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44 yo right carotid clot vs occlusion

Andrew Barbash — Sat, 19 Jul 2008 00:09:44 +0000

44 yo male. Cardiomyopathy, pacemaker, htn, on transplant list. Was on coumadin due to cardiomyopathy till 5 days ago. Taken off for cardiac cath that did not show new occlusive disease, due to positive stress test. 12 noon fell down, not sure why. Came to hosp, systolic 75, While in ER felt to evolve left facial weakness and very minimal left arm weakness at 4 PM By 8 PM not changed. BP 95 with fluids, starting pressors. Ejection Fraction 5% on echo in past. CT high density right mca? and cant do mri due to above. CTA suggests clot in right carotid siphon with extension to proximal MCA but decent distal collateral filling. Tx pressor support to get systolic over 120, and heparin to keep from clot extension, but most likely not intraarterial unless he declines despite BP support and heparin. Transcranial doppler to be done. Any other thoughts?

Exercise exacerbated neuropathy

Andrew Barbash — Mon, 14 Jul 2008 22:13:02 +0000

Q: 53 year old diabetic with prefer neuropathy – who over the past 6 months has had increasing numbness that gets worse with exertion – he has baseline numbness in his toast bilaterally – and when he works out and when he exercises that numbness starts to creep up to about his knees – and then when he rests over the next 20 to 30 minutes it will go back down to baseline. – and this has been kind of a consistent behavior recently – he has some lumbar disc disease – I’m concerned about kind of this socking and glove(?) numbness – but more importantly – you know – kinda how it waxes and wanes with exercise – and I’m wondering if it’s has anything to do with something called neurogenic claudication…

A: If the sensory changes are brought on by standing up, walking and better with bending over, that is classic for spinal stenosis. I presume his pulses are normal in feet? Would get MRI lumbar with that story, though some can worsen with exercise and just be neuropathy

29 yo woman with headaches, dysphasia and temporal lesion

Andrew Barbash — Tue, 08 Jul 2008 09:47:29 +0000

Case discussion from Medscape, interesting differential diagnosis of an enhancing lesion with small satellite lesion distant to it. Suspected tumor, but biopsy surprising

40 yo pregnant woman with HELLP syndrome and intracranial bleed

Andrew Barbash — Wed, 18 Jun 2008 10:36:02 +0000

40 yo asian woman 38 weeks pregnant,
no pre eclampsia
headache, visual loss last night, cleared up
seizure in sleep 3 am
came to hosp, urgent c section, 2 seizure peri op
no pupil response, no dolls, no corneals
HELP syndrome sec to likely eclampsia
Presumptive Diagnosis is Sagittal Sinus Thrombosis with hemorrhagic venous infarct, diffuse elevation of ICP and early brainstem central herniation syncrome-eclampsia alone not explaining
Patient expired within 48 hours when family decided to withdraw life support
Neuroscience Case conference presented.
Third opinions obtained virtually and via family meeting at local academic institution.
Confirmed the above. (crit is 20, hemolysis from HELP, LFT elevated) Patient expired shortly after
terminal wean extubation on day 4.  View Medscape Article on HELLP

IMAGES of CT

72 yo woman with posterior circulation progressive stroke

Andrew Barbash — Mon, 09 Jun 2008 19:26:48 +0000

72 yo african american woman did not go to md much in past, probably has hx of hypertension, and possible old stroke affecting right side, but was able to talk and use right side. Presented with right side weakness and dysarthria that progressed over 48 hours, now with NG tube, denser right facial and arm, able to move leg well, bilateral nystagmus.

Imaging showed medulla infarct, but MRA and CTA seem to show distal basilar patent, bilateral left more than right distal vertebral stenosis and possibly caudal ¼ of basilar partially thrombosed? Just put on Lovenox BID therapeutic this morning, stable 36 hours we think, (came in thurs, got worse friday-saturday. BP was 220 on admit, lowered only to 180 or so, no major drop in systolic from what we can tell.. Question: if declines on anticoagulation, is she posterior circulation angioplasty candidate?? VIEW WORD FILE WITH EMBEDDED IMAGES