A*******s
发帖数: 9638 | 1 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 U/S: Retrograde basilar artery flow.
Thoughts?
|
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. |
n*******c
发帖数: 501 | 3 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 glucose level has been checked and it was normal. |
a*********d
发帖数: 2763 | 4 check thyroid function:)
【在 A*******s 的大作中提到】
: 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.
|
s**********t
发帖数: 217 | |
s********o
发帖数: 3319 | 6 到了医院都还晕乎乎的，显然是seizure啊 ：）
做个CT除外别的看看？ |
L****n
发帖数: 12932 | 7 She on any medication?
【在 A*******s 的大作中提到】
: 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.
|
s********p
发帖数: 1319 | 8 版大，
New Onset AF
——SN, AVN变时功能不良的信号，亦可能有快速心室反应，感觉需要做个Holter。
【在 A*******s 的大作中提到】
: 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.
|
a******3
发帖数: 1017 | 9 瞎猜一个
Bilateral Subclavian Steal Syndrome？ |
s******t
发帖数: 579 | |
|
|
A*******s
发帖数: 9638 | 11 The patient was confused on the day of admission. Next day, she was much
more awake. I noticed she has a right INO, all other exams had no change.
MRI showed a brain stem infarct, 2 small infarcts in cerebellum.
ECHO shows no clots.
EEG was nl.
CMP at admission including Glucose was 126.
【在 n*******c 的大作中提到】
: 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 glucose level has been checked and it was normal.
|
A*******s
发帖数: 9638 | 12 At 5:32 AM, you paged me for a stat TSH? lol
【在 a*********d 的大作中提到】
: check thyroid function:)
|
A*******s
发帖数: 9638 | 13 Sure, EEG was nl.
【在 s**********t 的大作中提到】
: r/o seizure
|
A*******s
发帖数: 9638 | 14 "做个CT除外别的看看？" 你是说做个别的检查？ 我的中文不是很好。
【在 s********o 的大作中提到】
: 到了医院都还晕乎乎的，显然是seizure啊 ：）
: 做个CT除外别的看看？
|
A*******s
发帖数: 9638 | 15 She was on ASA only。
【在 L****n 的大作中提到】
: She on any medication?
|
A*******s
发帖数: 9638 | 16 同意， 她有telemetry。
【在 s********p 的大作中提到】
: 版大，
: New Onset AF
: ——SN, AVN变时功能不良的信号，亦可能有快速心室反应，感觉需要做个Holter。
|
A*******s
发帖数: 9638 | 17 为什么bilateral？ 因为BP没有差别？
【在 a******3 的大作中提到】
: 瞎猜一个
: Bilateral Subclavian Steal Syndrome？
|
A*******s
发帖数: 9638 | 18 Good thought， MRA of what？
【在 s******t 的大作中提到】
: ECHO, MRA
|
S******9
发帖数: 2837 | 19 CVS:irregularly irregular
AF发作
【在 A*******s 的大作中提到】
: 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.
|
A*******s
发帖数: 9638 | 20 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.
【在 b******a 的大作中提到】
: 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.
|
|
|
A*******s
发帖数: 9638 | 21 A good thought, but not in this case.
【在 S******9 的大作中提到】
: CVS:irregularly irregular
: AF发作
|
k********n
发帖数: 756 | 22 How US demonstrated basilar retrograde flow? |
A*******s
发帖数: 9638 | 23 Dopplar can detect the flow direction.
【在 k********n 的大作中提到】
: How US demonstrated basilar retrograde flow?
|
a******3
发帖数: 1017 | 24 嗯，是这样想的，但BP似乎又高了些，不知她平时血压水平如何。
【在 A*******s 的大作中提到】
: 为什么bilateral？ 因为BP没有差别？
|
a******3
发帖数: 1017 | 25 wow，我典型的瞎猫逮着死耗子了，还有包子吃，哈哈。
【在 A*******s 的大作中提到】
: 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.
|
A*******s
发帖数: 9638 | 26 stroke后血压一般都高， 另外stress可以让血压增高。
【在 a******3 的大作中提到】
: 嗯，是这样想的，但BP似乎又高了些，不知她平时血压水平如何。
|
k********n
发帖数: 756 | 27 How Doppler can see basilar?
【在 A*******s 的大作中提到】
: Dopplar can detect the flow direction.
|
A*******s
发帖数: 9638 | 28 Because it is Dopplar。 ：）
not optimal but still able to see the flow。 Modern tech can color the flow
direction so it is easy to distinguish the difference.
Echocardiogram can do the same thing.
【在 k********n 的大作中提到】
: How Doppler can see basilar?
|
a*********d
发帖数: 2763 | 29 i don't get it, why do i want to page you for TSH?
for any new onset of a fib, TSH should always be checked, i understand it
might not be the concern here, but i mentioned it just for reference.
【在 A*******s 的大作中提到】
: At 5:32 AM, you paged me for a stat TSH? lol
|
A*******s
发帖数: 9638 | 30 You posted your reply at 5：32 am
【在 a*********d 的大作中提到】
: i don't get it, why do i want to page you for TSH?
