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10 commonly asked questions about stroke answered

1. Stroke affects heart
#stroke affects brain and causes paralysis.
#heart attack is known by the term myocardial infarction.
#MedTwitter #NeuroTwitter…
2. Common symptoms of stroke:
*Weakness of arm, leg or face, usually on one side
*Inability to understand spoken words or to speak
*Imbalance while walking
*Reduced vision on one half or in one eye
*Sudden onset severe headache
3. Risk factors for stroke
*High blood pressure
*High total and LDL cholesterol or high triglycerides and low HDL
*High homocysteine
*Heart diseases
*Alcohol consumption
*Lack of sleep
Overweight or obesity
*Older age
*Family history of stroke
Read 10 tweets
1/Does PTERYGOPALATINE FOSSA anatomy feel as confusing as its spelling? Does it seem to have as many openings as letters in its name?

Let this #tweetorial on PPF #anatomy help you out

#meded #medtwitter #FOAMed #FOAMrad #neurosurgery #neurology #neurorad #neurotwitter #radres Image
2/The PPF is a crossroads between the skullbase & the extracranial head and neck. There are 4 main regions that meet here. The skullbase itself posteriorly, the nasal cavity medially, the infratemporal fossa laterally, and the orbit anteriorly. Image
3/At its most basic, you can think of the PPF as a room with 4 doors opening to each of these regions: one posteriorly to the skullbase, one medially to the nasal cavity, one laterally to the infratemporal fossa, and one anteriorly to the orbit Image
Read 18 tweets
Differential Diagnosis for cortically based masses


1️⃣Pleomorphic Xanthoastrocytoma (PXA)
2️⃣Dysembryoplastic neuroepithelial tumor (DNET)
#Neurology #neurosurgery #peds #radres #neurotwitter @The_ASPNR @TheASNR #MedTwitter ImageImageImageImage

Originate in the subpial astrocytes typically in children and young adults often with a seizure history

Temporal lobe is most common
Imaging (variable):

▶️Classically appear as a cortically based mass with cyst and enhancing nodule and overlying DURAL TAIL or enhancing leptomeninges

▶️Calcifications are RARE ImageImage
Read 14 tweets
An important teaching case

A 45 year old lady with significant vascular risk factors presented with hyperacute onset dimness in the L side of her field of vision, specially in the bottom half.

There is no other significant neurological or systemic hx.
Clinical examination revealed only a BP - 150/90, R arm, sitting position with confrontation perimetry showing an incongruent, incomplete L sided homonymous hemianopia.
A homonymous hemianopia localizes posterior to the optic chiasma where the nasal hemiretinal fibers decussate.

A L sided HH localizes a lesion to the R post-chiasmatic visual pathway.

Incongruency argues for a relatively anterior localization of the lesion ie away from cortex. Image
Read 10 tweets
A lot of referrals to neurology are basically what I like to call 'lazy' referrals.

For example, you get a patient with paraparesis and instead of performing a detailed clinical evaluation, you shotgun some MRI and NCS and send a quick referral to neurology.
Since these investigations are poorly chosen and poorly aimed, the end result is mass confusion where localization goes for a toss.

General medicine has been particularly egregious in this regard.
If your knee jerk reaction is to just get an MRI LS spine for every low back pain, don't be surprised when the patient then develops an LMN type of lower limb weakness. Low back pain can be severe in GBS.
Read 6 tweets
Tuberculous Meningitis in this child w/ fevers and lethargy

💡 COMMUNICATING HYDROCEPHALUS with DEEP INFARCTION is highly suggestive of granulomatous meningitis
#neurology #MedTwitter #neurotwitter @TheASNR #MedEd #futureradres ImageImageImageImage
▶️In children, primary TB infection is commonly associated w/ meningitis

▶️Exudative meningitis of the basal cisterns can obstruct the normal CSF flow resulting in hydrocephalus
▶️Infectious vasculitis or spasm can result in infarction (particularly of the basal ganglia)

▶️Cranial nerve palsy can also be seen due to infectious neuritis
Read 4 tweets
Ten lesser-known symptoms that could point towards a diagnosis of brain tumor

