Abstract
BACKGROUND:
Remote ischemic conditioning (RIC) is a powerful endogenous mechanism whereby a sublethal ischemic stimulus confers a protective benefit against a subsequent severe ischemic ...insult. RIC has significant potential clinical implications for the prevention of delayed ischemic neurological deficit after aneurysmal subarachnoid hemorrhage (aSAH). Although RIC has been extensively investigated in animal models, it has not been fully evaluated in humans.
OBJECTIVE:
To assess the feasibility and safety of RIC for aSAH in a phase I clinical trial.
METHODS:
Consecutive patients hospitalized for treatment of an aSAH who met the inclusion/exclusion criteria were approached for consent. Enrolled patients received up to 4 RIC sessions on nonconsecutive days. Primary end points were the development of a symptomatic deep venous thrombosis, bruising, or injury to the limb and request to stop by the patient or surrogate. The secondary end points were the development of new neurological deficits or cerebral infarct, demonstrated by brain imaging after enrollment, and neurological deficit and condition at follow-up.
RESULTS:
Twenty patients were enrolled and underwent 76 RIC sessions, 75 of which were completed successfully. One session was discontinued when the patient became confused. No patient developed a deep venous thrombosis or injury to the preconditioned limb. No patient developed delayed ischemic neurological deficit during enrollment. At follow-up, median modified Rankin Scale score was 1 and Glasgow Outcome Scale score was 5.
CONCLUSION:
The RIC procedure was well tolerated and did not cause any injury. RIC for aSAH warrants investigation in a subsequent pivotal clinical trial.
History of present illness: A 34-year-old male presented to the Emergency Department with fever, sore throat, and difficulty swallowing. On exam, the patient had trismus, a deviated uvula, and ...swelling of his left peritonsillar space. An intraoral point of care ultrasound (POCUS) was performed, which revealed a fluid collection in the patient’s left peritonsillar space. The patient was diagnosed with a peritonsillar abscess (PTA) and needle aspiration was performed under direct ultrasound guidance. The patient tolerated the procedure well and was sent home with a course of antibiotics. Significant findings: The first video is an intraoral ultrasound using the high frequency endocavitary probe demonstrating an anechoic fluid collection adjacent to the patient’s enlarged left tonsil. The second video shows real-time ultrasound-guided successful drainage of the PTA. Discussion: Peritonsillar abscesses are the most common deep space infection of the head and neck1, most commonly affecting children and young adults.2 The ability of physicians to accurately differentiate PTA from peritonsillar cellulitis (PTC) by physical exam alone is limited. Traditionally, PTA has been treated using landmark-based needle aspiration.3 If unsuccessful, computed tomography (CT) imaging and otolaryngology (ENT) consultation is usually required.3 Although diagnosis of PTA using intraoral ultrasound has a sensitivity and specificity of between 89%-95% and 79%-100% respectively, it is still underutilized in comparison to these traditional methods.4 Studies have shown the use of ultrasound for diagnosis and treatment of PTA leads to significantly better outcomes and higher success rates of drainage (when compared to landmark-based needle aspiration), less need for CT imaging, and less need for ENT consultation.3 Utilizing intraoral point-of-care ultrasound is an efficient, safe, and cost-effective way of diagnosing and treating PTA.
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