: for any new onset of a fib, TSH should always be checked, i understand it
: might not be the concern here, but i mentioned it just for reference.
|
|
|
a*********d
发帖数: 2763 | 31 我早起早睡不行么
【在 A*******s 的大作中提到】
: You posted your reply at 5：32 am
|
A*******s
发帖数: 9638 | 32 Sense of humor好像跟年龄成正比， 呵呵
【在 a*********d 的大作中提到】
: 我早起早睡不行么
|
a*********d
发帖数: 2763 | 33 怪不得我这么没有幽默感，悲催的
【在 A*******s 的大作中提到】
: Sense of humor好像跟年龄成正比， 呵呵
|
A*******s
发帖数: 9638 | 34 我怎么觉得是BSO啊， lol
【在 a*********d 的大作中提到】
: 怪不得我这么没有幽默感，悲催的
|
s********p
发帖数: 1319 | 35 版大，介病人的AF如果持续下去，48小细后，就要上药的。
——我到其他科细去会了灯，看到有好的盒饭，也要顺手牵羊抢两盒走的。
所以，包子也应该有我的。
【在 A*******s 的大作中提到】
: 同意， 她有telemetry。
|
A*******s
发帖数: 9638 | 36 不是48小时， 是马上。 所以你没有包子， 哈哈
你觉得这个病人的emboli是从哪里来的？
【在 s********p 的大作中提到】
: 版大，介病人的AF如果持续下去，48小细后，就要上药的。
: ——我到其他科细去会了灯，看到有好的盒饭，也要顺手牵羊抢两盒走的。
: 所以，包子也应该有我的。
|
R*******t
发帖数: 367 | 37 Afib来的吧？不会是carotid plaque，那是anterior circulation。也许subclavian
artery plaque.
【在 A*******s 的大作中提到】
: 不是48小时， 是马上。 所以你没有包子， 哈哈
: 你觉得这个病人的emboli是从哪里来的？
|
A*******s
发帖数: 9638 | 38 你来的正好， 你们看到carotid u/s 有retrograde flow一般怎么做？
【在 R*******t 的大作中提到】
: Afib来的吧？不会是carotid plaque，那是anterior circulation。也许subclavian
: artery plaque.
|
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。
【在 A*******s 的大作中提到】
: 你来的正好， 你们看到carotid u/s 有retrograde flow一般怎么做？
|
A*******s
发帖数: 9638 | 40 如果看到vertebral artery retrograde flow， 你们怎么做呢？
【在 R*******t 的大作中提到】
: 我们这里常规carotid ultrasound不包括basilar，只记录两侧vertebral arteries，
: 是antegrade还是retrograde。
|
|
|
R*******t
发帖数: 367 | 41 Tech用blood pressure cuff人为造成arm ischemia，然后再看看vertebral artery
flow。 |
s********p
发帖数: 1319 | 42 倒——彻底昏倒！我细专指AF而言。
New Onset的AF, 48小细以内的Emboli很罕见。还是考虑颈动脉、椎-基底动脉系统来的Emboli， 常见。
一过性黑蒙的椎-基底动脉的TIA，和颈动脉系统的TIA一样，也相当容易导致脑梗塞，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。
你看看别银，都是高档旗袍或者时装，就你和我，大冬天的，还光着膀子，好冷——你
先发点包子给我，我再回扣点给你，咋们也买件衣服，好不好？
【在 A*******s 的大作中提到】
: 不是48小时， 是马上。 所以你没有包子， 哈哈
: 你觉得这个病人的emboli是从哪里来的？
|
A*******s
发帖数: 9638 | 43 你们不直接看subclavian？
【在 R*******t 的大作中提到】
: Tech用blood pressure cuff人为造成arm ischemia，然后再看看vertebral artery
: flow。
|
A*******s
发帖数: 9638 | 44 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。
【在 s********p 的大作中提到】
: 倒——彻底昏倒！我细专指AF而言。
: New Onset的AF, 48小细以内的Emboli很罕见。还是考虑颈动脉、椎-基底动脉系统来的Emboli， 常见。
: 一过性黑蒙的椎-基底动脉的TIA，和颈动脉系统的TIA一样，也相当容易导致脑梗塞，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。
: 你看看别银，都是高档旗袍或者时装，就你和我，大冬天的，还光着膀子，好冷——你
: 先发点包子给我，我再回扣点给你，咋们也买件衣服，好不好？
|
k********n
发帖数: 756 | 45 What you mean is transcranial doppler (TCD) instead carotid doppler you
mentioned?
Carotid doppler can only detect the basilar artery in newborns.
flow
【在 A*******s 的大作中提到】
: Because it is Dopplar。 ：）
: not optimal but still able to see the flow。 Modern tech can color the flow
: direction so it is easy to distinguish the difference.
: Echocardiogram can do the same thing.
|
R*******t
发帖数: 367 | 46 Subclavian很难看得好，相当一部分被锁骨挡着。
【在 A*******s 的大作中提到】
: 你们不直接看subclavian？
|
A*******s
发帖数: 9638 | 47 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.
【在 k********n 的大作中提到】
: 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 | 48 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.
