Pseudo-wound infection after a caesarean section:Case report of unrecognized Pyoderma Gangrenosum

Background: Pyoderma Gangrenosum (PG) is a rare auto-inflammatory disease, characterized by painful ulcerative skin-lesions often developing at sites of injury or surgery because of the typical pathergy phenomena. We describe an unusual case of PG after a caesarean section with excessive extra-cutaneous manifestation within internal organs. Presentation of case: A 21-year-old Dutch primigravida developed signs of sepsis after a caesarean section. Despite antibiotic treatment, fast clinical deterioration occurred. Exploration of the wound showed necrosis of the uterus and surrounding tissues. Due to the progression of necrosis, consecutive debridement procedures were executed resulting in a substantial abdominal wall defect. The progressive clinical course of the necrosis combined with absence of positive wound cultures and histology of prominent interstitial neutrophilic infiltration, led to the diagnosis ‘Pyoderma Gangrenosum’. Treatment with high dose corticosteroids led to rapid regression of the disease. After several weeks, the abdominal wall defect was surgically corrected under systemic corticosteroid therapy. Discussion: This case of PG is unique due to the excessive extra-cutaneous presentation, which contributed to delayed diagnosis. Several surgical interventions in the active stage of disease resulted in expansion of PG and substantial morbidity for the patient. Conclusion: Post-operative PG can mimic infectious diseases, but treatment is substantially different. This case of extensive PG highlights the importance of timely recognition and treatment of the disease to reduce iatrogenic morbidity

Skeletal muscle atrophy and myosteatosis are not related to long-term aneurysmal subarachnoid hemorrhage outcome

The prognosis of aneurysmal subarachnoid hemorrhage (aSAH) is highly variable. This study aims to investigate whether skeletal muscle atrophy and myosteatosis are associated with poor outcome after aSAH. In this study, a cohort of 293 consecutive aSAH-patients admitted during a 4-year period was retrospectively analyzed. Cross-sectional muscle measurements were obtained at the level of the third cervical vertebra. Muscle atrophy was defined by a sex-specific cutoff value. Myosteatosis was defined by a BMI-specific cutoff value. Poor neurological outcome was defined as modified Rankin Scale 4–6 at 2 and 6-month follow-up. Patient survival state was checked until January 2021. Generalized estimating equation was performed to assess the effect of muscle atrophy / myosteatosis on poor neurological outcome after aSAH. Cox regression was performed to analyze the impact of muscle atrophy and myosteatosis on overall survival. The study found that myosteatosis was associated with poor neurological condition (WFNS 4–5) at admission after adjusting for covariates (odds ratio [OR] 2.01; 95%CI 1.05,3.83; P = .03). It was not associated with overall survival (P = .89) or with poor neurological outcomes (P = .18) when adjusted for other prognostic markers. Muscle atrophy was not associated with overall survival (P = .58) or neurological outcome (P = .32) after aSAH. In conclusion, myosteatosis was found to be associated with poor physical condition directly after onset of aSAH. Skeletal muscle atrophy and myosteatosis were however irrelevant to outcome in the Western-European aSAH patient. Future studies are needed to validate these finding

Impact of Treatment Delay on Outcome in the International Subarachnoid Aneurysm Trial

Background and Purpose - ISAT (International Subarachnoid Aneurysm Trial) demonstrated that 1 year after aneurysmal subarachnoid hemorrhage, coiling resulted in a significantly better clinical outcome than clipping. After 5 years, this difference did not reach statistical significance, but mortality was still higher in the clipping group. Here, we present additional analyses, reporting outcome after excluding pretreatment deaths. Methods - Outcome measures were death with or without dependency at 1 and 5 years after treatment, after exclusion of all pretreatment deaths. Treatment differences were assessed using relative risks (RRs). With sensitivity and exploratory analyses, the relation between treatment delay and outcome was analyzed. Results - After exclusion of pretreatment deaths, at 1-year follow-up coiling was favorable over clipping for death or dependency (RR, 0.77 [95% CI, 0.67-0.89]) but not for death alone (RR, 0.88 [95% CI, 0.66-1.19]). After 5 years, no significant differences were observed, neither for death or dependency (RR, 0.88 [95% CI, 0.77-1.02]) nor for death alone (RR, 0.82 [95% CI, 0.64-1.05]). Sensitivity analyses showed a similar picture. In good-grade patients, coiling remained favorable over clipping in the long-term. Time between randomization and treatment was significantly longer in the clipping arm (mean 1.7 versus 1.1 days; P<0.0001), during which 17 patients died because of rebleeding versus 6 pretreatment deaths in the endovascular arm (RR, 2.81 [95% CI, 1.11-7.11]). Conclusions - These additional analyses support the conclusion of ISAT that at 1-year follow-up after aneurysmal subarachnoid hemorrhage coiling has a better outcome than clipping. After 5 years, with pretreatment mortality excluded, the difference between coiling and clipping is not significant. The high number of pretreatment deaths in the clipping group highlights the importance of urgent aneurysm treatment to prevent early rebleeding

