Massive right-sided hemorrhagic pleural effusion due to pancreatitis; a case report

BACKGROUND: Hemorrhagic pleural effusion, especially in the right hemithorax rarely occurs as the sole presentation of pancreatitis. CASE PRESENTATION: This article reports massive right-sided hemorrhagic pleural effusion as the sole manifestation of pancreatitis in a 16-year-old Iranian boy. The patient referred to Nemazee Hospital, the main hospital of southern Iran, with right-sided shoulder and chest pain accompanied with dyspnea. His chest x-ray showed massive right-sided pleural effusion. The pleural fluid amylase was markedly elevated (8840 U/L), higher than that in the serum (3318 U/L). Abdominal CT scan showed a cystic structure measuring about 5·2 cm in the head of pancreas, highly suggestive of a pancreatic pseudocyst. Pleural effusion resolved after 3 weeks of chest tube insertion but not completely. After this period of conservative therapy another CT scan showed that pseudocyst was still in the head of pancreas. So, external drainage was done with mushroom insertion and the patient was discharged after 40 days of hospitalization. The cause of pancreatitis could not be identified. CONCLUSION: Pancreatitis should be taken into consideration when hemorrhagic pleural effusion, especially in the right hemithorax occurs

Abstract Number: LBA23 Endovascular treatment of large vessel occlusion stroke caused by infective endocarditis

Introduction Infective endocarditis (IE) often presents as an acute ischemic stroke (AIS) secondary to a thromboembolic event leading to large vessel occlusion (LVO). These patients are at significant risk for intracerebral hemorrhage when given intravenous thrombolytics (IT) and are therefore better candidates for mechanical thrombectomy (MT). Current reports in the literature are divided on the safety of MT in this setting and no randomized control studies exist. With the advent of modern thrombectomy devices, we believe MT might be safe in this patient population. Methods Here we report a patient with IE who presented with LVO stroke (MCA syndrome) and underwent MT leading to first‐pass Thrombolysis inCerebral Infarction (TICI) score of 3 revascularization. In addition to presenting our case, we did a comprehensive review of the current literature on this topic. Results A thirty‐year‐old female with a history of cocaine abuse presented with acute onset left hemiplegia, dysarthria, and rightward gaze deviation. NIHSS was 19 and she presented 90 minutes from her last known well time . Computed Tomography (CT) head and CT perfusion imaging demonstrated a large MCA distribution stroke, an AlbertaStrokeProgram Early CT Score (ASPECTS) of 10, with significant perfusion mismatch of right MCA territory. CT angiography (CTA) confirmed a proximal large vessel occlusion (LVO) at the proximal M1. On initial assessment, the patient was febrile with a temperature of 40 degrees Celsius with a high clinical suspicion for IE; therefore, intravenous thrombolytic was not administered. MT was performed with one pull of stent retrieval under aspiration led to a successful opening of the vessel with TICI score of 3. Positive cocaine on urine toxicology was noted as well as, two sets of gram‐positive blood cultures which later resulted in Staph Aureus, oxacillin susceptible, unremarkable transthoracic echo, but with TEE demonstrating vegetative thickening within atrial aspects of both anterior andposterior mitral valve leaflets(Figure1). On hospital day two, magnetic resonance imaging of the brain shows small acute infarct with no bleed. The patient underwent a mitral valve replacement on hospital day nine. The patient was discharged to rehabilitation facilities with an NIHSS of two for mild left facial droop and mild left arm weakness; her degree of disability was measured as a modified Rankin Scale (mRS) one at 3 months. Conclusions In case IE is suspected, giving IV tPA (tissue‐type plasminogen activator) is contraindicated as it increases the chance of hemorrhagic complications and when LVO is confirmed in the setting of AIS, MT might be safe and effective to be considered

Abstract Number: LBA17 SARS‐CoV‐2 Infection Might be a Predictor of Mortality in Intracerebral Hemorrhage

