Carotid artery stents for blunt cerebrovascular injury: risks exceed benefits

BACKGROUND: Carotid stenting has been advocated in patients with grade III blunt carotid artery injuries (hereafter referred to as "blunt CAIs") because of the persistence of the pseudoaneurysm and concern for subsequent embolization or rupture. HYPOTHESIS: Carotid stenting is safe and effective for blunt CAIs. DESIGN: Analysis of a prospective database of all patients with blunt CAIs. SETTING: A state-designated, level I, urban trauma center.Patients and METHODS: In January 1, 1996, we initiated comprehensive screening for blunt CAIs with angiography based on injury patterns. Patients without contraindications receive anticoagulation therapy immediately for documented lesions. Patients with persistent pseudoaneurysms on a second angiography at 7 to 10 days after injury are candidates for stent placement. RESULTS: During the study period (January 1, 1996, to May 1, 2004), 46 patients sustained blunt carotid pseudoaneurysms; 23 (50%) underwent carotid stent placement. There were 4 complications in patients undergoing carotid stent placement: 3 strokes and 1 subclavian dissection. Follow-up angiography was performed in 38 patients (18 patients with stents who received antithrombotic agents, 20 patients who received antithrombotic agents alone); 8 patients had poststent carotid occlusion despite having received concurrent anticoagulation therapy. Carotid occlusion rates were significantly different (45% in patients with stents vs 5% in those who received antithrombotic agents alone). In the patients not undergoing stent placement, the only complication was a middle cerebral artery stroke in a patient not treated with antithrombotic therapy. CONCLUSIONS: Patients who have carotid stents placed for blunt carotid pseudoaneurysms have a 21% complication rate and a documented occlusion rate of 45%. In contrast, patients treated with antithrombotic agents alone had an occlusion rate of 5%; no asymptomatic patient treated with antithrombotic agents for their injury had a stroke. Antithrombotic therapy remains the recommended therapy for blunt CAIs, but the role of intraluminal stents remains to be defined.     

Phase II study of amonafide in patients with recurrent glioma

Summary Amonafide, a novel imide derivative with broad preclinical antitumor activity, achieves significant cerebrospinal fluid levels in animal models. In order to test its antitumor activity in patients with recurrent diffuse infiltrative glioma of the astrocytic and oligodendroglial type, we performed a phase II clinical trial. Of the 22 eligible and evaluable patients treated, 2 (9%) experienced tumor regression lasting more than one year. No other patients experienced tumor regression; one remained stable more than six months. Toxicities consisted primarily of myelosuppression, vomiting, and venous irritation at the infusion site. We conclude that amonafide has minimal activity in recurrent glioma patients. Further investigations are not warranted in this study population.     

Factors predicting the outcome of regional streptokinase therapy for peripheral arterial occlusions

Low dosage regional streptokinase therapy has become increasingly popular as an alternative to surgical treatment in acute and chronic arterial occlusions. Success rates are reported between 70 and 100 per cent. This is surprising, considering the paucity of data in the literature regarding the type of lesion treated, objective criteria for good results and predictive factors of success. In a review of 22 acute and chronic arterial occlusions of the lower extremity treated with low dosage regional streptokinase, the outcomes were grouped as either favorable or unfavorable. A success rate of 36 per cent was achieved. The two outcome groups were compared with regard to pre-existing diseases or risk factors, indications for treatment, duration of symptoms or level of occlusion. No significant difference was found. With regard to pretreatment runoff, 100 per cent of the patients in the favorable outcome group were found to have good runoff as opposed to only 21 per cent of the patients in the unfavorable outcome group. Of the patients who also had PBD procedures, all of those in the favorable group had good runoff, and all in the unfavorable group had poor runoff. In nearly achieving statistical significance, a trend was noted establishing embolic lesions as more favorable than thrombotic lesions. We conclude that our low success rate with low dosage regional streptokinase therapy is due to our strict criteria for success and the nonselective nature of the patients we studied. As a result of these findings, we do not support the preferred use of low dosage regional streptokinase therapy in arterial occlusion. However, in patients who represent high surgical risks, a trial of low dosage streptokinase therapy seems indicated if favorable predictors of success, such as good pretreatment runoff, embolic lesion and mild symptoms, are present.     

Posttraumatic Empyema

Background: Posttraumatic empyema remains a significant clinical problem occurring in 2–10% of victims with thoracic trauma. Many of the factors responsible for the development of posttraumatic empyema are preventable and iatrogenic in nature. As such, it is a source of morbidity and mortality and an additional expense for the institutions who care for these patients. Pathogenesis: The primary feature associated with posttraumatic empyema is a retained hemothorax following chest trauma. Blood trapped within the pleural space impairs its own absorption and acts as an ideal culture medium for bacterial proliferation. Contamination of a retained hemothorax is derived from several sources, including tube thoracostomy, pneumonia, or from the mechanism of injury itself. The combination of tube thoracostomy and retained blood within the pleural space is implicated in most cases of posttraumatic empyema. Diagnosis: The diagnosis of posttraumatic empyema involves the use of clinical parameters and imaging studies. Chest computed tomography, the most useful imaging modality, has a high degree of sensitivity and specificity but must also be correlated with clinical findings of leukocytosis, fever, and often respiratory dysfunction. Treatment: Effective treatment of posttraumatic empyema centers on effective decortication and complete reexpansion of the involved lung. This can be achieved physically either at the time of thoracotomy or thoracoscopy or chemically through the use of fibrinolytic agents. Thoracotomy with decortication is the most successful form of therapy, and the rate of morbidity associated with this procedure is improving. Thoracoscopy with decortication is technically more difficult to perform and mor successful when performed early.