Thrombolysis and outcome of young stroke patients over the last decade: insights from the Nationwide Inpatient Sample

BACKGROUND

A recent study found a trend toward increasing hospitalizations for acute ischemic stroke (AIS) among young adults, raising concern for this subgroup. In the present study, we evaluated trends of use of thrombolysis and outcome among young adults (19-44 years of age) with AIS using a nationally representative administrative database.

METHODS

Discharge data were obtained from Nationwide Inpatient Sample between 2001 and 2009. Hospitalizations with a discharge diagnosis of AIS for patients 19 to 44 years of age were included. Use of thrombolysis was determined within this subset. The Cochran-Armitage test was used for trend analysis.

RESULTS

Thrombolysis in young patients with AIS increased from 354 (1.84%) in 2001 to 1,237 (4.97%) in 2009 (P < .0001). The highest increase was noted at urban teaching hospitals. There was a progressive decrease in mortality in young AIS patients, from 6.81% in 2001 to 5.43% in 2009 (trend P = .027) and significant increase in discharges to rehabilitation (3.42% in 2002 to 12.7% in 2009 [trend P < .0001]). Discharge to other facilities decreased significantly (29.1% in 2001 to 17.8% in 2009 [trend P < .0001]). The rate of intracranial hemorrhage (2.70% in 2001; 2.69% in 2009) did not show any significant change despite the increase in the use of thrombolysis (trend P = .39).

CONCLUSIONS

The rate of thrombolysis among young patients with AIS increased significantly between 2001 and 2009. A decrease in deaths with increased rehabilitation placements of young patients with AIS was noted over the last decade, suggesting improving outcomes. The lower rate of use of thrombolysis in rural hospitals may be improved with the widespread use of telestroke.

Arrival by ambulance is associated with acute stroke intervention in young adults

BACKGROUND AND PURPOSE

Timely intervention in young stroke patients minimizes long term disability. We hypothesized that arrival to the emergency department by ambulance would be associated with increased rate of stroke intervention with intravenous t-PA or intra arterial procedures.

METHODS

Charts of 77 patients aged 15-49 years diagnosed with ischemic stroke were analyzed. Data was collected on demographics, arrival to emergency department by ambulance, whether initial hospital at presentation was a Primary Stroke Center, and intervention by intravenous t-PA or intra arterial procedures. Data was analyzed by Fisher's exact test, and significant variables were included in multivariable analysis.

RESULTS

Arrival by ambulance was significantly associated with acute stroke intervention in young adults (p=0.016). Gender and Primary Stroke Center certification did not make a difference in patients getting stroke intervention.

CONCLUSION

Young adults with stroke symptoms were more likely to receive acute stroke intervention if they arrived by ambulance. Larger multi-center studies should address whether Primary Stroke Centers are more likely to provide either IV thrombolysis or interventional therapies in young patients with acute ischemic stroke.

Abstract 3060: Racial Disparities in Early Institution of “Do Not Resuscitate” Orders Influence Survival in Acute Ischemic Strokes

Background: The importance of early institution of “Do Not Resuscitate” (DNR) orders in determining outcomes from intracerebral hemorrhage is established. In the setting of acute ischemic stroke, African Americans tend to utilize critical care interventions more and palliative care options less than Caucasians. Recent epidemiological studies in acute ischemic stroke have shown a somewhat better survival for African Americans compared with Caucasians. Our hypothesis was that racial differences in early institution of DNR orders would influence mortality in acute ischemic stroke.

Methods: a retrospective chart review was conducted on consecutive admissions for acute ischemic stroke across 10 hospitals in Michigan for the year 2006. Subjects with self reported race as African American or Caucasian were selected. Demographics, stroke risk factors, pre morbid status, DNR by day 2 of admission, stroke outcome and discharge destination were abstracted.

Results: The study included 574 subjects (144 African American, 25.1%; 430 Caucasian, 74.9%). In-hospital mortality was significantly higher among Caucasians (8.6% vs. 1.4% amongst African Americans, p=0.003). More Caucasians had institution of DNR by day 2 than African Americans (22.5% vs. 4.3%, p<0.0001). When adjusted for racial differences in DNR by day 2 status, Caucasian race no longer predicted mortality. Caucasians were significantly older than African Americans (median age 76 vs. 63.5 years, p<0.0001); and age was a significant predictor of DNR by day 2 and mortality. In the adjusted analysis, however, age marginally influenced the racial disparity in mortality ( table ). Caucasians with coronary disease, atrial fibrillation, severe strokes and unable to walk prior to the stroke tend to be made DNR by day 2 more frequently. Only 27.1% of Caucasians with early DNR orders died in the hospital, whereas 20.8% were eventually discharged home.

