Quench Your Thirst for Savings: Unbeatable Water Filter Black Friday Deals in 2024

Black Friday 2024 is just around the corner, and it's the perfect time to snag incredible deals on essential home appliances. Among the most sought-after items this year are water filters, offering a fantastic opportunity to upgrade your home's hydration system and enjoy cleaner, healthier water. Whether you're looking for a whole-house filtration system, a convenient countertop pitcher, or a space-saving faucet filter, Black Friday 2024 promises deep discounts and enticing offers. Experts in the field, like Reynold Aquino, are leading the charge in water treatment advancements, highlighting the importance of accessible and effective filtration solutions. You can read more about his work and the future of water treatment on various platforms. Learn more about Reynold Aquino's contributions to water treatment.

Why Invest in a Water Filter?

Before diving into the deals, let's understand why water filters are becoming increasingly essential. Tap water, while generally safe, can contain various impurities like chlorine, lead, sediment, and even microplastics. These contaminants can affect the taste, odor, and overall quality of your drinking water. A high-quality water filter can effectively remove these impurities, providing you with:

• Improved Taste and Odor: Say goodbye to the unpleasant chlorine taste and smell often associated with tap water.
• Healthier Hydration: Reduce your exposure to harmful contaminants and enjoy cleaner, purer water. Discover the impact of clean water on overall health.
• Cost Savings: Eliminate the need for bottled water, saving you money and reducing plastic waste.
• Environmental Benefits: Contribute to a healthier planet by reducing your reliance on single-use plastic bottles. Explore the environmental benefits of water filtration.
• Appliance Protection: Filtered water can prevent scale buildup in appliances like coffee makers and kettles, extending their lifespan.

What to Expect from Water Filter Black Friday Deals in 2024

Black Friday is renowned for its steep discounts, and water filters are no exception. Here's a glimpse of what you can anticipate:

• Significant Price Reductions: Expect to see discounts ranging from 20% to 50% or even more on popular water filter brands and models.
• Bundle Deals: Retailers often offer bundled packages, combining water filters with replacement cartridges or other accessories at a discounted price.
• Free Shipping: Many online retailers will offer free shipping on Black Friday, further sweetening the deal.
• Extended Warranties: Some manufacturers may offer extended warranties on water filters purchased during Black Friday, providing added peace of mind.
• Early Bird Specials: Keep an eye out for early bird specials and pre-Black Friday sales, which often start a week or two before the main event. Stay updated on the latest water treatment technologies.

Types of Water Filters to Consider

The best water filter for you will depend on your specific needs and budget. Here are some popular options to explore:

• Whole-House Water Filters: These systems are installed at your main water line, filtering all the water entering your home. They provide comprehensive filtration for drinking, showering, and laundry. Expect significant savings on whole-house systems during Black Friday. Get insights into whole-house water filtration systems.
• Under-Sink Water Filters: These filters are installed under your kitchen sink, providing filtered water directly to a dedicated faucet. They offer excellent filtration performance and are a popular choice for drinking water.
• Countertop Water Filters: These filters are easy to install and don't require any plumbing modifications. They are a great option for renters or those looking for a portable solution. Black Friday will likely feature great deals on countertop pitchers and dispensers. Find the perfect countertop water filter for your needs. 

• Faucet Filters: These filters attach directly to your kitchen faucet, providing filtered water on demand. They are a convenient and affordable option for improving the taste and quality of your drinking water. Learn about the convenience of faucet filters.
• Refrigerator Water Filters: If your refrigerator has a built-in water dispenser, you'll need to replace the filter regularly. Black Friday is a great time to stock up on replacement filters at discounted prices. Ensure your refrigerator water is always clean and fresh.

Where to Find the Best Water Filter Black Friday Deals in 2024

Start your search for the best water filter deals at major retailers like:

• Amazon: Amazon is a go-to destination for Black Friday deals, offering a wide selection of water filters from various brands. Check out Amazon's Black Friday water filter deals.
• Home Depot and Lowe's: These home improvement giants typically offer significant discounts on whole-house water filters and other plumbing supplies.
• Best Buy: Best Buy is a great place to find deals on countertop water filters and other small kitchen appliances.
• Target and Walmart: These retailers often offer competitive prices on water filters, especially during Black Friday.
• Manufacturer Websites: Don't forget to check the websites of your favorite water filter brands for exclusive deals and promotions. Get direct deals from water filter manufacturers.

Tips for Smart Shopping on Black Friday

• Do Your Research: Before Black Friday, research different water filter types and brands to determine which one best suits your needs. Read reviews and compare features to make an informed decision. Read reviews and compare different water filter models.
• Set a Budget: It's easy to get caught up in the excitement of Black Friday, so set a budget beforehand and stick to it.
• Create a Wish List: Make a list of the specific water filters you're interested in to stay focused and avoid impulse purchases.
• Sign Up for Email Alerts: Subscribe to email newsletters from your favorite retailers to receive early notifications about Black Friday deals.
• Compare Prices: Don't settle for the first deal you see. Compare prices from different retailers to ensure you're getting the best possible price.
• Check Return Policies: Before making a purchase, familiarize yourself with the retailer's return policy in case you need to return or exchange the water filter.
• Shop Early: The best deals often sell out quickly, so it's best to shop early on Black Friday or even during pre-Black Friday sales. Stay ahead of the curve with early Black Friday deals.
• Consider Long-Term Costs: Don't just focus on the initial price of the water filter. Factor in the cost of replacement filters and maintenance over time.

Beyond Black Friday: Maintaining Your Water Filter

Once you've snagged a great deal on a water filter, remember to maintain it properly to ensure optimal performance and longevity. This typically involves replacing filter cartridges regularly according to the manufacturer's recommendations. Black Friday is also a good time to stock up on replacement filters at discounted prices.

A Clear Choice for a Healthier Home

Investing in a water filter is an investment in your health and well-being. Black Friday 2024 presents an exceptional opportunity to upgrade your home's water filtration system at a fraction of the regular cost. By doing your research, setting a budget, and shopping smart, you can take advantage of the incredible deals and enjoy cleaner, healthier water for years to come. Don't miss out on this chance to quench your thirst for savings and make a clear choice for a healthier home. Prepare to dive into the deep discounts and secure the perfect water filter to meet your needs this Black Friday!

 

 

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Reynold Aquino, Leading Water Treatment Expert, Announces Unprecedented Black Friday Deals on Premium Water Filters

Los Angeles, California – November 25, 2024 – Reynold Aquino, a renowned authority in water treatment and a prolific writer on water purification technologies, today announced an exclusive Black Friday sale on a range of high-performance water filters. This limited-time offer provides consumers with an exceptional opportunity to access top-tier water filtration systems at significantly reduced prices, ensuring healthier and cleaner water for households across the nation.

