Management and outcomes in critically ill nonagenarian versus octogenarian patients.

BACKGROUND: Intensive care unit (ICU) patients age 90 years or older represent a growing subgroup and place a huge financial burden on health care resources despite the benefit being unclear. This leads to ethical problems. The present investigation assessed the differences in outcome between nonagenarian and octogenarian ICU patients. METHODS: We included 7900 acutely admitted older critically ill patients from two large, multinational studies. The primary outcome was 30-day-mortality, and the secondary outcome was ICU-mortality. Baseline characteristics consisted of frailty assessed by the Clinical Frailty Scale (CFS), ICU-management, and outcomes were compared between octogenarian (80-89.9 years) and nonagenarian (> 90 years) patients. We used multilevel logistic regression to evaluate differences between octogenarians and nonagenarians. RESULTS: The nonagenarians were 10% of the entire cohort. They experienced a higher percentage of frailty (58% vs 42%; p < 0.001), but lower SOFA scores at admission (6 + 5 vs. 7 + 6; p < 0.001). ICU-management strategies were different. Octogenarians required higher rates of organ support and nonagenarians received higher rates of life-sustaining treatment limitations (40% vs. 33%; p < 0.001). ICU mortality was comparable (27% vs. 27%; p = 0.973) but a higher 30-day-mortality (45% vs. 40%; p = 0.029) was seen in the nonagenarians. After multivariable adjustment nonagenarians had no significantly increased risk for 30-day-mortality (aOR 1.25 (95% CI 0.90-1.74; p = 0.19)). CONCLUSION: After adjustment for confounders, nonagenarians demonstrated no higher 30-day mortality than octogenarian patients. In this study, being age 90 years or more is no particular risk factor for an adverse outcome. This should be considered- together with illness severity and pre-existing functional capacity - to effectively guide triage decisions. TRIAL REGISTRATION: NCT03134807 and NCT03370692

Vertebro-Vertebral Fistula Occlusion Using a Woven EndoBridge-Device

Vertebro-vertebral fistulas (VVFs) are vascular lesions that may develop after trauma or spontaneously in association with connective tissue disorders. We present a rare case of a post-traumatic VVF in a young patient presenting with a painless swelling and a bruit in her left upper neck. Digital subtraction angiography showed an arteriovenous fistula between the left vertebral artery (VA) and the vertebral venous plexus with significant steal phenomenon. Endovascular therapy was performed using a Woven EndoBridgeTM (WEB)-device combined with coils that allowed preservation of the VA. The patient fully recovered from her symptoms and follow-up imaging showed stable occlusion. In conclusion, VVFs can be effectively treated using intrasaccular flow diverters such as the WEB-device, allowing for complete and stable occlusion while preserving the parent artery

Case Report:Giant Paraganglioma of the Skull Base With Two Somatic Mutations in <i>SDHB</i> and <i>PTEN</i> Genes

Head and neck paragangliomas (HNPGLs) are neuroendocrine tumors. They arise from the parasympathetic ganglia and can be either sporadic or due to hereditary syndromes (up to 40%). Most HNPGLs do not produce significant amounts of catecholamines. We report a case of a giant paraganglioma of the skull base with an unusually severe presentation secondary to excessive release of norepinephrine, with a good outcome considering the severity of disease. A 39-year-old Caucasian woman with no prior medical history was found unconscious and emaciated in her home. In the intensive care unit (ICU) the patient was treated for multi-organ failure with multiple complications and difficulties in stabilizing her blood pressure with values up to 246/146 mmHg. She was hospitalized in the ICU for 72 days and on the 31(st) day clinical assessment revealed jugular foramen syndrome and paralysis of the right n. facialis. A brain MRI confirmed a right-sided tumor of the skull base of 93.553 cm(3). Blood tests showed high amounts of normetanephrine (35.1-45.4 nmol/L, ref G, p.C189G) and PTEN (c.834C>G, p.F278L) missense mutation in tumor DNA. The patient made a remarkable recovery except for neurological deficits after intensive multidisciplinary treatment and rehabilitation. This case demonstrates the necessity for an early tertiary center approach with a multidisciplinary expert team and highlights the efficacy of the correct treatment with alpha-blockade

