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Journal of Clinical Medicine May 2024Coronary artery vasospasm plays a crucial role in the prevalence of unstable angina. Despite common misdiagnosis, there is limited evidence on this topic. Here, we...
Coronary artery vasospasm plays a crucial role in the prevalence of unstable angina. Despite common misdiagnosis, there is limited evidence on this topic. Here, we present a rare case of unstable vasospastic angina in a female with severe thyrotoxicosis. : A 62-year-old female patient was admitted to the cardiac intensive care unit due to crushing chest pain at rest. The patient exhibited ischemic changes on the ECG with a normal troponin I level. Recurrent chest pain prompted urgent coronary angiography, revealing generalized vasospasm of all coronary artery branches including the left main coronary artery. Intracoronary nitroglycerin injection partially alleviated the vasospasm; however, there was a persistent stenosis in the left main artery. Subsequent intravascular ultrasound demonstrated an anatomically normal left main artery. Post-procedure, laboratory tests revealed undetectable levels of thyroid-stimulating hormone and thyroid hormones above the detectable level. The patient was initiated on methimazole and discharged symptom-free, expecting a good prognosis under conservative management. : Clinically significant coronary vasospasm triggered by thyrotoxicosis remains a rarity in clinical practice, often posing diagnostic challenges. This case emphasizes the significance of intracoronary nitroglycerin and intravascular ultrasound in discerning the etiology of coronary lesions seen on angiography. We advocate for these techniques to optimize invasive coronary artery diagnostics, enabling the selection of the appropriate treatment strategies and improving long-term prognosis.
PubMed: 38892840
DOI: 10.3390/jcm13113130 -
BMC Pulmonary Medicine Jun 2024In the general intensive care unit (ICU) women receive invasive mechanical ventilation (IMV) less frequently than men. We investigated whether sex differences in the use...
BACKGROUND
In the general intensive care unit (ICU) women receive invasive mechanical ventilation (IMV) less frequently than men. We investigated whether sex differences in the use of IMV also exist in the neurocritical care unit (NCCU), where patients are intubated not only due to respiratory failure but also due to neurological impairment.
METHODS
This retrospective single-centre study included adults admitted to the NCCU of the University Hospital Zurich between January 2018 and August 2021 with neurological or neurosurgical main diagnosis. We collected data on demographics, intubation, re-intubation, tracheotomy, and duration of IMV or other forms of respiratory support from the Swiss ICU registry or the medical records. A descriptive statistics was performed. Baseline and outcome characteristics were compared by sex in the whole population and in subgroup analysis.
RESULTS
Overall, 963 patients were included. No differences between sexes in the use and duration of IMV, frequency of emergency or planned intubations, tracheostomy were found. The duration of oxygen support was longer in women (men 2 [2, 4] vs. women 3 [1, 6] days, p = 0.018), who were more often admitted due to subarachnoid hemorrhage (SAH). No difference could be found after correction for age, diagnosis of admission and severity of disease.
CONCLUSION
In this NCCU population and differently from the general ICU population, we found no difference by sex in the frequency and duration of IMV, intubation, reintubation, tracheotomy and non-invasive ventilation support. These results suggest that the differences in provision of care by sex reported in the general ICU population may be diagnosis-dependent. The difference in duration of oxygen supplementation observed in our population can be explained by the higher prevalence of SAH in women, where we aim for higher oxygenation targets due to the specific risk of vasospasm.
Topics: Humans; Female; Retrospective Studies; Male; Respiration, Artificial; Middle Aged; Aged; Sex Factors; Switzerland; Intensive Care Units; Critical Care; Adult; Nervous System Diseases; Aged, 80 and over; Intubation, Intratracheal; Subarachnoid Hemorrhage; Respiratory Insufficiency
PubMed: 38890713
DOI: 10.1186/s12890-024-03094-7 -
JAMA Cardiology Jun 2024Vasospastic angina (VSA) is vasospasm of the coronary artery and is particularly prevalent in East Asian populations. However, the specific genetic architecture for VSA...