The Diagnostic Value of Near-Infrared Spectroscopy to Predict Delayed Cerebral Ischemia and Unfavorable Outcome After Subarachnoid Hemorrhage

OBJECTIVE: Near-infrared spectroscopy (NIRS) is a non-invasive tool to monitor cerebral regional oxygen saturation. Impairment of microvascular circulation with subsequent cerebral hypoxia during delayed cerebral ischemia (DCI) is associated with poor functional outcome after subarachnoid hemorrhage (SAH). Therefore, NIRS could be useful to predict the risk for DCI and functional outcome. However, only limited data is available on NIRS regional cerebral tissue oxygen saturation (rSO2) distribution in SAH. The aim of this study was to compare the distribution of NIRS rSO2 values in non-traumatic SAH patients with the occurrence of DCI and functional outcome at two months. In addition, the predictive value of NIRS rSO2 was compared with the previously validated SAFIRE grade (derived from Size of the aneurysm, Age, FIsher grade, world federation of neurosurgical societies after REsuscitation).METHODS: In this study, the rSO2 distribution of patient with and without DCI after SAH are compared. The optimal cutoff points to predict DCI and outcome are assessed, and its predictive value is compared to the SAFIRE grade.RESULTS: Out of 41 patients, 12 developed DCI, and 9 had unfavorable outcome at 60 days. Prediction of DCI with NIRS had an area under the curve (AUC) of 0.77 (95%CI 0.62-0.92; p=0.0028) with an optimal cutoff point of 65% (sensitivity 1.00; specificity 0.45). Prediction of favorable outcome with NIRS had an AUC of 0.86 (95%CI 0.74-0.98; p=0.0003) with an optimal cutoff point of 63% (sensitivity 1.00; specificity 0.63). Regression analysis showed that NIRS rSO2 score is complementary to the SAFIRE grade.CONCLUSION: NIRS rSO2 monitoring in patients with SAH may improve prediction of DCI and clinical outcome after SAH.</p

The Diagnostic Value of Near-Infrared Spectroscopy to Predict Delayed Cerebral Ischemia and Unfavorable Outcome After Subarachnoid Hemorrhage

OBJECTIVE: Near-infrared spectroscopy (NIRS) is a non-invasive tool to monitor cerebral regional oxygen saturation. Impairment of microvascular circulation with subsequent cerebral hypoxia during delayed cerebral ischemia (DCI) is associated with poor functional outcome after subarachnoid hemorrhage (SAH). Therefore, NIRS could be useful to predict the risk for DCI and functional outcome. However, only limited data is available on NIRS regional cerebral tissue oxygen saturation (rSO2) distribution in SAH. The aim of this study was to compare the distribution of NIRS rSO2 values in non-traumatic SAH patients with the occurrence of DCI and functional outcome at two months. In addition, the predictive value of NIRS rSO2 was compared with the previously validated SAFIRE grade (derived from Size of the aneurysm, Age, FIsher grade, world federation of neurosurgical societies after REsuscitation).METHODS: In this study, the rSO2 distribution of patient with and without DCI after SAH are compared. The optimal cutoff points to predict DCI and outcome are assessed, and its predictive value is compared to the SAFIRE grade.RESULTS: Out of 41 patients, 12 developed DCI, and 9 had unfavorable outcome at 60 days. Prediction of DCI with NIRS had an area under the curve (AUC) of 0.77 (95%CI 0.62-0.92; p=0.0028) with an optimal cutoff point of 65% (sensitivity 1.00; specificity 0.45). Prediction of favorable outcome with NIRS had an AUC of 0.86 (95%CI 0.74-0.98; p=0.0003) with an optimal cutoff point of 63% (sensitivity 1.00; specificity 0.63). Regression analysis showed that NIRS rSO2 score is complementary to the SAFIRE grade.CONCLUSION: NIRS rSO2 monitoring in patients with SAH may improve prediction of DCI and clinical outcome after SAH.</p

The Diagnostic Value of Near-Infrared Spectroscopy to Predict Delayed Cerebral Ischemia and Unfavorable Outcome After Subarachnoid Hemorrhage