Assessing response to stroke thrombolysis validation of 24-hour multimodal magnetic resonance imaging

Background: Imaging is used as a surrogate for clinical outcome in early-phase stroke trials. Assessment of infarct growth earlier than the standard 90 days used for clinical end points may be equally accurate and more practical. Objective: To compare assessment of the effect of reperfusion therapies using 24-hour vs day 90 magnetic resonance imaging. Design: Infarct volume was assessed on diffusion-weighted imaging (DWI) at baseline and 24 hours after stroke onset and on fluid-attenuated inversion recovery images at day 90. The DWI and fluid-attenuated inversion recovery lesions were manually outlined by 2 independent raters, and the volumes were averaged. Interrater consistency was assessed using the median difference in lesion volume between raters. Setting: Referral center. Patients: Imaging data were available for 83 patients; 77 of these patients received thrombolysis. Main Outcome Measures: Infarct volume at 24 hours and 90 days. Results: The 24-hour DWI infarct volume had a strong linear correlation with day 90 fluid-attenuated inversion recovery infarct volume (r = 0.98, 95% confidence interval, 0.97-0.99). Recanalization had a significant effect on infarct evolution between baseline and 24 hours but not between 24 hours and day 90. Infarct growth from baseline was significantly reduced by recanalization, whether assessed at 24 hours or day 90. Infarct volume at either time point predicted functional outcome independent of age and baseline stroke severity. Interrater agreement was better for DWI than fluid-attenuated inversion recovery (1.4 mL [8%] vs 1.8 mL [17%]; P = .002). Conclusions: Assessment of final infarct volume using DWI at 24 hours captures the effect of reperfusion therapies on infarct growth and predicts functional outcome similarly to imaging at day 90. This has the potential to reduce loss to follow-up in trials and may add early prognostic information in clinical practice. Infarct growth can be used as a surrogate marker for clinical outcome in ischemic stroke trials. This provides a meaningful intermediary between preclinical studies, where drug effects are often assessed on the basis of infarct volume attenuation, and phase 3 clinical outcomes. In the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) study and the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET), recanalization and reperfusion have been demonstrated to significantly reduce infarct growth. Although thrombolysis did not significantly attenuate infarct growth in the primary EPITHET analysis, subsequent analysis using more stringent optimized perfusion thresholds developed in positron emission tomography and magnetic resonance imaging has demonstrated reduced growth in patients who received thrombolysis. Traditionally, stroke trial clinical end points are assessed at 90 days following stroke. There has been less consensus around the timing of imaging outcome assessments. However, these have generally been delayed, eg, 30 days in the DEFUSE study and 90 days in EPITHET. However, these were arbitrary choices and have some distinct disadvantages. By days 30 to 90, significant atrophy of the infarcted region has taken place. This leads to an underestimate of the infarct volume relative to the baseline brain topography. There is also a real risk of loss to imaging follow-up given the requirement for in-person attendance at 1 to 3 months when the patient may be at home or in a nursing institution with limited access to transportation. Some loss to follow-up also occurs due to early mortality. In the DEFUSE study and EPITHET, 25% of patients were unable to participate in day 30 or day 90 imaging, respectively (16% died and 9% were unavailable). Assessment of final infarct volume at earlier time points may therefore be more accurate and yield major practical advantages.11 Magnetic resonance diffusion-weighted imaging (DWI) has recently been confirmed as a reliable indicator of irreversible infarction.10A 24-hour scan is commonly obtained in routine clinical practice to assess for hemorrhagic transformation after thrombolysis. We therefore examined the potential for 24-hour DWI to predict day 90 fluid-attenuated inversion recovery (FLAIR) lesion volumes and clinical outcome data. We also assessed the interrater variability in manually outlined lesion volumes using the 2 modalities