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?

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?

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?

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!

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.

1/A 60 year old man is brought to neurology clinic after injuring his spouse in the middle of the night

“I feel so bad, I was dreaming that a tiger was chasing me!”

This has happened multiple times.
A polysomnogram demonstrates the following.

What is going on? A #ContinuumCase 2/
I know you probably aren't an expert polysomnographer (I'm certainly not!) but what do you think is going on?

1/
A 73 yo woman is admitted for TIA-evaluation. While in the hospital you find her pacing the floor at night.

“I just have to move my legs at night!”

You see the blood work done by her PCP and her iron levels are… normal.

What’s going on?
A #ContinuumCase @ContinuumAAN 2/
What’s your guess about the cause of her "need to move" at night?

1/ Alright #neuroX (?!?!)

A 78 yo man is hospitalized with sepsis, he undergoes a long hospitalization complicated by ileus and AKI requiring HD (now resolved).

He has been hospitalized 62 days.

The ICU team calls you for ?refractory delirium?

A #ContinuumCase (image mine) 2/
On exam you find a man that is frail and inattentive. He is slow with tracking you around the room.

He does not participate in serial 7s or saying the days of the week backwards.

He’ll follow simple commands and is able to name simple objects.

1/
A 72 yo man w/ ESRD presented w/ worsening lethargy and poor arousal. He had missed 2 sessions of dialysis.

While in the ED he had some “twitching” and was hooked up to cEEG.

At first, the EEG looked like panel A.

But later, panel B.

A #continnumcase. 2/
What’s going on in panel A?

1/
#ContinuumCase for the New Academic Year!!!

Step 1⃣: Get an @AANmember resident membership and get @ContinuumAAN🆓!!!

Step 2⃣: play along
A 27 yo man is brought in obtunded.

Nothing is known about his PMH.

A head CT is completed demonstrating sulcal effacement and edema. 2/
Acute obtundation is a stressful situation.
🥴Toxic metabolic causes are more likely than primary neurologic issues. Think Narcan first.

But if that doesn’t work...

In any case with acute or unexplained AMS, I always ask myself—*is this a basilar thrombus*?

CTA exonerated.

1/
A 32 yo woman presents with headache and somnolence.

She is febrile to 102.6F.

Exam reveals neck stiffness and this rash…which, when your attending arrives, is absent #hatethat!

A #continuumcase @ContinuumAAN @LyellJ 2/
Rashes can be a sign of many neurocutaneous disorders & infectious etiologies.

High fever + neck stiffness + a rash=🔼 concern for neisseria meningococcal meningitis

However, the rash in meningococcal meningitis is often caused by DIC, looks more like this & doesn't vanish

1/ #ContinuumCase!!

A 50 yo man presented to the ED with acute onset aphasia. He is not able to report a history, but BP Is 215/95.

Non-contrast HCT reveals this bleed…
What do you want to see next? 2/
What do you most want next?

1/
🚨Code stroke to the Med-Surg floor!

53 yo M with hep C & IVDU admitted yesterday for fever & chills.

BCx=GPCs in clusters😨. An ECHO is planned.

He develops witnessed-onset R sided weakness & aphasia. Head CT👇

Do you push tPA?

A #continuumcase 2/
LSW <2 hours ago. Head CT with no ICH.

Do you push tPA?

1/
Back from #AANAM and missing the learning?
Enter #ContinuumCase
A 75-yo👩 presents to clinic.
- 1 month ago: monocular blurred vision in L👁️
- C U/S: 70% to 80% ICA stenosis
- On ASA 81 & Atorva 20mg; LDL 132 mg/dL b/f lipid therapy
How do you proceed?
[not her MRA] Next step in management, #neurotwitter?

1/
#ContinuumCase

A 67 yo man with a known, active cancer presents to the ED. His wife reports that he has had worsening headaches, forgetfulness, & confusion. Today, he was increasingly sleepy which triggered the presentation.

An MRI is ordered.
🤔🤔🤔 @ContinuumAAN @LyellJ 2/
Neurologic complications in cancer patients are tricky. They can be due to
✨Malignant lesions
✨Systemic complications of disease
✨Paraneoplastic disorders
✨Treatment Side effects

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 🤔

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:

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?

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

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✨

https://twitter.com/caseyalbin/status/1565379427349020675

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.

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?