Conclusions: Early DNR orders result in a racial disparity in mortality from acute ischemic stroke. A substantial proportion of patients with early DNR orders eventually go home. Postponing the use of DNR orders may allow aggressive critical care interventions that may potentially mitigate the racial differences in mortality.

Abstract 7: Has Patient Selection for Carotid Endarterectomy and Stenting changed over time? Carotid revascularization in the postCREST era

The results of CREST (Carotid Revascularization Endarterectomy versus Stenting Trial), announced in February 2010 added further insight to the issue of patient selection for carotid revascularization. Carotid artery stenting (CAS) was equivalent to carotid endarterectomy (CEA), perhaps better in the younger age group. CEA patients developed more perioperative myocardial infarctions, and CAS patients incurred more perioperative strokes. Our hypothesis was that following the announcement of the CREST results, characteristics of patients undergoing CAS would change to include younger patients and more cardiac disease compared with those undergoing CEA.

Methods: a retrospective chart review was conducted of all carotid revascularization procedures performed at four hospitals in a metropolitan region. The study duration was from June 2009 (8 months prior to CREST) through May 2011 (16 months after CREST). Demographics and high surgical risk criteria were recorded. Comparisons were drawn between patients receiving the procedures prior to and after CREST.

Results: The study included 483 procedures. Of the 174 preCREST procedures, 64(36.8%) were CEA and 110(63.2%) were CAS. Of the 309 postCREST procedures, 112(36.2%) were CEA and 197(63.8%) were CAS. The proportion of patients undergoing CEA for asymptomatic carotid disease did not change significantly (76.6% preCREST vs. 69.6% postCREST: p=0.42). There was a significant increase in the proportion undergoing CAS for asymptomatic disease (52.7% preCREST vs 65.5% postCREST: p=0.04). The patients undergoing CAS for nonspecific symptoms such as dizziness also increased(5.5% preCREST vs. 18.3% postCREST: p=0.002). The median age did not change significantly for either CEA(68.5years preCREST vs. 69.0years postCREST: p=0.95) or CAS(73.0years preCREST vs. 70years postCREST: p=0.23). The proportion of CAS patients ≥70 years somewhat decreased(58.2% preCREST vs.50.3% postCREST: p=0.18). In the CEA subgroup, there was a reduction in the proportion of patients with congestive heart failure (10.9% preCREST vs.2.7% postCREST: p=0.07) and recent myocardial infarction/angina(4.7% preCREST vs.0 postCREST: p=0.06). There was an increase in the proportion of patients undergoing CAS with congestive heart failure(27.3% preCREST vs.37.6% postCREST: p=0.05).

Conclusions: The utilization of CAS for asymptomatic carotid disease and nonspecific symptoms has increased after CREST. There is a trend towards patients with cardiac disease getting CAS more often. In spite of an increased risk of perioperative stroke among the elderly CAS patients, half of the CAS procedures postCREST were performed in subjects ≥70 years. Careful consideration of the choice of carotid revascularization procedures is warranted in the light of the CREST study.

Abstract 2801: Improved Outcomes among Patients with Decompressive Hemicraniectomy over the Last Decade: Insights from the Nationwide Inpatient Sample

Background: Hemicraniectomy provides a substantial survival benefit for patients with malignant middle cerebral artery infarcts. Over the last few years, our understanding of patient selection criteria for this potentially life-saving procedure has increased. Little is known about whether hemicraniectomy performance has improved outcomes following the procedure outside of clinical trials. Our objective was to evaluate trends in survival and discharge outcomes of ischemic stroke patients receiving hemicraniectomy in the United States over the last decade.

Methods: Data from the Nationwide Inpatient Sample for the years 2001 through 2009 were reviewed. Hospitalizations with a discharge diagnosis of an acute ischemic stroke (ICD-9 codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 424.01, 434.11, 434.91 and 436) were included. Hemicraniectomy utilization was determined using procedure codes 01.2, 01.25 and 02.01. Nationwide estimates of deaths and discharge destination were calculated for each year within the hemicraniectomy subset. The Cochrane Armitage test was used to assess trend across the years.

