Rohan Samant

Hematoma expansion in spontaneous intracerebral hemorrhage: predictors and outcome

Background: Hematoma growth is an independent determinant of outcome in patients with intracerebral hemorrhage (ICH). Predictors of hematoma expansion are poorly defined. Our aim is to determine predictors of hematoma expansion in patients with ICH. Methods: We reviewed our prospective database of patients with ICH between January 2009 and June 2012. Patients were divided into two groups based on the presence or absence of hematoma expansion. Hematoma volume was calculated by thin volumetric cuts using special software. Expansion was defined as 33% increase in hematoma volume over 24 hours. We compared risk factors, laboratory parameters, medications and CT findings between the two groups using Fishers exact test. A multivariate regression analysis was performed to identify predictors of expansion. Results: We identified 200 patients with ICH. On univariate analysis, patients with hematoma expansion were more likely to have Warfarin use (37% vs. 11% p = 0.001), low admission GCS (9 ± 4, 11 ± 4, p = 0.003), intraventricular hemorrhage (IVH) (79% vs. 45% p = 0.002) and hydrocephalus (43% vs. 22% p = 0.032). On multivariate regression analysis, prior Warfarin use (OR = 3.6, 95% CI: 1.3,10.3; p = 0.016) and IVH (OR = 5.7, 95% CI: 1.5,20.9; p = 0.009) were significant predictors of hematoma expansion. The ICU length of stay (8 ± 8 vs. 4 ± 6, p = 0.004), intubation rate (82% vs. 32%, p = 0.034), and hospital mortality (68% vs. 20%, p = < 0.001) were significantly higher among patients with hematoma expansion. Conclusion: Patient with prior Warfarin use and IVHs are at risk of hematoma expansion. Aggressive measures to prevent hematoma growth are important in these patients.

Nosocomial Infections in Patients With Spontaneous Intracerebral Hemorrhage

BACKGROUND Nosocomial infections are frequent complications in patients with intracerebral hemorrhage. OBJECTIVES To determine the prevalence, risk factors, and outcomes of nosocomial infections in patients with intracerebral hemorrhage. METHODS Prospectively collected data on patients with spontaneous intracerebral hemorrhage between January 2009 and June 2012 were retrospectively reviewed. Patients who had nosocomial infection during the hospital stay were compared with patients who did not. Poor outcome was defined as death or discharge to a long-term nursing facility. RESULTS At least 1 nosocomial infection developed in 26% of 202 patients with intracerebral hemorrhage. The most common infections were pneumonia (18%), urinary tract infection (12%), meningitis or ventriculitis (3%), and bacteremia (1%). On univariate analysis, independent predictors of nosocomial infection were intraventricular hemorrhage, hydrocephalus, low score on the Glasgow Coma Scale at admission, hyperglycemia at admission, and treatment with mechanical ventilation. On multivariate regression analysis, the only significant predictor of nosocomial infection was intraventricular hemorrhage (odds ratio, 5.4; 95% CI, 1.2-11.4; P = .02). Patients with nosocomial infection were more likely than those without to require a percutaneous gastrostomy tube (odds ratio, 33.1, 95% CI, 23.3-604.4; P < .001) and to have a longer stay in the intensive care unit or hospital without a significant increase in mortality. Patients with nosocomial pneumonia were also more likely to have a poor outcome (P < .001). CONCLUSION Pneumonia was the most common infection among patients with intracerebral hemorrhage.

Vertebral augmentation in the treatment of pathologic compression fractures in 792 patients with multiple myeloma

Vertebral augmentation in the treatment of pathologic compression fractures in 792 patients with multiple myeloma

Features of infratentorial-predominant posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic process that typically occurs in the setting of immune dysregulation. In contrast to the characteristic pattern involving parieto-occipital and posterior frontal regions, predominant involvement of the infratentorial brain occurs in a minority of PRES patients. We examined six patients with infratentorial predominant posterior reversible encephalopathy syndrome (IPPRES) relative to those with typical PRES in terms of clinical factors of toxicity and outcomes. We review the current understanding of PRES pathophysiology. An institutional database of PRES patients was created through an IRB-approved search of the electronic record from 2007 to 2012. MR images were reviewed and classified by two neuro radiologists. Clinical data including laboratory data, blood pressure, and discharge outcome were collected through review of existing electronic medical records. Characteristics of the two groups were compared. Six cases among 80 PRES patients displayed an atypical distribution of signal abnormality predominantly involving the infratentorial brain. In IPPRES patients, signal abnormalities within the supratentorial brain, when present, showed a predominantly central distribution rather than the typical peripheral distribution. IPPRES patients showed higher rates of extreme hypertension, renal dysfunction, abnormal serum calcium, and abnormal serum magnesium relative to typical PRES patients. Outcomes were similar between the two groups. In our small series, IPPRES differs from typical PRES patients not only in the distribution of imaging abnormalities but also in rates of extreme hypertension and several laboratory indices. Despite these differences, clinical outcome in the IPPRES group was similar to that of typical PRES.

