A*******s
发帖数: 9638 | 1 一个不常见，容易忽视的诊断。
Subclavian stenosis disorder is a relatively rare disorder. There are only
about 2% in today’s population and about 7% of the clinical population that
suffer from subclavian stenosis. On most cases, SSP or subclavian steal
phenomenon is only incidentally found during sonography conducted in the
vertebral system. About 2% to 5% of those who are examined are discovered
this way. Of all these incidents, only 5% of the patients actually
manifested symptoms of subclavian stenosis syndr... 阅读全帖 |
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A*******s
发帖数: 9638 | 2 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 | 3 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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b******a
发帖数: 704 | 4 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. |
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b******a
发帖数: 704 | 5 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. |
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b******a
发帖数: 90 | 6 I am quite puzzled by the following question. One answer key says B, but A
seems to be better, because air embolism can be a serious complication of
subclavian venous catheterization. The onset of symptoms is sudden, and it
can explain the hypotension very well. Any idea? Thank you!
form 3-2-44. A 57-year-old hospitalized man undergoes right subclavian
venous catheterization for hyperalimentation. He is currently being treated
for a small bowel fistula. While the results of an x-ray film of the |
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d********y
发帖数: 616 | 7 Heart & Blood Vessels
Flask-shaped / Pear-shaped / Leathe- bottle / Money-bag shaped heart -
Pericardial effusion
Boot-shaped heart / Coer-en-sabot - Fallot's tetralogy
Box shaped appearance - Tricuspid atresia
Jug Handle appearance - Primary pulmonary artery hypertension
"3" like appearance - Coarctation of Aorta
Egg on side appearance - Transposition of great vessels
Egg in cup appearance - Constrictive pericarditis
Snow-man heart - TAPVC (total anomalous pulmon... 阅读全帖 |
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e****0
发帖数: 678 | 8 • Exaggerated deep tendon reflexes can be seen in lock in syndrome.
• Non bleeding varices are managed with nonselective beta-
adrenergic antagonists, such as propranolol.
• Sclerotherapy, endoscopic band ligation, and surgery are
indicated after a patient has a first episode of variceal bleeding.
• TIPS is a last resort in variceal bleeding unresponsive to
medical and endoscopic intervention.
• Ischemic colitis
CT—thickening of eth bowel ... 阅读全帖 |
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A*******s
发帖数: 9638 | 9 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. |
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A*******s
发帖数: 9638 | 10 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 | 11 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 |
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A*******s
发帖数: 9638 | 12 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. |
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A*******s
发帖数: 9638 | 13 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 | 14 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 |
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A*******s
发帖数: 9638 | 15 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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A*******s
发帖数: 9638 | 16 我不明白为什么大家都把syncope当stroke？ 去年神经科5大不可以就包括syncope不要
做carotid dopplar。 道理很简单，神志的改变必须是两侧大脑半球都有问题，TIA/
CVA却往往是一侧。
Subclavian steal syndrome应该是比较容易诊断的，但有多少医生测量双臂的血压？
所以这个病应该是underdiagnosed。 今天一个cardiologist看到这个case时感叹，我们
平时有多少syncope，有几个想到subclavian steal的？
这个病历我引以为骄傲的是我没有相信2个月前的医院carotid dopplar， 而是把一个
星期后她在诊所做的翻了出来。 报告中提到了右侧基底动脉的逆向flow，放射科医生
居然一带而过，没有提一下可能的鉴别诊断。 所以大多数医生都认为carotid就是看颈
动脉狭窄而已。 我因为认定这个病人的神志改变与carotid无关，所以特别关注了基底
动脉，终于功夫不负有心人。 |
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P**k
发帖数: 264 | 17 Without knowing the whole history, PE, and reviewing neuroimages, difficult
to make any comments. But a few things to consider:
1. SSS more common on L side. Reversal of vertebral artery flow may not
indicate SSS. Need to r/o vertebral artery origin stenosis.
2. SSS need to be confirmed by blood pressure cuff test. Most of SSS is
asymptomatic.
3. Even if SSS, not sure there is enough evidence there is "clot" in
subclavian artery. not sure role of anticoagulation in this situation. Most
of time, ... 阅读全帖 |
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l*h
发帖数: 4124 | 18 1. whether his symptoms are angina?
2. if yes, then will need to image aorta and subclavian arteries. both left
and right coronary normally originate from aorta, but there are
abnormalities. |
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b*h
发帖数: 637 | 19 > 1. whether his symptoms are angina?
