scholarly journals Clinical status and evolution in moyamoya: which angiographic findings correlate?

2019 ◽  
Vol 1 (1) ◽  
Author(s):  
Andrea Rosi ◽  
Coleman P Riordan ◽  
Edward R Smith ◽  
R Michael Scott ◽  
Darren B Orbach
Keyword(s):  
Digital Subtraction Angiography ◽  
Clinical Status ◽  
Arterial Stenosis ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Digital Subtraction ◽  
Correlation Studies ◽  
Presenting Symptoms

Abstract Moyamoya is a progressive steno-occlusive cerebrovascular pathology of unknown aetiology that usually involves the terminal portions of the internal carotid arteries and/or the proximal portions of the anterior and middle cerebral arteries bilaterally. The pre-operative Suzuki staging system and post-operative Matsushima grade are nearly universally used markers of natural history and surgical revascularization results, respectively, but their correlation with clinical and radiographic manifestations of moyamoya has not been systematically evaluated in a large cohort. This study evaluated the strength of correlations between pre- and post-operative angiographic parameters and clinical status among paediatric patients with moyamoya. The participants included 58 patients of mean age 11 years at the time of surgery who underwent bilateral indirect revascularization in the same procedure at Boston Children’s Hospital, between January 2010 and December 2015. All included patients had available pre-operative and 1-year post-operative digital subtraction angiography. Clinical data included presenting symptoms, degree of functional incapacity, and peri-operative and long-term complications. Radiographic data included pre-operative Suzuki stage, degree of arterial stenosis, a novel collateral score, the presence of hypovascular territories on digital subtraction angiography, and post-operative Matsushima grade and evolution of stenosis. Chi-squared test and Pearson coefficient were used for correlation studies for categorical variables and Spearman’s rho was used for correlation studies for continuous variables. Results showed that Suzuki stage, collateral score and degree of stenosis were insufficient to predict clinical presentation, pre-operative incapacity and radiographic presentation, whereas the presence of hypovascular territories was correlated with all of these. At 1-year follow-up, Matsushima grade was insufficient for predicting peri-operative or long-term complications, nor did it correlate with post-operative incapacity. The presence of hypovascular territories at 1-year follow-up was correlated with the incidence of post-operative ischaemic symptoms.

Short Paper: Risk Factors for Long-Term Persistent Symptoms in COVID-19 in an Outpatient Cohort (Preprint)

2020 ◽  
Author(s):  
James O'Keefe ◽  
Ghazala A Datoo O’Keefe ◽  
Anthony Mufarreh
Keyword(s):  
Risk Factors ◽  
Categorical Variables ◽  
Short Paper ◽  
Symptom Duration ◽  
Continuous Variables ◽  
Cross Sectional ◽  
Persistent Symptoms ◽  
Long Term Follow Up

BACKGROUND Symptom descriptions in outpatients with COVID-19 are limited to cross-sectional surveys and longitudinal follow-up of long term symptoms has not been reported. Symptom duration is important for patient and provider knowledge in managing outpatient COVID-19. OBJECTIVE Describe the presence of symptoms at long term follow-up of patients managed in an outpatient telemedicine program for acute COVID-19. METHODS Chart review of clinical notes for acute COVID-19 and long term follow-up calls. Descriptive analysis were conducted using Wilcoxon rank-sum for continuous variables and chi-square or Fisher’s Exact as appropriate for categorical variables. RESULTS Minor symptoms were reported by 55 patients (34.8%) and 7 (4.4%) reported major ongoing symptoms at follow-up call. Factors associated with prolonged symptoms include older age, provider reported higher symptom severity at intake visit, and BMI >30. Symptoms which persisted include shortness of breath on exertion, wheeze, nausea, and joint pain. CONCLUSIONS Persistence of symptoms after acute COVID-19 in outpatients is common. Risk factors may help predict which patients are more likely to have prolonged symptoms.

scholarly journals Value of Three-Dimensional Digital Subtraction Angiography for Detection and Classification of Intracranial Aneurysm Remnants After Clipping

2021 ◽  
Author(s):  
Serge Marbacher ◽  
Matthias Halter ◽  
Deborah R Vogt ◽  
Jenny C Kienzler ◽  
Christian T J Magyar ◽  
...  
Keyword(s):  
Intracranial Aneurysm ◽  
Digital Subtraction Angiography ◽  
Diagnostic Yield ◽  
Three Dimensional ◽  
P Value ◽  
Digital Subtraction ◽  
Patient Demographics ◽  
Included Patient ◽  
2D And 3D