June 8th is celebrated as “World brain tumor day” to raise awareness about brain tumors. I would like to focus on the symptoms, presence of which, can make one suspect the presence of brain tumor.…
Common symptoms of brain tumor include headache, vomiting, reduced alertness, fits & paralysis. However, in several cases, these classical symptoms may be missing. It is important to know the lesser-known symptoms of brain tumors so that they can be diagnosed & treated early.
1. Increase in hat and shoe size over time- A tumor of pituitary gland of brain producing excess growth hormone (GH) causes a condition known as acromegaly, which can result in increasing head and feet size, necessitating a need for larger hats and bigger shoes.
Read 13 tweets
What is the most likely diagnosis in this 30 y/o w/ history of discitis/osteomyelitis presenting w/ fevers, chills, and neck pain? 🧠
#ent #Neurosurgery #Neurology #medtwitter #MedEd @The_ASSR #NeuroTwitter ImageImageImageImage
Answer: Longus Colli Calcific Tendinitis

▶️Etiology: inflammatory reaction in response to deposition of calcium hydroxyapatite crystals (just like in the rotator cuff)

▶️This case is a bit tricky as the history is somewhat misleading (though it often is in radiology)

▶️Sagittal STIR shows marked retropharyngeal/prevertebral edema (yellow arrow) and focal hypointensity from the hydroxyapatite crystals (green arrow)

▶️Axial T2 again shows the marked edema ImageImage
Read 9 tweets
Interesting case, what is the most likely diagnosis in this 25 y/o F w/ 1 year history of migraine headaches, left hand numbness, and b/l retinal artery occlusions? 🧠 👁️
#Ophthalmology #neurology #neurosurgery #neurotwitter #MedEd @TheASNR #MedTwitter ImageImageImageImage
Answer: Susac syndrome 🧠

▶️Susac syndrome is a microangiopathy (likely autoimmune affecting the precapillary arterioles) with a strong female predilection, typically occurring in women age 20-40
Clinical presentation:

Classic triad
2️⃣Branch retinal artery occlusions
3️⃣Hearing loss

💡Though most patients do not present with the complete triad (it may develop over years)
Read 7 tweets
Participated in a very interesting multidisciplinary POTS conference at @HopkinsMedicine on the topic of #FND, #syncope and #POTS where we discussed and debated the numerous issues surrounding FND diagnosis in our patient population. 1/🧵
#MedTwitter #NeuroTwitter
@HopkinsMedicine After conference, saw a patient who highlighted the issues discussed at conference.
👩‍🦽30 yo woman with POTS/MCAS/EDS triad with one TTT positive for POTS, but a 2nd TTT negative
❌ A neurologist diagnosed her with FND
💉 She is on allergy shots & many H1/H2 blockers.
@HopkinsMedicine 🚫 Neurologist didn't take into consideration neurologic and psychiatric manifestations of SYSTEMIC DISEASE (MCAS)
❌ This is not FND because there is underlying systemic disorder driving symptoms and signs.
🧠 Patient needs to be treated for the SYSTEMIC DISORDER first.
Read 6 tweets
Eyes are the windows into the Brain

Here, I discuss 9 situations where symptoms are related to eyes or vision, but disease pertains to brain or nervous system.
1. Sudden onset painless loss of vision- Optic neuritis (inflammation of optic nerve)- Multiple sclerosis
2. Sudden onset loss of vision on one half (left or right)- called homonymous hemianopia- usually caused by an infarct (clot) of occipital lobe of brain.

3. Inability to see on outer aspects of visual field (temporal visual field loss)- usually caused by pituitary tumor.
4. Drooping of one or both eyelids- called ptosis, usually caused by myasthenia gravis or third cranial nerve palsy.

5. Double vision (diplopia)- caused by 3rd, 4th or 6th cranial nerve palsies; also myasthenia gravis.
#neurotwitter #eyes #Neurology
Read 7 tweets
1/Time is brain! So you don’t have time to struggle w/that stroke alert head CT.
Here’s a #tweetorial to help you with the CT findings in acute stroke.

