cerebral venous sinus thrombosis,and the probability of their combined occurrence is only 1%-2%.As such,it is easily overlooked clinically,thus increasing the difficulty of diagnosis and treatment.CASE SUMMARY A 29-year-old young woman presented with postural headache.Lumbar puncture suggested a pressure of 50 mmH2O(normal 80 mmH2O-180 mmH2O),and magnetic resonance imaging cerebral venography suggested thrombosis of the supratentorial sinus.These findings were considered indicative of cerebral venous sinus thrombosis due to spontaneous intracranial hypotension syndrome after ruling out immunological causes,tumor,infection,abnormal coagulation mechanism,and hypercoagulable state,etc.She was treated with rehydration and low-molecular heparin anticoagulation for 15 d,and follow-up magnetic resonance imaging cerebral venography suggested resolution of the thrombus.The patient had complete improvement of her headache symptoms.CONCLUSION Spontaneous intracranial hypotension syndrome is one of the rare causes of cerebral venous sinus thrombosis,which is frequently misdiagnosed or missed and deserves consideration by clinicians during differential diagnosis.Dehydration should be avoided in such patients,and early rehydration and anticoagulation therapy are effective treatment options.

Posterior reversible encephalopathy syndrome following uneventful clipping of an unruptured intracranial aneurysm:A case report

BACKGROUND Posterior reversible encephalopathy syndrome(PRES)is characterized mainly by occipital and parietal lobe involvement,which can be reversible within a few days.Herein,we report a rare case of PRES that developed after craniotomy for an unruptured intracranial aneurysm(UIA).CASE SUMMARY A 59-year-old man underwent clipping surgery for the treatment of UIA arising from the left middle cerebral artery.Clipping surgery was performed uneventfully,and he regained consciousness quickly immediately after the surgery.At the 4th hour after surgery,he developed a disorder of consciousness and aphasia.Magnetic resonance imaging revealed cortical and subcortical T2/FLAIR hyperintensities in the parietal,occipital,and frontal lobes ipsilaterally,without restricted diffusion,consistent with unilateral PRES.With conservative treatment,his symptoms and radiological findings almost completely disappeared within weeks.In our case,the important causative factor of PRES was suspected to be a sudden increase in cerebral perfusion pressure associated with temporary M1 occlusion.CONCLUSION Our unique case highlights that,to our knowledge,this is the second report of PRES developing after craniotomy for the treatment of UIA.Surgeons must keep PRES in mind as one of the causes of perioperative neurological abnormality following clipping of an UIA.

Epidural Blood Patches Performed with Miethke Sensor Reservoir for Continuous Intracranial Pressure Monitoring

An epidural blood patch (EBP) is a procedure performed by injecting autologous blood into a patient’s epidural space, usually at the site of a suspected CSF leak. It is typically performed in patients with characteristic postural headaches due to low intracranial pressure. We report a case of a young female with an implanted Miethke Sensor Reservoir, which was used for continuous intracranial pressure (ICP) monitoring during a two-level epidural blood patch. ICP increased only with thoracic injection, suggesting thoracic EBP may have greater efficacy than lumbar EBP in treating SIH and PDPH when the site of CSF leak is unknown.

Subintimal recanalization for non-acute occlusion of intracranial vertebral artery in an emergency endovascular procedure:A case report

BACKGROUND Endovascular recanalization of non-acute intracranial artery occlusion is technically difficult,particularly when the microwire enters the subintima.Although the subintimal tracking and re-entry technique has been well established in the endovascular treatment of coronary artery occlusion,there is limited experience with its use in intracranial occlusion due to anatomical variations and a lack of dedicated devices.CASE SUMMARY A 74-year-old man was admitted to the hospital two days after experiencing acute weakness in both lower extremities,poor speech,and dizziness.After admission,imaging revealed acute ischemic stroke and non-acute occlusion of bilateral intracranial vertebral arteries(ICVAs).On the fourth day of admission,the patient's condition deteriorated and an emergency endovascular recanalization of the left ICVA was performed.During this procedure,a microwire was advanced in the subintima of the vessel wall and successfully reentered the distal true lumen.Two stents were implanted in the subintima.The patient's Modified Rankin Scale was 1 at three months postoperatively.CONCLUSION We present a technical case of subintimal recanalization for non-acute ICVA occlusion in an emergency endovascular procedure.However,we emphasize the necessity for caution when applying the subintimal tracking approach in intracranial occlusion due to the significant dangers involved.