IMPORTANCE
Vasospastic angina (VSA) is vasospasm of the coronary artery and is particularly prevalent in East Asian populations. However, the specific genetic architecture for VSA at genome-wide levels is not fully understood.
OBJECTIVE
To identify genetic factors associated with VSA.
DESIGN, SETTING, AND PARTICIPANTS
This was a case-control genome-wide association study of VSA. Data from Biobank Japan (BBJ; enrolled patients from 2002-2008 and 2013-2018) were used, and controls without coronary artery disease (CAD) were enrolled. Patients from the BBJ were genotyped using arrays or a set of arrays. Patients recruited between 2002 and 2005 were classified within the first dataset, and those recruited between 2006 and 2008 were classified within the second dataset. To replicate the genome-wide association study in the first and second datasets, VSA cases and control samples from the latest patients in the BBJ recruited between 2013 and 2018 were analyzed in a third dataset.
EXPOSURES
Single-nucleotide variants associated with VSA.
MAIN OUTCOMES AND MEASURES
Cases with VSA and controls without CAD.
RESULTS
A total of 5720 cases (mean [SD] age, 67 [10] years; 3672 male [64.2%]) and 153 864 controls (mean [SD] age, 62 [15] years; 77 362 male [50.3%]) in 3 datasets were included in this study. The variants at the RNF213 locus showed the strongest association with VSA across the 3 datasets (odds ratio [OR], 2.34; 95% CI, 1.99-2.74; P = 4.4 × 10-25). Additionally, rs112735431, an Asian-specific rare deleterious variant (p.Arg4810Lys) experimentally shown to be associated with reduced angiogenesis and a well-known causal risk for Moyamoya disease was the most promising candidate for a causal variant explaining the association. The effect size of rs112735431 on VSA was distinct from that of other CADs. Furthermore, homozygous carriers of rs112735431 showed an association with VSA characterized by a large effect estimate (OR, 18.34; 95% CI, 5.15-65.22; P = 7.0 × 10-6), deviating from the additive model (OR, 4.35; 95% CI, 1.18-16.05; P = .03). Stratified analyses revealed that rs112735431 exhibited a stronger association in males (χ21 = 7.24; P = .007) and a younger age group (OR, 3.06; 95% CI, 2.24-4.19), corresponding to the epidemiologic features of VSA. In the registry, carriers without CAD of the risk allele rs112735431 had a strikingly high mortality rate due to acute myocardial infarction during the follow-up period (hazard ratio, 2.71; 95% CI, 1.57-4.65; P = 3.3 × 10-4). As previously reported, a possible overlap between VSA and Moyamoya disease was not found.
CONCLUSIONS AND RELEVANCE
Results of this study suggest that vascular cell dysfunction mediated by variants in the RNF213 locus may promote coronary vasospasm, and the presence of the risk allele could serve as a predictive factor for the prognosis.