Results: The study included information from 4,917,217 stroke discharges over 9 years. Of these, an estimated 3,447 (0.07%) patients received a hemicraniectomy. There was a progressive decrease in mortality among hemi-craniectomy patients, from 50.1% in 2001 to 26.2% in 2009; trend p=0.016. This survival benefit over the years was primarily seen amongst males (trend p=0.04) and in the younger age group (age <45 years trend p=0.06). Discharges to home (independent or with home care) showed a small decrease in trend over the 9 years. However discharges to rehabilitation facilities and nursing homes have increased over the years ( Figure ).

Conclusions: Over the last decade, deaths from hemicraniectomy have decreased. A considerable proportion of survivors are being discharged to rehabilitation facilities and nursing homes. Appropriate patient selection and timing for hemicraniectomy has improved survival outcomes for these patients over the last decade. Data on long term neurologic recovery and patient satisfaction are needed.

Abstract 2956: Carotid Revascularization in Elderly Asymptomatic Patients: Are the Results Optimal?

Objectives: Assess the hypothesis that patients with asymptomatic carotid stenosis older than 75 years are not on “best medical therapy” and their operative complication exceeds the AHA/ASA 3% threshold.

Background: According to the Asymptomatic Carotid Atherosclerosis Study (ACAS), the Asymptomatic Carotid Surgery Trial (ACST) and recent AHA/ASA guidelines; benefits of carotid revascularization in asymptomatic patient >75 years would be offset if the operative complications rate exceed 3% and it would be more prudent to manage such patients on “best medical therapy”. How often these guidelines are being followed remains unclear.

Methods: A retrospective chart review (2009-2011) at three urban, one suburban hospital within 30 miles was performed. Information of carotid revascularization (CEA & CAS) in asymptomatic elderly patients, in-hospital outcomes of stroke/death and/or MI and pre-procedural medications were evaluated. Statistical analysis with chi square testing was used.

Results: A total of 114 patients met our inclusion criteria. Their features are described below.At four hospitals, the proportion of carotid revascularization done was 62% (114/185). More then quarter and one-third of patients undergoing carotid revascularization were not on statin and beta-blockers, respectively. Further, the rate of in hospital stroke was 4.4%.

Conclusions: The majority of elderly patients with asymptomatic carotid stenosis patients are still undergoing carotid revascularization with operative complications that exceeded the AHA/ASA 3% threshold. More then quarter of patients in this subgroup are not on “best medical therapy”. These results reinforce the need for a new clinical trial comparing aggressive medical therapy alone vs. aggressive medical therapy and revascularization.

Abstract 2968: Outcomes Of Young Acute Ischemic Stroke Over The Last Decade: Insights From Nationwide Inpatient Sample

Background: The burden of young ischemic stroke has increased over the years. However, outcomes of young patients with acute ischemic stroke (AIS) remain unknown. Over the last decade, with increasing utilization rate of iv tpa, our objective was to evaluate trends in survival and discharge outcomes of young AIS patients in the United States.

Methods: Data from the Nationwide Inpatient Sample for the years 2001 through 2009 were reviewed. Hospitalizations with a discharge diagnosis of an acute ischemic stroke (ICD-9 codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 424.01, 434.11, 434.91 and 436) were included. Nationwide estimates of deaths and discharge destination were calculated for each year within the young AIS subset. The Cochrane Armitage test was used to assess trend across the years

Results: From 2001 through 2009, there were an estimated 4,917,217 admissions for acute ischemic stroke. Out of that, 204,703 (4.16%) were young patients with AIS. Thrombolysis in young ischemic stroke increased from 354 (1.84% of young AIS) in 2001 to 1237 (4.97%) in 2009 (p<0.0001). There was a progressive decrease in mortality in young AIS patients, from 6.81% in 2001 to 5.43% in 2009 (trend p= 0.027). Discharge to home or home with home health did not show any significant change (trend p= 0.52). Discharge to rehabilitation facilities showed significant increase over the years, 3.42% in 2002 to 12.7% in 2009 (trend p <0.0001). Discharge to other facilities other than rehabilitation showed significant decrease over the years, 29.1% in 2001 to 17.8% in 2009 (trend p<0.0001). Rate of intracranial hemorrhage, 2.70% in 2001 to 2.69% in 2009, did not show any significant change despite increasing use of iv tpa (trend p=0.39).