Abstract BACKGROUND The current gold standard for evaluation of the surgical result after intracranial aneurysm (IA) clipping is two-dimensional (2D) digital subtraction angiography (DSA). While there is growing evidence that postoperative 3D-DSA is superior to 2D-DSA, there is a lack of data on intraoperative comparison. OBJECTIVE To compare the diagnostic yield of detection of IA remnants in intra- and postoperative 3D-DSA, categorize the remnants based on 3D-DSA findings, and examine associations between missed 2D-DSA remnants and IA characteristics. METHODS We evaluated 232 clipped IAs that were examined with intraoperative or postoperative 3D-DSA. Variables analyzed included patient demographics, IA and remnant distinguishing characteristics, and 2D- and 3D-DSA findings. Maximal IA remnant size detected by 3D-DSA was measured using a 3-point scale of 2-mm increments. RESULTS Although 3D-DSA detected all clipped IA remnants, 2D-DSA missed 30.4% (7 of 23) and 38.9% (14 of 36) clipped IA remnants in intraoperative and postoperative imaging, respectively (95% CI: 30 [ 12, 49] %; P-value .023 and 39 [23, 55] %; P-value = <.001), and more often missed grade 1 (< 2 mm) clipped remnants (odds ratio [95% CI]: 4.3 [1.6, 12.7], P-value .005). CONCLUSION Compared with 2D-DSA, 3D-DSA achieves a better diagnostic yield in the evaluation of clipped IA. Our proposed method to grade 3D-DSA remnants proved to be simple and practical. Especially small IA remnants have a high risk to be missed in 2D-DSA. We advocate routine use of either intraoperative or postoperative 3D-DSA as a baseline for lifelong follow-up of clipped IA.

scholarly journals COPD Clinical Control: predictors and long-term follow-up of the CHAIN cohort

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Myriam Calle Rubio ◽  
◽  
Juan Luis Rodriguez Hermosa ◽  
Juan P. de Torres ◽  
José María Marín ◽  
...  
Keyword(s):  
Triple Therapy ◽  
Clinical Status ◽  
Airflow Limitation ◽  
Psychological Status ◽  
Prognostic Information ◽  
Clinical Control ◽  
All Cause Mortality ◽  
Long Term Follow Up

Abstract Background Control in COPD is a dynamic concept that can reflect changes in patients’ clinical status that may have prognostic implications, but there is no information about changes in control status and its long-term consequences. Methods We classified 798 patients with COPD from the CHAIN cohort as controlled/uncontrolled at baseline and over 5 years. We describe the changes in control status in patients over long-term follow-up and analyze the factors that were associated with longitudinal control patterns and related survival using the Cox hazard analysis. Results 134 patients (16.8%) were considered persistently controlled, 248 (31.1%) persistently uncontrolled and 416 (52.1%) changed control status during follow-up. The variables significantly associated with persistent control were not requiring triple therapy at baseline and having a better quality of life. Annual changes in outcomes (health status, psychological status, airflow limitation) did not differ in patients, regardless of clinical control status. All-cause mortality was lower in persistently controlled patients (5.5% versus 19.1%, p = 0.001). The hazard ratio for all-cause mortality was 2.274 (95% CI 1.394–3.708; p = 0.001). Regarding pharmacological treatment, triple inhaled therapy was the most common option in persistently uncontrolled patients (72.2%). Patients with persistent disease control more frequently used bronchodilators for monotherapy (53%) at recruitment, although by the end of the follow-up period, 20% had scaled up their treatment, with triple therapy being the most frequent therapeutic pattern. Conclusions The evaluation of COPD control status provides relevant prognostic information on survival. There is important variability in clinical control status and only a small proportion of the patients had persistently good control. Changes in the treatment pattern may be relevant in the longitudinal pattern of COPD clinical control. Further studies in other populations should validate our results. Trial registration: Clinical Trials.gov: identifier NCT01122758.

scholarly journals OP0271 REAL-WORLD CLINICAL BURDEN AND GLUCOCORTICOID USE IN PATIENTS WITH POLYMYALGIA RHEUMATICA

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 169.1-169
Author(s):  
R. Punekar ◽  
P. Lafontaine ◽  
J. H. Stone
Keyword(s):  
Cardiovascular Disease ◽  
Health Plan ◽  
Polymyalgia Rheumatica ◽  
Data Availability ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Rank Tests ◽  
Medical Claim ◽  
Diagnosis Codes