PubMed: 38888930
DOI: 10.1001/jamacardio.2024.1483 -
American Journal of Translational... 2024Intracranial aneurysms (IA) can induce increased intracranial pressure, headache, and the development of nausea and vomiting if not treated in time, and failure to... (Review)
Review
Intracranial aneurysms (IA) can induce increased intracranial pressure, headache, and the development of nausea and vomiting if not treated in time, and failure to receive timely diagnosis and treatment can lead to disability or death. However, the efficacy and prognostic value of craniotomy and endovascular embolization in patients with IA remains a controversial topic. This meta-analysis systematically evaluated the efficacy of endovascular coiling versus cranial aneurysm clamping on the immediate postoperative outcome and prognosis of patients with IA. PubMed, EMBASE, and the Cochrane Library databases were searched for retrieval of relevant references. Literature was screened according to pre-defined inclusion and exclusion criteria, and data were extracted and assessed for quality. A total of 10 studies, including 2,654 cases, were included in the analysis. Among them, 1,313 cases underwent craniotomy clipping surgery (clip group), and 1,341 cases underwent endovascular coiling (coil group). The quality of the studies in 8 articles evaluated using the Newcastle-Ottawa Scale (NOS) was ≥6. Meta-analysis was conducted using Rev Man 5.3 and Stata 17 software. The results of meta-analysis showed that no significant difference in complete occlusion rate [=1.76, 95% (0.78, 3.96), =0.17] when comparing the clip and coil group. Compared to the clip group, the coil group had a better clinical short-term outcome [=1.55, 95% (1.05, 2.27), =0.03], but an increased rate of postoperative residual or recurrence [=0.40, 95% (0.17, 0.91), =0.03]. In addition, there were no significance differences identified in terms of complications, including the rates of postoperative rebleeding [=1.60, 95% (0.97, 2.63), =0.07], ischemic stroke [=1.12, 95% (0.45, 2.79), =0.81], and cerebral vasospasm [=0.90, 95% (0.13, 6.03), =0.91]. Subsequently, we conducted experimental sequence analysis for each indicator, and the results were consistent with the results of meta-analysis. According to the recent clinical prognosis, a funnel plot was constructed, showing significant asymmetry on both sides, indicating some publication bias. However, the results of Begg's test with =0.734 and Egger's test with P=0.633 suggest no significant publication bias. In general, endovascular coiling and microsurgical clipping appear to be equally effective in achieving vascular occlusion. Endovascular coiling may be more effective in improving the short-term clinical outcomes for patients. However, this approach may increase the rate of postoperative residual issue or recurrence.
PubMed: 38883342
DOI: 10.62347/PCLZ5157 -
Turkish Neurosurgery Jan 2024Subarachnoid haemorrhage (SAH) often leads to shunt-dependent hydrocephalus (SDH). This study compares microsurgical clipping and endovascular therapy (EVT) for managing...
AIM
Subarachnoid haemorrhage (SAH) often leads to shunt-dependent hydrocephalus (SDH). This study compares microsurgical clipping and endovascular therapy (EVT) for managing SDH in SAH patients with hydrocephalus.
MATERIAL AND METHODS
A retrospective study conducted from July 2018 to December 2022 included 67 SAH patients with acute hydrocephalus. Data on demographic, clinical, and radiological parameters, such as age, gender, GCS scores, Hunt and Hess grade, Fischer score, EVD duration, complications, Omaya reservoir placement, CSF drainage, and outcomes, were collected. Statistical analyses, including univariate analysis and stepwise logistic regression, identified significant risk factors for shunt dependence.
RESULTS
Among the 67 patients, 33 underwent microsurgical clipping, and 34 received EVT. Spasmolysis reduced shunt dependency, while early EVD placement correlated with reduced shunt dependence (p = 0.002). The Omaya reservoir helped manage meningitis but was associated with shunt dependency (p = 0.04). Perioperative infarct was a significant risk factor for shunt dependence on multiple logistic regression analysis (p = 0.05). No significant difference was observed in patient outcomes between the two treatment groups. However, EVT patients had shorter ICU and hospital stays.
CONCLUSION
This study underscores that clinical vasospasm management through spasmolysis may reduce shunt dependency. Overall, both microsurgical clipping and EVT offer similar long-term outcomes and efficacy to prevent shunt dependence, but EVT has the advantage of shorter hospital stays. These findings provide crucial insights for clinical decision-making and patient care in SDH following SAH.
PubMed: 38874254
DOI: 10.5137/1019-5149.JTN.45739-23.1 -
Turkish Neurosurgery Jul 2023To determine the risk factors affecting the mortality rate and outcomes of patients with subarachnoid hemorrhage (SAH).
AIM
To determine the risk factors affecting the mortality rate and outcomes of patients with subarachnoid hemorrhage (SAH).