Association of bone turnover biomarkers with severe intracranial and extracranial artery stenosis in type 2 diabetes mellitus patients

BACKGROUND Intracranial and extracranial artery stenosis is associated with cerebral infarction.Vascular calcification and atherosclerosis are the main causes of stenosis and major risk factors for cardiovascular and cerebrovascular events in patients with type 2 diabetes mellitus(T2DM).Bone turnover biomarkers(BTMs)are associated with vascular calcification,atherosclerosis,glucose,and lipid metabolism.AIM To investigate the association of circulating BTM levels with severe intracranial and extracranial artery stenosis in patients with T2DM.METHODS For this cross-sectional study including 257 T2DM patients,levels of the BTMs serum osteocalcin(OC),C-terminal cross-linked telopeptide of type I collagen(CTX),and procollagen type I N-peptide were measured by electrical chemiluminescent immunoassay,and artery stenosis was assessed by color Doppler and transcranial Doppler.Patients were grouped according to the existence and location(intracranial vs.extracranial)of artery stenosis.Correlations between BTM levels,previous stroke,stenosis location,and glucose and lipid metabolism were analyzed.RESULTS T2DM patients with severe artery stenosis had a higher frequency of previous stroke and levels of all three tested BTMs(all P<0.05)than patients without.Some differences in OC and CTX levels were observed according to the location of artery stenosis.Significant associations were also observed between BTM levels and some glucose and lipid homeostasis parameters.On multivariate logistic regression analysis,all BTMs were significant predictors of artery stenosis in T2DM patients with and without adjustment for confounding factors(all P<0.001),and receiver operating characteristic curve analysis demonstrated the ability of BTM levels to predict artery stenosis in T2DM patients.CONCLUSION BTM levels were found to be independent risk factors for severe intracranial and extracranial artery stenosis and were differentially associated with glucose and lipid metabolism in patients with T2DM.Therefore,BTMs may be promising biomarkers and potential therapeutic targets for artery stenosis.

Interobserver reliability of computed tomography angiography in the assessment of ruptured intracranial aneurysm and impact on patient management

BACKGROUND Aneurysmal subarachnoid hemorrhage is an emergency that can lead to a high mortality rate and many severe complications.It is critical to make a rapid radiological evaluation of ruptured intracranial aneurysms(RIAs)to determine the appropriate surgical treatment.AIM To assess the reliability of computed tomography angiography(CTA)in assessing different features of ruptured intracranial aneurysm and its impact on patient management.METHODS The final cohort of this study consisted of 146 patients with RIAs(75 male and 71 female)who underwent cerebral CTA.Their age ranged from 25 to 80,and the mean age±SD was 57±8.95 years.Two readers were asked to assess different features related to the aneurysm and perianeurysmal environment.Inter-observer agreement was measured using kappa statistics.Imaging data extracted from non-contrast computed tomography and CTA were considered to categorize the study population into two groups according to the recommended therapeutic approach.RESULTS The inter-observer agreement of both reviewers was excellent for the detection of aneurysms(K=0.95,P=0.001),aneurysm location(K=0.98,P=0.001),and(K=0.98,P=0.001),morphology(K=0.92,P=0.001)and margins(K=0.95,P=0.001).There was an excellent interobserver agreement for the measurement of aneurysm size(K=0.89,P=0.001),neck(K=0.85,P=0.001),and dome-to-neck ratio(K=0.98,P=0.001).There was an excellent inter-observer agreement for the detection of other aneurysm-related features such as thrombosis(K=0.82,P=0.001),calcification(K=1.0,P=0.001),bony landmark(K=0.89,P=0.001)and branch incorporation(K=0.91,P=0.001)as well as perianeurysmal findings including vasospasm(K=0.91,P=0.001),perianeurysmal cyst(K=1.0,P=0.001)and associated vascular lesions(K=0.83,P=0.001).Based on imaging features,87 patients were recommended to have endovascular treatment,while surgery was recommended in 59 patients.71.2%of the study population underwent the recommended therapy.CONCLUSION CTA is a reproducible promising diagnostic imaging modality for detecting and characterizing cerebral aneurysms.