Elevation of serum lactate dehydrogenase at posterior reversible encephalopathy syndrome onset in chemotherapy-treated cancer patients

The pathophysiology of posterior reversible encephalopathy syndrome (PRES) is incompletely understood; however, an underlying state of immune dysregulation and endothelial dysfunction has been proposed. We examined alterations of serum lactate dehydrogenase (LDH), a marker of endothelial dysfunction, relative to the development of PRES in patients receiving chemotherapy. A retrospective Institutional Review Board approved database of 88 PRES patients was examined. PRES diagnosis was confirmed by congruent clinical diagnosis and MRI. Clinical features at presentation were recorded. Serum LDH values were collected at three time points: prior to, at the time of, and following PRES diagnosis. Students t-test was employed. LDH values were available during the course of treatment in 12 patients (nine women; mean age 57.8 years [range 33-75 years]). Chemotherapy-associated PRES patients were more likely to be normotensive (25%) versus the non-chemotherapy group (9%). LDH levels at the time of PRES diagnosis were higher than those before and after (p=0.0263), with a mean difference of 114.8 international units/L. Mean time intervals between LDH measurement prior to and following PRES diagnosis were 44.8 days and 51.4 days, respectively. Mean elapsed time between last chemotherapy administration and PRES onset was 11.1days. In conclusion, serum LDH, a marker of endothelial dysfunction, shows statistically significant elevation at the onset of PRES toxicity in cancer patients receiving chemotherapy. Our findings support a systemic process characterized by endothelial injury/dysfunction as a factor, if not the prime event, in the pathophysiology of PRES.

Initial experience with GeneXpert MTB/RIF assay in the Arkansas Tuberculosis Control Program.

BACKGROUND Mycobacterium tuberculosis remains one of the most significant causes of death from an infectious agent. Rapid and accurate diagnosis of pulmonary and extra-pulmonary tuberculosis (TB) is still a great challenge. The GeneXpert MTB/RIF assay is a novel integrated diagnostic system for the diagnosis of tuberculosis and rapid detection of Rifampin (RIF) resistance in clinical specimens. In 2012, the Arkansas Tuberculosis Control Program introduced GeneXpert MTB/RIF assay to replace the labour-intensive Mycobacterium Tuberculosis Direct (MTD) assay. AIMS To rapidly diagnose TB within two hours and to simultaneously detect RIF resistance. OBJECTIVES Describe the procedure used to introduce GeneXpert MTB/RIF assay in the Arkansas Tuberculosis Control Program.Characterise the current gap in rapid M. tuberculosis diagnosis in Arkansas.Assess factors that predict acid fast bacilli (AFB) smearnegative but culture-positive cases in Arkansas.Illustrate, with two case reports, the role of GeneXpert MTB/RIF assay in reduction of time to confirmation of M. tuberculosis diagnosis in the first year of implementation. METHOD Between June 2012 and June 2013, all AFB sputum smearpositive cases and any others, on request by the physician, had GeneXpert MTB/RIF assay performed as well as traditional M. tuberculosis culture and susceptibilities using Mycobacteria Growth Indicator Tube (MGIT) 960 and Löwenstein-Jensen (LJ) slants. Surveillance data for January 2009-June 2013 was analysed to characterise sputum smear-negative but culture-positive cases. RESULTS Seventy-one TB cases were reported from June 2012- June 2013. GeneXpert MTB/RIF assay identified all culture-positive cases as well as three cases that were negative on culture. Also, this rapid assay identified all six smear-negative but M. tuberculosis culture-positive cases; two of these cases are described as case reports. CONCLUSION GeneXpert MTB/RIF assay has made rapid TB diagnosis possible, with tremendous potential in determining isolation of TB suspects on one hand, and quickly ruling out TB whenever suspected.

