Article 1
A comparison of computed tomography angiography and digital subtraction angiography for the diagnosis of penetrating cerebrovascular injury: a prospective multicenter study. Meyer RM, Grandhi R, Lim DH, et al. Journal of Neurosurgery. 2024 Feb 2;141(2):306-309.
Penetrating brain injuries (PBI) in civilian contexts can have mortality rates as high as 90%. Cerebrovascular complications, including intracranial pseudoaneurysms, vascular occlusions with ischemic strokes, venous sinus thrombosis, and traumatic arteriovenous fistulas, are detected in up to 60% of PBI cases. Notably, pseudoaneurysms can occur in up to 42% of these patients. Pseudoaneurysm rupture can result in catastrophic intracranial hemorrhage and poor outcomes.
The study by Meyer et al., explores the diagnostic capabilities of computed tomography angiography (CTA) versus digital subtraction angiography (DSA) in identifying cerebrovascular injuries from penetrating trauma. This prospective, multicenter study, included patients with penetrating head injuries and aimed to evaluate the diagnostic accuracy of CTA in comparison to DSA. Secondary objectives involved assessing the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each imaging modality.
A total of 400 patients were enrolled, all of whom underwent both CTA and DSA. The inclusion criteria ensured a diverse patient population, capturing various types and severities of cerebrovascular injuries. All patients received a CTA of the head upon initial presentation, followed by a DSA as soon as possible, usually within two days, unless specific factors prevented the DSA.
The primary findings revealed that CTA had a sensitivity of 85% and a specificity of 90% for detecting cerebrovascular injuries. In contrast, DSA exhibited a higher sensitivity of 95% and a specificity of 98%. The PPV and NPV for CTA were 80% and 92%, respectively, while for DSA, these values were 94% and 99%. Importantly, it took an average of 5.6 DSAs to identify one patient with an injury that required a change in clinical management, such as the need for surgical or endovascular treatment.
Overall, this study represents the first prospective comparison of the two imaging modalities, CTA and DSA. These data suggest that CTA alone does not adequately diagnose cerebrovascular injuries in PBI and that DSA should be used routinely in screening for these injuries.
Article 2
Cefepime vs Piperacillin-Tazobactam in Adults Hospitalized With Acute Infection: The ACORN Randomized Clinical Trial. Qian ET, Casey JD, Wright A, et al. JAMA. Oct 24;330(16):1557-1567.
The usage of empiric broad spectrum antibiotics for presumed sepsis is a common action by any physician. A common choice is Cefepime (Cef) or Piperacillin-tazobactam (Pip-tazo) for gram-negative coverage, especially for Pseudomonal coverage. However, there remain concerns for the safety of Pip-tazo with regards to renal injury, especially with regular concomitant usage of Vancomycin. Cef has its own observational safety concerns regarding neurotoxicity. This study, Antibiotic Choice on Renal Outcomes, looked to compare these antibiotics.
This was a pragmatic, open-label, parallel-group, randomized comparative safety trial. They enrolled adults >18 yrs of age with suspected infection in the Emergency Department or Medical Intensive Care Unit within 12 hours of hospital presentation. They excluded allergies to either medication class, receipt of more than one dose of a antipseudomonal cephalosporin or penicillin (did NOT exclude other antipseudomonal antibiotics), or clinician felt strongly about a specific antibiotic choice. Treating clinicians chose how long to administer the antipseudomonal antibiotic, as well as if additional ones were needed; i.e. Vancomycin. Primary outcome was death or highest stage of Acute Kidney Injury (AKI; per Kidney Disease: Improving Global Outcomes definitions). Secondary outcomes were twofold: those that experienced a major adverse kidney event at day 14, and, number of days alive and free of delirium and coma within 14 days.
The study analyzed 2511 patients between November 2021, and October 2022. They had 1214 pts (48.3%) within the Cef group, and 1297 pts (51.7%) within Pip-Tazo group. These groups had similar characteristics. Of note, 1362 pts (54.2%) had sepsis diagnosis at enrollment, and 612 pts (24.4%) had a suspected intra-abdominal source, the most common location. Patients received a dose for a median of 3 days. Also, the groups received Vancomycin as an additional antibiotic, 77.6% and 76.9%, respectively.
For primary outcome, the highest stage of AKI was not different between the groups (OR 0.95 [95% CI, 0.80-1.13], p=0.56). This remained the same with intention to treat analysis, sub-group analsysi to those that received at least 48, 72, and 96 hours of antipseudomonal antibiotics, and those at enrollment with AKI or receiving renal replacement therapy. However, those in the Cef group experienced fewer days alive and free of delirium and coma within 14 days comparatively, (11.9 vs 12.2 days; OR, 0.79[95% CI 0.65-0.95]). Additional measures of highest stage of AKI, major adverse kidney events, renal replacement therapy needs, or death, at 7 and 28 days, were the same between the groups.
This pragmatic study demonstrated there is no increased risk of AKI in choosing an antipseudomonal antibiotic for sepsis. It did demonstrate increased delirium within the Cef group, however, here lies one of their weaknesses. It was open label, and there is the possibility of bias by those administering the related assessments (CAM-ICU, RASS). This is a very relevant study to consider as an Acute Cary Surgery surgeon given the regular initiation of empiric antibiotics for sepsis; this is further demonstrated by the abdomen being the most common presumed source of sepsis in their analysis. One concern though for an ACS surgeon is the median time of antibiotic usage of 3 days. With complicated peri-operative infections, it is not uncommon for us to not have an identified organism as the source of sepsis and thus having prolonged courses of empiric antibiotics. I would summarize then, that in sepsis, especially those with no anticipated need for a prolonged course, selection of antipseudomonal Cefepime or Piperacillin-Tazobactam empiric antibiotic has no increased risk of acute kidney injury.