Conclusion: Over the last decade, deaths from AIS among young patients have decreased. The increase in rehabilitation placement and decrease in nursing home discharges suggest improving neurologic outcomes. Modern treatments such as stroke units, thrombolysis, and mechanical thrombectomy may be responsible for the reductions in mortality and morbidity.

Abstract 128: The Increasing Utilization of Hemicraniectomy for Acute Ischemic Stroke in the United States

Background: The survival outcome of malignant middle cerebral artery infarcts is dismal. In 2007, the pooled analysis from the DECIMAL (Decompressive craniectomy in malignant middle cerebral artery infarcts), DESTINY (Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery) and HAMLET (Hemicraniectomy after middle cerebral artery infarction with life-threatening edema) trials demonstrated a substantial survival benefit from this procedure with a number needed to treat of two for survival. Our objective was to review the nationwide utilization of this potentially life-saving procedure over the last decade.

Methods: Data from the Nationwide Inpatient Sample for the years 2001 through 2009 were reviewed. Hospitalizations with a discharge diagnosis of an acute ischemic stroke (ICD-9 codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 424.01, 434.11, 434.91 and 436) were included. Hemicraniectomy utilization was determined using procedure codes 01.2, 01.25 and 02.01 within this subset. Nationwide estimates of utilization were calculated for each year. The Cochrane Armitage test was used to assess trend across the years.

Results: From 2001 through 2009, there were an estimated 4,917,217 admissions for acute ischemic stroke. Over the 9 years of the study period, the estimated frequency of hemicraniectomy procedures progressively increased from 123 (0.02% of stroke discharges in 2001) to 850 (0.16% of stroke discharges in 2009); trend p<0.0001. The rate of utilization increased largely after 2006. The increase was noted for younger subjects (age < 45 years; trend p<0.0001) and older subjects (age ≥ 45 years; trend p<0.0001). Utilization significantly increased for males and females (trend p<0.0001 for both subgroups). For each year, utilization of hemi-craniectomy was greater amongst males. In contrast with rural and urban nonteaching hospitals, urban teaching hospitals were responsible for the greatest increase in hemicraniectomy utilization: from 0.05% of stroke discharges in 2001 to 0.30% of stroke discharges in 2009.

Conclusion: The utilization of hemicraniectomy for acute ischemic stroke has increased significantly, coinciding with the publication of compelling results from clinical trials. Early transfer of patients with large middle cerebral artery infarcts to urban teaching centers could potentially extend the survival benefit to a larger population.

Abstract 2802: Age and Stroke Severity Influence the Association between Blood Pressure Variability and Stroke Recovery

Blood pressure elevations after ischemic stroke are regarded as the body's response to maintain cerebral perfusion. Extremes of blood pressure have correlated with poor stroke recovery. Recently, blood pressure variability was shown to predict outcome better than mean blood pressures. Variables such as age, National Institute of Health stroke scale (NIHSS) and diabetes are established predictors of poor outcome and may potentially affect the degree of blood pressure variability. Our hypothesis was that age, NIHSS and diabetes would influence the association between blood pressure variability and stroke recovery.

Methods: a retrospective chart review of consecutive patients discharged with an acute ischemic stroke based on ICD-9 codes was conducted. Successive blood pressure recordings during the 1st 5 days of hospitalization were noted. Blood pressure variability was calculated for systolic, diastolic and mean arterial pressures separately using published methods. Demographics, comorbidities, and modified Rankin score (mRS) at discharge were abstracted.

Results: The study included 295 stroke patients, (median age 60 years; median NIHSS of 4.0). Age >60, NIHSS 4-9, NIHSS ≥ 10 and diabetes were associated with poor recovery (mRS 3-6). The mean pressures in the study group ranged from 105-195 mmHg for systolic blood pressure (SBP), 51-159 mm Hg for diastolic blood pressure and 70-163 mm Hg for mean arterial pressure. The median variability for SBP was 21.0mmHg; diastolic blood pressure was 12.7mmHg; mean arterial pressure was 13.6mmHg. Subjects with higher SBP variability (greater than the median of 21.0) had significantly higher rates of poor recovery. Stratifying by age, the association of SBP variability and poor outcome was significant for age > 60(OR: 2.16; 95%CI 1.06-4.38) but not for the younger subgroup with age≤ 60. Stratifying by stroke severity, the association of SBP variability and poor recovery was significant for NIHSS 4-9 (OR 3.41; 95%CI 1.55-8.23). All patients with high SBP variability in the NIHSS ≥ 10 group had poor recovery. The association was also significant in the subgroup without diabetes (OR 1.97; 95%CI 1.10-3.51), not in the subgroup of diabetic patients. Overall, the odds of a poor recovery due to high SBP variability were highest among subjects > 60 years with moderate to high NIHSS.