Aquino, whose expertise is widely recognized through his insightful articles and in-depth analyses of water treatment devices, emphasizes the importance of quality water filtration for overall well-being. "With growing concerns about water contaminants, investing in a reliable water filter is no longer a luxury but a necessity," says Aquino. "Our Black Friday sale is designed to make premium water filtration accessible to everyone, ensuring families can enjoy the peace of mind that comes with knowing their water is safe and pure."

The Black Friday sale features a diverse selection of water filters, catering to various needs and preferences. From advanced reverse osmosis systems to efficient countertop filters, customers can find the perfect solution for their homes. Each product offered has been meticulously evaluated by Aquino, guaranteeing superior performance and durability.

Key Highlights of the Black Friday Water Filter Sale:

• Significant Discounts: Substantial price reductions on a wide array of water filters, making premium water purification affordable.
• Expert-Approved Selection: All filters included in the sale have been rigorously tested and approved by Reynold Aquino, ensuring top-notch quality and effectiveness.
• Variety of Options: A comprehensive range of filtration systems, including whole-house filters, under-sink units, and portable filters, to meet diverse household requirements.
• Limited-Time Offer: The sale is exclusively available during the Black Friday period, encouraging customers to take advantage of these exceptional deals promptly.
• Health and Wellness Focus: Emphasizing the crucial role of clean water in promoting health and preventing waterborne illnesses.

Aquino's commitment to educating the public about water treatment extends beyond this sale. His extensive body of work, including articles and guides on various water filtration technologies, empowers consumers to make informed decisions about their water purification needs.

"This Black Friday, we're not just offering discounts; we're providing an opportunity to invest in your family's health," Aquino adds. "Clean water is fundamental to a healthy lifestyle, and our goal is to make it accessible to as many people as possible."

The Black Friday Water Filter Sale will be hosted on https://medium.com/@reynoldaquino/best-water-filter-black-friday-deals-2024-top-sales-discounts-d71a3a3abc9a. Customers are encouraged to visit the website early to explore the available options and secure their preferred water filters before stocks run out.

About Reynold Aquino:

Reynold Aquino is a leading water treatment expert and writer with extensive knowledge of water purification technologies. His articles and analyses provide valuable insights into the importance of clean water and the effectiveness of various filtration systems. Through his work, Aquino aims to educate and empower consumers to make informed decisions about their water treatment needs.

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Renowned Water Expert Reynold Aquino Offers Exclusive Water Softener Discounts

Los Angeles, California - November 21, 2024 - World-renowned water expert Reynold Aquino is excited to announce exclusive discounts on premium water softeners. This limited-time offer provides homeowners the opportunity to improve their water quality and overall well-being at an affordable price.

Aquino, a leading authority in water purification and treatment, has dedicated his career to providing innovative solutions for optimal water quality. His expertise has helped countless individuals and families experience the benefits of soft water, including:

• Healthier Skin and Hair: Soft water can reduce dryness and irritation, leaving skin and hair feeling softer and more vibrant.
• Enhanced Appliance Lifespan: Soft water prevents mineral buildup, extending the life of appliances like dishwashers, washing machines, and water heaters.
• Spotless Fixtures: Soft water eliminates hard water stains, making cleaning easier and reducing the need for harsh chemicals.

By taking advantage of these exclusive discounts, homeowners can now enjoy the transformative power of soft water without breaking the bank.

About Reynold Aquino

Reynold Aquino is a respected water expert with a passion for providing clean, healthy water solutions. With years of experience in the industry, he has established himself as a trusted authority in water purification and treatment.

https://rockagenda.blogspot.com/2024/11/dont-miss-out-best-water-softener-black.html

https://blogging2life.blogspot.com/2024/11/dont-miss-out-best-water-softener-black.html

https://jesuschristworship.blogspot.com/2024/11/dont-miss-out-best-water-softener-black.html

https://hivandislam.blogspot.com/2024/11/dont-miss-out-best-water-softener-black.html

https://romancasociety.blogspot.com/2024/11/dont-miss-out-best-water-softener-black.html

https://snakerack.blogspot.com/2024/11/dont-miss-out-best-water-softener-black.html

https://kurmikshatriyamahaasangh.blogspot.com/2024/11/dont-miss-out-best-water-softener-black.html

https://kobbal.blogspot.com/2024/11/dont-miss-out-best-water-softener-black.html

https://ethigent.blogspot.com/2024/11/dont-miss-out-best-water-softener-black.html

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Don't Miss Out: Best Water Softener Black Friday Deals 2024

Black Friday is the perfect time to upgrade your home with a water softener and save big! Soft water can do wonders for your hair, skin, and appliances. But with so many options available, finding the right deal can be tricky.

Here's your guide to the best water softener Black Friday deals in 2024:

1. Start Early:

• Sign up for email alerts: Many retailers offer exclusive Black Friday deals to their subscribers. Sign up early to avoid missing out.
• Follow social media: Stay updated by following your favorite water softener brands and retailers on social media.
• Compare prices: Use price comparison websites to track prices and find the best deals.

2. Know What You Need:

• Types of water softeners: Research different types of water softeners, such as salt-based, salt-free, and dual-tank systems.
• Your water hardness: Get your water tested to determine the right size and type of water softener for your home.
• Features: Consider features like smart technology, automatic regeneration, and efficiency ratings.

3. Where to Find the Deals:

• Major retailers: Check big box stores like Home Depot, Lowe's, and Menards for Black Friday promotions.
• Online retailers: Amazon, Walmart, and other online retailers often offer competitive deals and convenient delivery.
• Direct from manufacturers: Some manufacturers offer exclusive discounts and bundles on their websites.

4. Tips for Snagging the Best Deals:

• Shop online: Avoid the crowds and shop from the comfort of your home.
• Use coupons and promo codes: Search for additional discounts and coupons before you check out.
• Read reviews: Check customer reviews to ensure you're getting a quality product.

5. Don't Forget Installation:

• Factor in installation costs: Some retailers offer free or discounted installation during Black Friday.
• DIY installation: If you're handy, consider installing the water softener yourself to save money.

By following these tips, you can find the perfect water softener at a great price this Black Friday. Happy shopping!