我又问了我爸关于到底是不是心绞痛，他说是他自己觉得的，没有医生给他诊断过。他
的硝酸甘油也是问医生要，医生就给开的（晕。。。）他的犯病的时候就是胸口中中间
痛，反射到后背，再反射到右边的一颗牙痛。
》2. if yes, then will need to image aorta and subclavian arteries. both
left and right coronary normally originate from aorta, but there are
abnormalities.
我理解您是说CT应该去照（或是至少包括）大通脉和锁骨下动脉，因为左右两个冠状动
脉都是起源于主动脉。 但是我们现在的片子只照了左、右的冠状动脉，心肌和肺野（
对我们外行来说就是肺部）说没有异常。但是CT应该也照主动脉和锁骨下动脉。
想问一下，我们是不是直接应该要求做冠状动脉造影。之前有个大侠说过觉得做心脏CT
是鸡肋。 我父亲和医生要求做冠状动脉造影，医生说检查要一步一步来，先做个心脏
增强CT. 我爸爸周一... 阅读全帖 |
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l*h
发帖数: 4124 | 20 1. whether his symptoms are angina?
2. if yes, then will need to image aorta and subclavian arteries. both left
and right coronary normally originate from aorta, but there are
abnormalities. |
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b*h
发帖数: 637 | 21 > 1. whether his symptoms are angina?
我又问了我爸关于到底是不是心绞痛，他说是他自己觉得的，没有医生给他诊断过。他
的硝酸甘油也是问医生要，医生就给开的（晕。。。）他的犯病的时候就是胸口中中间
痛，反射到后背，再反射到右边的一颗牙痛。
》2. if yes, then will need to image aorta and subclavian arteries. both
left and right coronary normally originate from aorta, but there are
abnormalities.
我理解您是说CT应该去照（或是至少包括）大通脉和锁骨下动脉，因为左右两个冠状动
脉都是起源于主动脉。 但是我们现在的片子只照了左、右的冠状动脉，心肌和肺野（
对我们外行来说就是肺部）说没有异常。但是CT应该也照主动脉和锁骨下动脉。
想问一下，我们是不是直接应该要求做冠状动脉造影。之前有个大侠说过觉得做心脏CT
是鸡肋。 我父亲和医生要求做冠状动脉造影，医生说检查要一步一步来，先做个心脏
增强CT. 我爸爸周一... 阅读全帖 |
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S**********s
发帖数: 4534 | 22 抵肩的地方垫个厚点硬点的东西， 不仅可以抵消可感后座， 还可以减少心跳和
subclavian/axillary artery脉搏对瞄准的影响。
其实冬天穿的衣服就够把.308的可感后座降低到夏天打.223的水平。 |
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t*********m
发帖数: 360 | 23 if not operated on during infancy, patients could develop an extensive
collateral circulation, from the branches of the subclavian, the superior
intercostal, and the internal mammary arteries, bypassing the area of
coarctation.
send me an email,then i have a pic for you. i can't post if here somehow.
FYI, if ask in English, you can make our life easier. |
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s*******8
发帖数: 118 | 24 一般每个program在毕业前都会要求resident完成些procedure.比如我们这里5个IJ,5个
A-line,5个胸穿，5个腰穿，3个腹穿，3个关节穿刺和5个pap smear.
建议刚开始的intern们作procedure前，一定要看好NEJM的录像，讲的简明易懂。下面
只是本人的一点体会，希望大家一起讨论。
先讲讲central line,只是在ICU必做的procedure,分为femoral,IJ,subclavian,因为
femoral line的高感染率，除了紧急情况，一般不会首选，我本人比较喜欢IJ,特别是
有超声波，成功率超过90%。无论做那种作之前都要摆好病人体位，找一个自己最舒服
的姿势，刚开始最爱忘的是saline flush，最好和护士和你的上级事先讲好，不要等到
换好衣服后才想起来。我的习惯是做procedure前把needle,guidewire都从kit里拿出来
按顺序摆放好，做完后第一件事就是扔掉所有的sharps.如果不养成好的习惯，很容易
被针扎到。如果你的senior是个急性子，你也要沉住气。越是紧张越容易出事。
关于IJ的并发症主 |
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t******9
发帖数: 270 | 25 Left subclavian artery stenosis? |
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a*i
发帖数: 1652 | 26 治疗心律不齐，把病变的控制心脏跳动得心血管电路破坏掉。问题是然后心脏怎么有节
律跳动？再来起搏器吗？
http://en.wikipedia.org/wiki/Catheter_ablation
Catheter ablation is an invasive procedure used to remove a faulty
electrical pathway from the hearts of those who are prone to developing
cardiac arrhythmias such as atrial fibrillation, atrial flutter,
supraventricular tachycardias (SVT) and Wolff-Parkinson-White syndrome.
