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The Use of Prasugrel and Ticagrelor in Pipeline Flow Diversion 普拉格雷与替格瑞洛在管道导流中的应用

JHN Journal

Pub Date : 1900-01-01 DOI: 10.29046/JHNJ.013.2.005

E. Atallah, H. Saad, K. Bekelis, N. Chalouhi, S. Tjoumakaris, D. Hasan, Gorge Eller, D. Stidd, Md Mba Facs Faha Robert H. Rosenwasswer, P. Jabbour

Background: Despite the routine clopidogrel/aspirin anti-platelet therapy, complications like thromboembolism, continue to be encountered with PED. We studied the safety and the efficacy of prasugrel in the management of clopidogrel non-responders treated for intracranial aneurysms. Methods: 437 consecutive neurosurgery patients were identified between January 2011 and May 2016. Patients allergic or having <30% platelet-inhibition with a daily 75mg of clopidogrel were dispensed 10mg of prasugrel daily (n=20) or 90mg of ticagrelor twice daily (n=2). The average follow-up was 15.8 months (SD=12.4 months). Patient clinical well being was evaluated with the modified Rankin Scale (mRS) registered before the discharge and at each follow-up visit. To control confounding we used multivariable mixed-effects logistic regression and propensity score conditioning. Results: 26 of 437(5.9%) patients (mean of age 56.3 years; 62 women [14,2%]) presented with a sub-arachnoid hemorrhage. 1 patient was allergic to clopidogrel and prasugrel simultaneously. All the patients receiving prasugrel (n=22) had a mRS<2 on their latest follow-up visit (mean=0.67; SD=1.15). In a multivariate analysis, clopidogrel did not affect the mRS on last follow-up, p=0.14. Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (odds ratio[OR], 0.17; 95%Confidence Interval [CI95%], 0.01-2.70; p=0.21) neither with an increased thromboembolic accident rate (OR, 0.46; CI95%, 0.12-1.67; p=0.36) nor with an increased hemorrhagic event rate (OR, 0.39; CI95%,0.91-1.64; p=0.20). None of the patients receiving prasugrel deceased or had a long-term recurrence nor a hemorrhagic event, only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. 3 patients on clopidogrel passed during the study: (2) from acute SAH and (1) from intra-parenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR, 2.18; CI95%,0.11-43.27; p=0.61). The same associations were present in propensity score adjusted models. Conclusion

背景:尽管常规的氯吡格雷/阿司匹林抗血小板治疗，血栓栓塞等并发症，仍然会遇到PED。我们研究了普拉格雷治疗氯吡格雷无反应颅内动脉瘤的安全性和有效性。方法:选取2011年1月至2016年5月连续进行神经外科手术的患者437例。对每日75mg氯吡格雷过敏或血小板抑制<30%的患者，每日给予10mg普拉格雷(n=20)或90mg替格瑞洛，每日两次(n=2)。平均随访15.8个月(SD=12.4个月)。在出院前和每次随访时采用改良的兰金量表(mRS)评估患者的临床健康状况。为了控制混杂，我们使用了多变量混合效应逻辑回归和倾向评分条件反射。结果:437例患者中26例(5.9%)，平均年龄56.3岁;62名女性[14.2%]表现为蛛网膜下腔出血。1例同时对氯吡格雷和普拉格雷过敏。所有接受普拉格雷治疗的患者(n=22)最近一次随访时mRS<2(平均=0.67;SD = 1.15)。在多变量分析中，氯吡格雷对最后一次随访的mRS没有影响，p=0.14。多变量logistic回归显示氯吡格雷与长期复发率增加无关(优势比[OR]， 0.17;95%置信区间[CI95%]， 0.01-2.70;p=0.21)，也没有增加血栓栓塞事故率(OR, 0.46;CI95%, 0.12 - -1.67;p=0.36)，与出血事件发生率增加无关(OR, 0.39;CI95%, 0.91 - -1.64;p = 0.20)。接受普拉格雷治疗的患者均无死亡或长期复发或出血事件，只有1例患者在血栓栓塞事件后出现轻度失语。3例服用氯吡格雷的患者在研究期间死亡:(2)急性SAH和(1)实质内出血。氯吡格雷与死亡率增加无关(OR, 2.18;CI95%, 0.11 - -43.27;p = 0.61)。同样的关联也存在于倾向得分调整模型中。结论

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引用次数: 3

Catastrophic Failure of Conservatively Treated Odontoid Fracture in the Elderly 老年齿状突骨折保守治疗的灾难性失败

JHN Journal

Pub Date : 1900-01-01 DOI: 10.29046/jhnj.007.2.004

J. Harrop, J. Ratliff, Sonia Teufack, Jeffrey A Rihn, T. Albert, A. Vaccaro

Spine ABSTRACT Background: Odontoid fractures are the most common type of axis injury. Elderly patients can develop odontoid fractures after minor trauma with hyperextension injuries. The optimal treatment of type II fractures is controversial.

