b******a
发帖数: 704 | 1 Carotid U/S: Retrograde basilar artery flow? --subclavian artery steno-occlusive disease caused by thromboembolism? lacunar infarcts? brain stem stroke caused by vertebral artery (VA) diseases such as dissection?
The Subclavian steal phenomenon SSP may additionally cause a basilar artery (BA) steal phenomenon (BSP). When this occurs, the inversion of flow in the subclavian artery provokes additional retrograde flow in the basilar artery. However, this patient had same bilateral BPs. |
|
b******a
发帖数: 704 | 2 Carotid U/S: Retrograde basilar artery flow? --subclavian artery steno-occlusive disease caused by thromboembolism? lacunar infarcts? brain stem stroke caused by vertebral artery (VA) diseases such as dissection?
The Subclavian steal phenomenon SSP may additionally cause a basilar artery (BA) steal phenomenon (BSP). When this occurs, the inversion of flow in the subclavian artery provokes additional retrograde flow in the basilar artery. However, this patient had same bilateral BPs. |
|
g*2
发帖数: 658 | 3 刚刚把堆积了几个星期的nejm翻看了一下，居然在11月底的那期case discussion就是
讲得这个病
http://www.nejm.org/doi/full/10.1056/NEJMcpc1103565
Case 36-2011 — A 93-Year-Old Woman with Shortness of Breath and Chest Pain
Presentation of Case
Dr. Pooja Agrawal (Emergency Medicine): A 93-year-old woman was seen in the
emergency department at this hospital because of chest pain and shortness of
breath.
The patient had been in her usual state of health, with hypertension and
chronic renal insufficiency, until the morning of admission, wh... 阅读全帖 |
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A*******s
发帖数: 9638 | 4 Surgery/stenting for asymptomatic carotid artery stenosis over 70% is still
controversial.
The key is what caused syncope?
Left carotid artery stenosis usually is not the cause of syncope. Basilar
artery stenosis, however, could induce brain stem ischemia and cause vertigo
and syncope. I did not see basilar artery flow direction on the U/S. If retrograde, a
subclavian steal could cause the syncope.
So you may fix the carotid artery stenosis but not the syncope. The patient
has to be informed pri... 阅读全帖 |
|
n*******c
发帖数: 501 | 5 Very interesting case.
I wonder where the brain stem infarct is. Are they (with cerebellum infarct)
acute? How is the blood flow in vertebral arteries?
My impression is that the syncope was due to brain stem infarct rather than
SSS. SSS is probably an incidental finding.Having said that I haven't seen a
case with retrograde basilar flow from SSS(just realize our hosp doppler
ultrasound never reports basilar :( ）
Has the patient had syncope before?
Just for my curiosity. Did the MRA showing SSS ... 阅读全帖 |
|
R*******t
发帖数: 367 | 6 Time of flight will give you information of flow direction, while contrast
MRA doesn't. As long as there is flow in a vessel, retrograde or ante grade,
it will light up with contrast enhancement. In time of flight, retrograde
flow will lose signal and the vessel would be dark.
发信人: newprozac (中人), 信区: Medicalpractice
标 题: Re: 【case discussion】 Syncope
发信站: BBS 未名空间站 (Mon Feb 6 03:22:35 2012, 美东)
Very interesting case.
I wonder where the brain stem infarct is. Are they (with cerebellu... 阅读全帖 |
|
n*******c
发帖数: 501 | 7 Very interesting case.
I wonder where the brain stem infarct is. Are they (with cerebellum infarct)
acute? How is the blood flow in vertebral arteries?
My impression is that the syncope was due to brain stem infarct rather than
SSS. SSS is probably an incidental finding.Having said that I haven't seen a
case with retrograde basilar flow from SSS(just realize our hosp doppler
ultrasound never reports basilar :( ）
Has the patient had syncope before?
Just for my curiosity. Did the MRA showing SSS ... 阅读全帖 |
|
R*******t
发帖数: 367 | 8 Time of flight will give you information of flow direction, while contrast
MRA doesn't. As long as there is flow in a vessel, retrograde or ante grade,
it will light up with contrast enhancement. In time of flight, retrograde
flow will lose signal and the vessel would be dark.
