A 49-year-old man with no past medical history is admitted to the medicine service for 2 weeks of intermittent night sweats, myalgia, and progressive headache. Other than febrile, his vital signs are normal at the time of admission. His neurologic examination at the time of admission is normal, and basic laboratory workup is unrevealing. A lumbar puncture is performed with a normal opening pressure, pleocytosis with 41 white blood cells/microL (94% polymorphonuclear cells), 5 red blood cells/microL, glucose 58 mg/dL, and protein 53 mg/dL. There was concern for potential infectious meningitis, so vancomycin, ceftriaxone, and acyclovir were started. One day following the lumbar puncture, the patient had acute onset of marked expressive aphasia and right facial weakness. A head computed tomography (CT) was completed and demonstrated in the figure that follows.
Additional workup was completed to determine the etiology of his stroke, and he was found to have a mobile target on the anterior leaflet of the mitral valve, concerning for endocarditis (shown in the figure below), and the mitral valve has severe mitral valve regurgitation.
What is the next best step in management of the patient’s possible endocarditis?
Correct Answer: D
The patient meets Duke criteria for possible endocarditis, given he has one major criteria (transthoracic echocardiography [TTE] with new regurgitation and mobile target) and two minor criteria (fever and emboli). The patient has a severe mitral regurgitation, which will require surgical repair. There are mixed criteria for early intervention, but the American Heart Association recommends early intervention if any of the following is observed:
This patient does not meet the criteria above, and there is no need to repair his mitral valve urgently. In addition, given his intraparenchymal hemorrhage, undergoing anticoagulation is not an option at this acute time of his presentation. Overall, endocarditis patients with intracerebral hemorrhage are at high risk for clinical worsening during the first month after symptom onset and have a higher mortality than those without (75% vs. 40%).
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A 53-year-old woman is postbleed day 8 from a subarachnoid hemorrhage (SAH) from a, now secured, right middle cerebral artery (MCA) aneurysm. Since admission, the patient has been closely watched and the data from her external ventricular drain (EVD), brain tissue oxygenation monitor, and microdialysis catheter are all monitored. Recordings from the previous day shows PbtO2 (partial pressure of brain tissue O2 ) to be consistently greater than 25 and lactate/pyruvate (L/P) ratio less than 35, while her most recent readings from this morning are noted in the table that follows:
What is the best next step in management to reduce the patient’s risk of delayed cerebral ischemia?
Correct Answer: A
All SAH patients are at risk for delayed cerebral ischemia and cerebral infarction during the acute and subacute stages of their disease. Some centers use multimodality monitoring for evaluation of delayed cerebral ischemia as well as evaluation of interventions attempting to prevent or treat this disease. This particular patient has a brain tissue sensor which measures the partial pressure of oxygen in the brain interstitial cortical tissue. PbtO2 is a balance between oxygen delivery and oxygen consumption in brain cells. It can be affected by a number of parameters, such as cerebral metabolism, cerebral blood flow, sedation, low inspired oxygen, ICP and CPP changes, and other traumatic changes in the cellular environment. The microdialysis catheter is a semipermeable membrane that allows diffusion of water and solutes down the concentration gradient, and is used to measure the concentrations of these solutes. This particular example has both glucose, lactate, and pyruvate as markers of cerebral metabolism. During times of oligemia, glucose level will drop and lactate levels will rise, marking a shift to anaerobic metabolism.
In this scenario, PbtO2 and lactate-pyruvate ratio (LPR) were within goal the day before and changed significantly this morning to show low brain oxygenation and increased LPR as shown in the table. The goal with PbtO2 monitoring is to assess which change will have the greatest effect on PbtO2 trends. In this case, increasing CPPs (as shown in the table) reversed the changes in PbtO2 and LPR (this morning) and improved brain oxygenation (PbtO2) and metabolism.