MATERIAL AND METHODS
The records of patients who underwent aneurysm treatment and intensive care unit (ICU) follow-up in our hospital between 2013-2021 were reviewed retrospectively. Demographics of the patients, aneurysm characteristics, complications in the ICU, the Hunt Hess score, Glasgow Coma Scale (GCS), Acute Physiologic Assessment and Chronic Health Evaluation II score (APACHE II), sepsis status, and mechanical ventilation (MV) needed during ICU admission were collected. The generalized linear mixed modeling method was used to determine independent risk factors affecting mortality Results: The records of 91 patients who met the inclusion criteria were analyzed. The age of the patients ranged from 21 to 86 years, and the female-to-male ratio was 6 / 7, with a mean age of 49.9 ± 13.06 years. The aneurysm treatment modality was surgical in 79 patients (86.8%) and endovascular in 12 patients 13.2%. The length of the ICU stay was mean 10.96 ± 13.66 days. While 64.8% (n = 59) of the patients were discharged, 7.7% (n = 7) were referred to palliative care units, and 25% (n = 25) died. A one-unit increase in the APACHE II score was determined to increase the risk of vasospasm 1.154 times (p 0.001). Analysis showed that a one-day increase in the MV day increased the mortality risk 1.838 times (p 0.001), and vasospasm increased the mortality risk 32.151 times (p = 0.004) Conclusion: The length of hospital stay, the day of MV, and the presence of vasospasm were determined as independent risk factors affecting mortality. Early diagnosis and rapid treatment of vasospasm, which increases mortality during ICU follow-up, positively impact patient outcomes.
PubMed: 38874239
DOI: 10.5137/1019-5149.JTN.43486-23.5 -
Neurointervention Jul 2024Delayed ischemic stroke associated with intractable vasospasm after clipping of unruptured intracranial aneurysms (UIAs) has been rarely reported. We report a patient...
Delayed ischemic stroke associated with intractable vasospasm after clipping of unruptured intracranial aneurysms (UIAs) has been rarely reported. We report a patient with delayed ischemic stroke associated with intractable vasospasm following UIA clipping. A middle-aged female underwent surgery for unruptured middle cerebral artery bifurcation aneurysms. The patient tolerated the neurosurgical procedure well. Seven days postoperatively, the headache was unbearable; a postcraniotomy headache persisted and abruptly presented with global aphasia and right-sided hemiplegia after a nap. Emergency digital subtraction angiography showed severe luminal narrowing with segmental vasoconstriction, consistent with severe vasospasm. The patient's neurological deficit improved after chemical angioplasty. Neurosurgeons should pay close attention to this treatable/preventive entity after neurological deterioration following UIA clipping, even in patients without subarachnoid hemorrhage.
PubMed: 38871004
DOI: 10.5469/neuroint.2024.00150 -
Frontiers in Neurology 2024
PubMed: 38867887
DOI: 10.3389/fneur.2024.1419224 -
Acute and Critical Care May 2024This study evaluates the effectiveness of Therapeutic Hypothermia (TH) in treating poor-grade aneurysmal subarachnoid hemorrhage (SAH), focusing on functional outcomes,...
BACKGROUND
This study evaluates the effectiveness of Therapeutic Hypothermia (TH) in treating poor-grade aneurysmal subarachnoid hemorrhage (SAH), focusing on functional outcomes, mortality, and complications such as vasospasm, delayed cerebral ischemia (DCI), and hydrocephalus.
METHODS
Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a comprehensive literature search was conducted across multiple databases, including Medline, Embase, and Cochrane Central, up to November 2023. Nine studies involving 368 patients were selected based on eligibility criteria focusing on TH in poor-grade SAH patients. Data extraction, bias assessment, and evidence certainty were systematically performed.
RESULTS
The primary analysis of unfavorable outcomes in 271 participants showed no significant difference between the TH and standard care groups (risk ratio [RR], 0.87). However, a significant reduction in vasospasm was observed in the TH group (RR, 0.63) among 174 participants. No significant differences were found in DCI, hydrocephalus, and mortality rates in the respective participant groups.
CONCLUSIONS
TH did not significantly improve primary unfavorable outcomes in poor-grade SAH patients. However, the reduction in vasospasm rates indicates potential specific benefits. The absence of significant findings in other secondary outcomes and mortality highlights the need for further research to better understand TH's role in treating this patient population.
PubMed: 38863359
DOI: 10.4266/acc.2024.00612