发信人: newprozac (中人), 信区: Medicalpractice
标 题: Re: 【case discussion】 Syncope
发信站: BBS 未名空间站 (Mon Feb 6 03:22:35 2012, 美东)
Very interesting case.
I wonder where the brain stem infarct is. Are they (with cerebellu... 阅读全帖 |
|
f**d
发帖数: 768 | 9 这是一本计算神经科学的优秀著作，全文拷贝这里（图和公式缺），有兴趣的同学可以
阅读
如需要，我可以分享PDF文件（－－仅供个人学习，无商业用途）
From Computer to Brain
William W. Lytton
From Computer to Brain
Foundations of Computational Neuroscience
Springer
William W. Lytton, M.D.
Associate Professor, State University of New York, Downstato, Brooklyn, NY
Visiting Associate Professor, University of Wisconsin, Madison
Visiting Associate Professor, Polytechnic University, Brooklyn, NY
Staff Neurologist., Kings County Hospital, Brooklyn, NY
In From Computer to Brain: ... 阅读全帖 |
|
H******7
发帖数: 34403 | 10 http://www.buytigers.com/#
Buy a Tiger online? NOW it's possible
Our stores provide you the most original pets EVER!
It was a dream until yesterday, now it's true. Directly from our India
breedings, we give you the possibility to buy a tiger ONLINE and without any
trouble.
Tiger is probably the strongest feline predator on earth, but you will
discover that it can be a lovely pet as well, loyal, friendly and TOTALLY
HARMLESS.
We have been shipping tigers worldwide since 1984, giving our lucky
cus... 阅读全帖 |
|
g******2
发帖数: 73 | 11 最近又有一次发作，天旋地转，以前从未有过。去看过神经科一生，诊断我为Basilar
Migraine, 口服Nortriptyline and beta blocker，不见好转。
前一段时间去见精神科医生，认为可能是抑郁症，remeron and ativan as needed. 症
状时好时重。自己上网了解，自我诊断为 Migraine Associated Vertigo (MAV)，不知
道有人了解吗？另外，这两种药Nortriptyline 和remeron 可以同时口服吗？谢谢大家！
这几天头晕，呕心，心悸的很厉害，现在压力很大，有时候觉得不能工作了。家人不理
解，感觉没有人可以帮助我！ 谢谢大家给与帮助，或是有同样症状的朋友，大家可以
互相交流！ |
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w****r
发帖数: 17566 | 12 为什么家人不理解。你都已经有这么明显地症状了，要求修个假休息一下家人有什么不
可理解的。感觉你能从家人那得到的support不是很好
Basilar
家！ |
|
w****r
发帖数: 17566 | 13 照理说偏头痛的药用对了的话是会管住一段时间不痛的啊。
平时吃得好睡眠有规律么，生活工作上压力大么。
Basilar
家！ |
|
l*********e
发帖数: 158 | 14 I guess; Sitting - Deep Venous Thrombosis in the lower limb -Patent foramen
ovale- stroke in deep penetrating arteries that arises directly from the
constituents of the Circle of Willis, cerebellar arteries, and basilar
artery that irrigate posterior limb of the internal capsule-descending
corticospinal tracts- hemiplegia? How can the bilateral lesions happen with
one side of symptoms? |
|
L********g
发帖数: 17 | 15 Form 4 section 1
a 10 month old infant is brought to the emergency department because of
labored breathing for 1 hour. she has had cough, coryza, and fever for 18
hours. her temperature is 39 C, pulse is 120/min, respirations are 54/min,
and blood pressure is 82/60 mmHg. Pulse oximetry shows an oxygen saturation
of 92%. bilateral wheezes and basilar crackles are heard. select the most
likely pathophysiology of the respiratory problem
a) allergen induced bronchospasm
b) barotrauma related alveola |
|
l******p
发帖数: 71 | 16 1. A 16-year-old girl comes to the clinic because of vaginal itching for
the past 5 days. She requests that her parents not be informed about the
appointment. During the examination, she says she occasionally has
unprotected sexual intercourse and asks for oral contraceptives. Preliminary
laboratory studies show gram-negative diplococci. Which of the following is
the most appropriate next step in patient care?
