Aws Alawi

In-Hospital Mortality in Acute Ischemic Stroke Treated With Hemicraniectomy in US Hospitals

Hemicraniectomy is a surgical procedure performed to prevent cerebral herniation and death in patients who have sustained a massive ischemic stroke in the anterior circulation territory. Information on in-hospital mortality in patients with large ischemic stroke treated with hemicraniectomy outside randomized trials is lacking. We sought to identify in-hospital mortality associated with hemicraniectomy in a large US sample. We selected our cohort from the National Inpatient Sample database for the years 2000 through 2006 using the clinical classification software codes for acute ischemic stroke (AIS) and arterial occlusion, and identified those patients treated with thrombolysis or hemicraniectomy by the procedure codes. A multivariate logistic regression model was used for adjusted analysis. Among 502,231 patients with AIS, 252 (0.05%) underwent hemicraniectomy, and 7526 (1.5%) were treated with thrombolysis. Compared with the nonsurgical group, patients treated with hemicraniectomy were younger (mean age, 55.6 vs 71.5 years) and had lower Charlson Comorbidity Index scores (92.8% vs 76.0%). The mortality rate was higher in the hemicraniectomy group (32.1% vs 10.8%; adjusted odds ratio [OR] = 3.91; 95% confidence interval [CI] = 2.97-5.16). In patients treated with thrombolysis, mortality was higher in the hemicraniectomy group compared with the nonsurgical group (35.3% vs 13.1%; P = .01). The rate of hospital utilization of hemicraniectomy varied between 0.04% and 0.06% among all stroke admissions; the trend did not change significantly over the 7-year study period (P = .06). The mortality rate in hemicraniectomy-treated patients was significantly lower than in historical cohorts however, hemicraniectomy remains associated with high in-hospital mortality. The rate of utilization of hemicraniectomy for AIS in US hospitals has remained essentially unchanged.

Outcome of plasmapheresis in myasthenia gravis: Delayed therapy is not favorable

Introduction: The purpose of this study was to compare the in‐hospital mortality and complication rates after early and delayed initiation of plasma exchange (PLEX) in patients with myasthenia gravis (MG). Methods: Our cohort was identified from the Nationwide Inpatient Sample database for the years 2000 through 2005. Early treatment was defined as therapy with PLEX administered within the first 2 days from hospital admission. Univariate and multivariate analyses were employed. Results: One thousand fifty‐three patients were treated and included in the analysis. A delay in receiving PLEX was associated with higher mortality (6.56% vs. 1.15%, P < 0.001) and increased complications (29.51% vs. 15.29%, P < 0.001). Adjusted analysis showed increased mortality [odds ratio (OR) 2.812; 95% confidence interval (CI) 1.119–7.069] and complications (OR 1.672; 95% CI 1.118–2.501) with delayed PLEX therapy. Conclusions: Delaying PLEX therapy for MG by more than 2 days after admission may lead to higher mortality and complication rates, and thus prompt therapy is warranted. Muscle Nerve 43: 578–584, 2011

Traumatic carotid-rosenthal fistula treated with Jostent Graftmaster.

Traumatic injuries of the carotid artery may result in severe morbidity and mortality. The most common location of carotid artery injury is the cavernous segment, which may result in fistulous connection to the cavernous sinus and ophthalmic veins, which in turn lead to pressure symptoms in the ipsilateral orbit. Unlike the commonly reported direct traumatic carotid-cavernous fistula, we describe an unusual case of a 38-year-old man presented with a traumatic brain injury led to a fistula connection between the cavernous carotid artery and the ipsilateral basal vein of Rosenthal, with eventual drainage to the straight and transverse sinuses. The basal vein of Rosenthal is usually formed from confluence of anterior and middle cerebral veins deep in the Sylvian fissure and drain the insular cortex and the cerebral peduncles to the vein of Galen. Immediate endovascular deployment of a covered stent in the cavernous carotid artery allowed sealing the laceration site. Three months follow up showed a non-focal neurological examination and healed carotid laceration over the covered stent.

E-072 Post-coital MCA Dissection Presenting with SAH: A Case Report and Review of the Literature

Background Post-coital dissections are uncommon and have been reported rarely in the aorta and coronary arteries. Intracranial arterial dissections are rare and data regarding this disease process is scant. We present a case of post-coital middle cerebral artery (MCA) dissection in a young man presenting with subarachnoid haemorrhage (SAH). Methods Case report and review of the literature. Case report A 35-year-old man with no past medical history presented with severe headache that started immediately after sexual intercourse. This was also associated with transient left facial weakness which resolved after a few minutes. His headache subsided initially but recurred spontaneously three days later prompting a visit to the ER. He denied any history of trauma. His neurologic exam was unremarkable. A head CT showed SAH in the right Sylvian fissure and sulci of the superior right frontal lobe. He underwent a catheter angiogram which revealed an area of focal narrowing in the right MCA M1 segment caused by a dissection flap and slow flow distal to the area of the luminal stenosis (Figure 1a). MRI of the brain showed small punctate right hemispheric infarcts. Anticoagulation with warfarin was initiated and patient was discharged home. The patient remained clinically stable and underwent a follow up angiogram after 4 months, which showed interval change in the right MCA dissection with development of severe stenosis in the proximal M1 segment (Figure 1b). There was slow antegrade flow distal to the stenotic segment and collateral flow through pial collaterals from the right ACA to the distal right MCA branches. Discussion Intracranial arterial dissections are uncommon and may present with severe headache. These may cause cerebral infarctions or subarachnoid haemorrhage. Most reported intracranial arterial dissections affect the vertebrobasilar circulation. In addition, nontraumatic spontaneous dissection of the MCA is rare. Rupture of the dissected arterial wall, either directly or at the site of an aneurysm, can cause subarachnoid haemorrhage. The natural history of this disease process is not very well understood. There may be resolution of the stenosis, formation of pseudoaneurysms, or, as seen in our case, worsening of the severity of stenosis. Our patient had no subsequent clinical events as he had good collateral circulation. Our case highlights this rare cause of non-aneurysmal SAH and we believe this to be the first reported case of post-coital MCA dissection. Abstract E-072 Figure 1 Disclosures A. Alawi: None. S. Mehta: None. R. Edgell: None.