Conclusions: SBP variability in acute ischemic stroke is especially harmful among the elderly, nondiabetic and the more severe strokes. Extreme caution is advised when prescribing blood pressure lowering medications in these subgroups.

Abstract 2945: Missed Opportunities for Primary Stroke Prevention among Young Adults in the United States

The incidence of stroke is increasing in young adults. However, little is known about primary prevention in this population. Prevention of stroke among young and early middle-aged adults is particularly important as they face with years of disability after a stroke. Our objective was to define the prevalence of modifiable stroke risk factors and steps taken to address them among the younger adults during outpatient clinic visits within the United States.

Methods: Data from the 2008 and 2009 National Ambulatory Medical Care Survey dataset were analyzed. Young subjects (18 to 45 years) visiting medical specialties were selected. Weighted frequencies of diabetes, hypertension, tobacco abuse, hyperlipidemia, and obesity were estimated based on physician reported data about these conditions. Proportions of subjects receiving education about weight reduction, exercise, diet and nutrition, smoking cessation and prescriptions were estimated.

Results: There were an estimated 324.7 million medical office visits in 2008 and 2009. The majority of these visits were to Internal Medicine (20.5%) and Family medicine (45.8%) practices, whereas (2.5%) visits were to neurologists. Smoking (20.6%) was the most prevalent risk factor recognized by physicians, followed by obesity (16.7%), hypertension (12.3%), hyperlipidemia (7.7%) and diabetes (6.6%). Only 19.5% of all smokers were documented to have received smoking cessation advice. Weight reduction counseling was provided to 15.8% of obese patients, 14.9% of hypertensive, 16.2% of diabetic and 13.9% of hyperlipidemic subjects. Diet and nutrition counseling was provided to 23.4% of obese, 24.9% of hypertensive, 30.1% of diabetics and 29.9% of hyperlipidemic subjects. Exercise was advised to 19.5% of obese, 17.6% of hypertensive, 20.6% of diabetics and 24.1% of hyperlipidemic subjects. Statins were prescribed to 91.1% of subjects with hyperlipidemia, 89.9% of diabetics were on insulin and 10.7% were on oral drugs, whereas only 13.6% of hypertensive subjects were on prescription medication.

Conclusion: A substantial proportion of young adults are found to have modifiable stroke risk factors during office visits. There is a high use of prescriptions to treat hyperlipidemia and diabetes, however counseling regarding lifestyle changes is dismal. Efforts should be made fulfill the potential of the medical practioners in providing effective stroke prevention in young adults. Further research should concentrate on the systems of structured management of stroke prevention in primary care practice.

New insights in antiplatelet therapy for patients with ischemic stroke

BACKGROUND

Acute treatment and long-term secondary prevention of noncardioembolic ischemic stroke and transient ischemic attack (TIA) include initiation of antiplatelet therapy. Antiplatelet agents currently used in the treatment of ischemic stroke and TIA are aspirin, clopidogrel, and dipyridamole.

REVIEW SUMMARY

The safety and efficacy of antiplatelet therapy in patients with ischemic stroke, including a discussion of recent trial data and its influence on treatment guidelines, are presented. A brief discussion of the use of antiplatelet therapy in preventing stroke and embolism in patients with atrial fibrillation is also presented. For secondary prevention of ischemic events in patients with a history of stroke, clinical trials have shown the addition of dipyridamole to aspirin to be more effective than aspirin alone. The therapies are also similar from a standpoint of bleeding. The combination of aspirin and clopidogrel was not shown to be more efficacious and caused more bleeding than aspirin alone when evaluated for secondary prevention. However, dual antiplatelet therapy with aspirin and clopidogrel may have some benefit in the acute stroke setting or in the prevention of thrombotic events in patients with atrial fibrillation who cannot or will not take warfarin.