#medtwitter #FOAMed #FOAMrad #ESOC #medstudent #neurorad #radres #meded #radtwitter #stroke #neurology #neurotwitter Image
2/CT in acute stroke has 2 main purposes—(1) exclude intracranial hemorrhage (a contraindication to thrombolysis) & (2) exclude other pathologies mimicking acute stroke. However, that doesn’t mean you can’t see other findings that can help you diagnosis a stroke. Image
3/Infarct appearance depends on timing. In first 12 hrs, the most common imaging finding is…a normal head CT. However, in some, you see a hyperdense artery or basal ganglia obscuration. Later in the acute period, you see loss of gray white differentiation & sulcal effacement Image
Read 13 tweets
Child with a history of dental caries presents with a firm mass at the angle of the mandible. What is the most likely diagnosis? 🤔 🧠

#neurotwitter #ent #peds #Neurology #neurosurgery @ASHNRSociety @The_ASPNR #MedTwitter ImageImageImageImage
Answer: Sclerosing osteomyelitis of Garré

▶️Biopsy showed a reactive and reparative osseous process and bone culture grew oral flora (though cultures are usually negative)
▶️SOG is thought to be due to a low grade infection possibly 2/2 dental disease. However, there should be no signs of acute infection (suppuration, bony sequestration or draining tracts)
Read 7 tweets
Biggest thing to ever come out of my little group. Pls help spread this finding!

We found clean, CAUSAL evidence that the shingles vaccine prevents a good chunk of dementia cases. So, could a virus cause Alzheimer’s->YES!

Hear me out & see preprint:
🧵1/ Image
There’s recently been ⬆️ interest in the possibility that a virus may be involved in the causal pathways of dementia. Most attention has been on herpesviruses, incl the VZV that causes chickenpox and shingles, partly because of their lifelong latency (
In Wales starting in Sept 2013, the shingles vaccine was rolled out using an exact DOB cutoff. Those born on or after Sept 2 1933 were eligible, while those born earlier weren’t and remained ineligible for life. We analyzed EHR data for all of Wales with DOB exact to the week.
Read 18 tweets
Central to Alzheimer's pathology is a phenomenon known as brain hypometabolism. Let me explain better what that term means. 🧵 (1/25) #alzheimers #AD #neurotwitter
Brain hypometabolism refers to a state of reduced metabolic activity in the brain, characterized by a decreased uptake and utilization of glucose - the primary #energy source for brain cells. (2/25)
This disastrous metabolic slowdown is not just a mere lack of energy, although that would be devastating enough. It triggers a cascade of effects that impair neuronal function and disrupts communication between #brain cells. (3/25)
Read 25 tweets
Burden of Common Neurologic Diseases in Asian Countries (Global Burden of Disease Study 2019)

1. The 3 neurologic disorders with the highest prevalence and incidence-
*Tension type headache,
*Migraine, and
#MedTwitter #neurotwitter
2. The 3 leading causes of death from neurologic disorders were-
*Alzheimer's disease and other dementias
*Parkinson's disease
3. The top 3 burdensome neurologic disorders, as measured by disability-adjusted life years (DALYs)-
*Alzheimer's disease & other dementias.
Read 4 tweets
Interesting case in this patient with acute right-sided weakness

#neurorad #neurotwitter #meded #Neurosurgery #Neurology @TheASNR @RSNA #medtwitter ImageImageImageImage
Can you determine the diagnosis off the CT?
▶️Initial non-con CT shows a 3cm hyperdense lobulated extra-axial mass in the expected region of the left MCA bifurcation, consistent with a giant aneurysm. There are associated peripheral calcifications

▶️ What is the cause of the surrounding hypodensity?
Read 10 tweets
Shaking of hands: Essential tremor (ET) or Parkinson's disease (PD)

