Necrotizing pancreatitis is an inflammatory process that poses a strong risk of systemic venous thromboembolism. However, it is often challenging to opt for systemic anticoagulation since the disease is also associated with an increased risk of hemorrhage. Given these opposing complications, a risk versus benefit analysis has to be employed in the management of necrotizing pancreatitis on a case-by-case basis. We discuss a case where the team was faced with a dilemma regarding anticoagulation in a patient with newly developed atrial fibrillation in the setting of necrotizing pancreatitis. We found that there is a lack of guidelines that address the time of initiation and the type of systemic anticoagulation that should be administered in such patients.
Stroke is a leading cause of neurologic disability in the United States with the majority of cases a consequence of ischemia.
Background: Inpatient acute stroke identification may be challenging given the complexity related to both concomitant and comorbid illness. Rapid and accurate diagnosis requires a skilled clinician to discern acute stroke patients from other mimics such as hypoglycemia, hemiplegic migraine, post-ictal paresis, relapse of a demyelinating disease, or recrudescence of prior stroke. Hypothesis: Negative predictors of acute stroke can be identified in inpatients with inpatient stroke alerts. Methods: IRB approved, retrospective analysis of prospectively obtained data was performed for all inpatient stroke alerts between March 2017 and May 2020. Patients with MRI confirmed diagnosis of acute stroke were compared to all others. Univariant analysis was performed with Wilcoxon Ranked Sum test used for non-parametric data to identify risk factors to include in the logistic regression (p<0.05). Results: 674 inpatient stroke alerts resulted in 223 (33%) acute strokes and 451 (67%) non-stroke diagnoses. For stroke vs. non-stroke patients, median age 70.5 vs. 68.6 years, last seen well 77.5 vs. 65.0 minutes (p= 0.030), NIHSS score 10 vs. 4 (p<0.001). In the non-stroke group, 156 (23%) had a witnessed seizure documented during the alert compared to 0% in the stroke group. Negative predictors of stroke included previous diagnosis of epilepsy (0.302 odds, P<0.007), anti-seizure drug (ASDs) prescribed prior to (1.662 odds, p<0.001) or at time of the alert (2.479 odds), and previous EEG(P<0.001). Conclusions: It is imperative to consider post-ictal paresis as a differential diagnosis when assessing patients who present as stroke alerts. The administration of thrombolytics in stroke mimics is not without harm and incorrect diagnosis will delay appropriate treatment. Witnessed seizure at time of alert, history of epilepsy diagnosis, use of ASD prior to or at the time of the alert, and prior EEG findings may serve as a tool to help differentiate between acute stroke and seizure diagnosis. Further study will be aimed at identifying alternative pathways for rapid assessment of patients with acute changes in neurologic exam.
Background: There are few clinical indicators beyond imaging to aid in the prediction of improvement after treatment for acute ischemic stroke. We aimed to identify patient characteristics that serve as predictors to identify patients who may be less likely to have a clinically significant improvement after treatment. Methods: We performed a retrospective chart review of ischemic stroke treatment cases (tPA, EVT or both) at Hartford Hospital between January 1st, 2020 to December 31st, 2021. Stroke was diagnosed with MRI imaging. Patients were divided into those who had early improvement and those who did not have early improvement. Early improvement was defined as a reduction in NIH of 50% or more at 24 hours post treatment. We excluded patients who did not receive a routine CT scan at 24-hours for surveillance of hemorrhage. We identified potential predictors by comparing two demographic (age, gender) and 19 patient health characteristics between groups. Any variables that were significantly different (P<.05) between groups were then examined as a predictor in a multivariate logistic regression analysis, while controlling for therapeutic intervention and time to treatment in the model. Results: A total of 363 patient records met inclusion criteria; 223 had early improvement and 140 did not. Patients were aged 71.74±15.65yr and 52.1% were female. There were eight potential predictors identified and included in the regression analysis. Higher blood pressure [odds ratio (OR)=0.991; 95% confidence interval (CI)=0.98, 1.00; P=.02], and statin use (OR=0.276; 95% CI=0.16, 0.47; P<.001) were associated with a decreased likelihood of early improvement. Conclusion: Our findings indicate that patients who are taking statins and/or have high blood pressure have a decreased likelihood of having an early improvement following stroke treatment. Clinicians should consider these factors when putting together treatment plans for ischemic stroke patients. The association between statin use as well as systolic blood pressure and improvement after stroke treatment should be further examined in a randomized controlled trial.
Introduction Arteriovenous malformations (AVM) of the head and neck are vascular malformations composed of a cluster of connecting arteries and veins that form a central nidus without an intervening capillary network1. They make up 1.5% of vascular malformations and more than 90% of AVMs are located intracranially1. Extracranial AVMs are predominantly located in the head and neck and can manifest with pain, ulcerations, fatal hemorrhage, airway compromise, and cosmetic aberrations1,2. Methods We present a case of a 21 year old female with a medical history of multiple suspected neck hemangiomas status post microsurgical and laser resections, with a surrounding port wine stain, who presented to the hospital with growth of one of her posterior neck hemangiomas during and after pregnancy. In the postpartum period she reported increasing neck pain and persistent bleeding from the site. Initially, she was hemodynamically stable and her neurologic exam did not show any focal deficits. She underwent computed tomography angiogram of her neck which showed an extensive dorsal neck AVM with multiple arterial supplies frombranches of the bilateral subclavian, vertebral, and external carotid arteries.Her lesion continued to bleed with a precipitous drop in hemoglobin requiring blood transfusions. Subsequently, she underwent urgentpercutaneousN‐butyl‐2‐cyanoacrylate (n‐BCA) embolizationand endovascular onyx embolization of a left thyrocervical trunk branch.The procedure was completed without complications. Months later, she developed skin exfoliation and underwent successful elective embolization involving vertebral artery branches. This, to reduce profuse venous shunting in the paravertebral venous plexus, avoiding long term spinal cord injury. Results The management of complex head and neck AVMs is both challenging and complex. They may pose significant bleeding risk and can become infiltrative within surrounding tissue3. AVMs may be classified as either focal or diffuse. Focal lesions may be curable with resection, whereas diffuse lesions pose a significant challenge, with relapse in 90% of cases3. Head and neck AVMs require expert management and a multidisciplinary approach. The team may consist of neurosurgery, neuro‐endovascular,plastic surgery, and dermatology services. Treatment options include medical management, surgical resection, endovascular and percutaneous embolization. Percutaenous n‐BCA embolization is employed to prevent hemorrhage during surgical resection, or stabilization in acute hemorrhage4,5. This holds especially true when an endovascular approach is difficult; typically due to tortuous vasculature5. Treatment may require a staged target approach, with endovascular or percutaneous embolization prior to surgical excision. Conclusions This case highlights the complexities of AVM management and the multidisciplinary approach necessary, to provide optimal care. In this case, we believe that pregnancy could have contributed to the overall change in aggressive nature of the AVM. The patient underwent emergent percutaneous and endovascular embolization to prevent life threatening hemorrhage followed by palliative embolization to avoid long term cervical spinal cord injury due to venous hypertension.
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