A) Consult a colleague for advice about treating a minor without parental
consent
... 阅读全帖 |
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R*******t
发帖数: 367 | 17 Me too. Right before thanksgiving last year, a patient walked in for a
diagnostic cardiac cath, probably thinking he could rest a little during the
holiday time off. He ended up having dislodged emboli into his basilar
artery and infarcted both his cerebellums.... He was in the units for about
10 days before he passed. It was very sad to see his cerebellums got swollen
, then slowly dissolved away, day by day.
There are always risks for those interventions. Gotta think twice before
putting loved... 阅读全帖 |
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A*******s
发帖数: 9638 | 18 回答你的问题，首先我们要搞清楚一些基本概念， 大家有不同意见，请随便。
眩晕vertigo可以理解为位置感觉的错觉。 一个晕字可以是各种各样的症状。 眩晕分
为central和peripheral， central是CNS， 主要是脑干，小脑的问题； peripheral是
内耳的问题。
就像楼上说的，cervical degenerative disc disease or spondylosis是描述颈椎的
病变，如果引起vertigo， 主要是血液供应的问题， 可能你知道Vertibrobasilar
artery insufficiency， MRA可以看到basilar stenosis， 但vertibral artery
stenosis是不是可以引起临床症状有争论， 很多病人一侧的vertibral artery都封闭
了， 却没有任何临床症状。 所以如果MRA正常，central vertigo可能性就不大（当然
MRA经常underestimate）。 对于颈椎病， 因为骨刺引起椎动脉供血不足我是很少听说
， 但有一种情况我在一个thread里提过， 叫bow hu... 阅读全帖 |
|
A*******s
发帖数: 9638 | 19 Migraine？
aphasia is from ischemia of left middle cerebral artery. Ataxia, nausea and sluured speech are from basilar artery.
To put them togather, only migraine makes sense to me.
Food poisoning is another possibility but i doubt it.. |
|
r********n
发帖数: 48 | 20 Dear Dr. Lexian, I completely agree with Dr. Aplusplus on this case.
Unilateral carotid stenosis just does not do the job -- You just have to
have both sides of the brain out to make that person unconscious. If you
have to pick on stroke in this case, think about vertebral-basilar problems.
difference
well
it
our |
|
A*******s
发帖数: 9638 | 21 A real case to share:
A 67 yrs old female, with a history of HTN, presented with syncope. She
complained of a sudden onset of vertigo then LOC for 1 min. She was very
confused at the admission.
PMH: HTN.
SH: No smoking/ETOH
FMH: HTN
ROS: not remarkable except mild confusion.
PE: VSS stable. BP: 140/80 bilaterally per record.
OA x 2 and CVS:irregularly irregular. Other exams were not remarkable.
CNC/CMP/PT/PTT: nl
Cardiac enzyme: neg
EKG showed A-Fib （new onset).
A CT of brain was neg.
Carotid ... 阅读全帖 |
|
n*******c
发帖数: 501 | 22 sounds like a posterior circulation TIA/stroke.Is neurological exam all
normal? Any oculomotor and pupillary abnormalities (top of the basilar)?
I would do a MRI including DWI and MRA of brain and neck.
She will need an ECHO to exclude intracardial thrombus (as the source of
emboli) and assess LV function (for CHADS2 score in a new AF) , also to
cover causes of cardiogenic syncope.
confusion makes me think about postictal. I would do a EEG if the above is
not conclusive.
