Anton’s syndrome

The syndrome is quite astonishing. In our current case – a bilateral ICH under Marcumar (Phenprocoumon, a vitamine K antagonist) – it wasn’t realized until the second day that the patient doesn’t see anything.

We reviewed the components of the neurological examination of the visual system including optokinetic reflexes.

Unfortunately I couldn’t prepare my talk so I did not bring some current literature, so here is one very good article on Gabriel Anton and his syndrome from 2011 (it is always important to stay current, yet the developments around Anton’s syndrome have not been too hard to follow).

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Vibration sense and proprioception

You have an elderly man with gait disturbance, discover B12 deficiency which fits the clinical picture of afferent ataxia, substitute it, he gets better. Then your attending comes along, thrusts his Rydel-Seiffer-fork at the malleoli, comes up with 5/8 and wonders whether your diagnosis is correct. How can that be?

We discuss the peculiar neuroanatomy of vibration sense (as opposed to proprioception) as described in

  • Brazis Localization in Clinical Neurology

to which

We also mention the best way to measure pallesthesia (repeatedly, over skin vs. bone – the former being more sensitive), the bad interobserver reliability of Rydel-Seiffer-fork measurements and indications for doing pallesthesia in your average ER patient. Quite similarly we debate the various ways to examine joint position sense and why it is different from kinesthesia.

CT angiography

We discuss the differential use of neurovascular imaging – CTA, MRA, DSA and then concentrate on the technical aspects of CT-angiography, how to prepare for it, how to read the scans and how to do 3D-reconstructions on our workstations.

The most important message for our department: If you switch on “Dünnschichten” (thin sclices) in the list view you can use the MPR and HVR-modules of the IMPAXX software to do advanced 3D-imaging on the thin sliced (0,75 mm) images.

Antiaggregant medication

ASS, Clopidogrel, Prasugrel, Ticagrelor, Aggrenox, Cilostazin, Ticlopidin, Tirofiban and so on. It is hard to navigate the difficult topic of antiaggregant medication. Our focus in this talk is on the physiology of thrombocyte aggregation and the measurement of thrombocyte function in our lab – the Multiplate test.

Here is some literature on the topic:

Shift work

We are going to establish a 3-shift-system on our Stroke Unit coming month. So I wondered what literature there is about the best way to implement it. Rumour and a few recommendations have it that a forward shifting system (morning, late, night) is better than the converse, yet there is scant data to substantiate it. Even less obvious is how many night shifts in a row are best for a) the hospital b) the doctor.

If you can come up with some evidence, pls let me know.

Otherwise we can just list a few myths that are supposed to help to cope:

How to stay awake during long nights:

  • Keep your room brightly lit and not too warm.
  • Use coffee not for staying awake but to get into the mood.
  • If you start to nod off, try a power sprint (100 m), get fresh air, drink and eat light.
  • If you feel a dangerous dip, try to make room for a power nap.
How to get to sleep after a night shift:
  • Make time for decompression after work before going to sleep
  • Find something easy to read in bed
  • No coffee 6h before going to sleep
  • Eat light 1h before going to sleep
  • Use helpers such as ear plugs, night covers, thick curtains etc.
  • Use a standard routine (same book, same muzak etc.)
  • Don’t force your sleep: Nothing more dangerous than calculating your lack of sleep while trying to sleep. If it doesn’t happen, so be it.
  • Avoid sleeping pills and alcohol.
How to resynchronize:
  • Use everything you would do for jet lag resynchronization.
  • L-melatonin doesn’t help, but the retarded form might. Just for 1-2 days – if you have big resync issues.
  • Get into the normal rhythm as quickly as possible.
How to make the best of it:
  • Do morning business (shopping, bills, buerocratic stuff)
  • Sports (skiing on tuesdays!!!)
  • Show up at your spouse’s work with flowers (if applicable)
  • Show up at your children’s daycare/school etc.
  • Don’t expect to be able to do more than before on your free days – you need them to recover!