背景:齿状突骨折是最常见的脊柱损伤类型。老年患者在轻度创伤伴过伸性损伤后可发生齿状突骨折。II型骨折的最佳治疗方法存在争议。

引用次数: 0

Endovascular Management of Acute Proximal Internal Carotid Artery Occlusion: the JHN Experience 急性颈内动脉近端闭塞的血管内治疗:JHN的经验

JHN Journal

Pub Date : 1900-01-01 DOI: 10.29046/JHNJ.006.1.001

R. Dalyai, Vismay Thakkar, Thana Theofanis, P. Jabbour, L. Gonzalez, R. Rosenwasser, S. Tjoumakaris

Introduction Stroke is a major cause of serious, long-term disability and the third leading cause of death, accounting for one in every 18 deaths in the United States. Approximately 800,000 strokes occur in the United States each year, leading to an estimated cost of 74 billion dollars in 2010. The severity and prognosis of patients with an acute internal carotid artery (ICA) occlusion is extremely poor. Studies have shown that 16-55% of patients will die from complications related to the infarction, 40-69% will be left with a profound deficit, and only 2-12% will make a reasonable recovery2. In young patients, internal carotid artery dissections presenting as an acute occlusion or thrombotic clot are responsible for approximately 14-20% of ischemic strokes.1 Results from trials utilizing emergent open surgical carotid recanalization or IVtPA have not been encouraging2,3. Recently, there have been small case reports of endovascular stent-assisted thrombolysis as a treatment option for patients with carotid occlusions and near occlusions.4-8

中风是导致严重、长期残疾的主要原因，也是导致死亡的第三大原因，在美国，每18例死亡中就有一例中风。在美国，每年大约有80万人中风，据估计，2010年的成本为740亿美元。急性颈内动脉(ICA)闭塞患者的严重程度和预后极差。研究表明，16-55%的患者会死于与梗死相关的并发症，40-69%的患者会留下严重的缺陷，只有2-12%的患者会得到合理的恢复。在年轻患者中，颈内动脉剥离表现为急性闭塞或血栓形成，约占缺血性卒中的14-20%使用紧急开放手术颈动脉再通术或IVtPA的试验结果并不令人鼓舞2,3。最近，有小病例报道血管内支架辅助溶栓作为颈动脉闭塞和近闭塞患者的治疗选择

引用次数: 1

Cervical Intramedullary Ganglioma 颈髓内神经节瘤

JHN Journal

Pub Date : 1900-01-01 DOI: 10.29046/JHNJ.004.2.006

Harminder Singh, A. Sharan, John K. Ratliff

A 48 year male presented to the ER with severe headaches which were episodic in nature and which had been present for several weeks. Patient had a history of traumatic head injury (TBI) several years prior. Otherwise, he was in good health with no significant past medical or surgical history. On physical exam, patient was oriented x 3 with an intact cranial nerve exam. He had significant upper and lower extremity spasticity with mild hand intrinsic weakness. His motor exam was otherwise unremarkable. His gait was very spastic. He had sustained lower extremity clonus, upgoing toes, and increased tone in the upper and lower extremities. His sensation was intact to light touch, pinprick, proprioception and temperature.

一名48岁男性，因严重的间歇性头痛而就诊于急诊室，头痛已持续数周。患者有创伤性脑损伤(TBI)的历史几年前。除此之外，他身体健康，没有重大的既往病史或手术史。体格检查时，患者定向x 3，颅神经检查完整。他有明显的上肢和下肢痉挛，手有轻微的内在无力。他的运动检查在其他方面没有什么特别之处。他的步态很痉挛。患者有持续的下肢斜视，脚趾上翘，上肢和下肢张力增高。轻触、针刺、本体感觉和温度等感觉完好。