【在 R*******t 的大作中提到】
: Subclavian很难看得好，相当一部分被锁骨挡着。
|
b***b
发帖数: 13249 | 49 Kind of agree with this.
【在 s********p 的大作中提到】
: 版大，
: New Onset AF
: ——SN, AVN变时功能不良的信号，亦可能有快速心室反应，感觉需要做个Holter。
|
b******a
发帖数: 704 | 50 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
【在 A*******s 的大作中提到】
: 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.
|
|
|
A*******s
发帖数: 9638 | 51 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。
【在 b******a 的大作中提到】
: 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
|
s********p
发帖数: 1319 | 52 就是版大那个“New Onset”, 我理解为：“新近发生的......”
害死我，不但没拿到Baozi, 还被鄙视——倒！！
【在 b***b 的大作中提到】
: Kind of agree with this.
|
m****a
发帖数: 287 | 53 为什么不考虑动脉粥样硬化斑块啊？绝经期妇女发病率应该不低，而且可以和血栓同时存在吧。 |
A*******s
发帖数: 9638 | 54 Sure.
But any difference on treatment? Probably not.
时存在吧。
【在 m****a 的大作中提到】
: 为什么不考虑动脉粥样硬化斑块啊？绝经期妇女发病率应该不低，而且可以和血栓同时存在吧。
|
A*******s
发帖数: 9638 | 55 step， 千万不要自暴自弃， 呵呵。 在本版是没有鄙视一说的， 你说的有你的道理
， 应该有包子。 不过你还欠我10个包子加利息， 可别忘了。
【在 s********p 的大作中提到】
: 就是版大那个“New Onset”, 我理解为：“新近发生的......”
: 害死我，不但没拿到Baozi, 还被鄙视——倒！！
|
m****a
发帖数: 287 | 56 治疗上是不是可以加用抗血小板的药物？
【在 A*******s 的大作中提到】
: Sure.
: But any difference on treatment? Probably not.
:
: 时存在吧。
|
s******t
发帖数: 579 | 57 I have questions about how to order MRA:
Should we order to look at some specific locations most of the time or can
we order to see all the blood vessels from aorta to circle of Willis or even
higher level to look for any stenosis and embolization etc.?
If we need to see more blood vessels, it just takes longer and more
expensive or some else?
Thanks a lot!
【在 A*******s 的大作中提到】
: Good thought， MRA of what？
|
A*******s
发帖数: 9638 | 58 I would not due to the risk of hemorrhage.
【在 m****a 的大作中提到】
: 治疗上是不是可以加用抗血小板的药物？
|
A*******s
发帖数: 9638 | 59 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
【在 s******t 的大作中提到】
: I have questions about how to order MRA:
: Should we order to look at some specific locations most of the time or can
: we order to see all the blood vessels from aorta to circle of Willis or even
: higher level to look for any stenosis and embolization etc.?
: If we need to see more blood vessels, it just takes longer and more
: expensive or some else?
: Thanks a lot!
|
s********p
发帖数: 1319 | 60 我咋能不“自爆自弃”?大年十五来啦，还欠版主这么大一笔！——莫非叫我做杨白劳
不成？！
——不对，我的“伟哥”大贴，好像我俩连本带利结清啦！
——对，有啦，我有大钱花啦！我费了那么多心血帮版大搞的“形象设计”，我们还没
结账，对不？！
【在 A*******s 的大作中提到】
: step， 千万不要自暴自弃， 呵呵。 在本版是没有鄙视一说的， 你说的有你的道理
: ， 应该有包子。 不过你还欠我10个包子加利息， 可别忘了。
|
|
|
s********p
发帖数: 1319 | 61 如果考虑来自动脉系统的栓子，强力抗血小板 + 低分子量肝素；
如果考虑心房和静脉系统的栓子，主打药物是Vit K依赖的抗凝药或凝血酶抑制剂，以
肝素为过渡。
【在 m****a 的大作中提到】
: 治疗上是不是可以加用抗血小板的药物？
|
s******t
发帖数: 579 | 62 Thank you for telling me why did you order MRA, but my question was a very
general question about the techniques. Maybe， Ruby knows more about the
answer to my questions:
MRA一般是只看一个较小范围里的血管，还是常规地可以一次看所有的你感兴趣的血管？
在看指定的少数血管和大面积观察血管异常在操作上有什么大的差异？
什么是MRA的最常见indications？
a
no
【在 A*******s 的大作中提到】
: 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
|
s******t
发帖数: 579 | 63 Could you talk about the trearment plan for this case please?
【在 A*******s 的大作中提到】
: Sure.
: But any difference on treatment? Probably not.
:
: 时存在吧。
|
a******3
发帖数: 1017 | 64 谢谢A大,我很高兴自己居然还挣了个学术包子 ^_^ |
A*******s
发帖数: 9638 | 65 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？
【在 s******t 的大作中提到】
: Thank you for telling me why did you order MRA, but my question was a very
: general question about the techniques. Maybe， Ruby knows more about the
: answer to my questions:
: MRA一般是只看一个较小范围里的血管，还是常规地可以一次看所有的你感兴趣的血管？
: 在看指定的少数血管和大面积观察血管异常在操作上有什么大的差异？
: 什么是MRA的最常见indications？
:
: a
: no
|
A*******s
发帖数: 9638 | 66 I have mentioned above. Anticoagulation.