A 47-year-old male with untreated hypertension was brought to the emergency department for loss of consciousness while at home and an episode of emesis. A head CT demonstrated a diffuse SAH with intraventricular extension and early signs of hydrocephalus. A CT angiogram demonstrated a 6 mm fusiform aneurysm from the distal right posterior inferior cerebellar artery (PICA). He was admitted to the intensive care unit for ongoing management. Over the course of the evening, there was progressive somnolence and an EVD was placed with an elevated opening pressure. Once placed, the EVD remained clamped. Given the need to delay definitive management of the aneurysm, transexamic acid (TXA) was started. Within 8 hours of admission, there was acute worsening of the examination and an acute increase in the intracranial pressure (ICP), and on opening the EVD, blood actively drained.
What of the following is MOST true of aneurysmal rerupture?
Correct Answer: E
This SAH patient has suffered a rerupture of his PICA aneurysm. Rebleeding is a major complication of SAH and a major cause of mortality, which can occur at any time during the course. Early rebleeding has been commonly reported to take place between 3 and 5 days, yet the exact period of great risk is still debated. The correlation between risk of rebleeding and predictors such as poor clinical SAH grades, loss of consciousness, external ventricular drainage, and size of aneurysm has been debated. Posterior circulation aneurysms are more likely to rupture, yet overall they are not associated with an increased risk of rerupture.
In an attempt to decrease the risk of rebleeding, TXA has been evaluated in SAH patients and has shown to decrease the rate of early rebreeding; however, it did not associate with improvement in clinical outcome.
A 67-year-old female has had progressive tinnitus over the last 4 years. Initial laboratory workup has been unrevealing, so additional workup with brain imaging was completed. The CT angiogram is shown in the figure that follows:
Which of the following is MOST true regarding incidentally discovered aneurysms?
Correct Answer: C
The tinnitus is likely an unrelated symptom, but there is CT angiogram evidence of an incidentally discovered broad-based unruptured aneurysm arising from the left vertebral artery. The overall annual incidence of aneurysm rupture is 1.1% to 1.4%. Patient factors that increase the risk of aneurysmal rupture include smoking, female sex, and posterior circulation, and patient age inversely (younger patients at higher risk) increased the risk of rupture. Aneurysm factors that increase the risk of rupture include larger size in anterior circulation >7 and >6 mm in posterior circulation, multilobulated aneurysm, posterior circulation, and aneurysm growth in serial imaging are associated with increased risk of rupture. The different approaches to management of unruptured, and ruptured, aneurysm are open surgery with ligation or wrapping of the aneurysm and endovascular therapy with coiling of the aneurysm with or without stent assistance.
A 69-year-old male, who has not seen a doctor in at least 10 years, presents to the emergency department for left-sided numbness and weakness. He initially had symptoms 1 day before presentation that lasted for 30 minutes with complete recovery. A head CT did not demonstrate any ischemic changes. A magnetic resonance imaging (MRI) did not demonstrate any infarction. A magnetic resonance angiogram (MRA) of the intracranial and neck vessels demonstrated severe stenosis of the right MCA.
What is the next best step management?
This patient presents with a crescendo transient ischemic attack (TIA), defined as recurrent episodes of TIAs over hours to as long as 1 week. The potential mechanism may be embolic or hemodynamic. There are prior studies that examine patients with stroke or TIA attributed to stenosis of 70% to 99% diameter of a major intracranial artery—SAMPRIS trial. In this trial, patients were randomized to percutaneous transluminal angioplasty and stenting with aggressive medical management versus aggressive medical management alone (aspirin and clopidogrel, management of primary and secondary risk factors including lifestyle modification). In those undergoing stenting there was increased risk of stroke and death at 30 days and 1 year compared to medical therapy alone.
A second trial (POINT) evaluated the use of dual antiplatelet therapy versus single antiplatelet agent in patients with small ischemic stroke or TIAs due to intracranial atherosclerotic disease in China. Dual antiplatelet therapy is associated with a reduction in stroke recurrence from 11.7% to 8.2%. Although some advocate for anticoagulation in crescendo TIA, there is limited evidence of efficacy, but there are data that heparinization is safe.
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