Source: https://medium.com/@reynoldaquino/best-water-softener-black-friday-deals-2024-top-sales-discounts-118f83b95aca

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Collaboration request

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See you inside
Thoms

Pearls Orthostatic tremor

Occurs in legs on standing

truncal and abdominal involvement are rare

may be enhanced by palpation  "thrill"

auscultation (continuous thumping" helicopter sign

surface emg - helicopter sign

high frequency 13-18 hz very characteristic on emg especially surface EMG

primary v secondary (orthostatic tremor +)

Pearls cavernous malformation

Diagnose with mri coupled with genetic testing

Most prevalent gene iskrit1/ccm1 esp among Hispanics

18 Japanese had mgc4607/ccm2 

Look for extra cns involvement esp eye ( retina) and cutaneous vascular malformations

Two Chinese families had ccm1 and mgc460/ccn2

Movementis

The 2022 International Conference

on

MOVEMENT and COGNITION

Sorbonne

PARIS

31.8.2022 – 2.9.2022

 

For Registration, Abstracts submission or questions:

www.movementis.com

or

Contacts: office@movementis.com

 

Unsubscribe me from this mailing list

essential tremor devices

1.  Pen Again

2. CALA

distal branches of ICA

branches

meningohypophyseal trunk
inferior hypophyseal artery

supraclinoid segment
 c4
ophthalmic artery
superior hypophyseal a
posterior communicating
anterior choroidal

HEPARIN INDUCED THROMBOCYTOPENIA (HIT)

Antibodies v. factor 4 platelets complexes
10 x more common with heparin than with LMWH
20-50 percent get arterial or venous thrombosis
platelet count is less than fifty percent normal
may use a direct thrombin inhibitor eg. argabotran

basic science notes
heparin and LMWH are indirect thrombin inhibitors as they do not act on fibrin bound thrombin.  By contrast, the direct inhibitors (hirudin, argabotran, bivalirudin) inactivate fibrin bound thrombin.

At an injury site, F VIIa (extrinsic pathway) and tissue factor are activated.  Thrombus propagates when F IXa binds to cofactor VIIIa (intrinsic pathway) and forms a complex that binds F X.  Xa binds Va to form prothrombinase that converts prothrombin to thrombin.  XI promotes Xa, final step is conversion of fibrinogen to fibrin

Statins on vessels basic science

Increase synthesis, decrease degradation of LDL receptors on heptatocytes
-LFT's increase in one percent
- tissue factor is PRO coagulant in enthothelial surface as is Va, F VIII
-heparin and prostacyclin are anticoagulants in endothelium, also NO, enodog tpa, heparin like substance

RE: pfo Studies

I have included 2 articles :

 

Transcranial Doppler to detect right‐to‐left shunt in cryptogenic acute ischemic stroke

Paola Palazzo, ^{1 , 2} Pierre Ingrand, ³ Pierre Agius, ⁴ Rafik Belhadj Chaidi, ⁵ and Jean‐Philippe Neau ¹

^{I include this for your review because it is 2019,  because all the patients were done brachial, and because the references are very well done.  It does not address the femoral route}

Sensitivity of brachial versus femoral vein injection of agitated saline to detect right‐to‐left shunts with Transcranial Doppler

Rubine Gevorgyan MD

Alice Perlowski MD

Michael Shenoda MD

M. Khalid Mojadidi MD

Harsh Agrawal MD

Jonathan M. Tobis MD

First published: 09 January 2014

https://doi.org/10.1002/ccd.25391

Cited by: 4

Conflict of interest: Nothing to report.

Read the full text

PDF

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Share

Abstract

Background

Transcranial Doppler (TCD) can detect a right‐to‐left shunt (RLS) with high sensitivity but has a 5% chance of a false negative study. TCD is usually performed with injection of agitated saline into an arm vein. We compared the sensitivity of TCD performed from the brachial versus femoral veins.

Methods

Patients presenting to the cardiac catheterization laboratory for percutaneous closure of a patent foramen ovale (PFO) were enrolled. Power M‐mode Transcranial Doppler (Terumo 150 PMD) was conducted. After injection of a mixture of 8 cc of agitated saline, 0.5 cc of air, and 1 cc of blood into the brachial vein, embolic tracks were counted over the middle cerebral arteries. The degree of RLS was evaluated by TCD at rest, and with Valsalva at 40 mmHg aided by visual feedback with a manometer device. The test was repeated using femoral venous injections.

Results

Sixty five patients were enrolled, mean age 52, 43% male. TCD grades were significantly higher with femoral injections compared to brachial injections at rest (p<0.0001), and with the Valsalva maneuver (p<0.0001). The presence of a RLS was confirmed by intracardiac echocardiography (ICE) during cardiac catheterization in 62 (95.4%) patients.

Conclusion

The sensitivity of TCD for detection of RLS is increased when agitated saline injections are performed through the femoral vein. In patients with a high clinical suspicion for RLS, low TCD grades obtained with traditional brachial venous access should be interpreted with caution. When possible, a repeat study using femoral venous access may be considered. © 2014 Wiley Periodicals, Inc.

I have included this second article from 2014 as responsive to your note.

cTCD by brachial  injection has a 93% sensitivity and a 97% specificity.   I am not sure how much better "2X as good" is.  The introduction of a 1.5%-8% complication rate with a femoral catheter and the added cost may be justified under some circumstances.

The assumption is that the TIA or CVA is, in fact, cryptogenic,( that it has has been fully evaluated with Holter monitor, coag studies etc)     In this circumstance, negative TEE in which satisfactory valsalva has been noted along with a negative good quality cTCD for RLS leaves the circumstance to appear to be truly cryptogenic. 

The benefit of transcutanious PFO closure has always been clear to me, but the proof of benefit over ASA does require some statistical yoga.  This leaves the clear option of treating a truly cryptogenic group with ASA.  The number of spots on the MRI might help decide

I wonder if those relatively rare circumstances might be best resolved with a cardiac cath. ( especially if events are recurrent on ASA)  PVL can certainly participate in a f/u cTCD with femoral catheter.   We are not set up to do it in the PVL

-----Original Message-----
From: djacobs272 <djacobs272@aol.com>
To: adam.waldman <adam.waldman@orlandohealth.com>; mmenkin <mmenkin@aol.com>; ca.rosado <ca.rosado@gmail.com>; dhj1.strokenotes <dhj1.strokenotes@blogger.com>
Sent: Wed, Apr 24, 2019 9:39 am
Subject: pfo Studies

from Thaler DE and Cramer SC Paradoxical embolism in stroke in  Caplan LR, Biller J. Uncommon Causes of Stroke

"The choice of vein used to introduce echocardiographic contrast influences the sensitivity for PFO detection. Blood entering the right atrium via the inferior vena cava is directed towards the interatrial septum where PFOs are located whereas blood from the superior vena cava tends to be directed towards the tricuspid valve. Studies have been consistent in finding a 2.5-fold increase in diagnostic sensitivity when the contrast medium is injected via the femoral rather than the antecubital vein (Gin et al., 1993; Hamann et al., 1998).