【在 s******t 的大作中提到】
: Could you talk about the trearment plan for this case please?
|
R*******t
发帖数: 367 | 67 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 seen with a satisfactory exam and
therefore being evaluated and reported. If you are lucky, you can
track
distal sub segmental arteries almost to the cortex, but not always. There
are always MIP images of MRA, which shows nicely the circle of willies and
the posterior circulation pathways.
Seeing very distal tertiary branches is usually difficult due to resolution
and limitation of the exam. And it usually doesn't contribute much to
treatment plan especially combining the MRI brain and clinical findings in
the setting of non-hemorrhagic stroke.
Besides, very distal branches are often beyond interventional management for
thrombolectomy as well.
MRA head is commonly done with MRA neck. Many times we don't need contrast
for MRA neck with time of flight technique.
Common indications include but not limited to TIAs, headache, r/o aneurysm,
dizziness, abnormal CT or MRI of head which MRA was recommended, h/o stroke,
etc. Or whatever the clinicians feel like to fill in as indication. :P
管？
【在 s******t 的大作中提到】
: Thank you for telling me why did you order MRA, but my question was a very
: general question about the techniques. Maybe， Ruby knows more about the
: answer to my questions:
: MRA一般是只看一个较小范围里的血管，还是常规地可以一次看所有的你感兴趣的血管？
: 在看指定的少数血管和大面积观察血管异常在操作上有什么大的差异？
: 什么是MRA的最常见indications？
:
: a
: no
|
A*******s
发帖数: 9638 | 68 Very well explained.
Thanks, Ruby.
【在 R*******t 的大作中提到】
: 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 seen with a satisfactory exam and
|
n*******c
发帖数: 501 | 69 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 use contrast or just time of
flight. Also is there any carotid plaque？（If she has such a severe
atherosclerotic lesion in left subclavian artery I would expect consistent changes in
other arteries.
Again, thanks for sharing. |
R*******t
发帖数: 367 | 70 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 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 use contrast or just time of
flight. Also is there any carotid plaque？（If she has such a severe
atherosclerotic lesion in left subclavian artery I would expect consistent
changes in
other arteries.
Again, thanks for sharing. |
|
|
A*******s
发帖数: 9638 | 71 1. Syncope is from brain stem ischemia due to SSS, brain stem infarct is
just a part of it.
2. Not sure about vertebral A direction, I would assume it would be
antegrade on the right and retrograde on the left.
3. No syncope before.
4. It is not uncommon to see a single artery stenosis (atherosclerosis)on
MRA or CTA.
infarct)
than
a
of
【在 n*******c 的大作中提到】
: 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 use contrast or just time of
: flight. Also is there any carotid plaque？（If she has such a severe
|
n*******c
发帖数: 501 | 72 I see.If this is the case. The patient would expect recurrent episodes if
leaving SSS untreated.
I thought this acute event is mainly due to the acute infarct because she
has no syncope before.
I am just wondering if the doppler ultrasound reported retrograde flow on
vertebral as well.
Again, thanks for sharing. |
k********n
发帖数: 756 | 73 i asked several stroke guy and nobody seemed aware that US carotid can
detect blood flow in basilar. it is too high for US.
【在 A*******s 的大作中提到】
: I have mentioned above. Anticoagulation.
|
A*******s
发帖数: 9638 | 74 I think it is tech dependent. Just like U/S for subclavian, the hospital
tech said no but our clinic tech told me easy.
【在 k********n 的大作中提到】
: i asked several stroke guy and nobody seemed aware that US carotid can
: detect blood flow in basilar. it is too high for US.
|
s******t
发帖数: 579 | 75 Thank you soooooooooooo much!
【在 R*******t 的大作中提到】
: 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 seen with a satisfactory exam and
|
A*******s
发帖数: 9638 | 76 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.
【在 A*******s 的大作中提到】
: 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 | 77 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 U/S: Retrograde basilar artery flow.
Thoughts?
|
b******a
发帖数: 704 | 78 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. |
n*******c
发帖数: 501 | 79 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 glucose level has been checked and it was normal. |
a*********d
发帖数: 2763 | 80 check thyroid function:)
【在 A*******s 的大作中提到】
: 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.
|
|
|
s**********t
发帖数: 217 | |
s********o
发帖数: 3319 | 82 到了医院都还晕乎乎的，显然是seizure啊 ：）
做个CT除外别的看看？ |
L****n
发帖数: 12932 | 83 She on any medication?
【在 A*******s 的大作中提到】
: 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.
|
s********p
发帖数: 1319 | 84 版大，
New Onset AF
——SN, AVN变时功能不良的信号，亦可能有快速心室反应，感觉需要做个Holter。
【在 A*******s 的大作中提到】
: 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.
|
a******3
发帖数: 1017 | 85 瞎猜一个
Bilateral Subclavian Steal Syndrome？ |
s******t
发帖数: 579 | |
A*******s
发帖数: 9638 | 87 The patient was confused on the day of admission. Next day, she was much
more awake. I noticed she has a right INO, all other exams had no change.
