Diagnosis, treatment, and follow-up of patients with cerebral amyloid angiopathy-related inflammation

Purpose Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a rare potentially reversible encephalopathy associated with an autoimmune process against proteins deposited in the walls of cortical and leptomeningeal brain vessels. Definite diagnosis requires histopathological features of vascular inflammation and amyloid deposition from brain biopsy. Clinical-neuroradiological criteria have been recently introduced and validated to reduce the need for biopsy. The purpose of this paper is to report a historical retrospective review of clinical-neuroradiological follow-up of two patients with probable CAA-ri and five patients with a reasonably probable suspect of CAA-ri (4 females, 3 males, patient's age at admission: 66-79 years) seen at our institution between 2007 and 2021, focusing on clinical and neuroradiological awareness to this entity and variable response to immunotherapy. Materials and methods Clinical features at presentation included subacute to acute confusion (6/7), seizures (4/7), cognitive impairment (5/7), and focal neurological signs (3/7). Neuroradiology included braincomputed tomography followed by magnetic resonance imaging. Infectious diseases and autoimmune workups were then performed. Results CSF analysis was performed in two patients. Cerebral angiography was performed in two patients, to rule out vascular malformations. Hemorrhagic posterior reversible encephalopathy syndrome has been suspected in two patients. Four patients underwent immunotherapy with corticosteroids followed by reduction of brain dysfunctions. Three patients did not undergo immunotherapy but underwent clinical and/or neuroradiological remission. Conclusions Patients with CAA-ri present a rare steroid-responsive acute to subacute brain dysfunction. Thus, it has to be known and recognized both clinically and neuroradiologically. Spontaneous clinical and/or neuroradiological improvement is possible in patients with mild symptoms

Recruitment maneuver in prevention of hypoxia during percutaneous dilational tracheostomy: Randomized trial

BACKGROUND: Percutaneous dilational tracheostomy (PDT) can potentially lead to hypoxia and alveolar derecruitment. The aim of this prospective study was to evaluate the efficacy of performing a recruitment maneuver (RM) before tracheostomy, in order to improve oxygenation. METHODS: We enrolled 29 eligible trauma patients with acute lung injury criteria requiring tracheostomy in a university ICU. Subjects were ventilated on volume controlled mechanical ventilation (tidal volume of 6 mL/kg) and FIO2set at 1.0. Subjects were randomized into 2 groups: RM group (subjects who underwent RM 10 min before PDT, 15 subjects) and no-RM group (subjects without application of RM before PDT, 14 subjects). RM was performed by imposition of continuous positive airway pressure of 40 cm H2O for 40 seconds. We collected gas exchange, respiratory, and hemodynamic data 5 times: 1 hour before RM, 5 min after RM, 5 min after PDT, 30 min after PDT, and 6 hours after PDT. RESULTS: Subjects who underwent RM had a significant increase in PaO2; 5 min after the maneuver, PaO2increased from 222.6 \uc2\ub1 33.4 mm Hg to 341.3 \uc2\ub1 33.1 mm Hg (P <.01) and was always significantly maintained throughout the following times of the study, compared to the no-RM group: in the RM and no-RM groups, respectively, 260.7 \uc2\ub1 35.4 mm Hg vs 108.5 \uc2\ub1 36.9 mm Hg 5 min after PDT; 285.6 \uc2\ub1 29.1 mm Hg vs 188.4 \uc2\ub1 21.4 mm Hg 30 min after PDT; and 226.3 \uc2\ub1 24.8 mm Hg vs 147.6 \uc2\ub1 42.8 mm Hg 6 h after PDT (P <.01). CONCLUSIONS: Our study suggests that application of RM before PDT could be useful to avoid hypoxemia following such procedure, by reducing fall in PaO2and preventing the decrease in oxygenation values below baseline at 6 hours. \uc2\ua9 2012 Daedalus Enterprises