Casey Albin, MD Profile picture
Mar 30 13 tweets 5 min read Twitter logo Read on Twitter
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.
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!)
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

Mar 20
1/
A 59 year old woman presents with acute onset 10/10 headache (⛈️) and radiating occipital pain.

Non-con head CT is performed and reveals this👇

#problem

But the CTA shows no aneurysm.

So... now what?

A #ContinuumCase.
2/
The most feared cause of subarachnoid hemorrhage is aneurysm rupture, but it’s super important to remember that not all SAH is aneurysmal.

Before jumping to any conclusion. It’s critical to assess the pattern of SAH:
3/
Cortical SAH is rarely related to aneurysm unless it’s a mycotic aneurysm. Cortical SAH is much more likely to fall into one of these diagnoses:
Read 12 tweets
Feb 27
1/
A #ContinuumCase to start the week off!

21 yo👨 w/ a hx of traumatic brain & spinal cord injury presents to the ED for post-traumatic seizures.

MRI is ordered.

“No known implanted devices” is checked ✅

Then...The patient nearly suffers a life-threatening complication.
2/
What device was present?
3/
⛔️ANY of these devices can be MR-unsafe! ⛔️

Many are also MRI-conditional and can result in life-threatening emergencies if the conditions are not followed!

....A further clue🕵️

Several days later the patient has fever, altered mental status, rigidity and another seizure.
Read 13 tweets
Nov 9, 2022
1/ Step 1 - Don’t
👉Shut anything off
👉Touch the vent
👉Remove restraints
👉Pause sedation
if you have not explicitly asked permission to do so.

[This is a survival thing! For the pt… (and you 😉)]

A #tweetorial @medtweetorial about critical care things for #neurologists
2/
Vibe check for the #neurologists out there. Do you like doing ICU consults?
#MedEd #NeuroTwitter #NeuroTwitterNetwork #EmoryNCCTweetorials
3/
Tip 1⃣: Induction meds for intubation have different hemodynamic profiles.

In emergent situations, explicitly tell whoever is intubating the patient’s BP goals.

For ex: AIS = ⬆️ BP good; induction with propofol (frequently = hypotension) is suboptimal.

Reminders are 🔑
Read 25 tweets
Sep 2, 2022
1/
Wrote a #tweetorial (the first one in awhile!) about the role of hypercoag testing in acute ischemic stroke (Check out ⬇️)

But Twitter cut me off before we could think about the role of hyperhomocysteinemia.

In case you couldn’t sleep without this info… (lol)
✨Part II✨
2/
Also @CroninNeuro pointed out that high RoPE (>= 7) and PFO and you should close regardless thus no testing needed for FVL or PT gene mutation.

True! You could throw away all venous testing… closing a PFO in this situation is evidenced based regardless of test outcome.
3/
BUT, TBH, I think I might want to know if I were at potentially higher than average for benefit from closure since no procedure has zero risk...But, has not been looked at in any RCT!

Just another data for personalization, and these tests aren't
Read 14 tweets
Sep 1, 2022
1/
I *LOVE* candy (srsly love.)

Recently, at the airport, I saw a bag of sour patch kids (fav!).

It was v overpriced.
I did not NEED it.
And it might take a while to get.

‼️Same with the hypercoag panel in acute stroke‼️

A #tweetorial @MedTweetorials #NeuroTwitter
2/
There is small fraction of patients for whom some of these tests make sense.

But, what I hope this thread will address is a reflexic rx to send a hypercoag panel in any “young” stroke pt.

Out of curiosity has *anyone* ever diagnosed legit inherited Protein C deficiency?
3/
Goals for the scroll:

1⃣The concept of stroke in the young
2⃣The yield for the hypercoag panel tests
3⃣When it might be reasonable to send these tests
Read 28 tweets
Jul 7, 2022
1/
#NeuroPostItPearls #8 (early!): Practice thinking like a Neurologist.

To help you, a #Tweetorial Case adapted from my colleague and dear friend @emeltzermd's new book
“How to Think like a Neurologist.” amazon.com/How-Think-Like…

✨The Case✨
The Man Who Began To Drool.
2/
A 41 yo M w/ history of testicular cancer presents with a vague headache & several days of fatigue. A few days after these vague symptoms began, he developed burning over with left abdomen and right retroauricular pain. A day later his wife points out that he’s drooling.
🤤
3/
🛑Pause Here! (the book instructs you to do so!) 🛑

Just as suggested by this awesome chart shared by @LyellJ & @mayoneurores, all neurologic diagnosis starts with determining the tempo and focal/diffuse Image
Read 22 tweets

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