MRI showed a brain stem infarct, 2 small infarcts in cerebellum.
ECHO shows no clots.
EEG was nl.
CMP at admission including Glucose was 126.
【在 n*******c 的大作中提到】
: 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 glucose level has been checked and it was normal.
|
A*******s
发帖数: 9638 | 88 At 5:32 AM, you paged me for a stat TSH? lol
【在 a*********d 的大作中提到】
: check thyroid function:)
|
A*******s
发帖数: 9638 | 89 Sure, EEG was nl.
【在 s**********t 的大作中提到】
: r/o seizure
|
A*******s
发帖数: 9638 | 90 "做个CT除外别的看看？" 你是说做个别的检查？ 我的中文不是很好。
【在 s********o 的大作中提到】
: 到了医院都还晕乎乎的，显然是seizure啊 ：）
: 做个CT除外别的看看？
|
|
|
A*******s
发帖数: 9638 | 91 She was on ASA only。
【在 L****n 的大作中提到】
: She on any medication?
|
A*******s
发帖数: 9638 | 92 同意， 她有telemetry。
【在 s********p 的大作中提到】
: 版大，
: New Onset AF
: ——SN, AVN变时功能不良的信号，亦可能有快速心室反应，感觉需要做个Holter。
|
A*******s
发帖数: 9638 | 93 为什么bilateral？ 因为BP没有差别？
【在 a******3 的大作中提到】
: 瞎猜一个
: Bilateral Subclavian Steal Syndrome？
|
A*******s
发帖数: 9638 | 94 Good thought， MRA of what？
【在 s******t 的大作中提到】
: ECHO, MRA
|
S******9
发帖数: 2837 | 95 CVS:irregularly irregular
AF发作
【在 A*******s 的大作中提到】
: 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.
|
A*******s
发帖数: 9638 | 96 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.
【在 b******a 的大作中提到】
: 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.
|
A*******s
发帖数: 9638 | 97 A good thought, but not in this case.
【在 S******9 的大作中提到】
: CVS:irregularly irregular
: AF发作
|
k********n
发帖数: 756 | 98 How US demonstrated basilar retrograde flow? |
A*******s
发帖数: 9638 | 99 Dopplar can detect the flow direction.
【在 k********n 的大作中提到】
: How US demonstrated basilar retrograde flow?
|
a******3
发帖数: 1017 | 100 嗯，是这样想的，但BP似乎又高了些，不知她平时血压水平如何。
【在 A*******s 的大作中提到】
: 为什么bilateral？ 因为BP没有差别？
|
|
|
a******3
发帖数: 1017 | 101 wow，我典型的瞎猫逮着死耗子了，还有包子吃，哈哈。
【在 A*******s 的大作中提到】
: 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.
|
A*******s
发帖数: 9638 | 102 stroke后血压一般都高， 另外stress可以让血压增高。
【在 a******3 的大作中提到】
: 嗯，是这样想的，但BP似乎又高了些，不知她平时血压水平如何。
|
k********n
发帖数: 756 | 103 How Doppler can see basilar?
【在 A*******s 的大作中提到】
: Dopplar can detect the flow direction.
|
A*******s
发帖数: 9638 | 104 Because it is Dopplar。 ：）
not optimal but still able to see the flow。 Modern tech can color the flow
direction so it is easy to distinguish the difference.
Echocardiogram can do the same thing.
【在 k********n 的大作中提到】
: How Doppler can see basilar?
|
a*********d
发帖数: 2763 | 105 i don't get it, why do i want to page you for TSH?
for any new onset of a fib, TSH should always be checked, i understand it
might not be the concern here, but i mentioned it just for reference.
【在 A*******s 的大作中提到】
: At 5:32 AM, you paged me for a stat TSH? lol
|
A*******s
发帖数: 9638 | 106 You posted your reply at 5：32 am
【在 a*********d 的大作中提到】
: i don't get it, why do i want to page you for TSH?
: for any new onset of a fib, TSH should always be checked, i understand it
: might not be the concern here, but i mentioned it just for reference.
|
a*********d
发帖数: 2763 | 107 我早起早睡不行么
【在 A*******s 的大作中提到】
: You posted your reply at 5：32 am
|
A*******s
发帖数: 9638 | 108 Sense of humor好像跟年龄成正比， 呵呵
【在 a*********d 的大作中提到】
: 我早起早睡不行么
|
a*********d
发帖数: 2763 | 109 怪不得我这么没有幽默感，悲催的
【在 A*******s 的大作中提到】
: Sense of humor好像跟年龄成正比， 呵呵
|
A*******s
发帖数: 9638 | 110 我怎么觉得是BSO啊， lol
【在 a*********d 的大作中提到】
: 怪不得我这么没有幽默感，悲催的
|
|
|
s********p
发帖数: 1319 | 111 版大，介病人的AF如果持续下去，48小细后，就要上药的。
——我到其他科细去会了灯，看到有好的盒饭，也要顺手牵羊抢两盒走的。
所以，包子也应该有我的。
【在 A*******s 的大作中提到】
: 同意， 她有telemetry。
|
A*******s
发帖数: 9638 | 112 不是48小时， 是马上。 所以你没有包子， 哈哈
你觉得这个病人的emboli是从哪里来的？
【在 s********p 的大作中提到】
: 版大，介病人的AF如果持续下去，48小细后，就要上药的。
: ——我到其他科细去会了灯，看到有好的盒饭，也要顺手牵羊抢两盒走的。
: 所以，包子也应该有我的。
|
R*******t
发帖数: 367 | 113 Afib来的吧？不会是carotid plaque，那是anterior circulation。也许subclavian
artery plaque.
