R*******t
发帖数: 367 | 1 我们这里常规carotid ultrasound不包括basilar，只记录两侧vertebral arteries，
是antegrade还是retrograde。 |
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A*******s
发帖数: 9638 | 2 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. |
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A*******s
发帖数: 9638 | 3 sure， baozi会有的。
你说的对， 我也不明白，vascular surgeon更是说不可思议。 不过这是事实， 反复
量都没问题。
我来总结一下：
这个病人有两个问题： 1. A-fib 2.SSS
显然， syncope是因为SSS引起的VBI和相应的stroke而发生的。 MRI of brain，
carotid u/s and MRA of subclavian A证实了这一点。
问题是这个stroke是什么引起的？ 看上去像embolic， 因为有3个location。 从
subclavian是不可能的， 因为retrograde flow。 所以很可能是cardiac emboli， 原
因是A-fib。
病人refuse手术， 所以anticoagulation是唯一的治疗。
So far so good。 |
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A*******s
发帖数: 9638 | 4 原则上， 如果你order一个检查， 你肯定有动机。 比方说， aneurysm， MRA可以看
一般5mm以上的aneurysm。 carotid dissection， 你就需要注明neck MRA
不要order不必要的检查， 因为这些检查会带来不必要的麻烦。
管？ |
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R*******t
发帖数: 367 | 5 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 |
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n*******c
发帖数: 501 | 6 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 |
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R*******t
发帖数: 367 | 7 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 |
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k********n
发帖数: 756 | 8 i asked several stroke guy and nobody seemed aware that US carotid can
detect blood flow in basilar. it is too high for US. |
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A*******s
发帖数: 9638 | 9 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. |
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i*d
发帖数: 2640 | 10 请教
syncope查carotid u/s的具体目的都包括那些啊？普通常规的那种。总觉得用处很有限。 |
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A*******s
发帖数: 9638 | 11 I think physicians order carotid as a part of stroke workup.
限。 |
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d**o
发帖数: 618 | 12 这个SSS是不是发生在左侧比右侧的可能性要大得多？因为右侧的carotid branch
point到vertebral branch point之间的距离太短了，只有正好在那短短一段里clot才
能SSS？ |
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d****y
发帖数: 2180 | 13 呵呵。刚好NBME里面碰到一个这个病例。老大，你会选B还是C啊？
B) Magnetic resonance angiography
C) Ultrasonography of the carotid arteries |
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A*******s
发帖数: 9638 | 14 I would choose C.
MRA of subclavian is not a routine test.
Carotid u/s is able to identify vertebral retrograde flow and subclavian
artery stenosis although it is tech dependent. |
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d****y
发帖数: 2180 | 15 Is it right that use carotid/us as the initial screen test since it's
relately unexpensive, if identy vertebral retrograde flow and subclavian
artery stenosis, then do a MRA or angiogram of the subclavian ? |
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R*******t
发帖数: 367 | 16 There seems to be some calcified plaque at left internal carotid artery.
Which hand did she have the pain and numbness? |
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A*******s
发帖数: 9638 | 17 这就是evidence based medicine和经验医学的区别， 我觉得这是一个很好的topic。
医生治疗疾病， 都是为了防止病人死亡， 这个前提没错。 可是具体的做法并不是都
合情合理的。 PSA screen就是一个例子， 因为背后的商业利益实在太多了， family
medicine， 实验室， 病理， 放射， 泌尿科，OR，etc， 一个假阳性就可能牵涉到这
么多的程序， 不光给病人带来烦恼， 经济上的花销也是非常可观。 而前提是为了病
人的健康， 一旦有个家庭医生没有screen， 而病人恰恰得了cancer， 可能又是legal
的问题， 花费更大。
carotid U/S是另一个例子， 有一段时间在大的shopping mall就有这样的screening
service， 发现有问题， 不管有没有症状就做手术， 结果一些出了并发症的病人就不
买账。 还有一些imaging中心， 给没有症状的人做CT体检， 全身扫一个遍， 看到东西
就去看surgeon， 搞得大家一头雾水。
不得不承认， 经济利益在medicalpractice扮演着一个极其重要的角色， 而为病... 阅读全帖 |
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A*******s
发帖数: 9638 | 18 subclavian steal syndrome。
做个carotid Doppler， 不是看颈动脉，而是看锥动脉的血流方向， TCD也可以考虑。
MRA of subclavian也是个好办法。 |
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z****o
发帖数: 368 | 19 Pulsatile tinnitus. Possible reasons include carotid artery arteriosclerosis
or aneurysm, high jugular bulb. Need images to make the diagnosis, e.g.
thin slice CT with and without contrast. As for the slow heart rate, it may
or may not be related to the tinnitus. Need to see a doctor to make the
diagnosis.
建议看看primary医生，如果需要再转专科 |
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g*****d
发帖数: 991 | 20 Try this one.
3. A 75-year-old man presents with pain in both legs for the past six
months. He says that the pain has limited markedly his ability to walk. He
must sit down after walking a block. Stopping is not sufficient to decrease
the pain. At times, just standing causes his calves to ache, and he notices
tingling in both feet.
He has a 10-year history of systolic hypertension for which he has been
taking chlorthalidone. He has also been on warfarin and digoxin for a known
atrial fibrilla... 阅读全帖 |
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A*******s
发帖数: 9638 | 21 来自主题: Medicalpractice版 - 基因检测 A nice read.