引用次数: 0

Commentary: Tele-ICU Development and Application 点评:远程icu的发展与应用

JHN Journal

Pub Date : 1900-01-01 DOI: 10.29046/jhnj.012.1.005

Annalise DeJesus, M. Athar

引用次数: 1

Incidence and Prevalence of Deep Vein Thrombosis Among Neurocritical Intensive Care Unit Patients 神经危重重症监护室患者深静脉血栓形成的发生率和患病率

JHN Journal

Pub Date : 1900-01-01 DOI: 10.29046/jhnj.012.1.009

A. Dolla, M. Vibbert

引用次数: 0

Understanding Neurosurgery Through Experimental and Computer Models 通过实验和计算机模型理解神经外科

JHN Journal

Pub Date : 1900-01-01 DOI: 10.29046/JHNJ.004.1.003

C. Randazzo, A. Pandey, E. Veznedaroglu

引用次数: 0

Farber Hospitalist Service – Last 5 Years of a Service Dedicated to the Medical Management of Neurosurgical Patients 法伯医院服务-过去5年致力于神经外科患者的医疗管理服务

JHN Journal

Pub Date : 1900-01-01 DOI: 10.29046/jhnj.015.1.001

René Daniel, C. Harrop

引用次数: 0

Air in the L4-5 Epidural Space Appearing as Disc Herniation L4-5硬膜外间隙的空气表现为椎间盘突出

JHN Journal

Pub Date : 1900-01-01 DOI: 10.29046/JHNJ.007.2.005

Angud Mehdi, P. Amenta, J. Harrop

Disc degeneration or spondylosis, when severe, may lead to the development of a vacuum phenomenon in the spine caused by gas production. This gas is visible on plain X-ray films, and is even more clearly apparent on computed tomography (CT) imaging, but may not be apparent on MRI. We present the case of a 69 year-old female with MRI appearing to exhibit a significant L4-5 disc herniation that, on further imaging with CT, was determined to be air in the epidural space without disc herniation. The importance of correlating clinical presentation, neurologic examination, and multimodal imaging is stressed. CASE REPORT History and Presentation: A 69-year old female presented with musculoskeletal low back pain extending into her hips and thighs, in a non-radicular manner. She was neurologically intact and had received physical therapy and epidural steroid injections without symptomatic relief. Imaging: Anterior-posterior and lateral plain films of the thoracic and lumbar spine were unremarkable. T2-weighted MRI images showed marked loss of disc height at L4-L5, with a large central disc herniation and an “extruded disc fragment” resulting in left greater than right foraminal stenosis (Figures 1). A subsequent spine CT, however, revealed air in the L4-L5 disc space consistent with vacuum disc phenomenon which was chronic and appeared on abdominal ct scans done several years prior (Figure 2). DISCUSSION Gas production or “vacuum phenomenon” in the intervertebral space may be a byproduct of disc degeneration. Accumulated gas is composed of nitrogen and carbon dioxide and remains within the disc space.1,2 Gas may escape into the epidural space through a fissure in the annulus fibrosus. The vast majority of individuals with epidural gas are asymptomatic. Gas in the intervertebral disc space is a relatively common radiologic finding and is found in approxi- mately 46% of CT examinations.3 Air in the disc can be seen as a signal void on T1and T2-weighted MRI, however, CT is more sensitive for identifying air in the disc or epidural space. On T2-weighted MRI, disc herniations appear as isoto hypointense material extending beyond the confines of the disc space. These findings are often associated with the loss of disc height at the level of the herniated disc.4,5 These very findings were observed in the T2-weighted imaging of our patient (Figures 1 and 2). Our patient presented with low back pain and no symptoms consistent with radiculopathy referable to L4-L5. Despite the findings seen on MRI, the CT clearly illustrated air in the L4-L5 disc space and left anterolateral portion of the epidural space (Figure 2). In light of the clinical presentation and CT findings, the MRI findings were deemed to be the result of epidural air and the patient was treated with conservative management. We present a case of contrasting imaging findings as an example of the importance of correlating clinical presentation, neurologic examination, and multimodal imaging in the treatm