Factors influencing the surveillance of re-emerging intracranial infections in elective neurosurgical patients:A single-center retrospective study

BACKGROUND At present,many studies have reported the risk factors for postoperative intracranial reinfection,including age,sex,time to surgery,duration of postoperative catheterization,emergency procedures,type of disease and cerebrospinal fluid leakage,but the academic community has not reached a unified conclusion.AIM To find factors influencing the surveillance of re-emerging intracranial infections in elective neurosurgical patients.METHODS Ninety-four patients who underwent elective craniotomy from January 1,2015 to December 31,2022 in the Department of Neurosurgery,First Hospital of Jilin University,were included in this study.Of those,45 patients were enrolled in the infection group,and 49 were enrolled in the control group.The clinical data of the patients were collected and divided into three categories,including preoperative baseline conditions,intraoperative characteristics and postoperative infection prevention.The data were analyzed using SPSS 26.0 software.RESULTS There were 23 males and 22 females in the infection group with a mean age of 52.8±15.1 years and 17 males and 32 females in the control group with a mean age of 48.9±15.2 years.The univariate analysis showed that the infection group had higher systolic blood pressures and postoperative temperatures,fewer patients who underwent a supratentorial craniotomy,more patients with a history of hypertension and higher initial postoperative white blood cell counts than the control group,with statistically significant differences(P<0.05).The multifactorial logistic regression analysis showed that a history of hypertension and a high postoperative body temperature were independent risk factors for postoperative infection in neurosurgical patients.CONCLUSION The results obtained in this study indicated that a history of hypertension and a high postoperative body temperature were independent risk factors for postoperative neurological symptoms.

Efficacy of Willis covered stent of intracranial pseudoaneurysms in the internal carotid artery: A systematic review and meta-analysis

Objective:To evaluate the efficacy of a novel coated stent in the treatment of intracranial pseudoaneurysm.Methods:MEDLINE,EMBASE,and PubMed databases were searched for literature published between 1990 and April 2022 according to PRISMA guidelines.All studies with≥10 patients reporting successful implantation of Willis covered stent,therapeutic effect,complications,and postoperative follow-up were included.The combined incidence and corresponding 95%confidence intervals were assessed using a generalized linear mixed method and random effects model.Results:Five studies(116 patients with pseudoaneurysms)were included.The experimental groups in the selected studies showed a combined technical success rate of 81.03%(OR=18.31,95%CI=9.39-35.69,I^(2)=79%,P<0.001).Clinical follow-up showed that the complete cure rate was as high as 94.4%after the follow-up(OR=106.81,95%CI=39.08-291.88,I^(2)=0%,P=0.71).Conclusions:Willis covered stent is feasible,safe,and effective in the treatment of intracranial pseudoaneurysm.

A novel cerebrovascular drug-coated balloon catheter for treating symptomatic intracranial atherosclerotic stenosis lesions:Study protocol for a prospective,multicenter,single-arm,target-value clinical trial

Background:Previous single-center studies have demonstrated that drug-coated balloons(DCBs)may reduce restenosis rates,which is an important factor affecting the prognosis for intracranial interventional therapy.However,currently available cardiac DCBs are not always suitable for the treatment of intracranial atherosclerotic stenosis(ICAS).This study aimed to evaluate the safety and efficacy of a novel DCB catheter designed for patients with severely symptomatic ICAS.Methods:This prospective,multicenter,single-arm,target-value clinical trial was conducted in 9 Chinese stroke centers to evaluate the safety and efficacy of a novel DCB catheter for treating symptomatic severe ICAS.Primary metrics and other indicators were collected and analyzed using SAS version 9.4(SAS Institute,Cary,NC,USA).Results:A total of 155 patients were enrolled in this study.The preliminary collection of follow-up data has been completed,while data quality control is ongoing.Conclusion:Results of this study demonstrated the patency rate,safety,and effectiveness of a novel on-label paclitaxel DCB designed for the treatment of ICAS.Ethics and dissemination:This study,involving human participants,was reviewed and approved by the Ethics Committee of Drugs(Devices)Clinical Experiment at Henan Provincial People’s Hospital(reference number:2020-145-03)and other research centers participating in the clinical trial.The results of this study will be presented at international conferences and sent to peer-reviewed journals for publication.Standard protocol items:The Recommendations for Interventional Trials checklist was used when drafting the study protocol.Trial registration number:Registered with the Chinese Clinical Trial Registry on June 11,2021(Chi CTR2100047223).

