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Casey Albin, MD

Mar 30, 2023 • 13 tweets • 5 min read • Read on X

@ContinuumAAN

1/
Just how much can ultrasonography reveal about the neurovascular health of the brain?

A whole freaking lot!!

A #ContinuumCase about a man with transient dizziness after doing heavy lifting in the yard. @ContinuumAAN @LyellJ

2/
There are a lot of way this case could unfold…
Was he just dehydrated?
Did he have a dissection?
Have a PE?

But with more questions, it becomes clear that this has happened before.

Whenever he is doing heavy lifting, his left arm becomes tingly & then the room spins 🤔

3/
#NeuroTwitter, what's going on?

4/
The interesting thing about his symptoms are that they're stereotyped. Most vascular events are not stereotyped, maybe you get events that localize to the same hemisphere or vascular territory, but the exact same events??

Arm exercise and then dizziness??

5/
Dopplers were ordered.

which demonstrate ⬇️

Uh oh, no flow past this occlusion in the L ICA!

6/
Contralaterally, things aren't really looking great either.

Thats a very tight stenosis of the R ICA.

7/
TCDs demonstrate intracranial collateralization through the AComm, with inverted flow in the L A1.

So the L anterior circulation is largely supplied by the R critically stenosed ICA.😱😱

8/
But…. The guy did not present with transient right arm weakness or aphasia- symptoms of poor perfusion to the left hemisphere

& while you could make a case for artery-to-arty embolization from the R ICA to the R hemisphere to explain the L arm parestheisas.... why recurrent?

9/
And why the dizziness?

The answer…?

Inverted flow in the left vertebral artery!! And bidirection flow in the proximal basilar.

@radiopaedia

10/
What was happening?

MRA (not published in the issue, so I borrowed an example from our friends @radiopaedia.) confirmed severe stenosis of the proximal subclavian. His symptoms?

A subclavian steal effect!

11/
If subclavian steal is confusing, I like this diagram.

All suggested by a simple non-invasive, radiation free workup.

Patient underwent smoking cessation, lipid control and revascularization.

12/
12/
But wait!

There was one more thing!

Lets go back to the very first image... He had one more stroke risk factor.

Can you tell? (I know some of you probably did in the first poll!)

@ContinuumAAN

13/
Yes! An irregular heart rate suggestive of (EKG confirmed) occult a fib! All that. Just from ultrasound. Isn’t it amazing what neurosonography can do?!

All about it in this issue of @ContinuumAAN
journals.lww.com/continuum/Full…

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More from @caseyalbin

Casey Albin, MD

@caseyalbin

May 17

1/ A 20 yo woman comes in because she has recurrent headaches. She describes visual aura, photo-/phonophobia & pain that improves with rest. She also describes a sharp, stabbing, lancinating pain from the back of her head during the episodes.

A #ContinuumCase

2/
What is this?

(PS ChatGPT FTW with "what does an aura look like?" !!)

3/
The patient likely has TWO things:
1⃣Occipital neuralgia causing the pain that radiates from the back of her head
2⃣chronic migraine with aura.

Patients with occipital neuralgia OFTEN have both, and occipital neuralgia is very rarely an isolated headache syndrome

Read 10 tweets

Casey Albin, MD

@caseyalbin

Mar 7

1/
🥳Big News! This is the 1⃣0⃣0⃣th #CONTINUUMCASE!!

To celebrate? A must know dz, bc w/ this disease:

Time is Spine!

A 39 yo woman with Sjogren’s syndrome comes to the ED with sudden neck pain. Then arm weakness. Then leg weakness. All within 24 hours.

Now she can’t urinate

2/
On your exam, mental status=intact. But she has terrible vision in the right eye, which she reports is from a sjogrens attack.
She has 3/5 arm strength, 2/5 leg strength.
As shown above 🔼 she has a longitudinally extensive lesion w/ contrast at C2 and C3.

Is this Sjogrens?

3/
You complete a spinal tap.

‼️There are 120 WBC with a lymphocytic predominance‼️

Is this an infection?

Read 11 tweets

Casey Albin, MD

@caseyalbin

Jan 9

1/
A 25-year-old woman presented with a new-onset seizure.

She has no past medical history.

An MRI demonstrates the following and a resection confirms a glioblastoma.

A #ContinuumCase about tumor genetics.

2/
Honestly, I find this subject to be confusing.

But there is at least one molecular signature of gliomas that is worth knowing:

Is the tumor is Isocitrate Dehydrogenase (IDH)-wildtype or IDH mutant?

Which, generally, has a more favorable prognosis?

3/
IDH-mutant gliomas typically have a more indolent biological behavior and also tend to be more epileptogenic than IDH-wild type gliomas.

Read 11 tweets

Casey Albin, MD

@caseyalbin

Jan 2

1/
📟Onc floor pages you STAT:

A 58 yo woman with breast cancer on active chemo presented with shortness of breath.

She was just found to have (A).

Unfortunately, a head CT reveals (B).

They want to know – can she be a/c’ed? A #ContinuumCase

2/
Thoughts?

3/
Why does this feel like such a common conundrum? A few reasons.
1⃣incidence of brain mets may be 🔼 due to improved detection & better control of extracerebral dz
2⃣VTE is common in cancer patients & may also be 🔼 (more detection, longer life expectancy & novel treatments)

Read 15 tweets

Casey Albin, MD

@caseyalbin

Nov 22, 2023

1/
A 35 yo M has lower limb weakness & painful hand & foot paresthesias.
EMG suggested axonal neuropathy and a presumed diagnosis of GBS was made.
After PLEX he was not better, instead he was becoming confused & ataxic.

How might a Thanksgiving Turkey solve this #ContinuumCase?

2/
Note: PLEX does not work immediately. In fact, many pts fail to have a response to immunotherapy during their hospitalization. Many continue to progress DESPITE treatment.

This does not mean that the treatment isn’t working. More is not better!

3/
Ok, off my soap box!

As you should for all confusing cases, you go back to the bedside and the patient tells you that over the last 2 months, he’s had increasing stress that resulted in an escalation of alcohol intake and reduced food intake.

Read 14 tweets

Casey Albin, MD

@caseyalbin

Sep 21, 2023

1/
In 1965, 17-year-old Randy set the world record for sleep deprivation by staying awake 264.4 hours (about 11 days) for a science fair experiment.

11 days!!!

But what about the patient that desperately wants to sleep… and can’t?

A #ContinuumCase about 20 million US adults.

2/
Insomnia is the most common sleep disorder.

Almost everyone has experienced insomnia at some point, but 6% of the US population has chronic insomnia….

That’s the 20 million people.

3/
The pharm industry has noticed that there are this many people who crave sleep and this is unsurprisingly a huge market.

It also costs the the US 63 billion dollars in lost productivity.

💸💸💸💸

pubmed.ncbi.nlm.nih.gov/21886353/

Read 13 tweets

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