当椎间盘退变或颈椎病严重时，可能导致脊柱出现真空现象，产生气体。这种气体在x射线平片上可见，在计算机断层扫描(CT)上更明显，但在MRI上可能不明显。我们报告一位69岁女性的病例，MRI表现为明显的L4-5椎间盘突出，进一步的CT成像确定为硬膜外腔空气，无椎间盘突出。强调了将临床表现、神经系统检查和多模态成像相关联的重要性。病例报告病史和表现:一名69岁女性，腰背部肌肉骨骼性疼痛延伸至臀部和大腿，呈非神经根性。她的神经系统完好，接受了物理治疗和硬膜外类固醇注射，但症状没有缓解。影像学:胸椎、腰椎前后侧位平片无明显异常。t2加权MRI图像显示L4-L5椎间盘高度明显下降，伴有较大的中央椎间盘突出和“椎间盘碎片突出”，导致左侧椎间孔狭窄大于右侧(图1)。然而，随后的脊柱CT显示，L4-L5椎间盘间隙显示空气，与几年前腹部ct扫描中出现的慢性真空椎间盘现象一致(图2)。讨论椎间隙气体产生或“真空现象”可能是椎间盘退变的副产物。积聚的气体由氮气和二氧化碳组成，并留在阀瓣空间内。1,2气体可通过纤维环的裂缝进入硬膜外间隙。绝大多数有硬膜外气体的人是无症状的。椎间盘间隙气体是一种相对常见的放射学表现，约占CT检查的46%椎间盘内的空气在t1和t2加权MRI上可视为信号空洞，而CT对椎间盘或硬膜外间隙内的空气识别更为敏感。在t2加权MRI上，椎间盘突出表现为等向低信号物质，超出了椎间盘间隙的范围。这些表现通常与椎间盘突出处的椎间盘高度下降有关。这些发现在患者的t2加权成像中被观察到(图1和2)。患者表现为腰痛，没有与L4-L5神经根病一致的症状。尽管MRI上有此表现，但CT清楚显示L4-L5椎间盘间隙和硬膜外间隙左前外侧有空气(图2)。结合临床表现和CT表现，认为MRI表现为硬膜外空气所致，并对患者进行保守治疗。我们提出一个对比成像结果的病例，作为临床表现、神经系统检查和多模态成像在背痛治疗中的重要性的一个例子。引用1。Ford LT, Gilula LA, Murphy WA, Gado M.真空腰椎间盘气体分析。J·J·伦琴诺。128年6月1977;(6):1056 - 1057。2. Yoshida H, Shinomiya K, Nakai O, Kurosa Y, Yamaura I.腰椎内气体引起的腰神经根压迫。报告三例病例。《脊椎》(费城出版社1976)。1997年2月1日;22(3):348-351。3.李建军，李建军，李建军，等。脊髓真空现象的CT诊断及临床意义。J计算机辅助系统。8月1982;6(4):671 - 676。4. vidman T, Battie MC, Gill K, Manninen H, Gibbons LE, Fisher LD.胸椎和腰椎的磁共振成像结果及其相关性。脊柱退变的发病机制。《脊椎》(费城出版社1976)。1995年4月15日;20(8):928-935。5. 桥本K, Akahori O, Kitano K, Nakajima K, Higashihara T, Kumasaka Y.腰椎间盘突出症的磁共振成像。与脊髓造影的比较。《脊椎》(费城出版社1976)。11月1990;15(11):1166 - 1169。图2轴位CT图像清晰显示低衰减信号，代表椎间盘内侧和左侧前外侧硬膜外腔内有空气。图1 (A) t2加权轴向MRI显示左侧前外侧硬膜外腔低信号区。最初，这被认为是椎间盘突出，后来根据CT评估修改为硬膜外腔偶然发现的空气。(B) t2加权矢状位MRI。一个

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引用次数: 2

Transient Paraplegia in a Patient with Bilateral Posterior Frontal Contusions and Traumatic Thoracic Aortic Dissection 双侧额后挫伤并发外伤性胸主动脉夹层的短暂性截瘫1例