OBJECTIVE: Near-infrared spectroscopy (NIRS) is a non-invasive tool to monitor cerebral regional oxygen saturation. Impairment of microvascular circulation with subsequent cerebral hypoxia during delayed cerebral ischemia (DCI) is associated with poor functional outcome after subarachnoid hemorrhage (SAH). Therefore, NIRS could be useful to predict the risk for DCI and functional outcome. However, only limited data is available on NIRS regional cerebral tissue oxygen saturation (rSO2) distribution in SAH. The aim of this study was to compare the distribution of NIRS rSO2 values in non-traumatic SAH patients with the occurrence of DCI and functional outcome at two months. In addition, the predictive value of NIRS rSO2 was compared with the previously validated SAFIRE grade (derived from Size of the aneurysm, Age, FIsher grade, world federation of neurosurgical societies after REsuscitation).METHODS: In this study, the rSO2 distribution of patient with and without DCI after SAH are compared. The optimal cutoff points to predict DCI and outcome are assessed, and its predictive value is compared to the SAFIRE grade.RESULTS: Out of 41 patients, 12 developed DCI, and 9 had unfavorable outcome at 60 days. Prediction of DCI with NIRS had an area under the curve (AUC) of 0.77 (95%CI 0.62-0.92; p=0.0028) with an optimal cutoff point of 65% (sensitivity 1.00; specificity 0.45). Prediction of favorable outcome with NIRS had an AUC of 0.86 (95%CI 0.74-0.98; p=0.0003) with an optimal cutoff point of 63% (sensitivity 1.00; specificity 0.63). Regression analysis showed that NIRS rSO2 score is complementary to the SAFIRE grade.CONCLUSION: NIRS rSO2 monitoring in patients with SAH may improve prediction of DCI and clinical outcome after SAH.</p

The Diagnostic Value of Near-Infrared Spectroscopy to Predict Delayed Cerebral Ischemia and Unfavorable Outcome After Subarachnoid Hemorrhage

OBJECTIVE: Near-infrared spectroscopy (NIRS) is a non-invasive tool to monitor cerebral regional oxygen saturation. Impairment of microvascular circulation with subsequent cerebral hypoxia during delayed cerebral ischemia (DCI) is associated with poor functional outcome after subarachnoid hemorrhage (SAH). Therefore, NIRS could be useful to predict the risk for DCI and functional outcome. However, only limited data is available on NIRS regional cerebral tissue oxygen saturation (rSO2) distribution in SAH. The aim of this study was to compare the distribution of NIRS rSO2 values in non-traumatic SAH patients with the occurrence of DCI and functional outcome at two months. In addition, the predictive value of NIRS rSO2 was compared with the previously validated SAFIRE grade (derived from Size of the aneurysm, Age, FIsher grade, world federation of neurosurgical societies after REsuscitation).METHODS: In this study, the rSO2 distribution of patient with and without DCI after SAH are compared. The optimal cutoff points to predict DCI and outcome are assessed, and its predictive value is compared to the SAFIRE grade.RESULTS: Out of 41 patients, 12 developed DCI, and 9 had unfavorable outcome at 60 days. Prediction of DCI with NIRS had an area under the curve (AUC) of 0.77 (95%CI 0.62-0.92; p=0.0028) with an optimal cutoff point of 65% (sensitivity 1.00; specificity 0.45). Prediction of favorable outcome with NIRS had an AUC of 0.86 (95%CI 0.74-0.98; p=0.0003) with an optimal cutoff point of 63% (sensitivity 1.00; specificity 0.63). Regression analysis showed that NIRS rSO2 score is complementary to the SAFIRE grade.CONCLUSION: NIRS rSO2 monitoring in patients with SAH may improve prediction of DCI and clinical outcome after SAH.</p

The Diagnostic Value of Near-Infrared Spectroscopy to Predict Delayed Cerebral Ischemia and Unfavorable Outcome After Subarachnoid Hemorrhage

OBJECTIVE: Near-infrared spectroscopy (NIRS) is a non-invasive tool to monitor cerebral regional oxygen saturation. Impairment of microvascular circulation with subsequent cerebral hypoxia during delayed cerebral ischemia (DCI) is associated with poor functional outcome after subarachnoid hemorrhage (SAH). Therefore, NIRS could be useful to predict the risk for DCI and functional outcome. However, only limited data is available on NIRS regional cerebral tissue oxygen saturation (rSO2) distribution in SAH. The aim of this study was to compare the distribution of NIRS rSO2 values in non-traumatic SAH patients with the occurrence of DCI and functional outcome at two months. In addition, the predictive value of NIRS rSO2 was compared with the previously validated SAFIRE grade (derived from Size of the aneurysm, Age, FIsher grade, world federation of neurosurgical societies after REsuscitation).METHODS: In this study, the rSO2 distribution of patient with and without DCI after SAH are compared. The optimal cutoff points to predict DCI and outcome are assessed, and its predictive value is compared to the SAFIRE grade.RESULTS: Out of 41 patients, 12 developed DCI, and 9 had unfavorable outcome at 60 days. Prediction of DCI with NIRS had an area under the curve (AUC) of 0.77 (95%CI 0.62-0.92; p=0.0028) with an optimal cutoff point of 65% (sensitivity 1.00; specificity 0.45). Prediction of favorable outcome with NIRS had an AUC of 0.86 (95%CI 0.74-0.98; p=0.0003) with an optimal cutoff point of 63% (sensitivity 1.00; specificity 0.63). Regression analysis showed that NIRS rSO2 score is complementary to the SAFIRE grade.CONCLUSION: NIRS rSO2 monitoring in patients with SAH may improve prediction of DCI and clinical outcome after SAH.</p