I assume the blood gluco... 阅读全帖 |
|
A*******s
发帖数: 9638 | 23 Anyone mentoned subclavian steal will get Baozi。
Any other thoughts？
occlusive disease caused by thromboembolism? lacunar infarcts? brain stem
stroke caused by vertebral artery (VA) diseases such as dissection?
artery (BA) steal phenomenon (BSP). When this occurs, the inversion of flow
in the subclavian artery provokes additional retrograde flow in the basilar
artery. However, this patient had same bilateral BPs. |
|
k********n
发帖数: 756 | 24 How US demonstrated basilar retrograde flow? |
|
k********n
发帖数: 756 | 25 How Doppler can see basilar? |
|
R*******t
发帖数: 367 | 26 我们这里常规carotid ultrasound不包括basilar，只记录两侧vertebral arteries，
是antegrade还是retrograde。 |
|
k********n
发帖数: 756 | 27 What you mean is transcranial doppler (TCD) instead carotid doppler you
mentioned?
Carotid doppler can only detect the basilar artery in newborns.
flow |
|
A*******s
发帖数: 9638 | 28 No， both hospital tech and clinic tech told me they are able to see basilar
artery flow although not as well as carotid.
TCD is a different story. |
|
b******a
发帖数: 704 | 29 Am I eligible for a Baozi? Thank you so much!
Although SSP was my first differential, I still don't know why there is no
difference in left and right arm BP given there is only left subcalavian
stenosis. Maybe it's too early to detect the subtle difference in such a
stress.
stem
flow
basilar |
|
A*******s
发帖数: 9638 | 30 MRA is not routinely used for subclavian. But in this case, the lady has a
retrograde basilar artery flow, allergic to iodine, and the U/S tech had no
experiences on subclavian A. So MRA was the only choice.
even |
|
R*******t
发帖数: 367 | 31 Cerebral MRA has pretty standard protocol in terms of imaging acquisition.
When I dictate a report, I always include the following:
Intracranial portion of internal carotids including petreous, clinoid and
siphon
Anterior cerebral arteries, A1 and A2
Acom and pcom, look carefully for aneurysms
Mcas, need to follow at least to trifurcation
Pcas, p1 and p2, if there is fetal origin of pcas
Basilar artery, vertebral, superior cerebellar arteries, pica and Aica.
These arteries should be steadily see... 阅读全帖 |
|
k********n
发帖数: 756 | 32 i asked several stroke guy and nobody seemed aware that US carotid can
detect blood flow in basilar. it is too high for US. |
|
A*******s
发帖数: 9638 | 33 纠正一下， 今天问了一下tech， carotid u/s只能看vertebral， tech用另一种探头
看basilar。
I think it is tech dependent. Just like U/S for subclavian, the hospital
tech said no but our clinic tech told me easy. |
|
A*******s
发帖数: 9638 | 34 A real case to share:
A 67 yrs old female, with a history of HTN, presented with syncope. She
complained of a sudden onset of vertigo then LOC for 1 min. She was very
confused at the admission.
PMH: HTN.
SH: No smoking/ETOH
FMH: HTN
ROS: not remarkable except mild confusion.
PE: VSS stable. BP: 140/80 bilaterally per record.
OA x 2 and CVS:irregularly irregular. Other exams were not remarkable.
CNC/CMP/PT/PTT: nl
Cardiac enzyme: neg
EKG showed A-Fib （new onset).
A CT of brain was neg.
Carotid ... 阅读全帖 |
|
n*******c
发帖数: 501 | 35 sounds like a posterior circulation TIA/stroke.Is neurological exam all
normal? Any oculomotor and pupillary abnormalities (top of the basilar)?
I would do a MRI including DWI and MRA of brain and neck.
She will need an ECHO to exclude intracardial thrombus (as the source of
emboli) and assess LV function (for CHADS2 score in a new AF) , also to
cover causes of cardiogenic syncope.
confusion makes me think about postictal. I would do a EEG if the above is
not conclusive.