【在 A*******s 的大作中提到】
: 不是48小时， 是马上。 所以你没有包子， 哈哈
: 你觉得这个病人的emboli是从哪里来的？
|
A*******s
发帖数: 9638 | 114 你来的正好， 你们看到carotid u/s 有retrograde flow一般怎么做？
【在 R*******t 的大作中提到】
: Afib来的吧？不会是carotid plaque，那是anterior circulation。也许subclavian
: artery plaque.
|
R*******t
发帖数: 367 | 115 我们这里常规carotid ultrasound不包括basilar，只记录两侧vertebral arteries，
是antegrade还是retrograde。
【在 A*******s 的大作中提到】
: 你来的正好， 你们看到carotid u/s 有retrograde flow一般怎么做？
|
A*******s
发帖数: 9638 | 116 如果看到vertebral artery retrograde flow， 你们怎么做呢？
【在 R*******t 的大作中提到】
: 我们这里常规carotid ultrasound不包括basilar，只记录两侧vertebral arteries，
: 是antegrade还是retrograde。
|
R*******t
发帖数: 367 | 117 Tech用blood pressure cuff人为造成arm ischemia，然后再看看vertebral artery
flow。 |
s********p
发帖数: 1319 | 118 倒——彻底昏倒！我细专指AF而言。
New Onset的AF, 48小细以内的Emboli很罕见。还是考虑颈动脉、椎-基底动脉系统来的Emboli， 常见。
一过性黑蒙的椎-基底动脉的TIA，和颈动脉系统的TIA一样，也相当容易导致脑梗塞，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。
你看看别银，都是高档旗袍或者时装，就你和我，大冬天的，还光着膀子，好冷——你
先发点包子给我，我再回扣点给你，咋们也买件衣服，好不好？
【在 A*******s 的大作中提到】
: 不是48小时， 是马上。 所以你没有包子， 哈哈
: 你觉得这个病人的emboli是从哪里来的？
|
A*******s
发帖数: 9638 | 119 你们不直接看subclavian？
【在 R*******t 的大作中提到】
: Tech用blood pressure cuff人为造成arm ischemia，然后再看看vertebral artery
: flow。
|
A*******s
发帖数: 9638 | 120 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。
【在 s********p 的大作中提到】
: 倒——彻底昏倒！我细专指AF而言。
: New Onset的AF, 48小细以内的Emboli很罕见。还是考虑颈动脉、椎-基底动脉系统来的Emboli， 常见。
: 一过性黑蒙的椎-基底动脉的TIA，和颈动脉系统的TIA一样，也相当容易导致脑梗塞，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。
: 你看看别银，都是高档旗袍或者时装，就你和我，大冬天的，还光着膀子，好冷——你
: 先发点包子给我，我再回扣点给你，咋们也买件衣服，好不好？
|
|
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k********n
发帖数: 756 | 121 What you mean is transcranial doppler (TCD) instead carotid doppler you
mentioned?
Carotid doppler can only detect the basilar artery in newborns.
flow
【在 A*******s 的大作中提到】
: Because it is Dopplar。 ：）
: not optimal but still able to see the flow。 Modern tech can color the flow
: direction so it is easy to distinguish the difference.
: Echocardiogram can do the same thing.
|
R*******t
发帖数: 367 | 122 Subclavian很难看得好，相当一部分被锁骨挡着。
【在 A*******s 的大作中提到】
: 你们不直接看subclavian？
|
A*******s
发帖数: 9638 | 123 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.
【在 k********n 的大作中提到】
: 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 | 124 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.
【在 R*******t 的大作中提到】
: Subclavian很难看得好，相当一部分被锁骨挡着。
|
b***b
发帖数: 13249 | 125 Kind of agree with this.
【在 s********p 的大作中提到】
: 版大，
: New Onset AF
: ——SN, AVN变时功能不良的信号，亦可能有快速心室反应，感觉需要做个Holter。
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b******a
发帖数: 704 | 126 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
【在 A*******s 的大作中提到】
: 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.
|
A*******s
发帖数: 9638 | 127 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。
【在 b******a 的大作中提到】
: 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
|
s********p
发帖数: 1319 | 128 就是版大那个“New Onset”, 我理解为：“新近发生的......”
害死我，不但没拿到Baozi, 还被鄙视——倒！！
【在 b***b 的大作中提到】
: Kind of agree with this.
|
m****a
发帖数: 287 | 129 为什么不考虑动脉粥样硬化斑块啊？绝经期妇女发病率应该不低，而且可以和血栓同时存在吧。 |
A*******s
发帖数: 9638 | 130 Sure.
But any difference on treatment? Probably not.
