Saturday, April 18, 2009
Stroke Outcome by NIHSS and type
rates of recanalization after iv tpa BA 10 % M1 25 %, M2-5 50-60 %,
Outcome based on NIHSS
3-6 90 % excellent regardless
16-22 40 % excellent
lacunar-- 30 % greater chance of improved outcome
NIH > 23, high rate hemorrhage
Outcome based on NIHSS
3-6 90 % excellent regardless
16-22 40 % excellent
lacunar-- 30 % greater chance of improved outcome
NIH > 23, high rate hemorrhage
Tuesday, April 14, 2009
Critical management SAH
Pearls very quick hits new stuff last 20 y
Nimodipine is still used to prevent vasospasm, so is asa and tirilizad
fludrocortison is used to prevent /treat cerebral salt wasting
nonconvulsive seizures occur in about 18%
Nimodipine is still used to prevent vasospasm, so is asa and tirilizad
fludrocortison is used to prevent /treat cerebral salt wasting
nonconvulsive seizures occur in about 18%
CADASIL notes
Major criteria-- headaches, migraine, mood disorder, stroke, tia
Other neurologic --epilepsy, scord infarcts, ICH, episodic increased ICP
path-- osmiophilic granular deposits on vascular basal lamina
increased oxygen extraction rate
notch 3 protein beneficial
thalamic predominance
cerebral microbleeds
CSF may have mild increase protein, otherwise normal
prenanatal testing available with CVS or amnio
chr 19, 50 + mutations
cysteine residue mutation
Other neurologic --epilepsy, scord infarcts, ICH, episodic increased ICP
path-- osmiophilic granular deposits on vascular basal lamina
increased oxygen extraction rate
notch 3 protein beneficial
thalamic predominance
cerebral microbleeds
CSF may have mild increase protein, otherwise normal
prenanatal testing available with CVS or amnio
chr 19, 50 + mutations
cysteine residue mutation
Stroke pearls valvular disease
infective endocarditis== high stroke risk, 20 % usu in first 48 hours, dramatically reduced c ABX, late stroke risk lower 5 %
mechanical valves-- stroke risk highest MV on anticoag rate 3-4 %, AV is 1.2 %, ASA + warfarin is superior
Mycotic aneurysms-- distal branch point serial reimaging, clip if no response to ABX
mechanical valves-- stroke risk highest MV on anticoag rate 3-4 %, AV is 1.2 %, ASA + warfarin is superior
Mycotic aneurysms-- distal branch point serial reimaging, clip if no response to ABX
decompressive craniectomy
Cerebral hemorrhage pearls
peaks after age 50
women more than men
anterior more than posterior
aneurysm anterior, AVM posterior
Rupture risk: higher with BA, budding tip,
Size and risk: < 10 mm, 0.05 % per year; 10 mm 1 %/yr; > 25 mm 6 % per year
peaks after age 50
women more than men
anterior more than posterior
aneurysm anterior, AVM posterior
Rupture risk: higher with BA, budding tip,
Size and risk: < 10 mm, 0.05 % per year; 10 mm 1 %/yr; > 25 mm 6 % per year
U MASS protocol for patient selection for stroke
0-3 hours
*CT, CTA , CT perfusion
*BA, ICA, M-1 occlusion OR ineligible for iv-- consider IA alteplase
*Others i-v alteplase
3-6 hours
CT, CTA, CT perfusion
(alt.) MRI, MRA, MR D/P
Mismatch and occlusion-- proceed with intrarterial
No patient eligible for alteplase intravenously is denied.
*CT, CTA , CT perfusion
*BA, ICA, M-1 occlusion OR ineligible for iv-- consider IA alteplase
*Others i-v alteplase
3-6 hours
CT, CTA, CT perfusion
(alt.) MRI, MRA, MR D/P
Mismatch and occlusion-- proceed with intrarterial
No patient eligible for alteplase intravenously is denied.
Wednesday, April 01, 2009
VerifyNow Platelet function assay system (Accumetrix)
Distilled:
Plavix PF (for Plavix and Ticlid) ICD-9 code V58.63
Aspirin PF (For aspirin) ICD-9 Code V58.66
separate tests for integrilin and reopro (not interested)
Plavix PF (for Plavix and Ticlid) ICD-9 code V58.63
Aspirin PF (For aspirin) ICD-9 Code V58.66
separate tests for integrilin and reopro (not interested)
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