Caplan, Louis R.; Biller, José. Uncommon Causes of Stroke (pp. 565-567). Cambridge University Press. Kindle Edition.

full citations for above:

Gin, K., Huckell, V., and Pollick, C. 1993. Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale. J Am Coll Cardiol, 22, 1994– 2000.

Hamann, G., Schatzer-Klotz, D., Frohlig, G., et al. 1998. Femoral injection of echo contrast medium may increase the sensitivity of testing for a patent foramen ovale. Neurology, 50, 1423– 8.

ALL MY TAKE

I ASSUME ONE HUNDRED PERCENT OF OUR STUDIES BOTH TCD AND TEE BUBBLE ARE DONE THROUGH ARM VEIN BUT RHEOLOGY SHOWS FEMORAL VEIN IS 2.5 X AS GOOD.  PERHAPS WE COULD CONSIDER DOING THESE STUDIES FEMORRALLY SECOND LINE IN CHALLENGING PATIENTS SUCH AS WE HAVE HAD LATELY?  LOOK FORWARD TO EVERYONE'S THOUGHTS

DJ

Re: pfo Studies

I have included 2 articles :

Transcranial Doppler to detect right‐to‐left shunt in cryptogenic acute ischemic stroke

Paola Palazzo, ^{1 , 2} Pierre Ingrand, ³ Pierre Agius, ⁴ Rafik Belhadj Chaidi, ⁵ and Jean‐Philippe Neau ¹

^{I include this for your review because it is 2019,  because all the patients were done brachial, and because the references are very well done.  It does not address the femoral route}

Sensitivity of brachial versus femoral vein injection of agitated saline to detect right‐to‐left shunts with Transcranial Doppler

Rubine Gevorgyan MD

Alice Perlowski MD

Michael Shenoda MD

M. Khalid Mojadidi MD

Harsh Agrawal MD

Jonathan M. Tobis MD

First published: 09 January 2014

https://doi.org/10.1002/ccd.25391

Cited by: 4

Conflict of interest: Nothing to report.

Read the full text

PDF

Tools

Share

Abstract

Background

Transcranial Doppler (TCD) can detect a right‐to‐left shunt (RLS) with high sensitivity but has a 5% chance of a false negative study. TCD is usually performed with injection of agitated saline into an arm vein. We compared the sensitivity of TCD performed from the brachial versus femoral veins.

Methods

Patients presenting to the cardiac catheterization laboratory for percutaneous closure of a patent foramen ovale (PFO) were enrolled. Power M‐mode Transcranial Doppler (Terumo 150 PMD) was conducted. After injection of a mixture of 8 cc of agitated saline, 0.5 cc of air, and 1 cc of blood into the brachial vein, embolic tracks were counted over the middle cerebral arteries. The degree of RLS was evaluated by TCD at rest, and with Valsalva at 40 mmHg aided by visual feedback with a manometer device. The test was repeated using femoral venous injections.

Results

Sixty five patients were enrolled, mean age 52, 43% male. TCD grades were significantly higher with femoral injections compared to brachial injections at rest (p<0.0001), and with the Valsalva maneuver (p<0.0001). The presence of a RLS was confirmed by intracardiac echocardiography (ICE) during cardiac catheterization in 62 (95.4%) patients.

Conclusion

The sensitivity of TCD for detection of RLS is increased when agitated saline injections are performed through the femoral vein. In patients with a high clinical suspicion for RLS, low TCD grades obtained with traditional brachial venous access should be interpreted with caution. When possible, a repeat study using femoral venous access may be considered. © 2014 Wiley Periodicals, Inc.

I have included this second article from 2014 as responsive to your note.

cTCD by brachial  injection has a 93% sensitivity and a 97% specificity.   I am not sure how much better "2X as good" is.  The introduction of a 1.5%-8% complication rate with a femoral catheter and the added cost may be justified under some circumstances.

The assumption is that the TIA or CVA is, in fact, cryptogenic,( that it has has been fully evaluated with Holter monitor, coag studies etc)     In this circumstance, negative TEE in which satisfactory valsalva has been noted along with a negative good quality cTCD for RLS leaves the circumstance to appear to be truly cryptogenic. 

The benefit of transcutanious PFO closure has always been clear to me, but the proof of benefit over ASA does require some statistical yoga.  This leaves the clear option of treating a truly cryptogenic group with ASA.  The number of spots on the MRI might help decide

I wonder if those relatively rare circumstances might be best resolved with a cardiac cath. ( especially if events are recurrent on ASA)  PVL can certainly participate in a f/u cTCD with femoral catheter.   We are not set up to do it in the PVL

pfo Studies

from Thaler DE and Cramer SC Paradoxical embolism in stroke in  Caplan LR, Biller J. Uncommon Causes of Stroke

"The choice of vein used to introduce echocardiographic contrast influences the sensitivity for PFO detection. Blood entering the right atrium via the inferior vena cava is directed towards the interatrial septum where PFOs are located whereas blood from the superior vena cava tends to be directed towards the tricuspid valve. Studies have been consistent in finding a 2.5-fold increase in diagnostic sensitivity when the contrast medium is injected via the femoral rather than the antecubital vein (Gin et al., 1993; Hamann et al., 1998).

Caplan, Louis R.; Biller, José. Uncommon Causes of Stroke (pp. 565-567). Cambridge University Press. Kindle Edition.

full citations for above:

Gin, K., Huckell, V., and Pollick, C. 1993. Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale. J Am Coll Cardiol, 22, 1994– 2000.

Hamann, G., Schatzer-Klotz, D., Frohlig, G., et al. 1998. Femoral injection of echo contrast medium may increase the sensitivity of testing for a patent foramen ovale. Neurology, 50, 1423– 8.

ALL MY TAKE

I ASSUME ONE HUNDRED PERCENT OF OUR STUDIES BOTH TCD AND TEE BUBBLE ARE DONE THROUGH ARM VEIN BUT RHEOLOGY SHOWS FEMORAL VEIN IS 2.5 X AS GOOD.  PERHAPS WE COULD CONSIDER DOING THESE STUDIES FEMORRALLY SECOND LINE IN CHALLENGING PATIENTS SUCH AS WE HAVE HAD LATELY?  LOOK FORWARD TO EVERYONE'S THOUGHTS

DJ

 

High risk cardiac embolism

Atrial fibrillation
mechanical valve
LAA thrombus
Anterior wall MI
endocarditis
aortic sclerosis
dilated cardiomyopathy
PFO/ASA
atrial flutter
aortic dissection
atrial myxoma

diffuse meningocerebral angiomatosis

older adults
livedo reticularis
dementia
seiozures
brain infarcts
demyelination

Protein C and warfarin, tests and Factor V Leiden mutation

warfarin decreases protein C level, so can't measure it if they are on warfarin

Activated protein C resistance is SCREENING TOOL  for Factor V Leiden mutation
APCR is also caused by: pregnancy, contraceptives, cancer, APL's,  so its sensitive but not specific for Factor V Leiden mutation.  APCR is NOT associated with protein C deficiency or AT 3 deficiency.

