Citations

Background. Aortic dissection (AD) is a rare but serious medical emergency where the aorta’s inner layer tears. Females are less likely to develop it than males, and AD cases with unusual symptoms can be hard to diagnose. Diagnosing AD can be further complicated as its symptoms and electrocardiogram (ECG) changes can mimic acute coronary syndrome, and it is challenging to distinguish it without risk factors. Case Report. This case report describes a 60-year-old female patient who presented with unusual symptoms, including pain in her chest, neck, left arm, and lower extremities. An electrocardiogram (ECG) revealed ST elevation in leads aVR and V1, as well as severe ST depression and T wave inversion in the inferior and lateral leads, which can mimic acute coronary syndrome. Despite initial treatment with nitroglycerin, the patient’s pain worsened, and a CT angiography revealed type A aortic dissection extending from the aortic root to the right external iliac artery. Immediate surgery was recommended, which significantly improved the patient’s condition. Conclusions. Be aware of aortic dissection and its symptoms, even if there are no risk factors or recognizable symptoms. Consider aortic dissection as a potential diagnosis if ECG changes are present. Ongoing education can help decrease mortality and increase awareness.

Background Remarkable interest is rising around middle meningeal artery embolization (MMAE) as an emerging alternative therapy for chronic subdural hematoma (cSDH). The study aims to highlight a large center experience and the variables associated with treatment failure and build experimental machine learning (ML) models for outcome prediction. Material and Methods A 2-year experience in MMAE for managing patients with chronic subdural hematoma was analyzed. Descriptive statistical analysis was conducted using imaging and clinical features of the patients and cSDH, which were subsequently used to build predictive models for the procedure outcome. The modeling evaluation metrics were the area under the ROC curve and F1-score. Results A total of 100 cSDH of 76 patients who underwent MMAE were included with an average follow-up of 6 months. The intervention had a per procedure success rate of 92%. Thrombocytopenia had a highly significant association with treatment failure. Two patients suffered a complication related to the procedure. The best performing machine learning models in predicting MMAE failure achieved an ROC-AUC of 70%, and an F1-score of 67%, including all patients with or without surgical intervention prior to embolization, and an ROC-AUC of 82% and an F1-score of 69% when only patients who underwent upfront MMAE were included. Conclusion MMAE is a safe and minimally invasive procedure with great potential in transforming the management of cSDH and reducing the risk of surgical complications in selected patients. An ML approach with larger sample size might help better predict outcomes and highlight important predictors following MMAE in patients with cSDH.

This Viewpoint discusses how neural antibody–based diagnostic criteria for autoimmune encephalitis would complement the syndrome-based diagnostic algorithm to improve sensitivity while maintaining high specificity.

Significance Statement There is no standardized desensitization regimen for kidney transplant candidates. CD38, expressed by plasma cells, could be targeted for desensitization to deplete plasma cells producing alloantibodies and donor-specific antibodies. Few studies and case reports are available regarding the use of CD38 antibodies for desensitization in patients awaiting kidney transplant. This study shows that isatuximab, a CD38-targeting therapy, was well tolerated in kidney transplant candidates, with a durable decrease in anti-HLA antibodies and partial desensitization activity. The short treatment period and long follow-up of this study allowed for the understanding of the mechanism and timing for any antibody rebound. Isatuximab could be further investigated as an option for adjunct therapy to existing desensitization for patients on the kidney transplant waitlist. Background Patients with calculated panel reactive antibody (cPRA) ≥80.00%, particularly those with cPRA ≥99.90%, are considered highly sensitized and underserved by the Kidney Allocation System. Desensitization removes circulating reactive antibodies and/or suppresses antibody production to increase the chances of a negative crossmatch. CD38 is expressed highly on plasma cells, thus is a potential target for desensitization. Methods This was an open-label single-arm phase 1/2 study investigating the safety, pharmacokinetics, and preliminary efficacy of isatuximab in patients awaiting kidney transplantation. There were two cohorts, cohorts A and B, which enrolled cPRA ≥99.90% and 80.00% to <99.90%, respectively. Results Twenty-three patients (12 cohort A, 11 cohort B) received isatuximab 10 mg/kg weekly for 4 weeks then every 2 weeks for 8 weeks. Isatuximab was well tolerated with pharmacokinetic and pharmacodynamic profiles that indicated similar exposure to multiple myeloma trials. It resulted in decreases in CD38 + plasmablasts, plasma cells, and NK cells and significant reductions in HLA-specific IgG-producing memory B cells. Overall response rate, on the basis of a predefined composite desensitization end point, was 83.3% and 81.8% in cohorts A and B. Most responders had decreases in anti-HLA antibodies that were maintained for 26 weeks after the last dose. Overall, cPRA values were minimally affected, however, with only 9/23 patients (39%) having cPRA decreases to target levels. By study cutoff (median follow-up of 68 weeks), six patients received transplant offers, of which four were accepted. Conclusions In this open-label trial, isatuximab was well tolerated and resulted in a durable decrease in anti-HLA antibodies with partial desensitization activity. Clinical Trial registration number NCT04294459.

