Physician Approaches to Antithrombotic Therapies for Recently Symptomatic Carotid Stenosis

BACKGROUND

Whereas the beneficial effect of antiplatelet therapy for recurrent stroke prevention has been well established, uncertainties remain regarding the optimal antithrombotic regimen for recently symptomatic carotid stenosis. We sought to explore the approaches of stroke physicians to antithrombotic management of patients with symptomatic carotid stenosis.

METHODS

We employed a qualitative descriptive methodology to explore the decision-making approaches and opinions of physicians regarding antithrombotic regimens for symptomatic carotid stenosis. We conducted semi-structured interviews with a purposive sample of 22 stroke physicians (11 neurologists, 3 geriatricians, 5 interventional-neuroradiologists, and 3 neurosurgeons) from 16 centers on four continents to discuss symptomatic carotid stenosis management. We then conducted thematic analysis on the transcripts.

RESULTS

Important themes revealed from our analysis included limitations of existing clinical trial evidence, competing surgeon versus neurologist/internist preferences, and the choice of antiplatelet therapy while awaiting revascularization. There was a greater concern for adverse events while using multiple antiplatelet agents (e.g., dual-antiplatelet therapy (DAPT)) in patients undergoing carotid endarterectomy compared to carotid artery stenting. Regional variations included more frequent use of single antiplatelet agents among European participants. Areas of uncertainty included antithrombotic management if already on an antiplatelet agent, implications of nonstenotic features of carotid disease, the role of newer antiplatelet agents or anticoagulants, platelet aggregation testing, and timing of DAPT.

CONCLUSION

Our qualitative findings can help physicians critically examine the rationale underlying their own antithrombotic approaches to symptomatic carotid stenosis. Future clinical trials may wish to accommodate identified variations in practice patterns and areas of uncertainty to better inform clinical practice.

Twice Negative PCR in a Patient With Herpes Simplex Virus Type 1 (HSV-1) Encephalitis

Untreated herpes simplex virus type 1 (HSV-1) encephalitis is associated with high mortality. Missed cases can have devastating consequences. Detection of HSV-1 in cerebrospinal fluid (CSF) with polymerase chain reaction (PCR) is reported to have high sensitivity and specificity and is considered the diagnostic gold standard for HSV-1 encephalitis. In this article, we report a case of autopsy-confirmed HSV-1 encephalitis where CSF PCR returned negative on 2 occasions. A 64-year-old man presented with fever, left-sided weakness, and altered level of consciousness. Magnetic resonance imaging demonstrated right mesial temporal lobe diffusion restriction and electroencephalography showed right lateralized periodic discharges. Lumbar puncture was performed on day 1 for which CSF PCR returned negative for HSV-1. Empiric antiviral and antibiotic treatments were continued due to high clinical suspicion of HSV-1 encephalitis. Repeat lumbar puncture on day 5 was unchanged and empiric treatments were discontinued. On day 13, he developed status epilepticus requiring intensive care unit admission. A third CSF sample returned positive for HSV-1. Acyclovir was restarted but he continued to clinically worsen and supportive care was withdrawn. Autopsy confirmed widespread HSV-1 meningoencephalitis. Negative CSF PCR should be interpreted with caution in cases where there is high clinical suspicion of HSV-1 encephalitis. Current guidelines suggest repeating CSF HSV-1 PCR within 3 to 7 days in suspicious cases while continuing empiric therapy. However, missed cases can occur even with repeated testing. Empiric treatment with acyclovir should be considered in cases with high clinical suspicion of HSV-1 encephalitis, while investigations for alternate treatable diagnoses are continued.

Hemorrhagic encephalopathy associated with COVID-19

The mechanisms for neurological complications of COVID-19, the disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), are not yet well understood. We present a critically ill man with a COVID-19-associated hemorrhagic encephalopathy. SARS-CoV-2 RNA was not detected in cerebrospinal fluid (CSF) or blood. CSF analyses suggested dysregulation of pro-inflammatory cytokine pathways, particularly tumor necrosis factor-α and interleukin-6, consistent with a cytokine release syndrome. The patient gradually recovered with supportive care and neurological rehabilitation. Awareness of this clinical entity may facilitate the identification of patients with a potentially remediable cause of encephalopathy in COVID-19.

Intrathecal Morphine Following Lumbar Fusion: A Randomized, Placebo-Controlled Trial

BACKGROUND

Despite the potential for faster postoperative recovery and the ease of direct intraoperative injection, intrathecal morphine is rarely provided in lumbar spine surgery.

OBJECTIVE

To evaluate the safety and efficacy of intrathecal morphine following lumbar fusion.

METHODS

We randomly assigned 150 patients undergoing elective instrumented lumbar fusion to receive a single intrathecal injection of morphine (0.2 mg) or placebo (normal saline) immediately prior to wound closure. The primary outcome was pain on the visual-analogue scale during the first 24 h after surgery. Secondary outcomes included respiratory depression, treatment-related side effects, postoperative opioid requirements, and length of hospital stay. An intention-to-treat, repeated-measures analysis was used to estimate outcomes according to treatment in the primary analysis.

RESULTS

The baseline characteristics of the 2 groups were similar. Intrathecal morphine reduced pain both at rest (32% area under the curves [AUCs] difference, P < .01) and with movement (22% AUCs difference, P < .02) during the initial 24 h after surgery. The risk of respiratory depression was not increased by intrathecal morphine (hazard ratio, 0.86; 95% confidence interval, 0.44 to 1.68; P = .66). Although postoperative opioid requirements were reduced with intrathecal morphine (P < .03), lengths of hospital stay were similar (P = .32). Other than a trend towards increased intermittent catheterization among patients assigned to intrathecal morphine (P = .09), treatment-related side effects did not significantly differ. The early benefits of intrathecal morphine on postoperative pain were no longer apparent after 48 h.

CONCLUSION

A single intrathecal injection of 0.2 mg of morphine safely reduces postoperative pain following lumbar fusion.