Introduction SARS‐CoV‐2 infection may be associated with uncommon complications such as intracerebral hemorrhage (ICH), with a high mortality rate. We compared a series of hospitalized ICH cases infected with SARS‐CoV‐2 with a non‐SARS‐CoV‐2 infected control group and evaluated if the SARS‐CoV‐2 infection is a predictor of mortality in ICH patients. Methods In a multinational retrospective study, 63 cases of ICH in SARS‐CoV‐2 infected patients admitted to 13 tertiary centers from the beginning of the pandemic were collected. We compared the clinical and radiological characteristics and in‐hospital mortality of these patients with a control group of non‐SARS‐CoV‐2 infected ICH patients of a previous cohort from the country where the majority of cases were recruited. Results Among 63 ICH patients with SARS‐CoV‐2 infection, 23 (36.5%) were women. Compared to the non‐SARS‐CoV‐2 infected control group, in SARS‐CoV‐2 infected patients, ICH occurred at a younger age (61.4± 18.1 years versus 66.8± 16.2 years, P = 0.044). These patients had higher median ICH scores ([3 (IQR 2–4)] versus [2 (IQR 1–3)], P = 0.025), a more frequent history of diabetes (34% versus 16%, P = 0.007), and lower platelet counts (177.8± 77.8 × 109/L versus 240.5± 79.3 × 109/L, P< 0.001). The in‐hospital mortality was not significantly different between cases and controls (65% versus 62%, P = 0.658) in univariate analysis; however, SARS‐CoV‐2 infection was significantly associated with in‐hospital mortality (aOR = 4.3, 95% CI: 1.28‐14.52) in multivariable analysis adjusting for potential confounders. Conclusions Infection with SARS‐CoV‐2 may be associated with increased odds of in‐hospital mortality in ICH patients

Direct Mechanical Thrombectomy Versus Prior Bridging Intravenous Thrombolysis in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Background: The current guideline recommends using an intravenous tissue-type plasminogen activator (IV tPA) prior to mechanical thrombectomy (MT) in eligible acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). Some recent studies found no significant differences in the long-term functional outcomes between bridging therapy (BT, i.e., IV tPA prior to MT) and direct MT (dMT). Methods: We conducted a systematic review and meta-analysis to compare the safety and functional outcomes between BT and dMT in AIS patients with ELVO who were eligible for IV tPA administration. Based on the ELVO location, patients were categorized as the anterior group (occlusion of the anterior circulation), or the combined group (occlusion of the anterior and/or posterior circulation). A subgroup analysis was performed based on the study type, i.e., RCT and non-RCT. Results: Thirteen studies (3985 patients) matched the eligibility criteria. Comparing the BT and dMT groups, no significant differences in terms of mortality and good functional outcome were observed at 90 days. Symptomatic intracranial hemorrhagic (sICH) events were more frequent in BT patients in the combined group (OR = 0.73, p = 0.02); this result remained significant only in the non-RCT subgroup (OR = 0.67, p = 0.03). The RCT subgroup had a significantly higher rate of successful revascularization in BT patients (OR = 0.73, p = 0.02). Conclusions: Our meta-analysis uncovered no significant differences in functional outcome and mortality rate at 90 days between dMT and BT in patients with AIS who had ELVO. Although BT performed better in terms of successful recanalization rate, there is a risk of increased sICH rate in this group

Endovascular Treatment of Large Vessel Occlusion Strokes Caused by Infective Endocarditis: A Systematic Review, Meta-Analysis, and Case Presentation

Thromboembolic events such as acute ischemic strokes are frequently seen in patients with infective endocarditis (IE). It is generally recommended that the administration of intravenous thrombolytics is avoided in these patients as they might encounter a higher risk of intracranial hemorrhages. In this setting, particularly with a large vessel occlusion (LVO), a mechanical thrombectomy may be an alternative option. In this systematic review and meta-analysis, we aimed to investigate the outcomes and safety of mechanical thrombectomies for LVO stroke patients secondary to IE. A search strategy was developed and we searched PubMed, Scopus, Web of Sciences, and Embase using the words &ldquo;infective endocarditis&rdquo;, &ldquo;stroke&rdquo;, and &ldquo;mechanical thrombectomy&rdquo;. Including 6 studies and 120 patients overall, this study showed that a mechanical thrombectomy might reduce the National Institute of Health Stroke Scale (NIHSS), with a weighted mean difference of &minus;3.06 and a 95% CI of &minus;4.43 to &minus;1.70. The pooled rate of symptomatic intracranial hemorrhages and all-cause mortality were also determined to be 15% (95% CI: 4&ndash;47%) and 34% (95% CI:14&ndash;61%), respectively. The results of this study showed that a mechanical thrombectomy might be an effective and reasonably safe option for the treatment of LVO strokes caused by IE. However, more large-scale studies are needed to consolidate these results

Updates in the management of cranial dural arteriovenous fistula

Dural arteriovenous fistula (dAVF) accounts for approximately 10% of all intracranial vascular malformations. While they can be benign lesions, the presence of retrograde venous drainage and cortical venous reflux makes the natural course of these lesions aggressive high risk of haemorrhage, neurological injury and mortality. Endovascular treatment is often the first line of treatment for dAVF. Both transarterial and transvenous approaches are used to cure dAVF. The selection of treatment approach depends on the angioarchitecture of the dAVF, the location, the direction of venous flow. Surgery and, to a lesser extent, stereotactic radiosurgery are used when endovascular approaches are impossible or unsuccessful

Safety of Intravenous Thrombolysis Among Patients Taking Direct Oral Anticoagulants: A Systematic Review and Meta-Analysis.

