Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Multiple Peripheral Aneurysms of the Posterior Inferior Cerebellar Artery

Abstract Peripheral aneurysms of the posterior inferior cerebellar artery (PICA) are rare. The authors describe a case in which five distinct peripheral aneurysms of the PICA were diagnosed and microsurgically clipped while preserving the parent vessel. One of the aneurysmal sacs was excised and examined pathologically, and no evidence of an infectious etiology was found. The surgical approach to peripheral PICA aneurysms is discussed and the literature concerning these unusual aneurysms is reviewed.</jats:p

Multiple Peripheral Aneurysms of the Posterior Inferior Cerebellar Artery

Abstract Peripheral aneurysms of the posterior inferior cerebellar artery (PICA) are rare. The authors describe a case in which five distinct peripheral aneurysms of the PICA were diagnosed and microsurgically clipped while preserving the parent vessel. One of the aneurysmal sacs was excised and examined pathologically, and no evidence of an infectious etiology was found. The surgical approach to peripheral PICA aneurysms is discussed and the literature concerning these unusual aneurysms is reviewed

Aneurysm of the ICA petrous segment treated by balloon entrapment after EC-IC bypass Case report

✓ A 44-year-old man experienced the sudden onset of horizontal diplopia and hemifacial numbness. Arteriography demonstrated a left intrapetrous carotid artery aneurysm. The patient was successfully treated with a left superficial temporal artery to middle cerebral artery bypass followed by balloon entrapment of the aneurysm. There have been at least 40 previously reported cases of aneurysms of the petrous portion of the carotid artery. These aneurysms can be mycotic, traumatic, or developmental in origin. They can present with massive otorrhagia or epistaxis from acute rupture or with decreased hearing and paresis of the fifth through eighth cranial nerves and, less frequently, of the ninth, 10th, and 12th cranial nerves caused by direct pressure. They can also produce pulsatile tinnitus, and sometimes they are discovered as a retrotympanic vascular mass during otological examination. The treatment of choice is carotid artery occlusion. Trapping of the aneurysm by detachable balloons eliminates immediately the risk of hemorrhage, offers the possibility of test occlusion of the internal carotid artery with the patient awake prior to permanent occlusion, and should also reduce the risk of thromboembolism. It should be preceded by a bypass procedure when preliminary evaluation indicates that the patient will not tolerate internal carotid artery occlusion

Aneurysm of the ICA petrous segment treated by balloon entrapment after EC-IC bypass

✓ A 44-year-old man experienced the sudden onset of horizontal diplopia and hemifacial numbness. Arteriography demonstrated a left intrapetrous carotid artery aneurysm. The patient was successfully treated with a left superficial temporal artery to middle cerebral artery bypass followed by balloon entrapment of the aneurysm. There have been at least 40 previously reported cases of aneurysms of the petrous portion of the carotid artery. These aneurysms can be mycotic, traumatic, or developmental in origin. They can present with massive otorrhagia or epistaxis from acute rupture or with decreased hearing and paresis of the fifth through eighth cranial nerves and, less frequently, of the ninth, 10th, and 12th cranial nerves caused by direct pressure. They can also produce pulsatile tinnitus, and sometimes they are discovered as a retrotympanic vascular mass during otological examination. The treatment of choice is carotid artery occlusion. Trapping of the aneurysm by detachable balloons eliminates immediately the risk of hemorrhage, offers the possibility of test occlusion of the internal carotid artery with the patient awake prior to permanent occlusion, and should also reduce the risk of thromboembolism. It should be preceded by a bypass procedure when preliminary evaluation indicates that the patient will not tolerate internal carotid artery occlusion.</jats:p

Medulla oblongata edema associated with neurogenic pulmonary edema

✓ Neurogenic pulmonary edema (NPE) occurs in association with central nervous system disease without underlying cardiopulmonary problems. It is characterized by profound pulmonary vascular congestion and a fulminant clinical course. Although several reports document a role for experimental brain-stem lesions in the production of NPE, there have been only two studies in man correlating specific brain-stem lesions with NPE. The authors report a case of NPE occurring in a patient with von Hippel-Lindau disease and a dorsal medullary syrinx with postoperative dorsal medullary edema. The anatomical location of this patient's lesion is reviewed in the context of alternative theories of the pathogenesis of NPE.</jats:p

Lymphocytic Adenohypophysitis of Pregnancy with Complete Recovery

Abstract A case of lymphocytic adenohypophysitis in a postpartum woman who became symptomatic during her 8th month of pregnancy is presented. The clinical presentation, endocrine findings, pathological findings, and operative management are discussed. Transient hypopituitarism is documented. Unlike most previously published cases, this woman had complete recovery of anterior pituitary function.</jats:p

Cervical diastematomyelia presenting in adulthood

✓ A case of cervical diastematomyelia in an adult is reported. The patient first noted sensory and motor symptoms at 34 years of age after two episodes of cervical trauma. Metrizamide computerized tomography myelography of the cervical spine and cord showed the region of diastematomyelia and revealed a spur containing both bone and fat tissue projecting into the spinal canal and cord. The spur arose from the laminae and spinous processes of C-2 and C-3, and was successfully excised. Postoperatively, the patient's deficits gradually improved. The literature concerning adult cervical diastematomyelia is reviewed.</jats:p