我刚刚感兴趣，FDA就犯难。 其实昨天我就在想，这个检查跟以前流行的全身CT查肿瘤
是一个意义的，作为兴趣爱好可以，当真了后果绝对严重。 尤其在美国，会有法律上
的麻烦。 我以前一个病人，因为逛mall做了个carotid artery screen，结果发现有狭
窄，做手术后发生中风，一侧全瘫。所以任何医疗检查，需要通过医生， 只有你的医
生认为有必要做，这个检查才能付诸实施。 而肿瘤这种删选，如果阳性，对病人将来
的保险，比方说医疗保险，残废保险，nursing home保险，生命保险等等都有重大影响。 |
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A*******s
发帖数: 9638 | 22 24小时不睡啊，确实辛苦，我们以前是36小时，但晚上可以睡一会， 看运气，如果儿
科的急诊多就
没辙了。夜里两个医院间来回跑是最可恶的。
抗议一下这一段：“15：30 大学医院神经科病房。77岁老人高血压房颤中风病史因晕
厥待查入神经科，疑
是癫痫发作。多次心电图和心肌酶正常。无心脏科处理指证。真想说，Stupid的神经科
。”
除了vasovagal，syncope大多数是cardiogenic，与中风和癫痫没什么关系。心律失常
是最常见的，所以很多情况下病人出院需要带event monitor。而最新出台的新规矩不
提倡在syncope病人做carotid ultrasound就是要把syncope与CVA区分开来。
你这个病人我认为是心脏科问题，可怜神经科怎么收了这个病人，确实愚蠢，呵呵
★ 发自iPhone App: ChineseWeb 7.8 |
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n*******c
发帖数: 501 | 23 嗯，我们之前看过一个病人，反复syncope,多次心脏科入院及Holter查不出毛病,心脏
科要求神经科会诊多次，考虑Abcent seizure,我们老板还是考虑cardiogenic，要求他
们放Loop recorder，结果有一次在急诊的时候一位心脏科医生示范carotid massage,
病人出现7秒的asystole...最后放了Pacemaker
in |
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M***D
发帖数: 249 | 24 Agree, but CT is a quick and easy test to start a stoke work up. If cannot
get precert from the patient's insurance for a MRI, I will check lipid
profiles, UDS, ESR, ANA, and will the patient's insurance approve a carotid
echo? |
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M***D
发帖数: 249 | 25 Agree, but CT is a quick and easy test to start a stoke work up. If cannot
get precert from the patient's insurance for a MRI, I will check lipid
profiles, UDS, ESR, ANA, and will the patient's insurance approve a carotid
echo? |
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j****2
发帖数: 3211 | 26 你这听着不象是眼睛的问题，建议自己掏钱做个血管b超查carotid artery。distal
ica 堵塞造成ophthalmic artery供血不足，会出现短暂的视觉半黑，只是有可能啊，
具体你自己定，b超没多少钱 |
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k***m
发帖数: 30 | 27 Hi, sorry I could not type chinese on my computer.
I would suggest an ophthalmologist visit ( not optometrist).
It's hard to tell the diagnosis just from what you said in your post. Could
be posterior viteous detachment, which is more common and more benign. But
could be macular disease, less likely but more serious (edema, or hole, but
highly unlikely macular degeneration as you mentioned, unless mom is 75+).
Does not sounds like carotid problem, don't do ultra sound yet, unless your
eye doctor... 阅读全帖 |
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s*********8
发帖数: 1630 | 28
多谢南大指正。看来还是不能偷懒。
想再问南大夫一个问题，最近一年来，发现自己躺在床上时经常能清楚听到自己心跳，
侧卧时更明显。不知道是什么原因？有可能是Carotid 的问题吗？但是最近体检心跳血
压都正常，LDL<100, total<150. 自己年龄也不算大，没有任何疾病。多谢多谢！ |
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s*********8
发帖数: 1630 | 29 我也这样想过，不过我从来不耳鸣，所以有些疑惑。不好意思，借南大的楼问A大一个
问题，如果一个从来不头痛的人，突然开始头痛，不频繁，年龄不祘年轻（40 岁), 血
压正常，头痛是pulsatilve, 类似跟颅内压升高有关，（比如说激动，生气）。您觉得
这个主要的differential 有什么？需不需要做个MRI/mra rule out mass or carotid
dissection ? 多谢多谢。 |
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A*******s
发帖数: 9638 | 30 耳鸣就是听到了不该听到的杂音，心跳音可以是其中一种。
头疼的并发症有很多，但都是nonspecific的，你说的情况可以有，但可能性小，也不
一定相关。
carotid |
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M***D
发帖数: 249 | 31 Is the patient on OCP? A smoker? Obese? Any carotid US or MRA done for her? |
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l*********n
发帖数: 831 | 32 全铁选手KATHLEEN ALLEN参加全铁比赛前5天被卡车.撞成重伤，恢复很久，之后又参
加全铁比赛了
http://ironman.com/mediacenter/dont-miss-the-exciting-coverage-
Kathleen Allen was used to hearing her four children cheer "Go Mommy, Go!"
Most of the time those cheers came at races - the 39-year-old is one of the
top age group triathletes in the United States. Two years ago, though, her
children were cheering for her just to re-learn how to walk - motivation
which helped her overcome a horrific accident and return to triathlon racing
. Allen... 阅读全帖 |
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