By Ji Y. Chong
Sufferers struggling with cerebrovascular ailment pose many scientific demanding situations or even skilled clinicians can arrive on the aspect the place diagnostic, work-up, therapy, or prognostic considering falters.
Authored by means of a vascular neurologist whose paintings spans the total spectrum of this crew of mind dysfunctions, Cerebrovascular Disease is helping clinicians review and deal with sufferers being affected by stroke, embolism, thrombosis, hemorrhage, and different severe shows. In a scientific box the place it is frequently tricky to distill the massive array of analysis and follow it in any significant scientific method, this subsequent quantity within the "What Do I Do Now?" sequence makes a speciality of jogging the clinician via evidence-based decision-making. each one medical state of affairs featured in Cerebrovascular Disease describes in cautious aspect the presentation, diagnostic reports, healing procedures, and purpose for dealing with those difficult situations.
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However, studies of patients who were not treated with IV tPA because of rapid improvement or minor symptoms found these patients had worse outcomes at discharge. In one study evaluating outcomes in 41 patients who were deemed “too good to treat,” 27% died or were not able to be discharged home because of worsening. They also found that patients who had over 4-point improvement on the NIHSS were more likely to have subsequent worsening. This is consistent with clinical observation that rapid improvement is often a more ominous sign than static symptoms.
We had already alerted the neuroendovascular surgery team prior to the worsening, and the patient was in the angiography suite at ﬁve hours post-onset. The angiogram revealed complete occlusion of the LMCA. 8). 12). 6 Recanalization of occlusion after mechanical thrombectomy. 8 18 Cerebral angiogram lateral view showing occlusion and recanalization. WHAT DO I DO NOW? 12 MRI FLAIR sequence showing ﬁnal infarct limited only to small portion of the MCA territory. KEY POINTS ■ Patients post-tPA require frequent neurological monitoring.
Hemorrhage within already infarcted tissue may not cause any symptoms. Hemorrhagic transformation is more commonly seen in strokes due to cardiac embolus. 1 Non-contrast head CT prior to IV tPA showing no hemorrhage but a basal ganglia calciﬁcation. 2 Non-contrast head CT 24 hours post-tPA showing left MCA and ACA territory infarct with hemorrhagic transformation. 22 WHAT DO I DO NOW? CEREBROVASCULAR DISEASE It is important to distinguish asymptomatic hemorrhagic transformation from symptomatic hemorrhage.
Cerebrovascular Disease by Ji Y. Chong