Successful treatment of invasive liver abscess syndrome caused by Klebsiella variicola with intracranial infection and septic shock:A case report

BACKGROUND Klebsiella variicola(K.variicola)is a member of the Klebsiella genus and is often misidentied as Klebsiella pneumoniae.In this report,we present a rare case of invasive liver abscess caused by K.variicola.CASE SUMMARY We report a rare case of liver abscess due to K.variicola.A 57-year-old female patient presented with back pain for a month.She developed a high-grade fever associated with chills,and went into a coma and developed shock.The clinical examinations and tests after admission confirmed a diagnosis of primary liver abscess caused by K.variicola complicated by intracranial infection and septic shock.The patient successfully recovered following early percutaneous drainage of the abscess,prompt appropriate antibiotic administration,and timely open surgical drainage.CONCLUSION This is a case of successful treatment of invasive liver abscess syndrome caused by K.variicola,which has rarely been reported.The findings of this report point to the need for further study of this disease.

Clinical characteristics and risk factors of intracranial hemorrhage after spinal surgery

BACKGROUND Intracranial hemorrhage after spinal surgery is a rare and devastating complication.AIM To investigate the economic burden,clinical characteristics,risk factors,and mechanisms of intracranial hemorrhage after spinal surgery.METHODS A retrospective cohort study was conducted from January 1,2015,to December 31,2022.Patients aged≥18 years,who had undergone spinal surgery were included.Intracranial hemorrhage patients were selected after spinal surgery during hospitalization.Based on the type of spinal surgery,patients with intracranial hemorrhage were randomly matched in a 1:5 ratio with control patients without intracranial hemorrhage.The patients'pre-,intra-,and post-operative data and clinical manifestations were recorded.RESULTS A total of 24472 patients underwent spinal surgery.Six patients(3 males and 3 females,average age 71.3 years)developed intracranial hemorrhage after posterior spinal fusion procedures,with an incidence of 0.025%(6/24472).The prevailing type of intracranial hemorrhage was cerebellar hemorrhage.Two patients had a poor clinical outcome.Based on the type of surgery,30 control patients were randomly matched in 1:5 ratio.The intracranial hemorrhage group showed significant differences compared with the control group with regard to age(71.33±7.45 years vs 58.39±8.07 years,P=0.001),previous history of cerebrovascular disease(50%vs 6.7%,P=0.024),spinal dura mater injury(50%vs 3.3%,P=0.010),hospital expenses(RMB 242119.1±87610.0 vs RMB 96290.7±32029.9,P=0.009),and discharge activity daily living score(40.00±25.88 vs 75.40±18.29,P=0.019).CONCLUSION The incidence of intracranial hemorrhage after spinal surgery was extremely low,with poor clinical outcomes.Patient age,previous stroke history,and dura mater damage were possible risk factors.It is suggested that spinal dura mater injury should be avoided during surgery in high-risk patients.

Bedside ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure in nontraumatic neurocritically ill patients

BACKGROUND Delay in treatment of raised intracranial pressure(ICP)leads to poor clinical outcomes.Optic nerve sheath diameter(ONSD)by ultrasonography(US-ONSD)has shown good accuracy in traumatic brain injury and neurosurgical patients to diagnose raised ICP.However,there is a dearth of data in neuro-medical intensive care unit(ICU)where the spectrum of disease is different.AIM To validate the diagnostic accuracy of ONSD in non-traumatic neuro-critically ill patients.METHODS We prospectively enrolled 114 patients who had clinically suspected raised ICP due to non-traumatic causes admitted in neuro-medical ICU.US-ONSD was performed according to ALARA principles.A cut-off more than 5.7 mm was taken as significantly raised.Raised ONSD was corelated with raised ICP on radiological imaging.Clinical history,general and systemic examination findings,SOFA and APACHE 2 score and patient outcomes were recorded.RESULTS There was significant association between raised ONSD and raised ICP on imaging(P<0.001).The sensitivity,specificity,positive and negative predictive value at this cut-off was 77.55%,89.06%,84.44% and 83.82% respectively.The positive and negative likelihood ratio was 7.09 and 0.25.The area under the receiver operating characteristic curves was 0.844.Using Youden’s index the best cut off value for ONSD was 5.75 mm.Raised ONSD was associated with lower age(P=0.007),poorer Glasgow Coma Scale(P=0.009)and greater need for surgical intervention(P=0.006)whereas no statistically significant association was found between raised ONSD and SOFA score,APACHE II score or ICU mortality.Our limitations were that it was a single centre study and we did not perform serial measurements or ONSD pre-and post-treatment or procedures for raised ICP.CONCLUSION ONSD can be used as a screening a test to detect raised ICP in a medical ICU and as a trigger to initiate further management of raised ICP.ONSD can be beneficial in ruling out a diagnosis in a low-prevalence population and rule in a diagnosis in a high-prevalence population.