JHN Journal

Pub Date : 1900-01-01 DOI: 10.29046/JHNJ.007.2.002

Sonia Teufack, P. Nguyen, Atul S. Rao, J. Jenoff, J. Harrop

Background: In the setting of multi-system traumas, the etiology and pathophysiology of neurologic injuries can be difficult to identify. Methods: A unique case of a pedestrian struck by a motor vehicle that presented with acute paraplegia after an endovascular stent placement for a traumatic thoracic aorta dissection. The patient had no significant motor function in the lower extremities, but full preservation of all sensory modalities. Initial admission computed tomography (CT) imaging was negative for intracranial trauma, but noted an acute cranial fracture; no spinal trauma was identified. Results: The patient had a lumbar drain placed to maximize spinal perfusion pressures and was immediately evaluated with magnetic resonance imaging (MRI) of the neural axis. Acute bilateral posterior frontal contusions were identified on brain imaging, which were not present on preprocedural CT head. No spinal cord injury or ischemia was seen on spinal imaging. The patient recovered and regained use of his lower extremities following a short rehab stay. Conclusion: In the setting of multi-system trauma, a high level of suspicion should exist for alternative etiologies of neurologic injuries. Thorough neurologic examinations and imaging assessments of the nervous system should be conducted to avoid misdiagnosis and improper management of occult injuries. This is the first reported case of acute paraplegia due to vertex trauma which may be a rare mechanism of injury and/or under-recognized. INTRODUCTION Trauma is the leading cause of mortality for patients less than forty years of agecheck. Further multi-system trauma has been associated with increased mortality, especially when it involves vascular injuries.4 Therefore, prompt diagnosis and management is crucial and increases the probability of survival and a favorable outcome. Acute paraplegia is an associated complication of traumatic thoracic spinal cord and aortic injuries. Further, it can also result from open and endovascular repair of this injury due to decreased perfusion to the cord and ensuing ischemia and infarction.4,5,14 Few cases of acute lower extremity monoparesis have been reported from traumatic injury to the frontal lobe.2,10 We present the first case of acute paraplegia resulting from bilateral para-sagittal frontal contusions in a patient with concomitant thoracic aorta injury. CASE REPORT A 31 year-old male pedestrian was struck by a high velocity vehicle and thrown approximately seventy feet from the initial site of impact. The patient was intubated at the scene and transported to an outside hospital. At the time he was following commands and moving all extremities. CT of the brain revealed a bicoronal scalp laceration and underlying skull fracture with no intracranial hemorrhage or contusion; CT of the chest, abdomen and pelvis revealed an aortic isthmus tear, bilateral pneumo-hemothoraxes and pulmonary contusions, multiple ribs and right clavicle fractures, liver laceration with intr

背景:在多系统损伤的情况下，神经损伤的病因和病理生理是难以确定的。方法:一个独特的情况下，行人被一辆机动车，提出急性截瘫后血管内支架置入创伤性胸主动脉夹层。患者的下肢没有明显的运动功能，但所有感觉模式完全保留。入院时的计算机断层扫描(CT)显示颅内创伤阴性，但发现急性颅骨骨折;未发现脊髓损伤。结果:患者放置腰椎引流管以最大化脊柱灌注压力，并立即通过神经轴磁共振成像(MRI)进行评估。急性双侧后额挫伤在脑成像上被发现，这在术前CT上没有出现。脊髓显像未见脊髓损伤或缺血。在短暂的康复治疗后，患者恢复并重新使用了他的下肢。结论:在多系统损伤的情况下，对神经损伤的其他病因应保持高度的怀疑。应进行彻底的神经系统检查和影像学评估，以避免误诊和对隐匿性损伤的不当处理。这是首例报道的急性截瘫由于顶点创伤，这可能是一种罕见的损伤机制和/或未被充分认识。创伤是40岁以下患者死亡的主要原因。进一步的多系统创伤与死亡率增加有关，特别是当它涉及血管损伤时因此，及时诊断和管理是至关重要的，可以增加生存的可能性和良好的结果。急性截瘫是创伤性胸脊髓和主动脉损伤的相关并发症。此外，由于脊髓灌注减少和随后的缺血和梗死，这种损伤的开放和血管内修复也可能导致损伤。颅脑额叶外伤性损伤引起急性下肢单瘫病例报道较少。我们提出了第一例急性截瘫导致双侧矢状旁前额挫伤的患者，同时胸主动脉损伤。病例报告一名31岁的男性行人被一辆高速车辆撞倒并被甩出离最初撞击地点约70英尺的地方。患者在现场被插管，并被送往外部医院。当时他还能听从命令，四肢活动自如。脑部CT显示头皮双冠状裂伤，颅底骨折，无颅内出血或挫伤;胸部、腹部和骨盆CT显示主动脉峡部撕裂，双侧气胸血肿和肺挫伤，多根肋骨和右锁骨骨折，肝脏撕裂并腹腔内出血。在转移到我们的设施后，病人保持稳定。他会睁开眼睛听声音，瞳孔同样圆，反应灵敏，他会用四肢服从简单的命令，并努力对抗重力。患者被紧急送往手术室进行内窥镜修复胸主动脉撕裂。手术无并发症完成，植入Gore TAG 26mm x 10cm内假体。图1脑磁共振成像显示双侧矢状旁挫伤。(A) t2加权层序，轴向切割;(B) t2加权序列，冠状切面。一个B

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