Introducing
#NeudrawlogyCR
for our
#ClinicalReasoning
infographics!
The first one: approach to Chronic Daily Headache! 🤕🧠
Click the image to view the entire infographic, or see it on the website
Special thanks to Dr. Robert Kaniecki for reviewing it!
1/
It was a delight to work with
@caseyalbin
to explore the incredibly diverse CNS complications of infective endocarditis!
An
#infographic
&
#tweetorial
investigating the radiographic & clinical findings in IE, with some management pearls.
#MedEd
#Neurotwitter
Hey,
#NeuroTwitter
, are you feeling down? 😢
Check the new infographic about CN 3 palsy!
The clinical manifestation of a complete ophthalmoplegia is known as "Down and Out Syndrome" due to the eye position! 👁️👁️
🧠📚🎨
#ItsAllAboutPupils
episode 4!
Johann Friedrich Horner was a Swiss🇨🇭ophthalmologist. In 1873, one of his students published a thesis describing a woman with "oculosympathetic paresis".
A short🧵containing history and a bit of scientific gossip! 🙊
🧠📚🎨
A diagnosis that you can't miss: Wallenberg's Syndrome 🔥
- A
#DDx
for Acute Vestibular Syndrome 😵💫!
(Not shown in the infographic: hiccups ➡️ associated with reticular formation lesion)
#NeuroTwitter
#MedEd
#FOAMed
🧠🎨📚
Tolosa-Hunt syndrome is a rare disease that presents with headache 🤯 and diplopia 👀👀!
Check the infographic to learn more🧐
#NeuroTwitter
#MedEd
#FOAMed
🧠📚🎨
(1/4)
🧮Just do the math: 1 + 2 + 3 + 4 = Gerstmann Syndrome!
#NeuroTwitter
#NeuroTwitterNetwork
#MedEd
#FOAMed
📜Historical fact: it was first described in 1924, by Josef Gerstmann, and Austrian 🇦🇹 Neurologist, after evaluating a patient with a stroke!
🧠📚🎨
Sorry for bringing you step 1 📝 memories...
Thiamin is a cofactor for several key enzymes responsible for the maintenance of cerebral energy homeostasis ⚖️ !
An acute thiamine deficiency can cause Wernicke Encephalopathy 🧠⚡️!
🧠📚🎨
🎉Almost 1,5k fantastic neuro nerds follow this page!
So here goes an infographic about
#OneAndAHalfSyndrome
!
One eye doesn’t move horizontally, and the other can only abduct! 👀
PS: For me, it makes more sense to think of it as “Zero-and-a-half” syndrome ... 😂
🍭Are you ready to go back to your childhood,
#NeuroTwitter
?
Because ... today's topic is Alice in Wonderland 👧🐇🎩!
(Isn't neurology the best specialty ever?)
Thanks to our Instagram followers who chose this great topic for today!
🧠📚🎨
#FOAMed
#MedEd
Douglas Argyll Robertson was a Scottish 🏴 ophthalmologist 👁️who described this pupil in 1869 in a patient with neurosyphilis 🦠.
He also first described the effects of physostigmine, extracted from Calabar bean 🌿, which he tested on his own eyes!
#NeuroTwitter
#FOAMed
#ItsAllAboutPupils
!
Another famous pupil 👁️ is being featured!
📜Robert Marcus Gunn was a Scottish physician, that in 1902 described the "pathologic pupillary escape". Later (1959), Levitan better characterized this finding with the swinging light test 🔦.
Thoughts?
🧠📚🎨
The sun has almost set 🌇, which reminded me to post another infographic!
👀The impaired up gaze of Parinaud's Syndrome can lead to a preference of looking downwards, which resembles a sunset 🌞
#NeuroTwitter
#MedEd
#FOAMed
Welcome to
#NeudrawlogyMigraineEdition
, part 7! 🤕🧠
CRGP = Calcitonin gene-related peptide plays an important role on the pathophysiology of migraine
💊Their antagonists can be used for either migraine prophylaxis or acute treatment of a headache episode
Part 8 tomorrow!
#ItsAllAboutPupils
!
William Adie was an 🇦🇺 neurologist who bravely worked in World War 1 💣 with traumatic brain injury.
He and his friend Gordon Holmes independently described this finding in 1931!
What else is he famous for? Can you guess? 🧐
🧠📚🎨
#NeuroTwitter
#FOAMed
If you love 🧠 and 🎨, here's a special infographic for you!
💡How can neurological disorders change the creative process?
Let us know what else you have,
#NeuroTwitter
!
*Created in collaboration with
@MariaMjaleman
- check her fantastic tweetorial below!
Do you think creativity can be pathological? 🤔
Neuro says: maybe🧠❤️
What differential diagnosis can you come up for the CC: "new or improved bursts of creativity"? ⚡🔥
(Sorry for the made up schema, don't quote me on this)
#art
#neurotwitter
11/
Similarly, meningitis is another infectious complication. Most commonly with S. Aureus!
The 🔑: whatever abx are being used for the endocarditis MUST have CNS penetration (no cefazolin!)
A table of abx with good CNS penetration
@meganRx1
from
#AcuteNeurologySurvivalGuide
.
1/ Migraine’s pathophysiology is very complex and involves:
- Primary neuronal dysfunction
- Cortical spreading depression of Leão (it is thought to cause both the aura and the headache)
- Activation of trigeminal afferents causing inflammation
6/ There are four groups of Primary Headache Disorders: 1) migraine, 2) tension-type headache, 3trigeminal autonomic cephalalgias, and 4)other primary headache disorders.
Tolosa-Hunt syndrome is a rare disease that presents with headache 🤯 and diplopia 👀👀!