The Diagnostic Value of Near-Infrared Spectroscopy to Predict Delayed Cerebral Ischemia and Unfavorable Outcome After Subarachnoid Hemorrhage

OBJECTIVE: Near-infrared spectroscopy (NIRS) is a non-invasive tool to monitor cerebral regional oxygen saturation. Impairment of microvascular circulation with subsequent cerebral hypoxia during delayed cerebral ischemia (DCI) is associated with poor functional outcome after subarachnoid hemorrhage (SAH). Therefore, NIRS could be useful to predict the risk for DCI and functional outcome. However, only limited data is available on NIRS regional cerebral tissue oxygen saturation (rSO2) distribution in SAH. The aim of this study was to compare the distribution of NIRS rSO2 values in non-traumatic SAH patients with the occurrence of DCI and functional outcome at two months. In addition, the predictive value of NIRS rSO2 was compared with the previously validated SAFIRE grade (derived from Size of the aneurysm, Age, FIsher grade, world federation of neurosurgical societies after REsuscitation).METHODS: In this study, the rSO2 distribution of patient with and without DCI after SAH are compared. The optimal cutoff points to predict DCI and outcome are assessed, and its predictive value is compared to the SAFIRE grade.RESULTS: Out of 41 patients, 12 developed DCI, and 9 had unfavorable outcome at 60 days. Prediction of DCI with NIRS had an area under the curve (AUC) of 0.77 (95%CI 0.62-0.92; p=0.0028) with an optimal cutoff point of 65% (sensitivity 1.00; specificity 0.45). Prediction of favorable outcome with NIRS had an AUC of 0.86 (95%CI 0.74-0.98; p=0.0003) with an optimal cutoff point of 63% (sensitivity 1.00; specificity 0.63). Regression analysis showed that NIRS rSO2 score is complementary to the SAFIRE grade.CONCLUSION: NIRS rSO2 monitoring in patients with SAH may improve prediction of DCI and clinical outcome after SAH.</p

Early Circulating Lactate and Glucose Levels After Aneurysmal Subarachnoid Hemorrhage Correlate With Poor Outcome and Delayed Cerebral lschemia: A Two-Center Cohort Study

Objective: In critically ill patients, elevated blood lactate at admission is associated with poor outcome, but after aneurysmal subarachnoid hemorrhage, this has not been investigated. We studied the association between early circulating lactate and glucose with delayed cerebral ischemia and poor outcome. Lactate and glucose were both studied, hypothesizing that both may be increased due to sympathetic activation after subarachnoid hemorrhage similar to critically ill patients. Design: Retrospective cohort study. Setting: ICUs of two academic hospitals in the Netherlands. Patients: Patients with aneurysmal subarachnoid hemorrhage admitted to the ICU within 24 hours after the bleed surviving beyond 48 hours after ICU admission and who had at least one lactate measurement within 24 hours after admission. Interventions: None. Measurements and Main Results: In 285 patients, maximal lactate and glucose levels within the first 24 hours after admission were determined. Early lactate and glucose were related with delayed cerebral ischemia related infarction and poor outcome (a modified Rankin Scale score of 4, 5, or death at 3 mo). Delayed cerebral ischemia occurred in 84 patients (29%), and 106 patients (390%) had poor outcome. Multivariable analyses were performed with adjustment of established predictors for delayed cerebral ischemia and outcome: age, sex, World Federation of Neurological Surgeons grade at admission and Hijdra sum scores. Early lactate and glucose were strongly related (Spearman p = 0.55; p <0.001). Lactate and glucose were both independently associated with delayed cerebral ischemia and poor outcome in multivariable analyses with either lactate or glucose as covariates. When both lactate and glucose were included, only glucose showed an independent association with delayed cerebral ischemia (odds ratio, 1.14; 95% CI, 1.01-1.28) and only lactate showed an independent association with poor outcome (odds ratio, 1.42; 95% CI, 1.11-1.81). Conclusions: Early lactate and glucose levels after aneurysmal subarachnoid hemorrhage are associated with delayed cerebral ischemia and poor outcome, suggesting that they may be considered in conjunction with other parameters for future prognostic models