Background:Polymyalgia rheumatica (PMR) is a chronic inflammatory condition characterized by aching and morning stiffness in the neck, shoulders and pelvic girdle. It is a common inflammatory rheumatic disease in patients age >50 years, particularly women. While giant cell arteritis (GCA) is present in 9–21% of PMR cases, many PMR patients have symptoms independent of GCA. Current treatment options are limited to long-term glucocorticoid (GC), however, with risks of GC-related complications, including cardiovascular disease, osteoporosis, and diabetes mellitus.Objectives:To compare GC use and subsequent GC-related complications in patients with PMR vs a general population (GnP) cohort.Methods:This retrospective, observational cohort study was based on Optum’s de-identified Clinformatics®Data Mart Database (study period 01Jan2006-30June2018). The PMR cohort included patients with ≥1 inpatient or ≥2 outpatient claims ≥30 days apart with PMR related diagnosis codes (ICD-9: 725.xx or ICD-10: M35.3x) between 01Jan2006–30June2017 (patient identification period) during which first occurrence of a PMR-related medical claim was set as the index date (ID). Patients with ≥1 medical claim related to rheumatoid arthritis (RA) or GCA during the study period were excluded. The GnP cohort included patients without any RA, GCA or PMR diagnosis codes during the study period, with their ID set as 12 months from the start of continuous health plan enrollment. Patients in both cohorts were required to be age ≥50 years (on ID) with continuous health plan enrollment ≥12 months pre- and post-ID. Cohorts were 1:1 propensity score matched. GC use and incidence of GC-related complications were assessed from GC initiation, starting from the baseline period (12-months pre-ID) through to the end of GC use during the post-index period (i.e. the end of data availability, end of the study period or death [whichever occurred first]). Mean, standard deviation (SD) and median values for continuous variables, and frequency (n and %) for categorical variables were compared between the matched cohorts. Wilcoxon sum rank tests andt-tests on continuous variables and Chi-square tests or Fisher’s exact tests on categorical variables between matched cohorts were conducted. Duration of GC use was analyzed using the Kaplan-Meier method and compared between matched cohorts using log-rank tests.Results:In each of the PMR and GnP cohorts, 16,865 patients were included. In both matched cohorts, median age was 76 years, median Elixhauser comorbidity index score was 2.0, and the majority (~65%) were women. The median follow-up duration was 45 months and 51 months in the PMR and GnP cohorts, respectively. A higher proportion of patients in the PMR cohort than the matched GnP cohort (90.4% vs 62.8%;p<0.001) used GC. The mean (SD) duration of GC therapy was significantly longer in the PMR cohort than in the matched GnP cohort (242.1 [±317.2] days vs 35.5 [±124.6] days;p<0.001). Although patients in the PMR cohort had a lower average daily dose of GC (prednisone equivalent) vs the GnP cohort (mean [SD] mg 16.3 [± 21.9] vs 27.8 [±24.5], respectively [p<0.0001)], the cumulative GC dose was significantly higher in the PMR cohort than the GnP cohort (2125.4 [±3689.5] mg vs 476.6 [±1450.9] mg;p<0.001). This indicates PMR patients used chronic low dose GC while the GnP patients utilized higher dose GC burst therapy less frequently. The number of incident complications associated with GC use were significantly greater in the PMR cohort, and included hypertension, diabetes, skin toxicity, infections, neuropsychiatric effects, endocrine abnormalities, renal dysfunction/ failure, ocular effects, and cardiovascular disease (p<0.05).Conclusion:The overall GC burden in patients with PMR is high. With a higher incidence of GC-related comorbidities among PMR patients, early onset of these complications may be a significant contributor to long-term healthcare costs in these patients.Acknowledgments:This study was funded by Sanofi, Inc. Medical writing, under the direction of authors, was provided by Gauri Saal, MA Economics, Prime, Knutsford, UK, and funded by Sanofi.Disclosure of Interests:Rajeshwari Punekar Shareholder of: Sanofi, Employee of: Sanofi, Patrick LaFontaine Shareholder of: Sanofi, Employee of: Sanofi, John H. Stone Grant/research support from: Roche, Consultant of: Roche

Outcomes of 33 patients from the wars in Iraq and Afghanistan undergoing bilateral or bicompartmental craniectomy

2011 ◽  
Vol 115 (1) ◽  
pp. 124-129 ◽  
Author(s):  
Robert D. Ecker ◽  
Lisa P. Mulligan ◽  
Michael Dirks ◽  
Randy S. Bell ◽  
Meryl A. Severson ◽  
...  
Keyword(s):  
Medical Center ◽  
Systemic Infection ◽  
Categorical Variables ◽  
Cerebrovascular Injury ◽  
The Us ◽  
Long Term Follow Up ◽  
Initial Injury ◽  
Gcs Score

