Recurrent extracranial vasospasm

Neurovascular medicine is full of surprises. On Tuesday we saw a patient during our CME rounds that suffers from recurrent extracranial vasospasms and that for twenty years now. Last year he developed a proper stroke and was stented. This year the artery is stenotic again and he went through various interventions until we realized that his arteries are just too sensitive – we then switched to nimodipine and spasms remitted, only to develop on the other side.

This really is a very young disease entity, first described by Janzarik et al in Stroke 2006. It seems to have nothing to do with migraine, vasculitis, RCVS.

Cardiac workup of stroke

Guidelines, articles and institutional pathways all contradict eachother with respect to the necessary cardiac workup of stroke. Most of the voices I hear (yes, I am hearing voices) talk about echocardiography, scintigraphy and what not. We focus on the history, physical examination and basic cardiac workup (electrocardiography), the value of early monitoring and more in the early stroke phase, using this article as a reference.

We also mention what it is precisely that properly predicts intermittent arrhythmia in transthoracic echocardiography – namely the combination of atrial dilatation and contractility, at least that is what our Göttingen colleagues tell us in this recent article.

Talking with relatives (also about limiting therapy)

Everyday you are communicating with relatives about their loved ones development. One would expect us to have some training in the necessary communication skills, but hey: we haven’t. So we play through one of our standard situations (lol with big bleed, not too bad, yet bad prognosis).

As for reference I highly recommend the following link to a script for communication skills training for ICU residents.

Resistant hypertension workup and secondary hypertension

To diagnose hypertension, you need to qualify and quantify it (use 24h-RR), screen for endorgan failure (eyes, brain, heart, kidneys, peripheral vessels) with TTE, fundoscopy and basic labs (urine proteine).

Whenever you introduce the third antihypertensive agent in your stroke patient, you deal with resistant hypertension and thus should think of the AHA guidelines on this topic. In particular you ought to think of the ABCDE mnemonic for secondary hypertension causes (to be found here and slightly enhanced below):

  • A: Adherence [history], aldosterone [elytes, do a morning aldosterone/renin plasma test], apnea (obstructive) [history/physical]
  • B: Bruits (renal artery stenosis) [auscultation, ultrasound/MRA/CTA]), bad kidneys [urine proteine, creatinine, urea]
  • C: Cushing [physical, basic labs, cortisole profile], Catecholamines [history, 24h-urine for the homovanillin… thingy, metanephrines and normetanephrines], aortic Coarctation [RR left/right, legs]
  • D: Drugs (NSAIDS, estrogens, cortisone, bromocriptine, cyclosporine, tacrolimus, ephedrine/catecholamines, …), Diet (obesity!, sodium)
  • E: ndocrine [TSH, hyperparathyroidism], EPO

Carbamazepine

We do learn a lot about new inventions such as Zebinix, Trobalt and Lyrica, yet nearly forgot the age old knowledge about the good ole antiepileptic drugs, such as Carbamazepine and Valproate. We recapitulate the history of CBZ’s development, the chemical peculiarities (it is an oligocyclic with all the problems of tricyclic agents), pharmacokinetics and practical aspects. Did you know that most of the pharmacodynamics of CBZ is not really well understood – except perhaps for its Na-channel modifications?

As for literature, I am hard pressed. Most of my knowledge stems from standard textbooks, such as Engel’s textbook.