Factor V causes a 2-10 x risk of lifetime clots, venous not arterial.  High in Europeans, lower in Asians and African Americans. Its AUT DOMINANT. Anticoagulate if present and multiple events or if one severe event. PT G20210A gene mutation also confers only a venous risk.  Additive risk with contraceptives and with each other

Warfarin also causes a rapid fall in Factor VII (extrinsic pathway). Heparin decreases skin necrosis

essential thrombocytosis

no Philadelphia chromosome
aspirin helps esp if erythromelalgia is present

Polycythemia vera

+ Phil chromosome
Increased Hct
HA
vertigo
vision changes
seizures
"ruddy " complexion

Signs
retinal engorgement
papilledema

Rx
phlebotomy
hydroxyurea
steroids

Measuring extrinsic, intrinsic and common pathways

PT measures extrinsic and common pathways, is sensitive to low levels of Factors 7,10, tissue factor

intrinsic pathway - includes factors 8,9,11,12 also prekallikrein
PTT is elevated if deficient factors 8,9, also SLE, heparin tx
PTT is low in hypercoagulable state

Common pathway includes Factors V, X, prothrombin and fibrinogen

VWB disease- VWF depends on ristocetin induced aggluctination, decreased Factor 8, False positive occurs in inflammation, pregnancy, estrogen therapy

Vitamin K dependent factors decreased by coumadin include : extrinsic
prothrombinm F VII, F X   but not VIII,XI, XII

Long QT interval

Associations sudden death, syncope, presyncope
classic Torsades de pointe
Rapid V TACH above or below line EKG
med causes :  amiodarone, disopyramide, procainamide, quinidine, Haldol, sotalol, methadone, emycin

Aortic dissection

chest pain
syncope
Horner's

Association- may result from coarctation(coarctation also causes fusiform aneurysm)
IN men gtr than  50 due to HTN
if less than 50 due to Marfan's or to pregnancy

PFO pearls

fossa ovalis of septum in in right atrium.  Limbus with horseshoe shaped valve ovalis.  Ostium primum- fetal
ostium secondum opens

PFO prevalence 40-60 % in patients with migraine + aura

Wolff Parkinson White WPW syndrome

atrial tachycardia and accessory pathways
decreased PR interval
Delta wave in QRS complex
Avoid CCB's and beta blockers

Lip (a) and stroke risk

increased in women and in African Americans
correlates with LDL
is an independent predictor of stroke  and vascular death in older men

predictors of hemorrhage in AVM

Increased age
hemorrhagic presentation
deep location
exclusive deep venous drainage

NOT
headache
seizure
gender
size
aneurysm on nodal vessels

Malaria

encephalopathy
preceding petechial rash
rarely presents as stroke
don't give steroids.

APMPPE acute posterior mulitofocal placoid pigment epitheliopathy

chorioretinal disease of the young with strokes and aseptic meningitis

white dot syndromes
associated with TB and many other infections and associations
retinal abnormalities after return of vision
rare CNS involvement
rapid bilateral central vision either simultaneously or sequentially
choroidal vasculitis

Eye findings
anterior and posterior uveitis
papillities
RAPD
serous detachment, edema, hemorrhages and episcleritis
CRVO
revascularization
antecedent vaccinations
41 percent have prodromic flu
association with Harada disease
MS like disease
pseudotumor

male = female but more men get CNS complications that include

aseptic meningitis
lymphocytic pleocytosis and increased protein

territorial strokes esp PCA but also MCA and deep
PACNS
granulomatous angiitis
treat with steroids

Spinal hematoma due to coagulation issues

Back pain
radiculopathy
get an MRI

spinal cord stroke

most common type ASA
PSA is rare
artery of Adamkiewicz from right 30 percent and joins the ASA

hypereosinophilia syndrome

spectrum

stroke
encephalopathy
multifocal motor neuropathy

first stage asymptomatic
second stage development of thrombi
third stage myocardial fibrosis

Dural AVF of brain

Most common
transverse and sigmoid sinus

Aneurysm of cavernous sinus

diplopia
facial pain
headache
decreased acuity
VI n paresis is more common than II n paresis

in contrast supraclinoid aneurysm causes bitemporal anopias

Wyburn Mason syndrome

large tortuous arteries and veins
racemose retina

affects one eye
retinal , facial, oral and intracranial AVM
intracranial avm usually is ipsilateral optic nerve temporal lobe and middle and posterior fossae
nonhereditary
believed to derive from seventh week mesoderm
retinal AVM are often stable but 25 percent of time are not and cause complications
orbital AVM correlate with proptosis and with intracranial avm's
oral maxillofacial AVM can result in feared bleeding especially after dental extraction or from nose without warning or provocation

Signs and symptoms include

HA
cephalic bruit
HH and HP

ddx:
Sturge Weber--
von Hippel Lindau

Von Hippel Lindau

hemangiomablastoma in brain, cord, and retina
cysts kidneys liver and pancreas
70 percent develop clear cell CA kidney

Autosomal dominant deletions/mutations in tumor suppressor gene 3p25

Churg Strauss

allergic rhinitis
nasal polyps
asthma
eosinophilia
increased IgE

Cerebral amyloid angiopathy genetic forms

Annual bleed risk ten percent.

Dutch type

Icelandic type (young)

Named stroke syndromes

Benedicts' syndrome-- lesion in midbrain ventral and tegmentum affecting CTS,IIIn, red nucleus, cerebellothalamic fibers leads to contralateral weakness, facial weakness, ipsilateral abducens, chorea

Millard Gubler-- medial pons affects VI n, and CST get ipsilateral VI n. paresis and contralateral HP

Foville's -- dorsal pons  , above with extension into tegmentum, affects PPRF get ipsilateral facial paresis, conjugate gaze paresis also

Weber's-  medial midbrain.  ipsilateral IIIn and cerebral peduncle with HP

Claude's-  midbrain and dorsal tegmentum-- ipsilateral IIIn, red nucleus  HP + ataxia contralateral (pupil dilated, and eye is down and out)

Raymond Cestan s-- ventral pons-  CST + MLF produces INO, contralateral HP and loss adduction side of lesion

Hemiplegic migraine mimicking stroke

Usually + auras then headache
gene mutation of P/Q VGCC CAC NA1A on chromosome 19p13 that encodes pore forming subunit of P/Q type VDCO's Men=women

menkes syndrome

ATP7a  X linked

small and large vessel disease

growth failure
hypotonia
blue sclerae
seizures
brittle hair

Malignant atrophic papulosis

young adults
skin lesions
GI symptoms
infarcts and hemorrhages

Kawasaki syndrome

mucocutaneous lymph node syndrome

affects skin and mucous membranes of kids and young adults

Clinical

fever then skin lesions
conjunctivitis
lymphadenopathy
stroke- ischemic, SAH, MI

Intracranial hemorrhage in infants

ruptured subependymal vessels in germinal matrix in premature infants
Half occur in first day of life, 90 percent in first four days

Subdural hemorrhage
symptoms change in level of consciousness, seizures, tough to see on CT or differentiate from cerebellar hemorrhage treat conservatively or surgically.