Diffuse coronary artery vasospasm in a patient with subarachnoid hemorrhage: A case report

BACKGROUND Coronary artery vasospasm(CAV)is a reversible,transient form of vasoconstriction with clinical manifestations ranging from stable angina to acute coronary syndromes(ACS).Vasospasm of epicardial coronary arteries or associated micro-vasculature can lead to total or subtotal occlusion and has been demonstrated in nearly 50%of patients undergoing angiography for suspected ACS.The mechanism for CAV has been described in literature,but in a subgroup of patients presenting with intracranial hemorrhage,it appears to be multifactorial.These patients tend to have electrocardiographic changes,elevation of cardiac biomarkers of injury and neurogenic stress cardiomyopathy.CASE SUMMARY A 44-year-old woman presented with severe headaches and tonic-clonic seizures.She was found to have diffuse subarachnoid hemorrhage(SAH)requiring ventricular drain placement,coil embolization and induced hypertension.She subsequently developed chest pain with ST elevations in anterior precordial leads,elevated cardiac enzymes and apical ballooning with left ventricular ejection fraction of 35%on transthoracic echocardiogram.Coronary angiogram revealed severe diffuse triple vessel stenoses secondary to CAV seen distally.Subsequent cardiac MRI notable for apical non-viability and scar formation.CONCLUSION This case highlights a unique etiology of acute myocardial infarction in a patient with SAH leading to ST elevations,diffuse triple vessel CAV and apical scar.

Neuroprotective effect of bispectral index-guided fast-track anesthesia using sevoflurane combined with dexmedetomidine for intracranial aneurysm embolization

Dexmedetomidine has sedative, anxiolytic, analgesic, anti-sympathetic, and anti-shivering effects. Dexmedetomidine might be effective in combination with sevoflurane for anesthesia, but prospective randomized controlled clinical trials with which to verify this hypothesis are lacking. In total, 120 patients who underwent embolization of an intracranial aneurysm were recruited from Anhui Provincial Hospital and Renmin Hospital of Wuhan University of China and randomly allocated to two groups. After intraoperative administration of 2% to 3% sevoflurane inhalation, one group of patients received pump-controlled intravenous injection of 1.0 ~tg/kg dexmedetomidine for 15 minutes followed by maintenance with 0.3 ~tg/kg/h until the end of surgery; the other group of patients only underwent pump-controlled infusion of saline. Bispectral index monitoring revealed that dexmedetomidine-assisted anesthesia can shorten the recovery time of spon- taneous breathing, time to eye opening, and time to laryngeal mask removal. Before anesthetic induction and immediately after laryngeal mask airway removal, the glucose and lactate levels were low, the S100~ and neuron-specific enolase levels were low, the perioperative blood pressure and heart rate were stable, and postoperative delirium was minimal. These findings indicate that dexmedetomidine can effectively assist sevoflurane for anesthesia during surgical embolization of intracranial aneurysms, shorten the time to consciousness and extubation, reduce the stress response and energy metabolism, stabilize hemodynamic parameters, and reduce adverse reactions, thereby reducing the damage to the central nervous system. This trial was registered at the Chinese Clinical Trial Registry （http：//www.chictr.org. cn/） （registration number： ChiCTR-IPR- 16008113）.

Current advances in the understanding of coronary vasospasm

Recent years have witnessed progress in our understanding of coronary vasospasm(CVS).It is evident that this is not only an East Asian but also a global disease associated with significant symptoms and possible lethal sequelae for afflicted individuals.A correct diagnosis depends on the understanding of pathogenesis and symptomatology of CVS.With the correct diagnosis,we can manage CVS patients effectively and promptly,providing optimal patient safety.Advances in our understanding of interactions between inflammation,endothelium,and smooth muscle cells have led to substantial progress in understanding the pathogenesis of symptoms in CVS and have provided some insights into the basic etiology of this disorder in some patient subpopulations.We look forward to a time when therapy will address pathophysiology and perhaps,even the primary etiology.