I assume the blood gluco... 阅读全帖 |
|
A*******s
发帖数: 9638 | 36 Anyone mentoned subclavian steal will get Baozi。
Any other thoughts？
occlusive disease caused by thromboembolism? lacunar infarcts? brain stem
stroke caused by vertebral artery (VA) diseases such as dissection?
artery (BA) steal phenomenon (BSP). When this occurs, the inversion of flow
in the subclavian artery provokes additional retrograde flow in the basilar
artery. However, this patient had same bilateral BPs. |
|
k********n
发帖数: 756 | 37 How US demonstrated basilar retrograde flow? |
|
k********n
发帖数: 756 | 38 How Doppler can see basilar? |
|
R*******t
发帖数: 367 | 39 我们这里常规carotid ultrasound不包括basilar，只记录两侧vertebral arteries，
是antegrade还是retrograde。 |
|
k********n
发帖数: 756 | 40 What you mean is transcranial doppler (TCD) instead carotid doppler you
mentioned?
Carotid doppler can only detect the basilar artery in newborns.
flow |
|
A*******s
发帖数: 9638 | 41 No， both hospital tech and clinic tech told me they are able to see basilar
artery flow although not as well as carotid.
TCD is a different story. |
|
b******a
发帖数: 704 | 42 Am I eligible for a Baozi? Thank you so much!
Although SSP was my first differential, I still don't know why there is no
difference in left and right arm BP given there is only left subcalavian
stenosis. Maybe it's too early to detect the subtle difference in such a
stress.
stem
flow
basilar |
|
A*******s
发帖数: 9638 | 43 MRA is not routinely used for subclavian. But in this case, the lady has a
retrograde basilar artery flow, allergic to iodine, and the U/S tech had no
experiences on subclavian A. So MRA was the only choice.
even |
|
R*******t
发帖数: 367 | 44 Cerebral MRA has pretty standard protocol in terms of imaging acquisition.
When I dictate a report, I always include the following:
Intracranial portion of internal carotids including petreous, clinoid and
siphon
Anterior cerebral arteries, A1 and A2
Acom and pcom, look carefully for aneurysms
Mcas, need to follow at least to trifurcation
Pcas, p1 and p2, if there is fetal origin of pcas
Basilar artery, vertebral, superior cerebellar arteries, pica and Aica.
These arteries should be steadily see... 阅读全帖 |
|
k********n
发帖数: 756 | 45 i asked several stroke guy and nobody seemed aware that US carotid can
detect blood flow in basilar. it is too high for US. |
|
A*******s
发帖数: 9638 | 46 纠正一下， 今天问了一下tech， carotid u/s只能看vertebral， tech用另一种探头
看basilar。
I think it is tech dependent. Just like U/S for subclavian, the hospital
tech said no but our clinic tech told me easy. |
|
n*******c
发帖数: 501 | 47 Agree. I cannot see that neurologist's rationale of using ativan unless
there is evidence of nonconvulsive status epilepticus.If it is postictal,
the patient should improve overtime which cannot be proved while on
sedatives.
How long was CT done after onset? What is the size of left thalamocapsular
hypodensity? Lacunar infarct should not cause MS changes so even if it is
real it may not be relevant.Hard to say without imaging but should be
careful about post circulation infarct. I used to see a ... 阅读全帖 |
|
A*******s
发帖数: 9638 | 48 这三个药没一个会缓解你妈的症状。
有一种脑血管供血不足可以引起眩晕，叫做椎基底动脉供血不足，比方说subclavian
steal，basilar artery stenosis， 等等。 这个MRI结果不可能反映上述病症，所以
需要进一步检查。
通常情况下，头晕可以因为血压引起，如果一切正常，应该考虑内耳的问题，比方说
BPPV， 所以最最有效的治疗恐怕就是antivert了。 |
|
A*******s
发帖数: 9638 | 49 1. The MRA done most recently in the stroke center shows no evidence of
stenosis in the basilar artery system.
difficult |
|
n*******c
发帖数: 501 | 50 结脑basilar meningitis严重的话hydrocephalus并发率高，herniation和pressure
gradient关系更大，和普通脑膜炎/pseudotumor还是不太一样，可能他们是考虑了这一
点。我也觉得怕闹事的话更要做，诊断都无法明确说不过去，而且真的并发
hydrocephalus或是brain stem病变不做也是很凶险的... |
|