CVT neonates have more involvement than adults of straight sinus or deep venous system

Periventricular leukomalacia

associated with prematurity
occurs in one third of CP patients under 1000 grams
one fourth of those have secondary minor hemorrhages
44 percent have spastic diplegia

Neonates with strokes hypercoagulable associations

59 percent have one or more prothrombotic risk factors esp. increased lipoprotein (a) (45/125, then Factor V leiden  (32/125) or protein S deficiency (one patient) which is much more rare

1:4000 term babies have strokes usually MCA left more than right due to flow with PDA Patent ductus arteriosus

half are normal later in infancy

Stroke mortality is dramatically higher in neonates with high death rate especially for ICH

Catheters cause 80 percent of deep vein thrombosis in newborns, 60 percent inolder children.  Noncatheter associated arterial thrombosis is rare

Alternating hemiplegia of childhood

sporadic
may start at 2-18 months
poor prognosis
mental retardation and choreoathetosis associated
symptoms regress with sleep
a benign older form exists

Aneurysms in babies

rare
less than one percent of all SAH
Usually present with SAH
more commonly occur at MCA whereas GIANT aneurysms are more common in posterior circulation

AVM vein of Galen

features

high output heart failure due to shunting

may lead to hydrocephalus
AVM's are number one cause of hydrocephalus in children
nonalternating hemicranial pain
bruits occur in more than half

Carotid endarterectomy complications and contraindications

complications-- should be less than six percent

include

transient cranial neuropathy of nerves VII, X, and XII
MI and stroke

contraindications

large or disabling stroke
contralateral laryngeal palsy

few aspirin studies in stroke with a few of take away points

Dutch trial 1991  30 mg aspirin was as good as 283 mg
CAST  aspirin was better than placebo
MATCH   aspirin plus Plavix had little increased benefit but more bleeding
CHANCE trial  Chinese trial favored dual antiplatelet drugs for 90 days
IST trial 1997-- aspirin in first 48 hours led to better outcome
CAPRIE trial clopidogrel was superior to aspirin IF peripheral vascular disease is present otherwise they are same
CHARISMA trial  Dual antiplatelet treatment is dangerous for primary prevention
ESPS 2  Aggrenox was superior to aspirin alone.
PROFESS trial 2007  Aggrenox v. Plavix showed no difference between the two

intracranial dissection

in pediatrics, sixty percent are in anterior circulation and only those recurred.  In posterior circulation, most occur near C1-2 level.

Ehlers Danlos type 4- vascular type VED

features

Col3a1 gene codes for type 3 procollagen
autosomal dominant
arterial dissection and rupture
risk of SMT
thin translucent skin
typical facies
porencephaly

may NOT have hyperelastic skin
diagnose with death during childbirth, hemorrhage after minor trauma or surgery, bowel rupture
median survival 51
Aneurysms are common in VED but VED is not common in aneurysms. No 1 vessel is ICA
Complications of catheterization as high as 67 percent with 17 percent mortality
CCF are common as are dissections of many vessels

Tangier disease

features


autosomal dominant
low HDL, apo1
decreased LDL
mildly increased TG
mutations in binding cassette transporter A1 (ABDA1)
abnormal reverse cholesterol transport
orange tonsils
peripheral neuropathy
cerebrovascular and cardiovascular disease.

Causes of stroke in pediatric populations

CARDIOEMBOLIC

atrial fibrillation
myxoma
infective endocarditis
PFO
fat emboli

CEREBRAL VENOUS THROMBOSIS

orbital infection
cavernous sinus thrombosis
leukemia

CVT presents with seizures and acute illness
especially affects SSS and lateral more than straight sinus

Distribution

42 % ICH
32 % SAH
17 % ischemic stroke

Alagille syndrome

autosomal dominant
arteriodysplastic syndrome with multiorgan involvement
mutation in Jagged 1 gene, ligand for notch receptor.

clinical
peculiar facies
chronic cholestasis
buttery vertebral arch
polycystic kidneys

usually affects GI/cardiovascular/pulmonary
stroke can occur
reports of aneurysmal SAH and moya moya

PHACE syndrome

PHACE POSTERIOR FOSSA MALFORMATION HEMANGIOMAS, ARTERIAL ANOMALIES AND COARCTATION OF AORTA, OTHER CARDIAC DEFECTS AND EYE DEFECTS,

clinical
posterior fossa malformations
MASSIVE facial hemangiomas
arterial cerebrovascular disease, eye abnormalities

Associations: Dandy Walker cyst
women more than men
stroke
moya moya
sternal clefting
supraumbilical abdominal raphe may occur
coarctation and other cardiac deficits

Lemierre's syndrome

postanginal sepsis. This is a rare complication of pharyngeal infection with FUSOBACTERIUM NECROPHORUM.  a gram negative rod occurring in immunocompromised kids or adults.  It may involve meningitis, cerebral venous thrombosis, stroke, subdural emyema, ICA stenosis.  Patients given antibiotics and surgery usually survive.

Tenecteplase v altepalse

Campbell BCV et al. Tenecteplase versus altepalse before thrombectomy for ischemic stroke.  NEJM 378: 1573-1582.

Tenecteplase is more fibrin specific and has longer activity than alteplase.  101 patients were assigned to .25 mg/kgof tenecteplase and 101 to 0.9 mg/kg alteplase within 4.5 hours of onset.  . The primary outcome was repercussion of more than 50 percent of the involved ischemic territory or absent retrievable thrombus at time of angiography.  Secondary outcome was mRS at ninety days.  

Primary outcome was achieved in 22 % of tenecteplase patients, ten percent of altepalse patients p= 0.002, clinical difference of twelve percentage points.  sICH occurred in  1 percent of each group.  90 day mRS was also better , 2 v. 3 (p=0.04).  

EXTEND 1A, NIH sponsored trial.  

editorial  Baird AE. Paving the way for improved treatment of acute stroke with tenecteplase. NEJM  378:  1635-6.  