时存在吧。
【在 m****a 的大作中提到】
: 为什么不考虑动脉粥样硬化斑块啊？绝经期妇女发病率应该不低，而且可以和血栓同时存在吧。
|
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A*******s
发帖数: 9638 | 131 step， 千万不要自暴自弃， 呵呵。 在本版是没有鄙视一说的， 你说的有你的道理
， 应该有包子。 不过你还欠我10个包子加利息， 可别忘了。
【在 s********p 的大作中提到】
: 就是版大那个“New Onset”, 我理解为：“新近发生的......”
: 害死我，不但没拿到Baozi, 还被鄙视——倒！！
|
m****a
发帖数: 287 | 132 治疗上是不是可以加用抗血小板的药物？
【在 A*******s 的大作中提到】
: Sure.
: But any difference on treatment? Probably not.
:
: 时存在吧。
|
s******t
发帖数: 579 | 133 I have questions about how to order MRA:
Should we order to look at some specific locations most of the time or can
we order to see all the blood vessels from aorta to circle of Willis or even
higher level to look for any stenosis and embolization etc.?
If we need to see more blood vessels, it just takes longer and more
expensive or some else?
Thanks a lot!
【在 A*******s 的大作中提到】
: Good thought， MRA of what？
|
A*******s
发帖数: 9638 | 134 I would not due to the risk of hemorrhage.
【在 m****a 的大作中提到】
: 治疗上是不是可以加用抗血小板的药物？
|
A*******s
发帖数: 9638 | 135 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
【在 s******t 的大作中提到】
: I have questions about how to order MRA:
: Should we order to look at some specific locations most of the time or can
: we order to see all the blood vessels from aorta to circle of Willis or even
: higher level to look for any stenosis and embolization etc.?
: If we need to see more blood vessels, it just takes longer and more
: expensive or some else?
: Thanks a lot!
|
s********p
发帖数: 1319 | 136 我咋能不“自爆自弃”?大年十五来啦，还欠版主这么大一笔！——莫非叫我做杨白劳
不成？！
——不对，我的“伟哥”大贴，好像我俩连本带利结清啦！
——对，有啦，我有大钱花啦！我费了那么多心血帮版大搞的“形象设计”，我们还没
结账，对不？！
【在 A*******s 的大作中提到】
: step， 千万不要自暴自弃， 呵呵。 在本版是没有鄙视一说的， 你说的有你的道理
: ， 应该有包子。 不过你还欠我10个包子加利息， 可别忘了。
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s********p
发帖数: 1319 | 137 如果考虑来自动脉系统的栓子，强力抗血小板 + 低分子量肝素；
如果考虑心房和静脉系统的栓子，主打药物是Vit K依赖的抗凝药或凝血酶抑制剂，以
肝素为过渡。
【在 m****a 的大作中提到】
: 治疗上是不是可以加用抗血小板的药物？
|
s******t
发帖数: 579 | 138 Thank you for telling me why did you order MRA, but my question was a very
general question about the techniques. Maybe， Ruby knows more about the
answer to my questions:
MRA一般是只看一个较小范围里的血管，还是常规地可以一次看所有的你感兴趣的血管？
在看指定的少数血管和大面积观察血管异常在操作上有什么大的差异？
什么是MRA的最常见indications？
a
no
【在 A*******s 的大作中提到】
: 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
|
s******t
发帖数: 579 | 139 Could you talk about the trearment plan for this case please?
【在 A*******s 的大作中提到】
: Sure.
: But any difference on treatment? Probably not.
:
: 时存在吧。
|
a******3
发帖数: 1017 | 140 谢谢A大,我很高兴自己居然还挣了个学术包子 ^_^ |
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A*******s
发帖数: 9638 | 141 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？
【在 s******t 的大作中提到】
: Thank you for telling me why did you order MRA, but my question was a very
: general question about the techniques. Maybe， Ruby knows more about the
: answer to my questions:
: MRA一般是只看一个较小范围里的血管，还是常规地可以一次看所有的你感兴趣的血管？
: 在看指定的少数血管和大面积观察血管异常在操作上有什么大的差异？
: 什么是MRA的最常见indications？
:
: a
: no
|
A*******s
发帖数: 9638 | 142 I have mentioned above. Anticoagulation.
【在 s******t 的大作中提到】
: Could you talk about the trearment plan for this case please?
|
R*******t
发帖数: 367 | 143 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 seen with a satisfactory exam and
therefore being evaluated and reported. If you are lucky, you can
track
distal sub segmental arteries almost to the cortex, but not always. There
are always MIP images of MRA, which shows nicely the circle of willies and
the posterior circulation pathways.
Seeing very distal tertiary branches is usually difficult due to resolution
and limitation of the exam. And it usually doesn't contribute much to
treatment plan especially combining the MRI brain and clinical findings in
the setting of non-hemorrhagic stroke.
Besides, very distal branches are often beyond interventional management for
thrombolectomy as well.
MRA head is commonly done with MRA neck. Many times we don't need contrast
for MRA neck with time of flight technique.
