Surgical aspects of carotid endarterectomy

Indication, differential indication with CAS, complications – we know everything about the procedure except for the procedural details. So in our session today we talk about

  • cervical anatomy
  • surgical approach
  • anaesthesiological problems
  • surgical complications

of CEA, using the following resources:

  • Sobotta’s anatomy atlas
  • a video on youtube of about 10 mins showing the basic steps
  • the relevant chapter of Hobson’s Vascular surgery
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Stroke nursing – getting the hemiplegic patient out of bed

Morning rounds on our stroke unit. Regardless of the success of physiotherapy, the rounding team tries to mobilize a patient with recent ICH and hemiplegic left side out of bed, using all their strength to get her on the side, rushing every movement. Then some auscultation, lift your hands and back into bed.

There is quite some proficiency among our stroke nurses on how to do this properly, yet we tend to ignore all the basic nursing rules. We asked one of our favorite stroke nurses Gabi to give us a short introduction into how to do it right. This is actually quite easy and also fun to do, since the patient does most of the work, relishes the experience and our spine is spared…

Visual hallucinations in Lewy Body Dementia

We start with the case of Prof. Adrian Thomas in John Katzenbach’s The Professor – trying a differential of the described symptomatology (which is supposed to be CLBD, but then really isn’t). We use this current article to discuss visual hallucinations (VH) in movement disorders, a fascinating subject.

Some of the core messages:

  • They are really more of a late symptom, but very prevalent. Yet in my experience pseudohallucinatory presence-like phenomena occur quite often and even as prodrome in PD and LBD.
  • VH are usually not a symptom of L-Dopa-overdose, whereas psychosis and auditory hallucinations can be.
  • Many structures are suspected to be involved – from the Amygdala to the Thalamus, to the parietotemporal cortex.

Unilateral mydriasis

This is a straightforward diffential, so that you won’t find any recent reviews on the topic. We are stuck with our textbooks – you can probably judge the  quality and the uptodateness of your favorite textbook by it’s handling of this classic question.

Here are some remarks:

  •  Anisokoria: You can use apraclonidine if you have it to find out which side is the bad one.
  • Pathologically small: DD of Horner’s – too broad (separate CME session)
  • Pathologically big: can be pharmacological (use Pilocarpine to prove that further anti-M3 doesn’t change the big pupil), ophthalmological (use slit slamp), Adie’s/Ross syndrome or symptomatic ciliar ganglion disease (only after reinnervation the denervated pupil becomes tonic and accommodating, whereas in the acute phase often both is not true), peripheral oculomotor (compression mostly, can occur w/o other third nerve problems), mesencephalic.

A puff of smoke – Moya moya

Once considered rare in Europe, we see the puff of smoke quite often and not only in symptomatic patients. In spite of the literature

I have not yet understood what happens in Moya moya. In adult medicine we tend to see a lot of symptomatic Moya moya syndromes rather than the classical disease, although it is not clear to me whether the original disease is really always primary…

Moya moya seems to be the one disease where bypass surgery is still recommended, so we have to consider referring our 39 yo male patient with bilateral Moya moya for surgery.

Metronidazole induced encephalopathy

While the clinical picture (dysarthria, ataxia, possibly some sensory pnp-like symptoms) aren’t in any way specific, the MRI seemingly is – an instance can be found in this overview on imaging in metronidazole-induced encephalopathy. Metronidazole is an often used drug that has shown some benefit in non-infectious colitis and also a wide sprectrum of bacterial infections.

We discuss a literature case of metronidazole-induced encephalopathy, developing a differential and reviewing the literature a bit, using this case report in J Clin Pharmacol 2011.