CONCLUSIONS

Antiplatelet therapy is an important component of acute and long-term treatment of ischemic stroke and TIA. Ongoing clinical trials may help to refine what treatment regimens are best suited for acute and long-term therapy.

Are racial disparities in stroke care still prevalent in certified stroke centers?

Racial differences in stroke risk and risk factor prevalence are well established. The present study explored racial differences in the delivery of care to patients with acute stroke between Joint Commission (JC)-certified hospitals and noncertified hospitals. A retrospective chart review was conducted in patients sustaining ischemic stroke admitted to 5 JC-certified centers and 5 noncertified hospitals. Demographic data, risk factors, utilization of acute stroke therapies, and compliance with core measures were recorded. Racial disparities were investigated in the entire group as well as for JC-certified and noncertified hospitals separately. A total of 574 patients (25.1% African Americans) were included. African Americans were significantly younger and more likely to have previous stroke, whereas Caucasians were more likely to have coronary disease and atrial fibrillation. There were no racial differences in other risk factors or baseline functions. Median National Institutes of Health Stroke Scale scores were similar in African Americans and Caucasians, as were proportions receiving intravenous tissue plasminogen activator (tPA) therapy (2.1% in African Americans, 3.5% in Caucasians; P = .40) and intervention (4.2% in African Americans, 6.8% in Caucasians; P = .26). Caucasians were more likely to arrive by emergency medical services (65.5% vs 51.5%; P = .004), to be evaluated by a stroke team (19.1% vs 7.7%; P = .001), and to have a documented National Institutes of Health Stroke Scale score (40.2% vs 29.9%; P = .03). African Americans often did not receive intravenous tPA because of a delay in arrival. African Americans performed better on virtually all stroke care variables in JC-certified centers. JC certification reduced disparity in certain variables, including tPA and deep venous thrombosis prophylaxis administration. Important racial disparities exist in the delivery of several acute stroke care variables. Efforts must be focused on eliminating disparities in prehospital delays. Guideline-based care tendered at JC-certified centers might help narrow disparities in acute stroke care delivery.

Laparoscopic slit mesh repair of parastomal hernia using a designated mesh: long-term results

BACKGROUND

Parastomal hernia (PH) is a frequent complication of colorectal surgery, which incidence reaches 55% of all stoma formation. Currently, there is no definitive strategy for its repair. This study was designed to assess the outcome in patients who underwent laparoscopic PH repair using a slit mesh/keyhole technique.

METHODS

We undertook a retrospective case review of all patients who underwent laparoscopic PH repair with a designed slit mesh/keyhole between 2005 and 2010. Three ports were placed opposite the stoma site, and careful adhesiolysis and hernia content reduction were performed. The parastomal fascial defect was measured and covered with a designated mesh. Fixation of the mesh was achieved with concentric tacks and transcutaneous Prolene suture. Recurrence was diagnosed after examination of patients by two surgeons or by imaging demonstrating an indolent hernia.

RESULTS

Twenty-nine laparoscopic PH mesh repairs were performed with an average age of 63.5 (range 42-81, median 64) years to treat paracolostomy hernia in 18 of 29 cases (62.1%), para-ileostomy hernia in 10 of 29 cases (34.5%), and for an ileal conduit site hernia in 1 of 29 cases (3.4%). The average operative time was 179 (range, 80-300; median, 180) min. Two operations (6.9%) were converted to an open approach. Early postoperative complications were documented in four patients (13.8%), including one elderly patient with severe comorbidities who died from postoperative sepsis (mortality rate, 3.4%). Only one late complication was recorded (3.4%). The average hospital stay was 4.7 (range, 1-19; median, 3) days. Average follow-up time was 28 (range, 12-53; median, 30) months. Recurrence of the hernia was found in 13 of 28 patients (46.4%).

CONCLUSIONS

Laparoscopic slit mesh/keyhole repair is feasible, although it is a complex surgery reflected by extended operative time. The high recurrence rate suggests that technical improvement of the method is essential.

Metastatic angiosarcoma presenting as diffuse alveolar hemorrhage

Angiosarcoma is a rare malignant neoplasm of the vascular or lymphatic endothelium. Diffuse alveolar hemorrhage is a rare presenting manifestation of angiosarcoma. We describe a case of pulmonary metastasis of angiosarcoma who presented with diffuse alveolar hemorrhage as initial manifestation.