CT myelography has been traditionally used to evaluate post-operative paraspinal fluid collections to discern CSF leaking into a pseudomeningocele versus a contained seroma. Rather than performing a lumbar puncture and injecting intrathecal contrast for myelography, we present the first report of direct contrast injection into a post-operative paraspinal pseudomeningocele for CSF leak confirmation and localization. This is a simple procedure that has several advantages over a conventional CT myelogram for the evaluation of post-operative paraspinal fluid collections.

Objectives The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. Methods Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi‐institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. Results There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases ( n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases ( p = 0.002); postoperative diet was not different between open and endoscopic ( p = 0.26). Conclusions Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. Level of Evidence Level III Laryngoscope , 134:2678–2683, 2024

Background The comparison of mechanical thrombectomy (MT) outcomes between patients with the hyperdense middle cerebral artery sign (HMCAS) and non-HMCAS is important to evaluate the impact of this radiological finding on treatment efficacy. This meta-analysis aimed to assess the association between HMCAS and clinical outcomes in patients undergoing thrombectomy, comparing the outcomes over non-HMCAS. Methods A systematic literature search was conducted in PubMed, Ovid Embase, Google Scholar, and Cochrane Library to identify studies on MT outcomes for M1 occlusions of HMCAS over non-HMCAS. Inclusion criteria encompassed modified Rankin Scale (mRS) score, mortality, symptomatic intracranial hemorrhage (sICH), and successful recanalization. Using R software version 4.1.2, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI). Results The meta-analysis was performed for 5 studies with 724 patients. There was no association found between presence of HMCAS and achieving mRS 0–2 (OR = 0.65, 95% CI: 0.29–1.47; p = .544). Mortality analysis also showed no significant association with presence of HMCAS (OR = 0.78, 95% CI: 0.37–1.65; p = .520). No significant difference in sICH risk (OR = 1.54, 95% CI: 0.24–9.66; p = .646) was found between groups. Recanalization analysis showed a non-significant positive association (OR = 1.23, 95% CI: 0.67–2.28; p = .501). Heterogeneity was observed in all analyses. Conclusion Our findings showed that there is no statistically significant difference in mRS scores, mortality, sICH, and recanalization success rates between the HMCAS and non-HMCAS groups.

Background: There are few studies that examine relationships between cognitive function, illness perceptions, and medication adherence after heart transplantation, limiting the development of effective adherence-promoting interventions. Objective: The purpose of this study was to describe relationships between cognitive function, illness perceptions, and medication adherence among heart transplant recipients. Methods: A cross-sectional, observational design was used. Measures included the telephone-Montreal Cognitive Assessment (t-MoCA©), Patient Health Questionnaire-9, Brief Test of Adult Cognition by Telephone, Basel Assessment of Adherence to Immunosuppressive Medications Scale, and the Brief Illness Perceptions Questionnaire. Descriptive statistics, point-biserial correlations, Pearson’s correlations, and logistic regression were used to describe relationships. Results: Of the 35 participants (mean age: 61 years [SD: 10.3], 71.4% male, 71.4% white), 31.4% (n = 11) were classified as nonadherent to their immunosuppression medications. Higher immediate word recall, indicating better episodic memory (memory for autobiographical and recent events), and higher illness coherence scores were associated with not missing doses of medication. Higher t-MoCA© total scores, indicating normal cognitive function, and lower depression scores were associated with taking medications on time. More than 22% (n = 8) of participants scored less than 19 on the t-MoCA©, an indication of mild cognitive impairment. Conclusion: Cognitive impairment may be more common among heart transplant recipients than what is currently recognized, and specific domains of cognitive function were related to medication adherence after transplantation in this study. Future studies should include longitudinal evaluations of cognitive function, depression, and medication adherence. Consideration of these relationships is needed when designing adherence-promoting interventions for this population.

Objective Fluctuating sensorineural hearing loss (SNHL) has multiple etiologies, most commonly Ménière's disease (MD), recurrent sudden SNHL, and autoimmune inner ear disorders. Fluctuating SNHL has rarely been described as a symptom of spontaneous intracranial hypotension (SIH). Patient A 39-year-old previously healthy female presented with “Ménière's like” symptoms responsive to steroid treatment, which worsened during the day and improved in the supine position. Conservative treatment for MD consisting of low salt and caffeine diet and betahistine medication yielded no improvement. Secondary revision of brain imaging scans showed signs indicative of SIH, and a spinal cerebrospinal fluid leak was ultimately found and treated by a novel technique of transvenous fistula embolization by means of Onyx® glue, leading to gradual clinical improvement and near-complete resolution of symptoms. Conclusion SIH should be considered as part of the differential diagnosis of fluctuating SNHL. Clinical and radiological features should be known and sought. We suspect that early diagnosis and treatment can lead to cure and prevent permanent auditory damage.