Background and Purpose- There are scarce data regarding the safety of intravenous thrombolysis (IVT) in acute ischemic stroke among patients on direct oral anticoagulants (DOACs). Methods- We performed a systematic review and meta-analysis of the current literature. Data regarding all adult patients pretreated with DOAC who received IVT for acute ischemic stroke were recorded. Meta-analysis was performed by comparing the rate of symptomatic intracerebral hemorrhage in these patients with (1) stroke patients without prior anticoagulation therapy and (2) patients on warfarin with international normalized ratio <1.7. Meta-analyses were further conducted in subgroups as follows: (1) administration of DOAC within 48 hours versus an unknown interval before IVT, (2) consideration of symptomatic intracerebral hemorrhage outcome according to the National Institute of Neurological Disorders (NINDS) versus the European Cooperative Acute Stroke Study II (ECASS-II) criteria. Results- After reviewing 13 392 reports and communicating with certain authors of 12 published studies, a total of 52 823 acute ischemic stroke patients from 6 studies were enrolled in the present meta-analysis: DOACs: 366, warfarin: 2133, and 503 241 patients without prior anticoagulation. We detected no additional risk of symptomatic intracerebral hemorrhage following IVT among patients taking DOACs within 48 hours-DOACs-warfarin: NINDS (odds ratio [OR], 0.55 [95% CI, 0.19-1.59]), ECASS-II (OR, 0.77 [95% CI, 0.28-2.16]); DOACs-no-anticoagulation: NINDS (OR, 1.23 [95% CI, 0.46-3.31]), ECASS-II (OR, 0.87 [95% CI, 0.32-2.41]). Similarly, no additional risk was detected with no time limit between last DOAC intake-DOACs warfarin: NINDS (OR, 0.85 [95% CI, 0.49-1.45]), ECASS-II (OR, 1.11 [95% CI, 0.67-1.85]); DOACs-no-anticoagulation: NINDS (OR, 1.17 [95% CI, 0.43-3.15]), ECASS-II (OR, 0.87 [95% CI, 0.33-2.41]). There was no evidence of heterogeneity across included studies (I2=0%). We also provided the details of 123 individual cases with or without reversal agents before IVT. There was no significant increase in the risk of hemorrhagic transformation (OR, 1.48 [95% CI, 0.50-4.38]), symptomatic hemorrhagic transformation (OR, 0.47 [95% CI, 0.09-2.55]), or early mortality (OR, 0.60 [95% CI, 0.11-3.43]) between cohorts who did or did not receive prethrombolysis idarucizumab. Conclusions- The results of our study indicated that prior intake of DOAC appears not to increase the risk of symptomatic intracerebral hemorrhage in selected AIS patients treated with IVT

Tumor Embolic Stroke: The Importance of Pathological Assessment of Clots after Thrombectomy

While tumor emboli are a rare cause of stroke in cancer patients, they highlight the importance of gross observations and pathological assessments in the evaluation of clots. In this case report, a 70-year-old male with type 2 diabetes mellitus and coronary artery disease presented with acute left-sided weakness. He was clinically diagnosed with stroke and given alteplase at 1.5 h from last known normal. He then underwent CT angiography that showed right internal carotid artery occlusion and immediate thrombectomy. The recovered clot was white and lipid-like; due to its atypical appearance, it was sent for pathological assessment, where it was shown to bear features of malignancy. Subsequent imaging identified masses indicating malignancy in the left gluteus, right pleural hilum, and spine. Tumor embolic stroke is a rare pathology. Embolic diseases such as strokes and pulmonary embolisms are common in patients with cancer. Embolic stroke of undetermined source (ESUS) represents a significant portion of cancer strokes. Tumor emboli, though rare, may be an underappreciated source of ESUS in cancer patients. We intend for this case to demonstrate the value of pathological assessment for atypical thrombi as well as highlight the etiology of tumor embolic strokes