Cerebral Venous Thrombosis Associated with COVID-19

Despite the severity of coronavirus disease 2019 (COVID-19) being more frequently related to acute respiratory distress syndrome and acute cardiac and renal injuries, thromboembolic events have been increasingly reported. We report a unique series of young patients with COVID-19 presenting with cerebral venous system thrombosis. Three patients younger than 41 years of age with confirmed Severe Acute Respiratory Syndrome coronavirus 2 (SARS-Cov-2) infection had neurologic findings related to cerebral venous thrombosis. They were admitted during the short period of 10 days between March and April 2020 and were managed in an academic institution in a large city. One patient had thrombosis in both the superficial and deep systems; another had involvement of the straight sinus, vein of Galen, and internal cerebral veins; and a third patient had thrombosis of the deep medullary veins. Two patients presented with hemorrhagic venous infarcts. The median time from COVID-19 symptoms to a thrombotic event was 7 days (range, 2-7 days). One patient was diagnosed with new-onset diabetic ketoacidosis, and another one used oral contraceptive pills. Two patients were managed with both hydroxychloroquine and azithromycin; one was treated with lopinavir-ritonavir. All patients had a fatal outcome. Severe and potentially fatal deep cerebral thrombosis may complicate the initial clinical presentation of COVID-19. We urge awareness of this atypical manifestation.

The effects of alcohol celiac plexus block, pain, and mood on longevity in patients with unresectable pancreatic cancer: a double-blind, randomized, placebo-controlled study

OBJECTIVE

This additional analysis of data from a previously reported prospective trial comparing the effect of intraoperative alcohol or saline placebo neurolytic block in patients with pancreatic cancer was conducted in response to the development of a new theory, which explores the relationship of negative mood states to pain, pain-related behavior, and ultimately, longevity.

METHODS

The original study used a double-blind procedure to randomly assign 139 patients with histologically proven, unresectable pancreatic cancer to receive either an alcohol or a saline block. Data on visual analog pain, mood, and interference with activity were collected preoperatively and every 2 months postoperatively until death. The current analysis was conducted on the complete data sets received from 130 patients. Demographic data were submitted to chi-square analysis and to univariate and multivariate analysis of variance. Univariate and multivariate analyses of variance also compared 1) the effect of alcohol versus saline on pain, mood, interference of pain with activities, and longevity and 2) the impact of mood on pain with longevity as the dependent variable. Correlation and regression analyses examined the impact of mood on life expectancy.

RESULTS

The alcohol intervention had a significant positive effect on life duration and mood scores. High negative mood states correlated significantly with an increase in visual analog pain, the rating of pain intensity at its worse, and pain interference with patients' activities.

CONCLUSION

In these subjects, the neurolytic block, as compared with medical management alone, improved pain, elevated mood, reduced pain interference with activity, and was associated with an increase in life expectancy.

Common bile duct complications of pancreatitis evaluation and treatment

Five cases that illustrate the spectrum of biliary complications of pancreatitis and pancreatic pseudocyst are discussed. Obstructive jaundice, hemobilia, and bilious ascites were the major problems in these five patients. Sonography, transhepatic cholangiogram, endoscopic retrograde cholangiopancreatography, operative cholangiography, and arteriography are important in establishing the diagnosis and planning the treatment. Three patients had biliary obstruction caused by chronic pancreatitis, a pancreatic pseudocyst, or both. Two patients had a fistula between the common duct and the pseudocyst. Simple decompression of the pseudocyst was curative for only one patient. Three patients required decompression of the biliary tract, which emphasizes the need for intraoperative cholangiography. One patient required a Whipple operation to control hemorrhage but died in the immediate postoperative period. The operative findings determine the specific procedures for biliary tract decompression and pseudocyst drainage.

Malignant neoplasms of the duodenum

The records of 17 patients with primary malignant neoplasms of the duodenum were reviewed. Fiberoptic endoscopy is a valuable method for preoperative diagnosis. The results are consistent with previous reports, in that surgical resection is the only satisfactory treatment for most malignant tumors of the duodenum. Segmental resection may be the preferred procedure for localized tumors as it is associated with a much lower operative mortality than is pancreaticoduodenectomy. Radiation therapy, however, is often effective in patients with lymphomas of the duodenum.