Check the infographic to learn more🧐
#NeuroTwitter
#MedEd
#FOAMed
🧠📚🎨
(1/4)
3/ But… each person is different, and, again, migraine is a complex disease. Many other triggers are not listed above and not yet studied, so a careful history and a headache diary are essential steps in the treatment!
5/ Here are some the general recommendations 💊
Some authors suggest initial treatment with any of these 4 drugs since they work in 50% of the patients:
- Amitriptyline
- Propranolol or metoprolol
- Topiramate
- Venlafaxine
The sun has almost set 🌇, which reminded me to post another infographic!
👀The impaired up gaze of Parinaud's Syndrome can lead to a preference of looking downwards, which resembles a sunset 🌞
#NeuroTwitter
#MedEd
#FOAMed
If you want to localize the lesion using the Rule of Four of the brainstem: Sympathetic/Spinothalamic ➡️ S = Side ➡️ lateral syndrome
Hoarseness/dysphagia ➡️ CN 9 & 10 ➡️ medulla (4 cranial nerves in the medulla starting from 12, 4 in pons, 4 above pons)
9/
Although rare, intracranial abscesses may be a delayed complication of IE… even after valve replacement & BCx clearance!
For the pt w/ persistent fevers & leukocytosis, low threshold for MRI brain to r/o abscess.
Note, these may present with just AMS!
2/ Migraine attacks may be caused by triggers.
Common studied triggers are alcohol 🍻, sleep disturbances 😴 (either sleeping late, not sleeping or sleeping too much), some types of food 🍽, hormones✨, and emotional stress🤯.
5/
In addition to ischemic stroke, IE may cause cortical SAH & IPH
BOTH may be associated w/ infective intracranial aneurysms (IIAs)!
⭐️ICH in IE = vessel imaging, preferably w/ DSA ⭐️
When to screen for asymptomatic IIA?
Debatable. At least once & ideally also b/f CT Surg
7/ There is still no cure for migraine, but there are many effective treatment options, and a life without recurring incapacitating pain episodes is possible.
2/
The most common cause of neurologic injury in IE is ischemic stroke.
But! Management is somewhat different.
Notably, due to the high risk of hemorrhagic transformation, tPA is relatively contraindicated or should be used with extreme caution.
You don’t want to end up with ⬇️
#ItsAllAboutPupils
episode 4!
Johann Friedrich Horner was a Swiss🇨🇭ophthalmologist. In 1873, one of his students published a thesis describing a woman with "oculosympathetic paresis".
A short🧵containing history and a bit of scientific gossip! 🙊
🧠📚🎨
8/ (1/2) If the patient meets all but one criteria A-D above and does not fulfill other ICHD-3 criteria for any other headache disorder, this person has a probable migraine.
2/ 👀 Visual symptoms are the most common. They occur in over 90% of patients with migraine with aura, are bilateral and can be either positive (scintillations, flashes, etc.) or negative (like scotomas).
12/
SUMMARY:Endocarditis
🧠Can present with any number of CNS complications!
❤️Requires thoughtful approach to the timing of cardiac surgery
🧠= Low threshold for neuroimaging.
🦠Necessitates good CNS coverage!
Great reviews:
4/ 🎯 Indications for preventive treatments are (2/3):
- >2 severe or disabling attacks or <4 less disabling attacks per month
- Patient preference
- Highly disabling migraine attacks (e.g., hemiplegic migraine, migraine with brainstem aura)
3/ Ok, now back to the goals.
🎯 Indications for preventive treatments are (1/3):
- Attacks that significantly interfere with patient’s daily routine despite acute treatment
- Ineffective or contraindicated acute migraine treatment
6/
The bleeding pattern resulting from ruptured IIA is often NOT the classic “aneurysmal pattern” bleed because unlike CoW aneurysms, IE aneurysms are often:
🎈Found in distal vessels
🎈Small
🎈Fusiform
@alialawiehmdphd
Like ⬇️
6/ Other recommendations are: (1/2)
- 🪫 Start at a low dose
- ⛔🏃♀️Do not hurry. Some drugs can take four weeks and some up to 6 months to be effective
- 👨🏫👩🏫 Set expectations, explain possible side effects 🤢, and 🥅 goals of care
I am thrilled to share that all my NeuroICU Tweetorials are now indexed on the
@neudrawlogy
website by the extremely talented
@gabifpucci
!
Check out all former
#tweetorial
cases and collect her awesome infographics!
3/ One common visual aura symptom is the fortification spectrum. It consists of zigzag ⦚⦚ lines that gradually enlarges and can either be colored 🌈 or black-and-white 🦓.
🧐Although Horner has not claimed the discovery of the syndrome, it became known as his name.
🗺️This is why in some countries it is called Claude Bernard-Horner Syndrome or Bernard-Horner Syndrome.
12/ Remember. Abortive drugs are helpful and safe for use. However, the use of abortives should be limited to < 15 days/month (simple analgesics/NSAIDs) and < 10 days/month (ergots, triptans, others) to avoid the development of medication overuse headache.
8/ (2/2) This occurs because migraine milder attacks or attacks treated early often do not achieve the full criteria, but even though they respond to migraine treatments.
📚The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice.
@ahsheadache
@HeadacheJournal
1/ Like a breeze 🌬 precedes a storm ⛈, the aura usually precedes the headache in up to 60 min.
But not always.
It can also:
- Occurs alone, not followed by any headache
- Occurs during the headache episode
5/ Two exceptions:
•Aspirin: irreversibly inhibits COX-1 and COX-2.
•Colecoxib: inhibits only COX-2.
Side effects: gastric ulcer and interstitial nephritis.
#Step1
#USMLE
#Pharmacology