Developmental venous anomaly coexisting with a true arteriovenous malformation: a rare clinical entity

Two patients diagnosed with arteriovenous malformation (AVM) in close association with a developmental venous anomaly (DVA) are reported. The first patient presented with episodes of left extremity weakness and numbness as well as chronic headaches. The second patient presented with spontaneous intracerebral hemorrhage. Cerebral angiography showed that both the AVM and the transmedullary veins of the DVA drained through the transcortical vein. The AVMs were treated by highly selective transarterial embolization with Onyx embolic agent while preserving the DVAs. It is suggested that the cause of the presentation in both patients was secondary to the association of the AVM with the delicate hemodynamic balance and less robust angioarchitecture of the DVA.

Lithium toxicity and PRES: a novel association.

We report two cases of posterior reversible encephalopathy syndrome (PRES) occurring in association with supra‐therapeutic serum lithium levels. Although the neurologic manifestations of lithium toxicity are well known, this is, to our knowledge, the first report describing a link between lithium toxicity and PRES. We discuss the current understanding of the pathogenesis of PRES and suggest mechanisms by which lithium may play a role in its development.

Root Cause Analysis: An Examination of Odontogenic Origins of Acute Maxillary Sinusitis in Both Immunocompetent & Immunocompromised Patients.

Background and Purpose Dental and periodontal diseases represent important but often overlooked causes of acute sinusitis. Our goal was to examine the prevalence of potential odontogenic sources of acute maxillary sinusitis according to immune status and their associations with sinusitis. Materials and Methods A retrospective review of maxillofacial computed tomography studies from 2013 to 2014 was performed. Each maxillary sinus and its ipsilateral dentition were evaluated for findings of acute sinusitis and dental/periodontal disease. Results Eighty-four patients (24 immunocompetent, 60 immunocompromised) had 171 maxillary sinuses that met inclusion criteria for acute maxillary sinusitis. Inspection of dentition revealed oroantral fistula in 1%, periapical lucencies in 16%, and projecting tooth root(s) in 71% of cases. Immunocompromised patients were more likely to have bilateral sinusitis than immunocompetent patients (67% vs 33%, P = 0.005). A paired case-control analysis in a subset of patients with unilateral maxillary sinusitis (n = 39) showed a higher prevalence of periapical lucency in association with sinuses that had an air fluid level—29% of sinuses with a fluid level had periapical lucency compared with 12% without sinus fluid (P = 0.033). Conclusions Potential odontogenic sources of acute maxillary sinusitis are highly prevalent in both immunocompetent and immunocompromised patients, although the 2 patient populations demonstrate no difference in the prevalence of these potential odontogenic sources. Periapical lucencies were found to be associated with an ipsilateral sinus fluid level. Increased awareness of the importance of dental and periodontal diseases as key components of maxillofacial computed tomography interpretation would facilitate a more appropriate and timely treatment.

Pulsatile Tinnitus Secondary to a Dural Arteriovenous Fistula.

A 51-year-old woman presented with a 3-month history of worsening unilateral pulsatile tinnitus, left ear pain, and vertigo. She reported no history of trauma. Otoscopic exam, audiometry, and tympanometry were normal. An initial magnetic resonance imaging (MRI) demonstrated asymmetrically diminished caliber of the left transverse/sigmoid sinus (Fig. 1A) relative to the normal right sinus (Fig. 1B). Axial contrast-enhanced T1-weighted imaging revealed ‘‘shaggy,’’ ill-defined transverse sinus margins, and foci of linear enhancement intermixed with flow voids within the adjacent temporal diploic space (Fig. 2A). Computed tomography (CT) of temporal bones revealed prominent transosseous channels within the left temporal, parietal, and occipital calvaria (Fig. 2B). Such CT and MRI findings were suggestive of a dural arteriovenous fistula (DAVF), and a catheter angiogram was obtained revealing abnormal vasculature along the left transverse sinus and early filling of the left sigmoid sinus confirming the diagnosis of DAVF (Fig. 2C). Endovascular embolization was performed using Onyx (eve3, Irvine, California) with uncomplicated closure of greater than 50% of the DAVF. After the procedure, the patient reported resolution of tinnitus and vertigo and marked improvement of her otalgia.