It involves advancing several flexible catheters into the patient's blood
vessels, usually either in the femoral vein, interna... 阅读全帖 |
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I****a
发帖数: 407 | 27 Paget-Schroetter disease, the one that can get you into malpractice trouble
if you just send those patients home with Lovenox and Coumadin. Untreated
symptomatic patients can sustain long-term disability from venous
obstruction resulting in significant loss of occupational productivity and
quality of life.For the same reason, early catheter directed thrombolysis
followed by anticoagulation and surgical intervention are recommended.
It is also known as Paget-von Schrötter disease or upper ex... 阅读全帖 |
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A*******s
发帖数: 9638 | 28 发信人: Icetea (冰瓜儿), 信区: Medicalpractice
标 题: Re: 【征文活动】 有趣的临床综合症。
发信站: BBS 未名空间站 (Sat Oct 8 15:17:55 2011, 美东)
Paget-Schroetter disease, the one that can get you into malpractice trouble
if you just send those patients home with Lovenox and Coumadin. Untreated
symptomatic patients can sustain long-term disability from venous
obstruction resulting in significant loss of occupational productivity and
quality of life.For the same reason, early catheter directed thrombolysis
followed by anticoagula... 阅读全帖 |
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R*******t
发帖数: 367 | 29 "核磁共振啊等各种方法都查过了。没有查出什么不好的地方。"
Degenerative disc disease or spondylosis can be easily seen on MRI. Has
subclavian steal been excluded? Besides physical exam, MRA would be of additional benefit for
further evaluation. |
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b*******s
发帖数: 954 | 30 今天又问了妈妈
我妈妈讲从片子上看，她的3,4,5节颈椎靠的过近。医生说这样就会压迫神经。
会提醒妈妈回国后做MRA.
不太清楚关于subclavian steal的情况。
多谢多谢！
additional benefit for |
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A*******s
发帖数: 9638 | 31 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 |
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a******3
发帖数: 1017 | 32 瞎猜一个
Bilateral Subclavian Steal Syndrome？ |
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R*******t
发帖数: 367 | 33 Afib来的吧？不会是carotid plaque，那是anterior circulation。也许subclavian
artery plaque. |
|
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A*******s
发帖数: 9638 | 35 new onset 是刚刚发现的， 没人知道什么时候的开始的。
这个病人做了MRA of subclavian artery。 99% stenosis on the left
的Emboli， 常见。
，如果不采取强力措施，大多数最后的结局也是Emboli脱落，脑梗塞。 |
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R*******t
发帖数: 367 | 36 Subclavian很难看得好，相当一部分被锁骨挡着。 |
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A*******s
发帖数: 9638 | 37 Hospital tech says no, but my clinic tech who works for a vascular surgeon
said he is doing it all the time.
In this case, the tech told me he should be able to tell me if there is
stenosis in subclavian on u/s only. |
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n*******c
发帖数: 501 | 38 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 | 39 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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A*******s
发帖数: 9638 | 40 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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A*******s
发帖数: 9638 | 41 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******3
发帖数: 1017 | 42 瞎猜一个
Bilateral Subclavian Steal Syndrome？ |
|
R*******t
发帖数: 367 | 43 Afib来的吧？不会是carotid plaque，那是anterior circulation。也许subclavian
artery plaque. |
|
|
A*******s
发帖数: 9638 | 45 new onset 是刚刚发现的， 没人知道什么时候的开始的。
这个病人做了MRA of subclavian artery。 99% stenosis on the left
的Emboli， 常见。
，如果不采取强力措施，大多数最后的结局也是Emboli脱落，脑梗塞。 |
|
R*******t
发帖数: 367 | 46 Subclavian很难看得好，相当一部分被锁骨挡着。 |
|
A*******s
发帖数: 9638 | 47 Hospital tech says no, but my clinic tech who works for a vascular surgeon
said he is doing it all the time.
In this case, the tech told me he should be able to tell me if there is
stenosis in subclavian on u/s only. |
|
n*******c
发帖数: 501 | 48 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 | 49 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 |
|
A*******s
发帖数: 9638 | 50 I think it is tech dependent. Just like U/S for subclavian, the hospital
tech said no but our clinic tech told me easy. |
|