Common indications include but not limited to TIAs, headache, r/o aneurysm,
dizziness, abnormal CT or MRI of head which MRA was recommended, h/o stroke,
etc. Or whatever the clinicians feel like to fill in as indication. :P
管？
【在 s******t 的大作中提到】
: Thank you for telling me why did you order MRA, but my question was a very
: general question about the techniques. Maybe， Ruby knows more about the
: answer to my questions:
: MRA一般是只看一个较小范围里的血管，还是常规地可以一次看所有的你感兴趣的血管？
: 在看指定的少数血管和大面积观察血管异常在操作上有什么大的差异？
: 什么是MRA的最常见indications？
:
: a
: no
|
A*******s
发帖数: 9638 | 144 Very well explained.
Thanks, Ruby.
【在 R*******t 的大作中提到】
: 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 seen with a satisfactory exam and
|
n*******c
发帖数: 501 | 145 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 use contrast or just time of
flight. Also is there any carotid plaque？（If she has such a severe
atherosclerotic lesion in left subclavian artery I would expect consistent changes in
other arteries.
Again, thanks for sharing. |
R*******t
发帖数: 367 | 146 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 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 use contrast or just time of
flight. Also is there any carotid plaque？（If she has such a severe
atherosclerotic lesion in left subclavian artery I would expect consistent
changes in
other arteries.
Again, thanks for sharing. |
A*******s
发帖数: 9638 | 147 1. Syncope is from brain stem ischemia due to SSS, brain stem infarct is
just a part of it.
2. Not sure about vertebral A direction, I would assume it would be
antegrade on the right and retrograde on the left.
3. No syncope before.
4. It is not uncommon to see a single artery stenosis (atherosclerosis)on
MRA or CTA.
infarct)
than
a
of
【在 n*******c 的大作中提到】
: 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 use contrast or just time of
: flight. Also is there any carotid plaque？（If she has such a severe
|
n*******c
发帖数: 501 | 148 I see.If this is the case. The patient would expect recurrent episodes if
leaving SSS untreated.
I thought this acute event is mainly due to the acute infarct because she
has no syncope before.
I am just wondering if the doppler ultrasound reported retrograde flow on
vertebral as well.
Again, thanks for sharing. |
k********n
发帖数: 756 | 149 i asked several stroke guy and nobody seemed aware that US carotid can
detect blood flow in basilar. it is too high for US.
【在 A*******s 的大作中提到】
: I have mentioned above. Anticoagulation.
|
A*******s
发帖数: 9638 | 150 I think it is tech dependent. Just like U/S for subclavian, the hospital
tech said no but our clinic tech told me easy.
【在 k********n 的大作中提到】
: i asked several stroke guy and nobody seemed aware that US carotid can
: detect blood flow in basilar. it is too high for US.
|
|
|
s******t
发帖数: 579 | 151 Thank you soooooooooooo much!
【在 R*******t 的大作中提到】
: 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 seen with a satisfactory exam and
|
A*******s
发帖数: 9638 | 152 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.
【在 A*******s 的大作中提到】
: I think it is tech dependent. Just like U/S for subclavian, the hospital
: tech said no but our clinic tech told me easy.
|
h*********t
发帖数: 116 | 153 a 78 year old male with past medical history of hypertension and DM
presented with an syncopal episode and had MRI and MRA head/neck. The MRI
showed no acute findings but MRA showed right vetebral artery high grade
stenosis. echo normal, no history of afib or sss, telemetry did not reveal
any arrhthmia. what would you do about the right vetebral artery high grade
stenosis? do you think his syncope is related to this vetebral art stenosis?
thanks!!!
【在 A*******s 的大作中提到】
: 1. Syncope is from brain stem ischemia due to SSS, brain stem infarct is
: just a part of it.
: 2. Not sure about vertebral A direction, I would assume it would be
: antegrade on the right and retrograde on the left.
: 3. No syncope before.
: 4. It is not uncommon to see a single artery stenosis (atherosclerosis)on
: MRA or CTA.
:
: infarct)
: than
|
A*******s
发帖数: 9638 | 154 I would not worry about the stenosis. It is irrelevant to syncope.
grade
stenosis?
【在 h*********t 的大作中提到】
: a 78 year old male with past medical history of hypertension and DM
: presented with an syncopal episode and had MRI and MRA head/neck. The MRI
: showed no acute findings but MRA showed right vetebral artery high grade
: stenosis. echo normal, no history of afib or sss, telemetry did not reveal
: any arrhthmia. what would you do about the right vetebral artery high grade
: stenosis? do you think his syncope is related to this vetebral art stenosis?
: thanks!!!
|
i*d
发帖数: 2640 | 155 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。
【在 A*******s 的大作中提到】
: 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.
|
h*********t
发帖数: 116 | 156 That's what I thought. thank you
【在 A*******s 的大作中提到】
: I would not worry about the stenosis. It is irrelevant to syncope.
:
: grade
: stenosis?
|
A*******s
发帖数: 9638 | 157 I think physicians order carotid as a part of stroke workup.
限。
【在 i*d 的大作中提到】
: 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。
|
i*d
发帖数: 2640 | 158 赞同。
多谢！
【在 A*******s 的大作中提到】
: I think physicians order carotid as a part of stroke workup.
:
: 限。
|