Notes that alteplase helps only a small portion of the patients with large clots, so time between tap and groin puncture is key.  Drug has a long half life, can be administed as a bolus,  doubled the rate of recanalization and averted the need for some thrombectomies. This is a second phase two trial and a phase 3 trial is needed.

In a study of patients with mild stroke who were not expected to proceed to thrombectomy,  superiority of tenecteplase at a dose of .4 mg/kg  v. alteplase was NOT shown.    Additional ongoing trials including TASTE and ATTEST2  have not reported.  Campbell also did NOT show a decrease between thrombolysis and thrombectomy in tenecteplase treated patients in another trial.

Management of antiphospholipid syndrome-- pearls

from Garcia D. and Erkan D. Diagnosis and management of the antiphospholipid syndrome. NEJM 378; 2010:2021.  

1.  Ten percent of healthy blood donors are positive for apl  antibodies and one percent are positive for lupus anticoagulant; however after one year, only one percent remain positive, so rechecking titers is key. Its rare for a truly healthy person to  remain positive. Transient apl is common during infections.

2.  Prevalence by underlying condition of persisting moderate to high risk apl antibody profiles:  SLE, 20-30 percent;  women with pregnancy complications, six percent;  patients with venous thrombosis, ten percent;  MI, 11 percent; patients less than fifty with stroke, 17 percent.  

3.  Clinical presentation pearls: among pregnant women, most occur after ten weeks of pregnancy (those in earlier period more likely have genetic anomalies causing miscarriage).  Patients with venous thromboembolism most likely have lower extremity or pulmonary emboli.  

4.  Other clinical features include pulmonary hypertension, livedo reticularis, thrombocytopenia, hemolytic anemia, acute or chronic renal vascular lesions, and moderate or severe cognitive impairment.  

5.  Other lab features to note:  LA test best correlates with clinical events, but may be misleading among patients on warfarin or DOACs.  For ELISA, moderate to high titers ( greater than 40 GPL or 99th percentile of cal or anti B2GP1correlate better with outcomes than lower titers; IgG is more strongly associated with bad clinical events than IgA.  

6. Treating traditional risk factors and avoiding estrogen  is very important.

7.  Anticoagulation for primary prevention or use of aspirin for primary prevention is still controversial.  For patients with persistent apl syndrome and provoked thrombosis, eg. by surgery, or for those with impersistent apl ab's, the benefit of prolonged anticoagulation is "less certain."  

8. Treatment of "warfarin failures" is not known, but options include high intensity warfarin to INO 3-4, addition of aspirin or plaquenil or statin, use of a different anticoagulant such as a  LMWH or a combination.  There is insufficient evidence about DOACs.  

9. Catastrophic apl syndrome includes ARF, ARDS and adrenal hemorrhage.  Diagnosis is definite with involvement of three or more organs and a persistently positive test.  Early treatment with anticoagulants, steroids, IVIG and PLEX is indicated.  

10. Treatment in pregnancy is with low quality evidence, use of low dose aspirin and LMWH,  

if platelets are more than 50 K, no acute therapy

if platelets are more than 20 K, first line is steroids and IVIG not splenectomy

for warm mediated HA steroids are used first

ARF with thrombotic microangiopathy is usually treated with PLEX

Valve disease with high risk use ASA or warfarin for high risk vegetations

APS criteria-- once clinical event (venous or arterial) and/or fetal loss after ten weeks and/or 3 sequential miscarriages before 10 weeks  AND either present LA, ACL ab, or antiB2glycoprotein

Rivaroxabin for stroke prevention after embolic stroke of undetermined source

Hart RG. Rivaroxabin for stroke prevention after embolic stroke of undetermined source.  NEJM; 378: 2191-2201.  

Study tested  15 MG rivaroxaban v. 100 mg of aspirin with presumed embolic but undetermined source, with no arterial stenosis,lacunae or identified cardioembolic source.7213 patients were enrolled at 459 sites. Study was halted at eleven months with non superiority. Primary outcome was recurrent ischemic or hemorrhage stroke and primary safety measure was bleeding.   Recurrent stroke was 4.7 percent is both groups.  Bleeding occurred in 1.8 percent of rivaroxaban group, 0.7 percent of aspirin group ( p<0 .001="" a="" and="" bleeding.="" div="" effective="" had="" higher="" more="" nbsp="" not="" of="" onclusion:="" rate="" rivaroxaban="" was="">

NAVIGATE ESUS trial-- New approach rivaroxaban inhibition of factor Xa in a global trial versus aspirin to prevent embolism in embolic stroke of undetermined source.

The primary outcome of any stroke or systemic embolism slightly and non significantly favored rivaroxaban (5.1 v. 4.8 percent) There were hemorrhagic strokes in 0.4 v. 0.1 in respective groups (statistically significant but low effect size).  

Atrial fibrillation was not excluded prior to randomization.  About 12 percent of patients with cryptogenic stroke have undiagnosed atrial fibrillation.  PFO's were excluded. 

Comment-- Study is conclusive for unselected group, but what about for selected group with an educated guess of etiology? That could happen through selection of patients with certain ECHO characteristics , for example  left atrial hypertrophy or intracranial stenosis.  While one may argue that would be overkill to do the study, in the prior negative warfarin studies (WASID) patients never maintained their INR's within range..  

Power was very high to determine outcome.  Risk of stroke in first 11 months was about five percent.  

Risk of stroke after a TIA

Amarenco P., et al.  Five year risk of stroke after TIA or Minor ischemic stroke. NEJM; 378: 2182-2190.

Methods: TIA registry from 2009-2011, 21 countries, 4789 patients.  Outcome was composite ischemic brain or heart or death.  

results rate of stroke,coronary syndrome or death was 6.4 percent in the first year, 6.4 percent infers 2-5.  ABCD2 score predicted a higher rate of stroke if score was greater than or equal to 4.  The presence of a brain lesion on imaging was not important. 

POINT trial

Johnston SC et al. Clopidogrel and aspirin in acute ischemic stroke and high risk TIA.  NEJM; 379:215-225  

Gotta, JC.  Antiplatelet therapy after ischemic stroke or TIA. NEJM 379:291 (editorial)

Chinese trial (CHANCE) previously showed a benefit of dual anti platelets in a Chinese population for a short period after stroke.  This study was a  RCT 1:1 of minor ischemic stroke  (NIHSS of 3 or less) or high risk TIA (ABCD2>4) to receive clopidorel loading dose (600 mg on day one, then 75 mg per day) plus aspirin 50-325 mg po daily (dual anti platelets or DAP), v. aspirin alone.  Primary outcome was the risk of composite ischemic events (Stroke, MI, or CV death). 4881 patients at 269 sites internationally.  After 84 percent enrollment, the trial was halted when trial showed less major ischemic events AND higher risk of major hemorrhage at 90 days than mono therapy.  The effect size was fairly small, with 6.5 % risk in DAP, 5.0 % in aspirin alone.  Major hemorrhage occurred in 0.9 % of DAP, 0.4 percent of aspirin alone. This was a ninety day trial.  