1. Shaking of hands (tremors) are common. The usual question among patients (and doctors) is what is the root cause- ET or PD?
Here I would highlight the clinical differences between the two.
2. ET affects both hands, whereas PD affects one hand (asymmetric ET- one hand more affected than other & unilateral ET- affecting only one hand can rarely occur).
If tremors remain confined to one hand for >3 years, one should look for structural brain disease (unusual for PD).
3. Tremor in ET is brought on by doing an activity (holding a cup of coffee or writing), whereas people with PD have resting tremors.
Tremors in ET can be better seen with outstretched arms and hands.
Tremors in PD can be better seen by distracting the patient (and observing).
Read 10 tweets
Case of emphysematous epiglottitis in an adult

Epiglottitis is an emergency as it can potentially cause airway compromise especially in children who have smaller airways #neurotwitter #ent #peds #Neurosurgery #MedTwitter #MedEd @ASHNRSociety ImageImage
▶️In children the diagnosis can be confirmed with upright plain film. CT requires placing the patient supine which may exacerbate inspiratory strider

▶️In adults, the diagnosis may not be suspected clinically so patients may end up with a CT scan as in this case
▶️Bacterial infection typically 2/2 H. Influenza in unvaccinated children

▶️In adults, possible pathogens include Strep, Staph, and H. influ
Read 4 tweets
Case of diffuse CSF seeding of tumor in this patient w/ WHO grade 4 diffuse hemispheric glioma

#NeuroTwitter #neurosurgery #Neurology #peds #futureradres @The_ASPNR #MedEd ImageImageImageImage
▶️Prospectively this mass was thought to be an embryonal tumor w/ multilayered rosettes given the marked diffusion restriction, hemorrhage, and lack of surrounding edema 🧠

▶️T2 shows a heterogenous slightly hyperintense mass w/ areas of hypointensity

▶️No surrounding edema/infiltrating tumor is seen on T2/FLAIR

▶️Fluid-fluid level is seen suggestive of hemorrhage (arrow) Image
Read 6 tweets
Learning case in this 40 y/o F with history of whole brain radiation as a child for brain tumor treatment
#NeuroRad #neurosurgery #Neurology @TheASNR #NeuroTwitter #meded #radres ImageImageImageImage
Brain radiation is a risk factor for the development of meningiomas …this patient subsequently developed multiple meningiomas including this large frontal meningioma Image
The mass was treated and immediate post op CT shows expected post op change with the resection cavity, some hemorrhage, and pneumocephalus Image
Read 9 tweets
Interesting case of complicated acute bacterial rhinosinusitis in this child with no PMH presenting w/ HA, fever & L sided weakness

#NeuroTwitter #ent #radres #neurosurgery @TheASNR @ASHNRSociety @PhilipRChapman1 #radres #futureradres ImageImageImageImage
CT shows opacification of the frontal and anterior ethmoid sinuses without evidence of cortical dehiscence

💡 In peds, infection can spread through vascular channels w/o destroying the bone ImageImage
MR shows abnormal signal filling the sinuses with associated restricted diffusion 2/2 purulent material

Post contrast we see areas of relative hypoenhancement in comparison to the normal mucosa on the contralateral side ImageImageImage
Read 9 tweets
If you or a loved one suffers from migraines, you are going to want to settle in for this thread going over the outcomes of a recently published study. 🧵(1/15) #migraine #neurotwitter
Migraine patients report sleep problems. But how much of that is due to pain or other factors going on with this neurological disease? (2/15)
These researchers wanted to see if the effects of a ketogenic diet could modify sleep issues in patients with migraines and to clarify whether those changes came from the ketogenic diet's effects on headache symptoms. (3/15)
Read 15 tweets
Atypical variants of motor neuron disease.



Does the phenotype matter?

Yes, as prognosis is different in some variants.

1/🧵 Image
a) Spinal-Onset ALS
b) Progressive Muscular Atrophy
c) Progressive Bulbar Palsy/Bulbar-onset ALS
d) Facial onset sensory and motor neuronopathy (FOSMN)
e) Flail-arm syndrome (Vulpian-Bernhardt syndrome): LMN upper limbs and UMN (usually only brisk reflexes in lower limbs)
f) Hirayama disease: monomelic amyotrophy
g) O’Sullivan-McLeod syndrome: slowly progressive distal amyotrophy of the hands and forearms extending over long periods of time
h) Flail-leg syndrome
Read 5 tweets

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