Object There are no published long-term data for patients with penetrating head injury treated with bilateral supratentorial craniectomy, or supra- and infratentorial craniectomy. The authors report their experience with 33 patients treated with bilateral or bicompartmental craniectomy from the ongoing conflicts in Iraq and Afghanistan. Methods An exploratory analysis of Glasgow Outcome Scale (GOS) scores at 6 months in 33 patients was performed. Follow-up lasting a median of more than 2 years was performed in 30 (91%) of these patients. The association of GOS score with categorical variables was explored using the Wilcoxon rank-sum test or Kruskal-Wallis analysis of variance. The Spearman correlation coefficient was used for ordinal/continuous data. To provide a clinically meaningful format to present GOS scores with categorical variables, patients with GOS scores of 1–3 were categorized as having a poor outcome and those with scores of 4 and 5 as having a good outcome. This analysis does not include the patients who died in theater or in Germany who underwent bilateral decompressive craniectomy because those figures have not been released due to security concerns. Results All patients were men with a median age of 24 years (range 19–46 years) and a median initial Glasgow Coma Scale (GCS) score of 5 (range 3–14). At 6 months, 9 characteristics were statistically significant: focus of the initial injury, systemic infection, initial GCS score, initial GCS score excluding patients with a GCS score of 3, GCS score on arrival to the US, GCS score on dismissal from the medical center, Injury Severity Score, and patients with cerebrovascular injury. Six factors were significant at long-term follow-up: focus of initial injury, systemic infection, initial GCS score excluding patients with a GCS score of 3, GCS score on arrival to the US, and GCS score on dismissal from the medical center. At long-term follow-up, 7 (23%) of 30 patients had died, 5 (17%) of 30 had a GOS score of 2 or 3, and 18 (60%) of 30 had a GOS score of 4 or 5. Conclusions In this selected group of patients who underwent bilateral or bicompartmental craniectomy, 60% are independent at long-term follow-up. Patients with bifrontal injury fared best. Systemic infection and cerebrovascular injury corresponded with a worse outcome.

Abstract 1122‐000107: Charles Bonnet Syndrome Secondary to Massive Dural Arteriovenous Fistula Disguised as Extensive Venous Sinus Thrombosis

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Ahmad A Ballout ◽  
Timothy G White ◽  
Athos Patsalides
Keyword(s):  
Digital Subtraction Angiography ◽  
Sinus Thrombosis ◽  
Sigmoid Sinus ◽  
Venous Sinus ◽  
High Grade ◽  
Retrograde Flow ◽  
Digital Subtraction ◽  
Venous Sinus Thrombosis ◽  
Charles Bonnet Syndrome

Introduction : Charles Bonnet Syndrome is characterized by visual hallucinations that can occur following severe visual insult, rarely due to dural arteriovenous fistulas (DAVF) or cerebral venous sinus thrombosis (CVST). Prompt differentiation between DAVF and CVST is important since treatments may differ and inadequate treatment may result in blindness. We highlight a patient who presented with Charles Bonnet Syndrome initially misdiagnosed with CVST by MR venography and later correctly diagnosed with a massive DAVF with superimposed CVST by digital subtraction angiography and underwent DAVF embolization with complete resolution. Methods : Case Report. Results : A 78 year‐old man with hypertension and hyperlipidemia presented with three weeks of bilateral vision loss associated with formed hallucinations exacerbated by dark rooms. Neurological exam revealed decreased visual acuity of 20/400 and grade five papilledema bilaterally. Non‐Contrast (TOF) MR venogram revealed lack of flow in the superior sagittal sinus (SSS), straight sinus (SS) and deep venous system, and partial flow of the left transverse and sigmoid sinus and left jugular vein. MR brain without gadolinium was unremarkable. Cerebral angiography revealed a high‐grade DAVF predominantly supplied by the occipital branch of the left external carotid artery [Figure 1; A‐C], with retrograde flow into the left sigmoid, transverse, superior sagittal, and straight sinuses, as well as retrograde flow into the right vein of Trolard [Figure 1; A‐D]. The left distal sigmoid sinus and left jugular bulb were occluded. The left transverse and proximal left sigmoid venous sinuses were compartmentalized from non‐occlusive thrombus, while the SSS and bilateral transverse sinuses where patent [Figure 1; A, B]. Embolization using coils and onyx was performed with complete occlusion of the left transverse and sigmoid sinuses, the points of main drainage of the fistula, as there was no single trans arterial pedicle suitable for embolization. Postembolization angiography demonstrated a Cognard Grade 1 fistula with some residual fistulous shunting of the occipital artery to the torcula. Follow up angiogram at six weeks showed interval occlusion of the residual shunt. He had minimal improvement in his vision at three months of follow up. Conclusions : This case highlights a patient with Charles Bonnet Syndrome due to a high flow DAVF. The MR venogram failed to capture the DAVF since the retrograde flow was interpreted as thrombosis on MRV. DAVF and CVST have a complex cause‐effect relationship, since thrombosis may open up venous channels that can lead to a fistula and sluggish blood flow from a fistula may stimulate thrombus formation. Treatments between CVST and DAVF differ since high grade DAVF often require endovascular embolization and anticoagulation may increase the risk of intracerebral hemorrhage in a subset of patients. Digital subtraction angiography and/or contrast enhanced MRV should be considered in cases of suspected extensive thrombosis to help differentiate between thrombosis and DAVF.

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