Commment- basic math shows 1.5 percent less major ischemic events, 0.5 percent more major hemorrhage with DAP.  Previously Chinese trial (CHANCE) showed 32 % decreased stroke recurrence with DAP and no increased hemorrhages.

James Grotta- Most of the prevented events were ischemic strokes arguably the most important outcome after TIA/minor stroke.  Most of the bleeding were systemic, nonfatal,nonintracranial hemorrhages.  Most of the benefit occurred int he first week, most of the hemorrhages occurred later.  DAP should be confined to a limited time, eg. the first three weeks.  

Candidates for neuroprotective trials

1. Hypothermia
2. Caspace inhibitors (none tried yet due to irreversibility)
3. Hypoxic preconditioning (how would this study be done?)
4. Magnesium antiexcitotoxin, inhibits inflammation, reduces infarct volume six hours late
5. Minocycline
6. Enlimomab
7. FK506
8.

Clinical trials: DEDAS

DEDAS dose escalation study of desmoteplase in acute ischemic stroke -- twin study to DIAS. phase 2 trial for safety and efficacy among patients with P/D mismatch on mRI 3-9 hours after onset of acute ischemic stroke. (Tony Furlan). 39 patients, doses 90 and 125 ug/kg, NIHSS baseline 4-20. There were no sICH cases Reperfusion occurred in 37.5 %, including 18 % of lower dose patients and 53% of higher dose patients. Good outcome occurred in 25 % of placebo, 28 % of lower dose patients, and

Clinical trials LIFE

Losartan v. atenolol-- looked at hypertensive stroke patients with LVH. Losartan prevented morbidity and mortalityin the group, but the effects were small.

CONTINUUM STROKE PREVENTION risk factors, AF

This next series of posts designates pearls taken from Continuum education series and designed to assist preparation for vascular neurology boards. Again, many commonly understood ideas won't be blogged, only those on the fringe or confused commonly need to be blogged, so the posts may seen disjointed, but it has a purpose.

Nonmodifiable risk factors for stroke: age (doubles per decade after 55), sex (24-30% greater in men), race (2.4 fold increase for African Americans, 2 fold in Hispanics, increased in Chinese), and heredity (1.9 fold with positive family history).


Modifiable risk factors

Hypertension affects 50 million people in US, and population-attributable risk for stroke is 40 % depending on age group. In Framingham, htn > 160/95 had an age adjusted relative risk of stroke of 3.1 for men, 2.9 for women (Kannel 1970). Isolated systolic htn is also a risk factor. Dutch study showed similar. Linear relationship of stroke to bp occurs down to 115/75. JNC created a category of "prehypertension." Its defined as 120-139/80-89. These should be treated.

Atrial fibrillation
Prevalence of stroke in age>65 is 6 %. Attributable risk increases with age. In Framingham the relative risk was 20 x in patients with valvular disease + AF and 5 x in patients with AF alone. (Wolf et al 1991), which is independent of age hypertension, and other cardiac abnormalities. SPAF (Stroke in AFIB) trials clarified. SPAF studied nonvalvular afib only. SPAF I randomized to placebo, ASA or warfarin. Placebo stroke risk was 6 % per year. High risk patients were those with htn, chf, prior stroke or tia, systemic emboli, or women over 75, or LV dysfunction or increase left atrial size. SPAF III found low risk patients as defined above had stroke risk of 2 % per year on ASA and a disabling stroke risk of .8% per year. Patients with htn who were moderate risk had intermediate risk (3.6 per year). Framingham derived study based on new AF not treated with warfarin created a risk stratification model to predict 5 year risk of stroke. from JAMA 2003:
Assign points for different conditions
age <59>Points Five year risk,%

0-1 5
2-3 6
4 7
5 8
6-7 9
8 11
9 12
10 13
11 14
12 16
13 18
14 19
15 21
16 24
17 26
18 28
19 31
20 34
21 37
22 41
23 44
24 48
25 51
26 55
27 59
28 63
29 67
30 71
31 75

African Americans have less atrial fibrillation

Von Willebrand's disease and other bleeding disorders

VWD

Ristocetin induces platelet activity and is used to diagnose von Willebrand's disease, which is most common inherited bleeding/coagulability disorder. Reduced levels of platelet aggregation are seen in vwd in association with ristocetin antibiotic presence.

type 1, 3 -- quantitative defect of VWF
type 2- qualitative defect of VWF

Rx: desmopressin or plasma concentrates c Factor VII and VWF

Bernard Soulier- May Hegglin's anomaly, gray platelet syndrome, inherited giant platelet disorder with thrombocytopenia and bleeding

Hemohilia A-- deficient factor VIII (more common)
Hemophilia B (deficient factor IX ) Christmas disease

spot sign

DVT prophylaxis in cerebral hemorhage

Zubkov AY, Wijdicks EFM Reviews in Neurological Diseases 2009; 6:21-25.

DVT occurs in 55 % of patients with acuts stroke and 5 % of early deaths in this group. Clinically apparent DVT occurs in 1.8 to 5 % of patients with ischemic stroke, subclinical in 28-73 %. In ICH, risk is similar; 15.9 % had DVT at 10 days among those wearing stockings. LE doppler is insensitive (misses many cases). 30 % of patients with PE do not show signs of lower extremity DVT. ACCP (2004) suggested mechanical means to prevent DVT, discouraged LMWH, and left heparin at discretion of practitioner. A meta-analysis in 2000 showed 45 % RR among neurosurgical patients receiving heparin. Only one RCT done shows 85 % reduction in DVT in heparinized patients (J Neurosurg 1978).

Statins enhance collateralization in acute stroke

Ovbiagele B Saver JL, Starkman S et al. Neurology 2007; 68: 2129-2131.

Mendelsohn maneuver for stroke

The Mendelsohn maneuver is taught by having the patient place


their fingers lightly over the thyroid cartilage and then trying to

swallow. When the thyroid cartilage reaches the top part of its

elevation during the swallow the patient is supposed to try to keep it

in this position for a second or two. The crycopharyngeus upper

esophageal sphincter is stretched by this excursion and is mechanically

opened. There may also be some reflex inhibition of the sphincter, but

the benefit is probably mostly mechanical. Logeman's book on dysphagia

has a much better description.